Power: a true test of character

As I mentioned in a previous post, the Department of Health and Human Services has contracted with the American Association for Respiratory Care to do a count of ventilators available in the US hospitals. This step is necessary in order to understand the capacity for accommodating the potential 300,000 victims of H1N1-induced acute respiratory failure. The AARC web site gives this interesting disclaimer:

"The U.S. Department of Health and Human Services further secures the privacy of your institution’s data through participation in the Protected Critical Infrastructure Information (PCII) program administered by the U.S. Department of Homeland Security. Resulting from the Critical Infrastructure Information Act (CII) of 2002, the PCII program protects voluntarily submitted critical infrastructure information from public release through Freedom of Information Act (FOIA), state and local disclosure laws, and use in civil litigation. Additionally, PCII can not be used for regulatory purposes. Institutions and facilities sending important data into the Federal government can be assured of the highest commitment to confidentiality and security of their data."

Why might the AARC feel the need to include it in order to conduct a legitimately needed survey? Clearly, they must feel that the responders would be reluctant to disclose publicly their vent numbers. Should the number of available ventilators really represent classified information under the current circumstances? How much more difficult does such secrecy make the already Sisyphean task of preparing our nation for what may be coming? It is like preparing for a war without knowing the number of rifles available to the army. And if it is this difficult to get a vent count, how impossible is it then to come up with an integrated triage plan? If the CEOs do not want known the number of shovels they can contribute to this sandbox, I hardly think they are running to volunteer the information on more advanced equipment (bulldozers, e.g.) or personnel to any foreman. Yet this is a very complicated sand castle construction, with many turrets, moats and portcullises, which without central oversight could do a lot of damage if not put together properly.

Having exhausted the sandbox metaphor, I will move on to several other, equally over-used ones. It is obvious that there are all-out preparations underway at the state, county and municipality levels. Further, hospitals are working hard as well to make sure they can provide best care possible to the greatest number of people. And the DHHS is working tirelessly to keep abreast of all the current developments to have mitigation measures in place. Unfortunately, all of the parties are brilliant musicians playing at the same time without a conductor. Federal regulators are constrained by state laws, regional agencies are confined to their own regions, and single institutions are ultimately driven by what is in their best interest; and besides, they are also beholden to the anti-trust laws!

Thus, suggestions (they are called "recommendations") are made, but there is currently no mandate that they be followed. It is like a surgeon suggesting that anesthesia be given to the patient before the first cut -- it may or may not happen. The President's advisers recommended in their report that he appoint an H1N1 Czar to oversee our preparedness efforts. But what is a Czar without the power to demand accountability, but a deposed monarch?

To me this fragmentation of effort falls in line with the mounting public paranoia that the government is using H1N1 as an excuse for a wholesale take over of the healthcare system, described nicely in a recent musing by Dr. Rob Lamberts, one of the top medical bloggers. In reality this is about turf battles and assertion of powers more than it is about any real threats to them. I know I keep referring to the NEJM piece that I reviewed a few days ago comparing Israel's state of medical preparedness to ours. I do not have to tell you that Israel has one of the most effective crisis mitigation systems in the world. Their healthcare system has to be ready for a mass casualty situation at a moment's notice. One of the central differences between them and us is competition between hospitals (they don't have it, we do). In the current instance, this competitiveness may be getting in the way of even the most rudimentary efforts at readiness. Hospitals already stand naked before a firing squad, having to report errors and other quality measures. What's the big deal about quantifying preparedness?

Abraham Lincoln once said "Nearly all men can stand adversity, but if you want to test a man's character, give him power." Let's look at this as an opportunity to show off our character, and share the power for the greater good.

Should 11-year old girls be mandated to get HPV vaccine?

Is it me or is there something wrong with the logic of the Gardasil debate? In a nation that has been reluctant to allocate public resources to teaching safe sex to our high schoolers, the move toward universal vaccination of pre-adolescent girls against a sexually transmitted disease seems illogical. Is the thought that we will teach them to abstain, but if that does not work, no need to teach them anything else -- they can just go ahead and have sex with impunity, as long as they are protected against HPV by the vaccine? What about unwanted pregnancy? What about HIV and other sexually transmitted illnesses? And how can we collude with such taciturn matter-of-factness in normalizing the idea that 11 years is an OK age for a child to make her sexual debut?

The manufacturer of Gardasil, in the name of public health, is calling for the government to mandate this as yet another vaccination required for school entry. This may make sense in a third-world country, where access to Pap smears is poor and the chances of using a condom are culturally slim, but in the US this seems over-the-top. How about instead, in the name of public health, halting the confusion of conflicting messages about sexual activity?

