Diabetes and CKD - Pitfalls: Estimating GFR

The routine use of estimating equations for GFR has revolutionized the way that we view renal disease over the last 15 years and although some argue that this has lead to overdiagnosis of CKD, I believe that this has been an extremely positive development both in clinical and research terms. One criticism of the MDRD equation in particular was that it did not perform well in patients with near normal GFR and the CKD-Epi equation was introduced, at least in part, because of this limitation. However, there remain concerns that in patients with diabetes, particularly in those with hyperfiltration, this formula still does not perform sufficiently well.

To answer this question researchers in Italy took patients from two clinical trials who had serial measured GFR for up to 8 years and compared the results with simultaneous estimates of GFR using the 14 different equations. Of the 600 patients included, 15% were hyperfiltering and 13% had a reduced GFR. Overall, all but one of the equations underestimated GFR in the group as a whole. The single equation that overestimated GFR (Ibrahim) tended to overestimate at all levels. The range of differences between the mGFR and eGFR was -40 to +20 ml/min/1.73m2 and the mean percent error (MPE) ranged from -28.14 to 0.98%. Not unexpectedly, the majority of the error was related to underestimation of GFR in patients with hyperfilatration (MPE -12.8 to -36.7%). It is notable that the MPE was lowest in participants with hyperfiltration using the CKD-Epi equation. In this group, the mean mGFR was 132 ml/min/1.73m2 while the mean eGFR ranged from 83-114 ml/min/1.73m2.

The bias was far lower for the normofiltration and low GFR groups. Because the authors had longitudinal data also, they were able to look at the ability of the formulas to measure GFR decline over time. Given that all of the equations underestimated GFR at baseline, it is unsurprising that there was systematic underestimation of GFR decline over time, particularly in the patients with hyperfiltration. This was less marked in the patients with CKD at baseline. Five of the equations actually estimated that GFR was increasing in the patients despite a consistent decline in mGFR.

This is all not to say that these formulas are not useful. It is always important to recognize the limitations of your tools and one of the major issues here is that creatinine is used as the marker of kidney function with all of the limitations that this introduces. It should also be said that although the agreement with mGFR might not be great, we know from large EPI studies that an eGFR of less than 60 ml/min/1.73m2 is associated with poorer outcomes and this is true no matter what the cause of the disease. The take home from this is that it is not possible to accurately diagnose hyperfiltration in diabetic patients without over nephropathy using current creatinine-based estimating equations and that other signs should be taken into account when assessing these patients.

(Click on images to enlarge)

UK: Market concentration leads to higher prices

In what should be an implicit advisory to the United States as geographically powerful ACOs become the norm, the UK Competition Commission has found that most patients in UK private hospitals are paying more than they should for treatment because of a lack of local competition.

CC Chairman and Chairman of the Private Healthcare Inquiry Group, Roger Witcomb said:

‘The lack of competition in the healthcare market at a local level means that most private patients are paying more than they should either for private medical insurance or for self-funded treatment.

"The lack of available and comparable information, often less than is available to NHS patients, also makes informed choices—which could help drive competition—for these patients difficult."
 
The BBC News summarizes that the financial results of this market power are clear:

Hospital groups BMI, Spire and HCA had been "earning returns substantially and persistently in excess of the cost of capital", the commission said.

How much does this amount to?  The conservative estimate is £173 million to £193 million a year.

"No insurer has countervailing buyer power that can fully offset the market power of BMI, Spire and HCA," the commission's provisional findings said.

The commission recommended moves to make more information available about the quality of hospitals' services and the level of fees charged by consultants. [Note to US readers: "Consultants" = "doctors".]

It also suggested that operators owning a cluster of hospitals in one area should have to sell off some of them. 

Disruptive noises from Pennsylvania

I'm not sure how I missed this, but it is still timely and worth noting.  In June, a new Disruptive Health Technology Institute was created at Carnegie Mellon University, in collaboration with Allegheny Health Network and Highmark, Inc.  The insurance company, Highmark, will make its claims data available to DHTI researchers.  By mining that data, the researchers will make suggestions to CMU researchers as to fruitful areas that might benefit from new technologies.  The focus will be on accessibility of medical diagnostics, behavior change, chronic disease management, data mining, improved endoscopy, improved diagnostic ultrasound and infection prevention. The DHTI will then fund a small number of those ideas each year, eventually building a large library of research studies that might generate disruptive technologies in the field.

As the story notes,

Alan Russell, who will serve as the director of DHTI and as both executive VP and chief innovation officer for the Allegheny Health Network, says that healthcare is a field that needs to be shaken up.

For sure!

In July, Lynn M. Brusco was chosen to be executive director.  She is well qualified for the role, having served as vice president and chief relationship officer at the Pittsburgh Life Sciences Greenhouse (PLSG) and director of the PLSG Accelerator Fund.

We'll look forward to the results from this new institute.  I also see a potential for an alliance with our friends at the National Center for Human Factors in Healthcare.  I imagine they will have a lot to share over the coming years.

Doctors tweet about IWantGreatCare

My post about the IWantGreatCare patient evaluation program prompted some interesting conversation among UK doctors on Twitter.  I'm not suggesting this is a statistically valid sample of physician responses to the program--after all, these are doctors who feel comfortable talking about such matters on Twitter--but it is an indication that IWGC is adding some value to the doctor-patient relationship. The doctors also note a desire to get more participation from patients and steps they are taking along those lines. I conclude that this is a work in progress, and it will be good to get more updates over the coming months.

First, Clare Rees @doccmr (a pediatric surgeon) noted she was impressed with Oliver Warren @DrOliverWarren (surgeon) on his engagement with the patient in the example I posted.  He responded:

Thank you! Bit nerve wracking sometimes but right thing to do.

Then Dermot O'Riordan @dermotor (surgeon and medical director in Suffolk) led us to his blog post on the issue:

I must confess it was an anxious leap of faith to start asking patients to take cards home and rate me anonymously. I have read lots of stories about the pitfalls of unmediated review sites, e.g. TripAdvisor.

I have been giving them to every patient I have seen in clinic for three months. To start with nothing happened. A couple of weeks later I received my first review & it wasn't that flattering: I wondered if I was doing the right thing.

However I persevered and further reviews started to come in. Fortunately some were much more positive and it is always nice to hear good things. Most patients after all do trust, respect and value their doctor, in contrast to many other professions. In addition I have received constructive comments that I have tried to learn from.

Without this sort of feedback I might never know how I am perceived by patients. The response rate is still not high but I feel that it is an incredibly powerful rebalancing of the doctor-patient relationship for the patient to know that I have invited them to feedback. It does involve trusting the patient but it is important to remember that the patient is trusting me to operate on them!

I am convinced a system such as this can play a major role in changing the culture of medicine towards transparency and putting the patient in charge. It also plays a major role in providing patient feedback for doctors to support their revalidation. A number of clinicians whom I spoke to were highly positive.

Clare noted reactions and then asked:

Every single parent has been surprised to be asked - need to change #culture.  What's your response rate? I give them to everyone but very few give feedback.