I know that once my kids are teens I will have very little to say about how they exercise their judgment. What I can hope for is that through honest dialogue I am preparing them now for the decisions they will be making on their own. One of the lessons we emphasize is that actions have consequences. Pushing Gardasil as the solution to a culturally created problem takes personal and societal responsibilities out of the equation. Yes, we may avoid a few cases of cervical cancer and even deaths from it, but we will have forgone the opportunity to teach our children to exercise their personal choices, responsibility and common sense. Moreover, we will be promoting further the culture of "a pill for everything", a philosophy that has brought our healthcare "system" to the brink of bankruptcy and our nation to unprecedented rates of bad behavior.

In view of the recent questions about the vaccine's risk-benefit profile, caution is needed more than ever. Vaccines should be mandated for highly infectious diseases spread via casual contact, likely to cause unmitigatable and frequent morbidity and mortality, and only if their benefits outweigh their risks. Gardasil fails this entire formula: HPV is pretty hard to get, cervical cancer is nearly 100% curable if detected early, and the vaccine's risk-benefit profile is in question. It is entirely clear that HPV is not smallpox. Let's stop pushing this false panacea on our kids and get back to teaching them the valuable skills and judgment that will serve them well as good people and responsible citizens of our nation.

Notes from a pandemic

Informative report in Eurosurveillance yesterday from New Zealand summarizing their H1N1 experience to date. A few encouraging signs are that a). the pandemic seems to be slowing down, b). proportion of people needing hospitalization is low, on the order of 0.3%, of whom ~12% require an ICU, and c). the case fatality rate is about 0.005%. All this in the face of an estimated attack rate of 11%. Very encouraging!

So, given what I said yesterday in my post, perhaps we can revise down our estimates for the US. If we were to do that on the back of a napkin, we would see a much less concerning picture of around 33 million infections, ~100,000 hospitalizations, ~12,000 ICU admissions and a little over 1,500 fatalities. Whew! Much better than what either our group or the White House advisers predicted. But is this the right time to recalculate? Maybe not.

Here is why. First, the Southern hemisphere is still in the middle of its flu season, and flu epidemics are known to come in multiple waves, separated by intervals from months to years. So, while the slow-down is encouraging, the fat lady has not yet sung. Second, the New Zealand report notes that the native Maori and Pacific peoples, two socio-economically disadvantaged ethnic groups with marked health disparities, exhibited triple to quintuple the attack and case fatality rates seen in their European counterparts. Given that 47 million people in the US are without routine access to the healthcare system, and racial and ethnic healthcare inequalities are rampant, we remain at high risk for seeing a lot of severe cases. Finally, and most importantly, New Zealand has a comprehensive nation-wide plan for mitigating a pandemic (and it is a much smaller nation than ours). Some of the phases include extensive pre-pandemic planning, improved surveillance, border control aimed at containment, and quarantining active cases if necessary. Our plan, which is actually many different plans, is still evolving and is unlikely to be this comprehensive, uniform or enforceable.

So, while I am encouraged by what is being reported, I am not willing to hang my hat on it yet, and neither should the US Department of Health and Human Services. It is true that we may get lucky this time. But this should serve as our national wake-up call, since in our global village it is only a matter of time until we are faced with a devastating health emergency. Do we really want to rely on luck next time?

H1N1 predictions demystified

The President's Council of Advisors on Science and Technology report on the US preparations for the 2009 H1N1 influenza estimate of 90,000 fatalities is getting a lot of heat from an unlikely source: the Centers for Disease Control and Prevention. According to a New York Times story, there is disagreement with this prediction. Anne Schuchat, the director of the National Center for Immunization and Respiratory Diseases is quoted as saying "We don't necessarily see this as a likely scenario". A CDC press officer apparently confirmed that no one at the CDC "expects anything like 90,000 deaths".

If you look at the report itself, even the authors hedge on this point: they prefer to present is as a "planning scenario", rather than a prediction. OK, I'll buy this but what is a prediction but a planning scenario? True, it could be fewer. But if we sit around and simply argue about the number, it could be a lot worse.

Let me tell you a little bit about why and how we create these predictions (or planning scenarios, your choice). The why is pretty self-evident: we want to be prepared. Preparation entails having an idea, vague though it may be, of what's to come. Why do you care about tomorrow's weather forecast? So that you can plan what to wear, how long to allocate to your commute, or whether or not to cancel that trip to Florida during the hurricane season. Similarly, policy makers need to have some idea of how to allocate resources in the future. So, we make predictions, create forecasts or planning scenarios.

The irony is that all this future planning is built on past events as we know them in the present. (So you can see how a rapidly-evolving pandemic can throw a monkey-wrench into any estimates.) What makes us think that there are likely to be 30,000-90,000 fatalities associated with H1N1 in the US this flu season? Its past behavior, of course -- we look at what has happened to date, both in the US, and, in this case, in the Southern hemisphere, where the flu season is in full swing, and we apply those numbers to our population. The result is a mathematical formula which, when populated with these carefully evaluated assumptions, spits out the desired estimate. Now, it is also possible to include some other assumptions into the model, such as what happens at different levels of vaccine availability, efficacy and penetration. However, since all of these factors are to date unknown, putting them into the model would create a tremendous amount of uncertainty, and the model would be useless.

But even without introducing conjecture around potential modifiers, these estimates are prone to a large degree of uncertainty. This is why whenever you hear a report of a single number as the estimate derived from a prediction model, ask for more: there is usually a confidence interval calculated around that number based on varying the assumptions across some justifiable range. Generally, the tighter the confidence interval, the more useful the prediction. For example, in our recent study we estimated that on average we can expect ~300,000 cases of acute respiratory failure associated with H1N1 in the US, with the confidence interval ranging from ~225,000 to ~450,000. Now, this is a wide range, and it betrays our uncertainty about assumptions that went into the model.

One final note. The estimates provided by the White House advisors and the ones derived by us do not necessarily account for the effect of an all-out effort at prevention. So, if we sit by and wait for the virus to hit, and if it does not get more or less virulent than its current incarnation, we will have the predicted number of fatalities. That is a lot of "ifs", some of which are certainly within our control -- aggressive education, prevention, containment, to name a few.

So, with all of the pitfalls of planning scenarios, they are necessary for us to appreciate the potential magnitude of the problem and to plan for it rationally. Sweeping them under the rug and throwing their creators under the bus is just playing politics with an uncertain situation: these numbers evolve, and we need to acknowledge that. After all, as that populist philosopher Yogi Berra once pointed out: "Predictions are very hard, especially about the future".

How technology can help contain H1N1

It makes sense to put a lot of resources into trying to prevent at least some of the estimated 46 million cases, 2.7 million hospitalizations, 300,000 cases of respiratory failure and 200,000 deaths expected this flu season from H1N1 in the US. I believe that technology can be leveraged to mitigate this epidemic. Here is how.

The obvious solutions are already here. We are using social media outlets, Twitter, Facebook, to keep up with the galloping epidemic. Making sure that the majority of the population has access to this relevant information could help local health departments to broadcast latest recommendations. The availability of remote learning and work environments should make it much easier to make sensible decisions about work and school closures without major adverse consequences to the economy, at least in the non-production sectors. Webcasting technology can be a good substitute for remote meetings, thus obviating the need potentially for many people to travel across the country or the world.

And there are other, less obvious ways, in which technology can be useful. We can leverage the thriving possibilities of geographic information systems (GIS) not only to track the epidemic as it spreads, but to plan sensible triage on the ground. Another engineering approach, discreet event simulation, can be used to help avoid the much anticipated bottlenecks in the hospital emergency departments and ICUs. And I am sure there are other opportunities that this vast web of communication can offer us that I am not even aware of, but someone is! I sure hope that we are firing up these technologies and learning how to simulate this epidemic, so that we have at least a little more idea of what we are doing when it descends upon us full force. It is heartening to me that the Department of Health and Human Services has commissioned a count of all the mechanical ventilators in the US hospitals -- this basic activity will certainly help. What I have not heard anything about is what efforts are underway leveraging the sophisticated 21st-century technologies to optimize our approach. My guess is that these efforts, if they exist, happen at the local level and are quite fragmented and haphazard.

I think that it now takes very little imagination to foresee the potential fall out from this virus. So, let's use our imagining energy on how we can mitigate the epidemic. The DHHS, if it has not done so yet, should convene a panel of docs, EMS professionals, engineers and IT experts to develop contingencies and test them virtually. This way, when the full epidemic strikes, we will not have to blame our collective lack of imagination for not preventing a catastrophe.

H1N1: Why we are unprepared

We just published a paper in PLoS Currents: Influenza estimating what our ICUs can expect this flu season in the US due to the H1N1 pandemic. The picture is not pretty: about 300,000 extra patients needing assisted breathing from ventilators, and some of them requiring advanced modes of ventilation available only in specialized centers! Herein lies the paradox of this flu: by and large it does not cause a particularly severe disease, save in a small proportion of its victims. However, its contagion potential is high, and large numbers of the US population are likely to be affected (about 46 million by our estimates), accompanied by a large number of critically ill, thus potentially overwhelming the ICUs.

Here is how it fits into the overall picture of critical care in the US. ICU beds are perennially occupied, personnel numbers are shrinking and the volume of the sickest of the sick is growing at a clip 6 times that of all hospitalizations. Not to mention that 1/3 of all hospitals are financially in the red, and ~1/2 of all EDs are on diversion at some point (and, by the way, in the majority of these situations the reason for diversion is lack of ICU bed availability). Given that there are about 1 million patients on ventilators in the US annually, we are talking about a 33% surge likely compressed into a few months of the flu season! So what do you think is going to happen?