Oliver answered:

Three packs of cards used 30 responses. Estimate about 1 in 20.

Dermot said:

Mine's bit lower but don't only do it for the response but cos change dynamic of consultation/trust.

Clare:

OK not just me then!

Dermot:  

But those that do respond do seem to like you.

Clare joked:

Guess I should look at the half full part of the glass more often!

I'd like to hand out iPad with link to improve response rate, but then it wouldn't be anonymous.

In a separate thread, Dermot has a conversation with Richard Bogle @RichardBogle (cardiologist), who notes:

The only thing we have to fear is fear itself.

Dermot replies:

Totally agree. The patient survey produced by @gmcuk was unhelpful. Using @iwgc changes consultation but accept is a big step.

Richard comments, too, on the previous system:

The 360 degree patient feedback is totally useless. It represents about 0.1% patients seen and is self selected.

Then they discuss how to get more responses from patients:

Dermot: Clinic nurse gives it to every patient I see.

Richard: I have the link to iwgc on my website and also a friends and family test on the site. I put the web address on all correspondence. The website gets lots if hits but no responses on iwgc. I think I will start using the cards.

Dermot: I too put my @iwgc URL in footer of all letters. Not sure if produces that many responses.

Communication Counts

Sign seen at the George Washington University Hospital:

Those are the basics!  Good for them to make it explicit. I'd love to hear from patients, families, and staff how it's working.

Badge buddy residents work together on adverse reporting

"Every resident should know how to make an adverse event report," says Nate Margolis, M.D., a fifth-year resident training in New York University's Radiology Residency Program.  (Nate is co-chair of the NYU School of Medicine’s House Staff Patient Safety Council.)

Nate's right, of course, and indeed this is now a requirement of the ACGME, the governing body of residency programs in America:

The Sponsoring Institution must ensure that residents/fellows have access to systems for reporting errors, adverse events, unsafe conditions, and near misses in a protected manner that is free from reprisal.

But this capability is often missing, the victim of a prejudice on the part of many hospitals against resident involvement in this kind of activity.  Often, too, residents feel cowed by a perception that their future career prospects will be damaged by honest reporting.  The situation is complicated, too, for residents who rotate through several hospitals.

Nate and his colleagues decided to help solve this problem using a “badge buddy”—a simple, effective tool to assist residents with the process of reporting events at the multiple hospitals in which they train.  Here's a video describing the initiative, which was strongly supported by the Committee of Interns and Residents (CIR), as well as the senior leaders at NYU.

IWantGreatCare

A group in the UK called iwantgreatcare.org has been running a consumer evaluation website about doctors and hospitals.  Analogous to TripAdvisor, people can post quantitative rankings as well as qualitative comments.  It covers 100% of the NHS hospitals and over 200,000 doctors.  All information is absolutely transparent to the public, the clinicians, and the hospitals.

I can already hear the complaints:  "Our patients are sicker."  "People don't understand enough about medicine to properly judge us." "This is just going to be a complaint board."

Taking the last objection first, well, no.  It turns out that the vast majority of people are actually pleased with their medical care and use the site to send a positive, thankful message to their caregivers.  Here is a touching example:

Everybody finds the GU clinic a bit scary. It just is. For me it's a bit more than scary. I was sexually assaulted 10 years ago and find the examinations difficult after my experiences. After the assault I was examined by a male doctor... it was traumatic to say the least. Just to add insult to injury I have also had cells removed from my cervix (bear with me I am trying to build up a scenario) so I have been examined by various doctors, nurses, blah blah. The point is this. Dr [Robin] Bell is extraordinary. His approach, helpful manner and wit are second to none. I have NEVER ever felt so at 'ease' (relatively speaking) when having said examination. Having seen him twice now I can honestly say I will not see any other GU doctor unless I really have to. I was nervous the first time I went to his clinic; nervous about the examination and (wrongly so) the fact, he is of course, a man! Pah! No female has ever treated me with such tenderness. I would like to thank Dr Bell and I meant to say it today but after my last visit I called my mum (confidant and aide) and cried (for quite some time) about the fact it was ok, that a man had dealt with me and it had gone well. I cried that my fear was over; believe me the police examination was horrific. I can't recommend Dr Bell highly enough. I never ever thought I'd get the chance to conquer the fear of a male examiner... but I did and he's the best :-) Who is in control? His patient :-) 

But sometimes, there are complaints.  Here's one, along with the response by the doctor, posted within 24 hours:

Saw my mother after an examination of her bowel because her GP was worried about something serious. Spent more time talking to student doctor than to my mum and kept asking me questions instead of my mum. She wears hearing aides but isn't stupid! She was still worried about her stomach pains but all he cared about saying was that it wasn't cancer. He is very professional and smart and probably very clever and not rude but he didn't address my mother's worries and talked down to us both a bit. Would ask for a different doctor next time.

Response from Mr Oliver Warren 

Thanks for your feedback. I'm very sorry that you feel I didn't live up to the high standards of care I expect from myself and that we all strive for at Chelsea and Westminster Hospital. I would never presume that someone who requires hearing aids is stupid, and would never wish to give the impression of talking down to a patient or a relative; it can sometimes be really difficult to get the balance right between explaining things in a way that people understand and aren't too complicated, and oversimplifying. Likewise with reassurance; many of our patients are very much focused on cancer, and ensuring they don't have it. On this occasion I read the concerns of your mother and you incorrectly. We try to ensure that the medical students are fully involved and seen as part of the team at our teaching hospital. Balancing their educational needs with the needs of patients can also sometimes be fraught with difficulty in a busy clinic. I would be delighted to organise a second opinion with a colleague if this would be of any help or benefit and am grateful for your feedback.

I don't know, but I bet the information collected here is more useful than the kind collected by Press Ganey and other such patient evaluation services.  Yes, this site suffers from a self-selection bias, but it would be difficult to know in which direction the bias acts.  As mentioned, lots of the comments are laudatory and appear to give people a chance to show gratitude.  If I were running a hospital, I would be sharing these results broadly among my staff, looking to see where trouble areas might be occurring.  As the site notes: "Quantitative and qualitative feedback for organisations, departments, wards and clinics gives real insight with data that actually allow continuous improvement and is proven to engage front-line clinical teams."  I would also celebrate the success of consistently fine reviews.

The site makes no representation that it is evaluating clinical decision-making and outcomes.  That's not the point. It collects reactions from patients in three categories:  Trust, Listening, and Recommend.  You don't have to be a genius to understand that these characterizations are going to be made anyway by patients to their families, friends, and associates.  Doesn't it make sense to hear them directly if you are running a hospital or physician practice?

Mindfulness now!

Here's a humorous take-off on the concept of mindfulness, perhaps distinct from that codified by medical education guru David Mayer, but agreeing with him on the hoped-for time frame.