My friends on the ground tell me that we are not ready. Jeremy Kahn, MD, MS, Assistant Professor of Medicine and Epidemiology at the University of Pennsylvania School of Medicine and Senior Scholar in the Leonard Davis Institute of Health Economics, who happens to be one of the foremost experts on ICU capacity and regionalization in the US, told me that "we are woefully under prepared" for this pandemic. He is very concerned that critical care bed and ventilator supply will be outstripped by demand. But what concerns him even more is that "most municipalities do not have resource allocation or disaster preparedness plans in place". What this means is that we do not have plans in place to use the available resources optimally.

There are other ways in which we are unprepared. One is manifesting itself in our current national discourse on healthcare reform. The level of immaturity and selfishness in this "debate" makes me worry that we are not prepared as a population to make the tough decisions that have to be made during a disaster, which is what this pandemic is promising to be. Canadian Critical Care investigators came up with a protocol for their ICU resource allocation in case of a mass casualty event. This is an explicit scheme spelling out how prioritization is to take place. (Oh, yes, there will be prioritization). In a Society of Critical Care Medicine's podcast Dr. Randy S. Wax, a co-author of the Canadian protocol to triage ICU care during a pandemic, talks about this scheme. He uses the phrase "distributive justice". What this boils down to is that in the face of a public health disaster a bedside doc is responsible to the society at large even more so than to an individual patient. It is critical to have an explicit and transparent prioritization protocol, developed and put into place with full participation of community members. This is necessary as much for clarity and community buy-in as it is for protection from liability. The Canadian scheme has been available for 3 years -- have we heeded the call? Clearly not. And what is the Society of Critical Care Medicine doing? Well, to be fair, they have offered some disaster management courses. Now, at the 11th hour, they are advertising a web cast on September 17 at a cost of $65.00 for individual non-members!

So, where does all this leave us? As I said before, with our pants down! Is this sad state of affairs another reminder why we need a healthcare system devoid of the profit motive? A few days ago I reviewed a paper in the New England Journal of Medicine comparing Israeli preparedness scheme to ours. Some of the pivotal differences between our two systems are the centralized nature of planing and enforcement functions (they have it, we don't), competition between centers (they don't have it, we do), and the profit motive (they don't have it, we do).

Since it is too late for this pandemic to benefit from a philosophical and infrastructural overhaul, we need to have a realistic national plan. We have to do as much as we can to put plans into place that optimize the use of currently available resources. At the same time, prevention is clearly going to be the cornerstone of this effort. I believe that we need to be exceedingly aggressive with preventive efforts, including school and business closures, travel restrictions and the like. In fact, this may be a great opportunity to test to its fullest our communications web. It is possible that if we handle this potential catastrophe with some measure of common sense, we may gain useful insights not only into who we are as a community, but how our vast technological resources can make us into a more compassionate and efficient work force.

This makes it simple

I found this appealing -- hope you do too!

PLoS: estimates of respiratory failure from H1N1 in US

My foray onto knols -- just published one in PLoS Currents: Influenza that models the H1N1 epidemic in the US and estimates the number of acute respiratory failure cases that we can expect during the season. Pretty huge numbers! The table is reproduced here:

Table. Model input parameters and outcome estimates

Input Parameters	Estimate*	Source
US population	307,024,641	[6]
Estimated attack rate	15% (6%-24%)	[2]
Hospitalization rate, relative to attack rate	6% (2%-10%)	6% = CA experience, personal communication 2% = assumption 10% = [5]
ARF rate (relative to hospitalization)	12% (6%-18%)	12% = [5] 6% and 18% = assumption
Mortality rate (relative to ARF)	58% (40%-80%)	58% = [5] 40% and 80% =assumption
Outcomesò	Mean estimate	95% CI
Total cases	46,053,696	36,937,583-55,094,920
Number hospitalizations	2,763,222	2,034,413-3,585,032
ARF cases	331,587	227,866-454,001
Deaths	192,320	125,945-276,482

*Each input parameter was assumed to be normally distributed

^òOutcome estimates and corresponding confidence intervals are based on Monte Carlo simulations, 10,000 trials for each outcome

CA = California, ARF = acute respiratory failure, CI = confidence interval

Week in review

On Wednesday, August 19, Grandma went to kevinMD

The sick and the dead

A school yard bully

Death and taxes

Barney Frank Town Hall, Dartmouth, MA

The highest form of patriotism

Pizza anyone?

Visit msnbc.com for Breaking News, World News, and News about the Economy

The highest form of patriotism

Historian Howard Zinn said "While some people think that dissent is unpatriotic, I would argue that dissent is the highest form of patriotism". I would go further to say that without dissent it is difficult to clarify one's thoughts on a subject. Take my post about killing grandma, for example, which has been making rounds this week -- kevinMD, doc2doc, Leftrightcenter, to name a few blogs that have posted it (or my edited version of it). Much of the feedback expresses agreement with the sentiments. However, it is the dissenters that are driving me to develop more clear thinking on the issue, and I thank them for that.