Getting sleep versus staying engaged with the patient

Lisa Rosenbaum has posted a thoughtful piece over at The New Yorker entitled "Why Doesn't Medical Care Get Better When Doctors Rest More?"  After introducing a story about a patient, she says,

A few days later, the resident caring for the patient neared the teaching hospital’s witching hour: whether or not his work was done, he had to leave at 6 P.M. That’s because, a decade ago, largely in response to widespread concerns that tired residents were making too many errors, the Accreditation Council for Graduate Medical Education enacted nationwide rules that limited the number of consecutive hours residents can work. Five years later, a review of the data suggested that, on average, the rules had failed to make our nation’s teaching hospitals any safer. Proponents of the reforms argued that the rules had neither gone far enough nor been properly enforced. Accordingly, in 2011, first-year residents were limited even more—to sixteen-hour shifts, rather than the thirty hours previously allowed. Training programs scrambled to comply.

Rosenbaum then leads to some of the intangible aspects of the work hours rules:

The data evaluating the impact of the 2003 reforms suggest that, when it comes to patient safety, little has changed in teaching hospitals. But when it comes to preparing young doctors to manage disease, the training environment has been completely transformed.

While these studies suggest the complex nature of patient safety—that manipulating one variable, like hours worked, inevitably affects another, like the number of handoffs—there is another tradeoff, more philosophical than quantifiable. It has less to do with the variables within the system and how we tinker with them, and more to do with what we overlook as we focus relentlessly on what we can count. 

Near the end of the article, she starts a story:

As a third-generation physician, I did not think the cultural transformation of our educational environment would affect my fundamental sense of what it means to be a doctor. But the other night I had a phone conversation with my mother, who’s also a cardiologist. 

I'll leave it to you to read the rest. 

Bending the Map

As I am reading the book The Lost Art of Finding Our Way by John Edward Huth, I am struck by a correspondence between the kind of confirmation bias experienced by a physician who has engaged in diagnostic anchoring and a phenomenon called "bending the map" that is experienced when people get lost in the wilderness.  Here's the quote from the book:

The correspondence between a mental or physical map and our perceptions helps us stay oriented, but one of the first stages of getting lost involves a process called "bending the map." The phrase comes from the sport of orienteering, in which competitors find their way around a series of waypoints that are revealed to them on a map at the start of the race.  Competitors can become lost and believe they are in one place indicated on the map and mentally try to force features they see to line up with ones indicated on the map even when the correspondence is poor.

Denial is an effective psychological defense mechanism, and map bending is one form that lost persons often engage in. A lost person might first believe he is located at a certain point on the map, but things around him do not seem quite right. He pays attention to details that confirm what he already believes to be true, ignoring all evidence to the contrary.  A lost person may be looking for a creek that flows south on the map. In his mind he's sure that he has arrived at the creek. It flows east, yet he conveniently ignores this fact and follows it anyway.  It can take some time, but there comes a moment when an eerie realization hits him that something is wrong and he doesn't know why.

The parallels to doctors who have settled prematurely on a patient's diagnosis are compelling.  Evidence that supports the conclusion is accepted.  Contrary evidence is ignored.

Recall the story Jerome Groopman tells in his book How Doctors Think:

One of my patients was a middle-aged woman with seemingly endless complaints whose voice sounded to me like a nail scratching a blackboard. One day she had a new complaint, discomfort in her upper chest. I tried to pin down what caused the discomfort--eating, exercise, coughing--to no avail. Then I ordered routine tests, including a chest x-ray and a cardiogram. Both were normal. In desperation, I prescribed antacids. But her complaint persisted, and I became deaf to it. In essence, I couldn't think in a different way. Several weeks later, I was stat paged to the emergency room. My patient had a dissecting aortic aneurysm, a life-threatening tear of the large artery that carries blood from the heart to the rest of the body. She died. Although an aortic dissection is often fatal even when discovered, I have never forgiven myself for failing to diagnosis it.  There was a chance she could have been saved.

I wish I had been taught, and had gained the self-awareness, to realize how emotion can blur a doctor's ability to listen and think. Physicians who dislike their patients regularly cut them off during the recitation of symptoms and fix on a convenient diagnosis and treatment. The doctor becomes increasingly convinced of the truth of his misjudgment, developing a psychological commitment to it. He becomes wedded to his distorted conclusion.

While Jerry focuses here on the situation where dislike of a patient leads to diagnostic anchoring, we now understand that it can apply in many situations, irrespective of the doctor's personal feelings about the patient.

Let's go further, though, and see if the following emotional reactions also apply to physicians. Huth says:

Suddenly, the lost hiker recognizes that his map and his perceptions don't line up.  Panic sets in. The emotional centers of the brain send out warning signals, and perceptions get distorted with a fight-or-flight reaction.  Massive amounts of adrenaline flood the mind and body. Breathing and heart rate increase. The person refuses to believe that he's lost and runs frantically in a direction that he's sure will lead back to the trail, only to get deeper into trouble. First one possibility, then another races through his overtaxed mind, and yet he cannot gain any certainty.

"Woods shock" is the term for this kind of anxiety attack brought on by the realization that the subject is lost. 

I have seen woods shock occur to physicians. I have seen it in clinics and on the floors and ICUs.  I have seen it during case reviews, when doctors are describing adverse events and trying to figure out what went wrong. When denial sets in, I have seen the figurative equivalent of "running frantically in a direction that he's sure will lead back to the trail." The flailing and emotion distress that occurs is painful to watch and, I'm sure, to experience for these people who have been trained not to be wrong.  Rationalization comes into play.  Blame of other parties--the nurses, the labs, the residents--is a common response.

In a post almost three years ago, I summarized a talk by Pat Croskerry from Dalhousie University, Halifax, Nova Scotia.  Pat says we need to spend more time teaching clinicians to be more aware of the importance of decision-making as a discipline. He feels we should train people about the various forms of cognitive bias, and also affective bias. Given the extent to which intuitive decision-making will continue to be used, let's recognize that and improve our ability to carry out that approach by improving feedback, imposing circuit breakers, acknowledging the role of emotions, and the like.  In summary, let's see if we can protect our clinicians from bending the map and experiencing woods shock.

Most wired?

Now that I am a "civilian," I get to experience the health care system like most of you. I marvel at the degree to which customer service mechanisms used by service providers in other sectors do not exist in health care. Please understand that I am not talking about the quality of care, or empathy, or attentiveness offered by doctors, nurses, rad techs, lab techs and the like.  On that front, I remain tremendously impressed.  Indeed, I am even more impressed that they can offer such fine care now that I get to witness the logistical "systems" in place to do the humdrum things that are required to provide service, work flows whose design not only makes things harder for patients but also for providers.  Examples:

I contact my PCP who recommends that I see a specialist.  The PCP is on the patient information portal, but the specialist is not.  This means that I cannot use the portal to set up an appointment.  Can I do it by email? No, I am told.  I must call the specialist's office.  This results in several back and forth telephone calls, using up the precious time of both the patient and the desk clerk.  An opportunity to benefit from the asynchronous nature of email or other electronic scheduling is lost.

I need to have an image made before seeing the specialist.  His office tries to enter the order for the image, but the system kicks it out because my insurance company does not have the name of my PCP in its records.  The person entering the order does not have the authority or ability to inform the insurance company of this piece of data, although it is known to her.  Instead, the specialist's office has to contact me, and then I have to contact the insurance company, and then I have to call the office back and tell them that I have done so, and then the order can be entered.

Then, because electronic scheduling does not exist, I have to call the radiology department to get an appointment for the scan.  Here's the first bit of good news.  The scan and the radiologist's reading is inserted into my electronic medical record so the specialist has access to it before my appointment. Indeed, I have access to the report, too, through the patient portal (oddly, in that the specialist does not participate in the patient portal.)

But my PCP and the specialist recommend that I see yet another specialist.  I search for his information and find that he uses the patient portal.  I go to my page in the patient portal and attempt to add him as one of my doctors so I can make an appointment electronically, but the following message appears saying that I must have an initial appointment with him before I can do so: 

 

Ah, Catch-22!

There is no email available for him, so I am left to call his clinic and make an appointment.

By the way, this occurs in a physician practice organization that regularly receives awards for being part of one of the "most wired" health care institutions in the country. And, truly, it deserves that honor compared to many others, but the kind of lacunae I describe above are indicative that the standard against which such awards are granted is low compared to what you would expect in many other industries.

Oh, also, the Press Ganey survey I received after the appointment with the first specialist had no questions related to any of these problems.

See them for who they are and not for the illnesses they have

Jane Carmody is Chief Nursing Officer at Alegent Creighton Health in Omaha, Nebraska.  She publishes a regular note from the CNO for the hospital staff.  This personal account moved me, and I reprint it with her permission.

Courage. My sister is about nine years older than me. For about ten years she has battled carcinoid tumors, and it is starting to take its toll.  I visit her about every weekend I can; she lives in Des Moines. I have to say how I admire her courage. She is a nurse and worked for years at her small town clinic with the physician and the nurse practitioner. They “huddled” every day (although they did not call it that) and discussed the patients for the day and who would need follow up, who would be called and who would come in for a “RN check.”  She was well known in the town. 

She retired a couple of years ago and tells me now, “Never retire…stay working as long as you can…it is hard for a nurse to retire…the work is too exciting and interesting…”.   I know she looks at me and wishes she were in good health, and I so I am careful not to complain about work schedules or work pressures because she would love to have them.

Over the past few months, she has progressed to a cane and soon I am sure a wheel chair. She hated the idea of a cane at first, so I took her an umbrella and bought cane tips. That way she looked stylish. She progressed to a 4-prong cane and has difficulty getting around. 

On a recent visit we took her shopping. My sister loves shoes, purses and hair and skin products…and certainly not the inexpensive ones. We thought about taking her to the mall so she could shop at Von Maur (her favorite) and yet the mall only provides wheel chairs…she hates that. So, we took her to Target: They have motorized carts and she had so much fun. Gave her freedom to shop and to knock down displays…she said she was so “embarrassed” to have to use the riding carts, but she had so much fun. She has lost most of her hair and so she wears lots of hats and so we bought matching ones.

I tell this story because she is courageously and gracefully managing. It reminds me of how you all experience the courage of your own patients and families and how we have to remind ourselves to see them for who they are and not for the illnesses they have. Please pray with me for my sister and all those suffering. She starts another round of radiation this week because the tumors grow more on her spine.  This further weakens her status and yet not her hope, humor and courage. 

Medical residents taking the lead on quality improvement

A note from my friends and colleagues at the Committee of Interns and Residents (CIR): 

Although medical residents are often the first line of contact for most patients in academic medical centers and teaching hospitals, medical residency offers little in the way of formal training on skills needed to keep patients safe from medical errors or on how to deliver high-quality, cost-effective care.

To cope with the pressures of today’s health system and new rules requiring clinically competency in patient safety, the national organization representing 13,000 of the nation’s interns and residents is launching the first online platform to give doctors in training information, tools, and best practices they need to deliver care that keeps patients from harm.  CIR calls the new site QIGateway, and it is a repository of research, case studies, and tools related to quality improvement and patient safety that are relevant to medical residents and interns. 

This new platform is more than just an important resource for physicians in training.  It reflects the leadership residents and interns are taking to reduce medication errors, reconcile medications, and make sure patients are discharged and transferred properly so they don’t return to the hospital unnecessarily. This leadership is important because by 2015, the Accreditation Council for Graduate Medical Education (ACGME) will require all resident physicians to demonstrate clinical competency related to quality improvement and patient safety.  Teaching hospitals are under pressure to avoid patient errors and to make sure they are teaching these competencies to doctors in training.

Check out this video.  (If you cannot see the video, click here.)

Safety and quality excellence in Gillette, WY

I'm always on the lookout for firms and institutions that embody a strong culture of quality and safety--in the work environment and in the products and services they produce or deliver.  While health care has its special characteristics, there is always something new to learn from places that have done this well.  Common features emerge, though:

Top-level leadership for whom excellence is an expectation and whose own behavior exemplifies what they expect for others in their organization;

Disdain for benchmarking against industry averages: People who understand that there is no virtue in benchmarking to a substandard norm;

A work environment in which front-line staff are empowered and encouraged and expecteded to call out quality and safety problems, with a special focus on near-misses, those conditions that represent systemic flaws in the organization, the time bombs that will one day lead to harm.

I've found the latest example of this combination of attributes in Gillette, Wyoming, at a family-owned firm called L&H Industrial.  The business of the firm is to provide repair services to the mining industry and to fabricate those huge and complicated parts and machines that are used to retrieve coal, gold, and other products in the ground.

The two brothers who own the firm, Jeff and Mike Wandler, say the following:

L&H Industrial considers safety to be the most important component of our success. Keeping our employees safe is our first priority. Our mission is zero Lost Time Accidents (LTA’s).

They have recently passed the four-year mark on this objective, an outstanding result considering the work their folks do:  Welding, heavy lifts, grinding, and so on.  One brother explains, "We have engineered unsafe practices out of this company."

Citing the field work their folks do, fixing and installing heavy equipment at coal mines and elsewhere, the brothers say:

We are responsible for the safety of our employees no matter where they’re working. L&H Industrial makes field service safety a priority with frequent trainings and peer monitoring.  Our on-site service business relies on our safety record - we don’t take that lightly. 

Quality is the company's other pillar:

The goal is that zero quality problems reach our customers.  Product quality is monitored through inspections at each step and non-conformances are documented and root-caused so corrective actions can be implemented to prevent recurrence.

Validation of this approach recently occurred when the firm was ask to fabricate and assemble a replacement lower roller assembly for NASA's Crawler Transporter, the world's largest self-powered land vehicle.  Wikipedia notes:

The crawler-transporter has a mass of 2,721 tonnes (2,721,000 kg; 6,000,000 lb) and has eight tracks, two on each corner. Each track has 57 shoes, and each shoe weighs 1,984 pounds (900 kg). The vehicle measures 131 by 114 feet (40 by 35 m). 