Some of those who disagree do so for two reasons: 1). They feel that the government does not belong in planning healthcare decisions, and 2). Some feel that intensivists are "glass-half-empty" people, and tend to exaggerate the gravity of every situation, conveying muted enthusiasm for "everything". Some of the commenters even suggested the I was a DNR (do-not-resuscitate) order hound and should not be listened to for that reason.

In fact, it is good to have dissent electronically -- it minimizes the opportunity for ugliness that has arisen in town hall meetings, and, if done civilly and without personal attacks, allows for clarification of everyone's valid objections. It also gives me the chance to respond thoughtfully rather than with a knee-jerk.

So, here are my measured responses. As far as the government being involved in bedside decisions, that is not my understanding of the bill. The provision for a physician to conduct advanced directives planning is there to establish a reimbursement mechanism for thoughtful care, rather than what exists today, procedure-oriented care. As for intensivists' attitudes, that is just not borne out in the literature. In fact, we are as bad at giving realistic predictions as any other specialty, and we are never willing to err on the side of withholding care. Another very important reason for advanced directives is that research indicates that family members usually will opt for more aggressive measures for their loved ones than they would for themselves in a similar situation. So, leaving these decisions to families is likely to result in more painful and useless interventions than the patient, were she able to express herself, would wish for. Not to mention the lasting pain for the family.

In the ICU I have held many hands and wiped many tears. I have had the privilege of offering soothing words and sitting quietly with grief. Most of these families would not have chosen to go through the agony, had they known what "everything" entailed, or what horrible life-altering decisions lay ahead. Feel free to disagree with me -- after all, dissent is patriotic. But if you know anyone who has gone through an ordeal like ones I am describing, ask them about it, listen to them respectfully, and draw your own conclusions about the virtues of advanced directives.

What would you recommend?

There is going to be a meeting on innovations in healthcare to develop the 21st century vision for healthcare delivery. In this video David Rosenman, MD, the Director of Mayo's Center for Innovation, talks about his vision for the conference.

Do you think he is on the right track?

Are you planning on attending?

Do you have ideas?

Discuss!

Death and taxes

This is a repost of a piece that I did for BMJ's doc2doc blog.

There is a familiar adage: "There are two things in life that you can't avoid -- death and taxes". The opponents of the US healthcare reform clearly tapped into this adage to formulate their anti-Obama strategy. Since the Americans seem to fear death and taxes more than anything, even being swindled by insurance company executives or losing their healthcare coverage if they lose their jobs, this has been a supremely effective way to shape the counter message. The cherry on top is that it leverages the perennial paranoia of socialism, so familiar to the generation that grew up during the cold war.

The message goes like this: This healthcare reform is going to broaden government powers, so that it will intrude in your lives. This newly empowered government will take away not only your money (as in raise your taxes), but your life as well (hence the "death panels" talk). Here you go, a tidy message combining all of our primal fears -- death, taxes, socialism. Who could ask for a better marketing tool? And who could ask for a more gullible audience accustomed to dealing with complex issues in fortune cookie sound bites?

Barney Frank Town Hall, Dartmouth, MA

A school yard bully

In my family we feel strongly about bullying. We encourage the kids to develop a sense of humor, but never at someone else's expense. We encourage them to stand strong on their principles, but never trample on someone else's. So far so good: they have not taken anyone else's lunch money or lunch, and they know how to win debates honestly, by exercising their powers of reason, not their fists. They also know that the truth, no matter how difficult, elevates everyone, while if they lie, they are disrespecting themselves and those they are lying to. No rocket science here so far -- this is parenting 101, pretty fundamental stuff.

Unfortunately, what they are learning from the political process playing our around so many issues in this country is just the opposite: lies and bullying get results. Look at the healthcare "debate". The bullies who paid for storming town hall meetings a couple of weeks ago are winning. The liars who, through clever twisting of the message, have manipulated the vulnerable masses into thinking that Obama is setting up death panels in the back rooms of the White House, are gaining traction. An NBC poll reveals that these sensationalized and insidious lies, instead of measured and well reasoned discussion of the actual points of reform proposals, are shaping the debate. So, the bullies are winning. What kind of a message does this send to my children?

I noticed a few years ago a trend in sports which I call the "cult of victory". This amounts to a philosophy that if you are not a winner, you are a loser. There has been little if any talk of good sportsmanship or integrity. And look what this has done to our sports heroes: there are daily shocking revelations of our most revered sports figures using performance-enhancing drugs, game fixing, felonious behaviors. While this all makes for good news copy, what is it telling my children?

We are now seeing the same philosophy play out in politics: victory at any cost. Never mind that lies diminish everyone, those who perpetrate them and those who believe them. Never mind that our current approach to the healthcare system is unsustainable. In this game of political rock-paper-scissors, a simple message filled with fear trumps a reasoned but sightly more complex argument. The only curve that is being bent in this "debate" is the public's intelligence curve. And we, the captive audience, are giving credibility to this school yard bully. What are we teaching our children?

Society of Critical Care Medicine P4P implementation guidelines

This appears in the September issue of Critical Care Medicine Journal on page 2625. Mostly makes sense, but voluntary participation? Opting out not affecting economics? What's the point? Somewhat self-serving in other points too.

Society of Critical Care Medicine pay-for-performance implementation guidelines

The goal of a P4P program is to improve patient care.

Quality measures must be evidence-based and be accurate indicators of patient care and outcomes.

Quality measures must be developed, maintained, and reviewed in an open and transparent process.

Quality measures must be under the direct control of the intensivist physician.

Before implementation, P4P programs must be pilot-tested to ensure valid data collection and accuracy.

Performance measures involving outcomes (i.e., mortality, morbidity) must be risk adjusted.

P4P programs must demonstrate improved quality of patient care as a result of implementation for outcome measures.

Quality measures must be reviewed at least every 2 years.

The best programs would also provide expert opinion and discussion with suggestions for improvement.

Physician participation is voluntary.

Physicians must be able to opt-in or opt-out of a P4P program.

Opting-out must not have negative economic consequences.

Physician participation in P4P must not be linked to participation in other health plans or governmental programs.

Programs must be phased in to allow physician participation.

Physicians must be notified at least 6 months in advance, in writing, regarding new P4P opportunities, changes in existing programs, or rewards.

Data collecting must be simple and valid.

Patient privacy and security of all data must be protected at all times consistent with the Health Insurance Portability and Accountability Act.

Data collection and reporting must be simple and reliable.

Audit systems must be implemented to ensure accuracy of data.

Physicians must be reimbursed for any added costs incurred as a result of participating in the program.

Performance data should be aggregated and analyzed by an independent entity, audited by an independent third party, and reviewed by the reporting physician or group with all costs paid for by the program.

Feedback of performance data should be provided monthly and compared against historical norms, peers, and performance targets in a clear and easy-to-understand format.

Confidentiality and public reporting.

Physicians should be assessed in groups or across systems rather than individually, if possible.

Physicians must be able to see preliminary ratings and given an opportunity to improve before ratings are publicly released.

There must be a formal appeal process before public release of ratings.

Results of P4P programs must not be used for health plan credentialing, hospital privileges, licensure, or board certification.

Individual physician P4P data must remain confidential and nondiscoverable in legal proceedings.

Use of IT should be encouraged, but not required for participation in P4P programs.

Programs must not favor physician practices by capabilities in IT.

Programs must not require practices to purchase health plan-specific IT programs.

Programs must be designed to minimize financial and IT barriers to physician participation.

Programs must provide tools to facilitate participation.

Programs must provide funds to encourage the use of IT.

P4P programs should be based on rewards and not penalties.

P4P programs should utilize new money funded by using a portion of the projected health plan savings.

There should be no reduction in existing fees paid to physicians as a result of implementing a P4P program.

P4P programs must provide additional incentives to purchase and utilize IT and electronic medical records.

Rewards must be greater than the costs associated with participation.

Rewards should be of a significant magnitude to encourage desired behaviors and support continuous improvement.

Rewards should be provided for both achieving program goals and performance improvement.

Ranking with other physicians participating in the program or groups should not occur, and rewards must not be based on rank.

Confusion: prescription for a big mess

An insightful discussion by NPR's Julie Rovner re: public option vs. co-ops and the political kuufuffle surrounding it all. At Kaiser Health News (via @dirkstanley, @ahier)

Healthcare, etc. now on BMJ blogs

You can now find some of my posts on British Medical Journal's Blog under "Marya".

Today, grandma went to Britain.

The sick and the dead

There is an overwhelming amount of stakeholder interests in this healthcare "debate". I can summarize the main stakeholder groups thusly:

1. Healthcare providers (physicians, other individual providers, hospitals)

2. Manufacturers (Pharma/Biotech, devices, information technology)

3. Payors (Insurance companies, state [Medicaid] and federal [Medicare, Medicaid] governments)

4. Government

Which ones do we as consumers of healthcare trust? Seems like those of us who want to keep the government from expanding its role in healthcare trust the other three more than their elected officials. It is baffling that they should. Ask yourselves, what are the interests of those parties? Manufacturers... Insurance companies... Healthcare providers... While it is heartening to me to think that you may consider your healthcare providers trustworthy, I may be engaging in self-deception there. I know that the public's trust in our venerable profession has eroded dramatically, and I do not need to reinvent the wheel telling you why, since Dr. Gawande has already done it for me, and much more eloquently than I ever could.