The specifications for this job are extremely demanding.  The metal tolerances are exacting.  There is essentially zero margin for error when a huge space rocket is being rolled from the fabrication building to the launch pad.  L&H received this job after an extremely competitive solicitation, with dozens of NASA engineers reviewing the company's opoertaional plans and facilities.

All in all, an impressive record and one with lots of lessons for those of us in the health care world.

Thirsty Thursdays are about to resume

A faculty member reports to me that a significant percentage of Emergency Room patients at St. Elizabeth's Hospital on Thursday nights come from a nearby college and arrive with a diagnosis of alcohol poisoning.

I was not aware of this cultural phenomenon in The Heights.  But it is has been place for some time, as this article summarizes:

Thursday is the new Friday for college students. On most campuses, early morning classes don’t exist on Fridays, so why not start the weekend even earlier? It’s hard to say no to booze, brews and a good time.

And aided and abetted by local pubs with ad leaders like this: "Thursdays have become one of Boston’s best nights for college students and young professionals!!"

On a related topic, the New York Times reports:

Five beer brands were consumed most often by people who ended up in the emergency room. They were Budweiser, Steel Reserve, Colt 45, Bud Ice and Bud Light.

My unscientific survey in our neighorhood near this college supports this finding, with a clear preference for the Budweiser products, as shown by the types of empty cans found on the streets and near the transit stations the morning after.

Don't Eat the Leaves

Hyperoxaluria is an important risk factor for kidney stones, approximately 80% of which are primarily composed of calcium oxalate. Hyperoxaluria is typically diagnosed by performing a 24 hour urine collection and levels above 45 mg/day are considered abnormal although, depending on the other urine constituents, the risk of CaOx stones increases when the urinary oxalate level is above 20 mg/dl. It is important to distinguish between hyperoxaluria that results from increased oxalate production (endogenous) and increased oxalate ingestion (enteric).

The classic disease associated with increased oxalate production is primary hyperoxaluria. There are 3 identified types although all result from defects in glycoxylate metabolism leading to oxalate accumulation. At first, the manifestations are primarily renal leading to nephrolithiasis and nephrocalcinosis. However, as the disease progresses,  the serum oxalate concentration increases eventually resulting in extra-renal oxalate deposition. Vitamin C is metabolized to oxalate also so that patients with oxalate-containing kidney stones should probably avoid excess vitamin C supplementation as this could increase the risk of stones.

Enteric hyperoxaluria results from increased absorption of oxalate in the large bowel. In general, there are 3 ways in which this might occur:

• Increased dietary oxalate ingestion
• Decreased dietary calcium intake - calcium binds oxalate in the gut and reduces absorption. This is why low calcium diets are not recommended in patients with idiopathic kidney stones. Calcium supplements are a different issue as they may contribute to hypercalciuria and not decrease oxalate ingestion, particularly if they are not taken at mealtimes
• In the setting of malabsorption syndromes and GI disease. This occurs in patients following bariatric surgery, fat malabsorption and inflammatory bowel disease. The mechanism is thought to be related to binding of calcium to fatty acids thus reducing the availability of calcium for oxalate-binding, along with increased large bowel permeability. There have been multiple cases of patients developing severe oxalosis following jejuno-ileal bypass surgery.

The treatment of hyperoxaluria depends on the cause. For all patients, increasing fluid intake is good advice. Some patients with primary hyperoxaluria respond to treatment with pyridoxine which promotes conversion of glycoxylate to glycine instead of oxalate. Recently, a bacterium has been identified that metabolizes oxalate in the gut and this has been proposed as a potential treatment for hyperoxaluria. Interestingly, antibiotic treatment has been shown to decrease oxalobacter colonization in individuals with peptic ulcer disease.

Of course, all patients with hyperoxaluria should be advised to reduce oxalate consumption in the diet. Foods high in oxalate include spinach, rhubarb, tea, chocolate, star fruit and soy products. A full list can be found here.

Rhubarb is an interesting case. In the First World War because of the lack of access to fresh vegetables, the British government recommended that families supplement their diets with rhubarb leaves which were not traditionally eaten. It turns out that this was very bad advice. Rhubarb leaves contain considerably more oxalate than the stalks and there was a flurry of case reports towards the end of the war detailing cases of oxalate poisoning from rhubarb leaf consumption (see also and this). The toxicity of the leaves was probably increased by advice to cool the leaves with soda which increases the solubility of oxalate. Although the MD50 of oxalate would require the ingestion of about 5kg of rhubarb leaves, one could imagine that much lower doses would be toxic in patients with chronic kidney disease.

One last point about oxalate. It is a terminal metabolite and was thought to not have any positive role. However, recent data have suggested that oxalate is important for chloride transport in the proximal tubule where it acts similarly to formate..

If you can't do one thing well, add another

A recent article in HealthLeaders Media covers a new trend, provider organizations branching out into the insurance industry.  Here's the lede by Margaret Dick Tocknell:

Health systems are increasingly taking on new roles and becoming health insurers. Spurred by healthcare reform, the creation of health insurance exchanges, and a shift to population health, health systems are assessing the opportunities of becoming a payer against the risk of taking that step in the ever evolving healthcare industry.

A growing number of health systems are deciding that it is worth the risk. In a June survey of more than 100 hospitals and health system across the country, 34% responded that they already own health plans. Another 21% said they plan to launch a health insurance plan by 2018, according to the Advisory Board Co., a Washington, D.C.-based research and consulting firm.

There are groups that have done this with notable success, like Geisinger, but as the article notes, "jumping into the health insurance game is not a parlor game.... [D]ecades ago hospitals and health systems lost a lot of money trying to take on capitation and broader risk.  Also, shifting from provider to provider-payer is a huge cultural change that involves thinking beyond managing facilities and capacity to a more holistic approach to patient care."

Here's what I think, based on unscientific site visits, surveys, and discussions with hospital leaders.  The vast majority of hospitals--and especially academic medical centers--have barely begun to crack the operational problems that exist in their facilities.  The quality and safety of patient care are substandard, compared to what they might be and what has been demonstrated in comparable facilities.  The degree of patient-centeredness, likewise, needs major work.  Finally, the engagement of front-line staff in process improvement efforts is scattered.

CEOs and Board of Trustees are understandably ill at ease with all of the changes occurring in the health care world, but it feels like the management consultants have been hard at work persuading this audience that the solution to the changing health care environment is to look outward rather than inward.  Grow and consolidate with mergers and acquisitions to create scale in a given geographic area.  And, now--as reflected in this article--bolt on an insurance plan with which you will share risk.

The problem is that the current generation of hospital CEOs and other C-suite members have no experience with these new business formats.  Even if these plans and activities appear to be attractive in the consultants' pro forma presentations, executing them is distracting and demanding and requires a different skill set that has led the current generation to their current positions.