Do you really trust the manufacturers to have your best interests at heart? If yes, why? They are a business, and like any other business they are driven by the need to increase investor value by making profit. Where is your interest in this equation? There are , of course, exceptions, but do we want to put all our eggs in that basket? And speaking of the profit motive, what are insurance companies' primary goal, if not to make as much of it as is humanly possible? What? You don't believe me? Why else would they have armies of employees responsible for denying reimbursements for needed services?

So this brings me to the government. Who are these people and why don't we trust them? Well, aside from the fact that we elect them, they seem to be mostly beholden to the special interests that contribute gobs of money to their campaign coffers. And these groups of course are the manufacturers, the payors, and the like. No wonder we do not trust them!

What is peculiar, though, is that the rhetoric opposing healthcare reform is centered around the government intruding in our personal choices, compelling us to do that which we are opposed to doing. Is that not strange? The solution seems to me to be quite simple: clean up the government, make them responsible to the people again, and make them accountable for fulfilling their responsibilities to the citizens. Why are we talking about killing grandmas as if all of the other stake holders are immune from this accusation? Pardon me for my crudeness, but could it be that we understand that a sick patient is more lucrative than a dead one?

Pit bull in lipstick

"I join millions of Americans in expressing appreciation for the Senate Finance Committee’s decision to remove the provision in the pending health care bill that authorizes end-of-life consultations (Section 1233 of HR 3200). It’s gratifying that the voice of the people is getting through to Congress; however, that provision was not the only disturbing detail in this legislation; it was just one of the more obvious ones."

Thus starts Sarah Palin's Facebook post from yesterday, August 14, 2009. Drunk with victory she warns us that she is not done; she remains a wingnut on the loose. She continues "As I noted in my statement last week, nationalized health care inevitably leads to rationing. There is simply no way to cover everyone and hold down the costs at the same time" [emphasis mine]. Does this statement shock anyone? Let's repeat what she said: "There is simply no way to cover everyone".

Now, let's deconstruct it. Is she in fact saying that it is OK to leave our fellow citizens in the healthcare dust? Meaning that if we as a nation do not think we have the means to cover you, you poor slob, well, too bad, you're on your own, hasta la vista, baby! Is she advocating what I think she is advocating? Death squads for those who are not deemed deserving of coverage? And, by the way, of course, dear Sarah, there is a way to cover everyone -- the rest of the developed world is doing it rather successfully. But of course, you know this, being the world's expert on foreign policy. What's that? You can see Russia from your window? Now about holding down the costs: I know that you are an expert on economics as well, so I am sure that you do not need to blame your economic advisors for not sharing the PriceWaterhouse Cooper's report, which estimates that over 50% of our national health expenditures is wasted on things like defensive medicine, inefficient claims processing and simply because of our national bad behavior? Finally, Dr. Palin, being an expert on healthcare, you have neglected the small detail, in the name of political expediency perhaps, of what the consequences of providing "everything" really are.

The Senate has caved in to a bunch of toothless thugs running around with pitchforks and threatening doomsday. In a Quixotian act they struck down a non-existent provision to appease them. But knowing that the senate does not really respond to the wishes of the public, it is a forgone conclusion that the thugs' strings are being pulled by powerful moneyed interests who know how to manipulate the gullible masses. Wake up, America, this is politics in the 21st century, neatly packaged in fortune cookie slogans shrouded in moral absolutism. Interesting experiment, but do we really want to be its guinea pigs?

Blogger or WordPress?

I am thinking about migrating my blog to WordPress. What are your thoughts? Please, help me decide by taking the poll ----->

Waste in healthcare, from PWC

PricewaterhouseCooper's Health Research Institute report on wasted healthcare spending

Key findings:

Wasteful spending in the health system has been calculated at up to

$1.2 trillion of the $2.2 trillion spent nationally, more than half of all

health spending.

• Spending can be classified into three waste “baskets”: behavioral, clinical

and operational. These baskets cross all of the health sectors and include

consumers, government and industry.

• The top three areas of wasted spending are defensive medicine ($210

billion annually), inefficient claims processing (up to $210 billion annually),

and care spent on preventable conditions related to obesity and

overweight ($200 billion annually).

• Eight out of 10 consumers surveyed by PricewaterhouseCoopers’ Health

Research Institute (HRI) said that inefficiency in the healthcare system is

not only driving up healthcare costs, but impacting the quality of care.

• Consumers see themselves, government and the industry at fault for

wasteful spending. For example, 86% of consumers surveyed by HRI

agreed that patients going to emergency rooms for non-emergency care

drives up healthcare costs. Two-thirds said that they personally had

received excessive medical testing.

• When U.S. consumers were asked why they believe the U.S. healthcare

system has inefficiencies that have not been resolved, nearly half said

“because it is not a priority for the government.” More than a third said it was

due to the health industry not being willing to change business practices.