Hospital CEOs would be better off creating trusting and reciprocal clinical relationships with other institutions and practices along the spectrum of care.  Likewise, they would be better off learning how to negotiate with insurers in the new environment by helping to develop commercial relationships that are mutually advantageous.  Meanwhile, let's get really good at providing a safe and high quality clinical environment, with an intensive and extensive partnership with patients, while engaging our staff in the kind of process improvement that leads to a better work environment and greater efficiency.

Twitter advice for hospital executives

Here's a really well done (and somewhat self-referential) story about how hospital executives should think about using Twitter by Helen Adamopoulos over at Becker's Hospital Review.

Sepsis heroes

Dr. Jim O'Brien reminds me (and now you!) about this important event in New York City On September 12.  Ticket information here.  It will honor the following people:

Gary Black, sepsis survivor and author of “Gyroscope: A Survival of Sepsis.” Gary is one of SA’s first Faces of Sepsis. On his website, Gary describes the book: “GYROSCOPE reveals my entire harrowing experience of cascading to the edge of death from severe sepsis. It explores my mental, physical, and spiritual traumas and triumphs from onset to recovery. It also includes 52 illustrations that express my pain, anguish, dreams, delirium, and personal awakenings, a brief medical glossary, and research references.”

Since publication of his book, Gary has given talks and presentations to many groups about the seriousness and impact of sepsis. Last September, Gary was invited by the Society of Critical Care Medicine to participate in the Post Intensive Care Syndrome (PICS) Stakeholders conference. His point of view as a sepsis survivor is invaluable to the people who work to fight the disease. Read more about Gary here.

Governor Andrew M. Cuomo: New York State Governor Cuomo is the first U.S. politician to directly address the issue of sepsis and the importance of sepsis awareness. During the State of the State address earlier this year, Gov. Cuomo announced that New York State will be the first state to require that all hospitals adopt best practices for the early identification and treatment of the disease. The measures are to be implemented through regulations issued by the Department of Health led by State Health Commissioner Nirav R. Shah, M.D., M.P.H..

These initiatives, together called "Rory's Regulations," pay particular attention to the needs of New York State’s children. Due to the tireless advocacy of Ciaran and Orlaith Staunton, whose 12-year old son, Rory, died of sepsis in April 2012, the proposed regulations will ensure that results of critical tests will be transmitted to parents in easy-to-understand terms upon their child’s hospital discharge. As well, the hospitals will have to post a “Parent’s Bill of Rights,” so parents are aware of the new regulations. Regulations like these enacted by Gov. Cuomo help raise sepsis awareness among both healthcare professionals and the general public and ultimately save lives.

GE Healthcare Education Services. The education arm of GE Healthcare has been in a leader in raising awareness about sepsis among healthcare professionals. Their push for sepsis education in their Nursing Library of Online Education, including their video Communication: Sounding the Alarm for Sepsis, has allowed nurses from all over to benefit from information that they may otherwise not be able to access. GE Healthcare also provides scientific posters and professional education sessions about sepsis at professional conferences, such as at the American Association of Critical Care Nurses. Since nurses are the front-line healthcare professionals, this education and awareness is invaluable.

David Goldhill, author of “Catastrophic Care: How American Health Care Killed My Father--and How We Can Fix It.” David, who is president and CEO of GSN (the Gameshow Network), lost his father to sepsis and after learning more about what happened, he wrote his book. “Catastrophic Care.” David gives many talks about issues regarding health care and he begins his talks by telling the audience how his father died. In March, David was the keynote speaker at a major conference for healthcare journalists – people who need to hear the word “sepsis.” Read more about David here.

Mark Lambert, former president of Sepsis Alliance. Mark was the first president of Sepsis Alliance and was instrumental in helping shape and guide Sepsis Alliance. Mark not only helped put together the team that works behind the scenes, but he was a major force behind developing SA’s mission. He also helped build the board of directors, spearheaded the creation of Sepsis Alliance’s first video, Sepsis: Emergency, and brought together the Merinoff Symposium 2010: Sepsis - Speaking with One Voice – an important turning point in how healthcare professionals around the world viewed sepsis. Read more about Mark here.

Surviving Sepsis Campaign. The Surviving Sepsis Campaign (SSC) was formed in 2002, a joint effort between the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. The SSC has since developed evolving guidelines for the management of severe sepsis and shock, something that had not previously existed. The SSC is committed to collecting data from 10,000 hospitals worldwide, to apply the guidelines to 100 percent of patients in whom the diagnosis is suspected, and developing a strategy to improve the care of septic patients in under-resourced areas. Recently, study findings showed that this is resulting improvement in sepsis care.

DO or MD?

I wrote to an associate, who is a DO (Doctor of Osteopathic Medicine), with the following question:

"I have a young friend who is trying to choose between a DO and an MD.  Would you have advice for her?"

The reply was immediate and strongly felt.  I copy it with permission and seek your responses:

This is really a philosophical choice. I applied to both and got in first to a DO school while wait-listed at a couple MD schools. I had no higher aspirations than to practice medicine and do good for people.

The sad reality is that there is a not so subtle and in many cases flagrant prejudice against DOs. Simply put, MDs and MD institutions discriminate against DOs. Hiring practices in many states or regions discriminate against DOs. I heard of a case recently where there was a sick patient on an airplane flying domestically, not foreign, and the responding doc was a DO. When the doc said we have to go down now in the best interest of the patient the pilot refused because the doc was “just” a DO.

It sounds cruel to say it but the question is similar in many ways to asking whether you want to be white or black, or whether you want to be male or female. As a DO you will be a discriminated against minority. Overall you will make less money, you will not have access to the best paying  or most prestigious jobs, you will unlikely be able to achieve an academic appointment at a prestigious MD led institution and you will constantly be asked to explain yourself. “Just what is a DO anyway, doc?” The good thing is that you will always do good work no matter where or for whom because the education is very good and all American.

If her aspirations are simple then it really doesn’t matter. The philosophy of osteopathic medicine is very appealing and I think most human and appropriate. The education is at least as good as MD, especially in a university affiliated school. But the dark side is that the MD world will always look down on you as something less than adequate or someone significantly less than worthy or competent. If her aspirations are to function in a university setting, maybe do research, maybe aspire to lofty public health goals or something along these lines, forget DO school and go to an MD school even if it is an offshore school. Sadly, it is the letters after her name that will count, not the education. Sure there are a few token DO stars here and there, but the MDs rule and DOs are viewed as second rate, generally speaking, in the towers of medicine, especially in the ivory ones.

My advice? See if you can discern your long term goals. Then make your choice based on that discernment. We are all idealists at first. Try to see past that. It is not an easy task.

Best of luck to her.

How would this play in the US?

The Telegraph reports about the NHS:

The number of patients waiting to be admitted for operations or other treatment in June was a quarter of a million higher than in the same month last year, official figures show. 

The figures come after a report by Monitor, the NHS regulator, which warned that some trusts were cancelling non-emergency procedures to deal with a higher load of emergency cases, resulting in longer waiting times.

The "referral to treatment" data reveals that waiting lists, which have hovered around 2.5 million patients in recent years, reached 2.88 million in June, the highest level since May 2008. 

However, the figures also show that the median waiting time for treatment is currently 5.7 weeks – the same duration as in June 2012.

I guess the last paragraph is supposed to represent good news. In the US, when you need surgery, you can get it reasonably quickly.  Look at this chart from the OECD for a related statistic, the percentage of people who have to wait four months or more for elective surgery.

Of course, in the US, that's if you have insurance or can otherwise afford the care.

But before you jump to conclusions about the relative gross inequity of that, please note that in the UK, you can get faster treatment if you can afford private insurance or can otherwise pay to go to private clinics or hospitals, where the same doctors who work in the NHS will offer you a different class of treatment.

It might be asserted that the NHS steady-state figures reflect a decision by the government to engage in congestion management to ration care.  Based on my experience in the UK, though, the more likely reason for the delays are work flows that are remarkably un-Lean.  This is hard to fix, but an example might come from our buddies in Saskatchewan.  There, the health authorities adopted the Saskatchewan Surgical Initiative Plan, with a goal of reducing surgical wait times to no more than three months by 2014.

While the results are mixed, the intent is noble, especially when seen in the context of adopting the Lean process improvement philosophy for the entire province.

There's a big difference, of course, in adopting an organizational philosophy for a province of one million people compared to adopting a goal for an organization of 1.7 million people, serving over one million patients every 36 hours!

The process improvement challenges in the NHS represent one of the largest examples I know of a system in need of repair.  All I can offer from this side of the Pond is the observation that improvement is likely to come from the individual hospitals and clinics when the central authority of this massive organization understands that its role is to support the development of learning organizations and not to impose arbitrary targets from above.

This is not courage

Here's a quick follow-up to my post about the traffic configuration blues facing the City of Newton. As mentioned, the Board of Alderman voted to deconstruct a renovation project that was recently completed.

Now comes the latest news that some of the Alderman sent an email to their constituents explaining their vote, using the following subject line: “Admitting our mistakes takes courage."

First of all, as I noted in a comment:

It is really poor form to attribute courage to one’s own actions. Others should always be the judge of what’s courage and what’s something else.

But then, I went further and stated:

IMHO, calling this “courage” is a vast overstatement and denigrates the real meaning of the word, as we would usually apply it, e.g., a firefighter rescuing a child from a burning building. 

Let's stick with this point for a minute.  Merriam-Webster defines courage in this way: "Mental or moral strength to venture, persevere, and withstand danger, fear, or difficulty."

When seen in that light, the Aldermanic vote is just the opposite from courage.  It was a way to avoid difficulty, i.e., the complaints from constituents.  But even if it is a tough vote, use of the terminology in this case weakens its meaning when there are real cases of courage.  I'd like us to retain the purity of meaning so we can apply it in truly inspirational instances: For an act to be courageous, it has to be not only selfless but also at variance with the usual human tendency for self-preservation.  If you want to see courage with regard to a mistake, for example, watch how a distraught doctor who has made an error openly and honestly discloses it and apologizes to a patient and displays his or her vulnerability in the process.

So, I ended my comment by saying:

No, taking these kinds of decisions is actually just part of the job of public officials. Let’s just call it making a judgment call–a good one or a bad one–and leave it at that.

The Aldermen's note is typical of the kind of "grade inflation" used by so many legislators today.  You know, the ones who constantly remind us how "hard they are working" to create jobs for Americans, to protect us from hazards, and so on.  Hey guys and gals, sitting in a legislative chamber and using your brains and abilities to decide which way to vote it not "hard work."  Yes, it is work, and when done right, it takes thoughtfulness, experience, and dedication.  But "hard work" is what many of your constituents do every day. If you want to see hard work, for example, shadow a transporter in a hospital, a nurse in an ICU, or a physician carrying out a delicate procedure. 

Plasma Exchange for Severe ANCA-Associated Vasculitis (AAV)?

There has been lots of new data in the AAV literature of late. We have new nomenclature, including the dropping of Freidrich Wegeners name for the more generic but descriptive granulomatosis plus angiitis (GPA), by the Chapel Hill consensus conference. A large genome wide association study by the European Vasculitis Genetics Consortium has reported genetic variants associated with AAV and show that polymorphism segregate with ANCA specificity (Anti-MPO and Anti-PR3). A recent follow-up to the RAVE study demonstrates non-inferiority of rituximab as compared to oral cyclophosphamide for severe AAV. Moreover, among patients who had relapsing disease at baseline, rituximab was superior to conventional immunosuppression, at least for the first year.

Removing pathogenic antibodies via plasma exchange (PE) is an attractive, if crude, treatment option for severe AAV and is generally recommended for severe alveolar hemorrhage (although without much evidence). In patients without severe lung involvement, it has gained a role in attempting to prevent ESRD in patients with severe renal disease at presentation, due largely to the MEPEX trial. MEPEX was published in 2007 and included patients with AAV who required dialysis at presentation or had a serum creatinine >500 µmol/L (5.8 mg/dL). This study included 137 patients who were randomized to 7 PE treatments or IV methlyprednsiolone pulse therapy. Both groups received oral steroids and cyclophosphamide. PE was associated with a risk reduction of ESRD of 24% at 1 year. Patient survival and severe adverse event rates were similar in the 2 groups. A follow up to MEPEX has been published in Kidney International this month where the original patients were followed for a median of 3.95 years. During this follow-up, over a half of patient died and almost two-thirds had either died or developed ESRD (the composite primary outcome), with no significant difference between the groups. Also, there was no significant differences in relapse rate.

It must be noted that the original MEPEX trial was designed to examine rate of ESRD alone and demonstrated a benefit with PE at 1 year. The current study looks at a composite of ESRD & death at 4 years. If the early effect on ESRD if real, it would be intuitive that later mortality would be improved which it seems is not. Overall this study questions the benefit of PE in severe AAV and certainly dampens our enthusiasm for its use in this sick patient cohort. A criticism of MEPEX is that IV methlyprednisolone is considered a standard of care in initial treatment of severe AAV and not an alternative to PE. In the real world, patients would receive IV methylprednisolone plus PE. It is also very possible that a beneficial effect of PE exists in cases of AAV earlier in their natural history before significant scarring has occurred, as suggested by a meta-analysis. At this point, PE can certainly be considered as part of the armamentarium of AAV treatment but its exact indication is unclear. The ongoing PEXIVAS trial is planned to enroll 500 patients and will hopefully clarify the role of PE, if any, in severe AAV.

The City's legislature at (re-)work

Here is a follow-up to my post about the traffic design wars in Newton, MA. The issue was returned to the city's legislative body for review and consideration.  I guess that was deemed necessary because any changes would require additional spending authorizations.

We neighbors received the following email from the city DPW reporting the results.  I offer it without comment.

As most of you are aware the Board of Alderman voted to restore the intersection of Cypress Street and Centre Street to its original configuation.  As a result, the city will be commencing the following construction activities in Newton Centre.

Dates: August 19, 2013 thru August 30, 2013 (M-F, possible Saturday work)

Time: 7:00 AM to 7:00 PM

Activity: Intersection work (Cypress at Centre)

In addition, the city will be conducting the following roadway milling operations.

Date: August 18,  2013 (Sunday night)

Time: 5:00 PM to 5:00 AM

Activity: Roadway milling

During all construction activities there will be adequate police details to handle traffic and

pedestrian flow.

We thank you for your patience during this construction phase.

Sorry, I understated the problem

When I wrote yesterday's post about the excessive charges collected by the Partners Healthcare System, I thought I had a good understanding of the dimensions of the problem. Apparently not.

In a follow-up story on boston.com, we find the following quote:

“What surprises me most is the difference between Partners and their next biggest competitor,’’ said Áron Boros, executive director of the Center for Health Information and Analysis, which compiled the report. He said Partners has been able to negotiate high prices with all insurers, unlike other systems. “None of them has the consistent success of Partners in driving prices up,’’ he said.

Whew.  Mr. Boros is probably the most knowledgable person in the state when it comes to the rates paid to hospitals and doctors.  In his previous job, he "hosted the annual Cost Trends hearings and presided over the first release of the Division’s All-Payer Claims Database for state agency and research uses."  It was at those Cost Trend hearings that the pricing inequities in the state were first disclosed, based on research conducted by the Office of the Attorney General.  Mr. Boros has continued with similar important activities since taking over CHIA.

Given this expertise, if Mr. Boros admits publicly to being surprised by the results of his agency's study, then I am confident that my assertions about the tax being imposed on the Commonwealth by Partners Healthcare have to be dramatically understated.  Why the head of the Health Policy Commission and other policymakers persist in denying the inflationary aspects of this problem is a mystery.  Partners really has succeeded in pulling the wool over the eyes of the Commonwealth's leaders.

Well, duh.

The Boston Globe prints as news a story that Partners HealthCare collects a lot of the dollars spent on medical care in Massaachusetts.  It's not news, but I guess later is better than never.  The lede:

Nearly one-third of all the money that Massachusetts insurers spent on acute hospital care last year went to Partners HealthCare, according to a new Patrick administration analysis that underscores the dominance of the state’s largest medical provider.

In addition, Partners-affiliated doctors received 25 percent of the money paid to physicians in 2011. In both cases, Partners received two to three times as much as the providers receiving the next most in payments.

The statements above are rendered less informative without some kind of metric that indicates what percentage of the hospital beds, or discharges, or whatever are owned by Partners.  Or, what percent of  the state's doctors (by specialty) are in the Partners network.  That is nowhere to be seen in the story. (Maybe some of these charts would have been helpful.)

Absent that information, too, the story's reported assertion by the head of the state's Health Policy Commission has no basis.  The story quotes him as saying that the report underlines “why we are the most expensive state in the US. It’s because of the structure of our system,’’ which leads residents to “use expensive teaching hospitals,” including those owned by Partners, more often than people in other states.

What if the explanation, instead, is that the amount Partners' hospitals and doctors receive for patient care--in its academic centers, in its community hospitals, and its physician office practices--has been substantially above the rest of the market for two decades? What if the percentage rate increases granted by the state's largest insurer to Partners exceeded the average rate increases given to other networks, even though the base on which those increases was applied was already well above the state average?

Both of those statements are true but are not part of the news story.  The underlying issue, with due respect, is not that people in Massachusetts use academic centers more than in other states (although that can certainly be a contributing cost factor.)  It's that the dominant provider--which is about to expand its holdings--is paid hundreds of millions of dollars in excess revenue relative to the market.  It's that the dominant insurer has displayed no capacity for taking on that behemoth.

Fortunately, buried in the story is the conclusion by the Center for Health Information and Analysis "that cutting spending on medical care will depend in part on controlling payments" to Partners and other systems that have used market power to extract high prices. You can't control health care costs in Massachusetts without equalizing the rates of pay among the health providers by basing the amounts paid on clinical value received, irrespective of market power.  However, there is no appetite in this state to make that happen.  Since it will not happen, we will simply see periodic reports and news stories about ever rising costs while the industry giants demand more. Meanwhile, hospitals and doctor groups outside of the market drivers will be left with the scraps.  As those latter hospitals slowly decapitalize and those doctors lose income, they will be inevitably drawn into the big systems, allowing those systems to exert still more influence over payment rates. It will not matter if those payment rates are based on fee-for-service or bundling or capitation.  Regardless of payment design, the rates of the monopolistic systems will generate supernormal returns.  Their income is our costs.

Chloride: Queen of the Electrolytes

In June's edition of JASN Jacques et al. highlighted the emerging importance of the role of chloride in the pathogenesis of hypertension. Their group developed a mouse model that over expressed the protein pendrin in the aldosterone-sensitive region of the distal tubule. These mice developed hypertension that was attributed to increased NaCl absorption driven by over expression and increased activity of the pendrin chloride exchanger.

Pendrin was first described as a chloride channel in the kidney in the early 2000s. Pendrin is a chloride-bicarbonate exchange protein that facilitates the electroneutral movement of chloride to the intracellular space and bicarbonate to the extracellular space or urinary space. This channel is also found in the thyroid and inner ear and is the gene that causes Pendreds syndrom.

It is now widely accepted that the pressor effects of salt (NaCl) are dependent on Na as the major determinant of intravascular volume and thus hypertension. It has also been demonstrated that for Na to mediate a hypertensive effect, it needs to be in the form of NaCl (Berghoff and Geraci, Intern Med J 56:395-397). In their study, Berghoff and Geraci showed that subjects on a high NaCl diet but not on a high NaBicarbonate diet developed hypertension. These experiments have been reproduced in human and animal models. Interestingly, hypertensive and normotensive subjects switched from a NaCl diet to an equimolar NaBicarbonate diet experienced a decrease in blood pressure.

Pendrin is normally found in the type B Intercalated cells of the aldosterone region of the nephron. Recently published studies by the same group suggest that pendrin can also work in tandem with the Na-dependent chloride/bicarbonate exchanger (this is a different channel to pendrin and is also found in the CCD) resulting in electroneutral NaCl absorption and that this process is thiazide sensitive.

In JASNs June edition, the Jacques group showed that pendrin mediates chloride absorption distally and that this is the driving force for Na absorption distally either through the ENaC and/or Ndcbe channels. The significance of their findings are that 1) chloride is required for NaCl absorption in ‘salt sensitive’ hypertension and that 2) pendrin is the channel that facilitates the absorption of chloride.

On the basis of this paper and other papers showing similar findings with regard to Pendrin's role in NaCl balance the authors suggest their work solidifies the concept of chloride-sensitive hypertension.

It must be remembered that these studies don’t dispute that Na is primary in maintaining blood volume and driving hypertension. However, chloride absorption is a necessary requirement for the absorption of Na in the setting of a salt load causing hypertension. Thus, Chloride might be the queen and Na the king of extracellular solutes!

See these previous posts on Pendrin function in the kidney.

Posted by Andrew Malone