• Key barriers to eliminating waste are culture, politics, funding and

incentives, and lack of a coordinated focus.

• Solving inefficiencies means developing system-wide incentives to

encourage partnerships and networks that work toward shared value.

Universal healthcare is terrorist recruitment tool

New message from the Republican propaganda machine. This is what it's come to... Who is Jerry Bowyer, you ask? A neocon who will say anything to derail the democratic agenda. This pseudo-logic is truly frightening! But how desperate they must be to have stooped to this.

Unintended consequences

Thomas Szasz said: "Formerly, when religion was strong and science weak, men mistook magic for medicine; now when science is strong and religion weak, men mistake medicine for magic". I used this quote as a jumping off point in an editorial that I wrote, coming out in Critical Care Medicine journal shortly. The editorial accompanied a study from North Carolina illustrating communication gaps between healthcare teams and families during the care of a critically ill member. You see, when a person is ill and old and frail, an acute illness can easily tip the balance for that person into a critical situation. Even something as simple as a urinary tract infection can be catastrophic and bring one to the brink, where death is inevitable without the use of "everything". Let's be very clear: when "everything" is instituted in this situation, it is the last ditch attempt to stabilize the individual so that he/she and the family can have some closure and time to make decisions before the next time comes; and it will because death is still an inevitable outcome.

Back to the study and my editorial. We have known for a long time that persons who require a prolonged course of ICU care do not do well in the long run: most of them will be dead within one year, and the survivors have persistent problems with cognition, self-care, anxiety, depression. Furthermore, the burden on the family care givers is substantial. In fact, in the North Carolina study, only 9% of the patients were alive and functioning independently one year after their critical illness. Because this knowledge is not particularly new, you would expect that the doctors talk to the patients' families about what to expect, right? Well, it turns out that this happens in less than one-third of all cases as the families are faced with making choices for their ill loved ones! And even in the rare instances when the communication does take place, families often make decisions that in retrospect seem misguided.

Of course, because nothing is completely straight-forward in medicine, there are many reasons, which I discuss in my editorial, that may account for the misaligned communications and poor decisions. For example, patients' families may be too distressed to hear the truth. Additionally, and this has happened to me, physicians may be reluctant to be completely honest about the dismal prognosis of their patient, particularly when they sense the families' distress. Also, and this is particularly shocking, the treating physician may simply be unaware of the data that I just mentioned indicating a dismal prognosis in the long term.

And these are all the reasons it is so important for the elderly and the ill and the frail to have these discussions with their families and physicians before they are tipped into critical illness; it is just a sensible and humane thing to do. This has nothing to do with the hysteria over rationing or cutting costs; it just has to do with avoiding useless and painful prolongation of real people's agony. In this vein, the fact that the Senate has removed the end-of-life discussion provision from their version of the healthcare reform bill is distressing, and has all the appearance of making an issue of critical importance into a political football. But, I have to ask myself, do we really need to legislate these discussions? Can we not simply rely on the good sense of our healthcare providers to hold them without being compelled to do so statutorily? Well, firstly, the legislation, as I understand it, is not aimed at compelling anyone to do anything of this sort. It merely provides a framework and a reimbursement mechanism for such planning. Secondly, doctors are a "mavericky" bunch, and do not like to be told what to do or be a part of the herd, and scientific evidence takes decades to diffuse into practice. And, as Dr. Gawande pointed out to us, some doctors are driven by their bottom line more so than by what is best for their patient. In the current system doing more, not doing better, buffets the bottom line. We deserve better as patients and as citizens!

As in everything about this so-called "healthcare debate", we are choosing to focus on quantity over quality. The rhetoric of "death panels" is being replaced by a less inflammatory and more culturally acceptable language of "unintended consequences". Unintended by whom? This whole bedlam is an unintended consequence of a very timely and humane idea. So, again, no good deed goes unpunished, and we continue to be told lies in the interest of political advantage. And instead of bringing in reason, the press are panting over this "debate", since it lathers the masses. Where are the voices of people who have lived "everything", who have delivered "everything", and who have learned the hard way what the term "unintended consequences" really means?

A narrowing window of opportunity

Catching up on last week’s journals, two seemingly unrelated pieces caught my eye: one in JAMA and the other in the New England Journal of Medicine. The one in JAMA talked about how the Israeli health system deals with mass casualty-related surge capacity, and the one in the NEJM focused on how growth of corporate medicine can benefit healthcare in the US. Juxtaposing these two papers made for an interesting exercise in gap analysis.

In their JAMA Commentary, Peleg and Kellermann point to evidence from studies by the Government Accountability Office, the Institute of Medicine and the House Committee on Oversight and Government Reform, that the US hospitals lack infrastructure and resources in case of a mass casualty event. The authors then offer a formalized schema used by the Israeli health authorities to address their contingencies for disasters. Their planning, testing and enforcement functions are centralized: a government body is not only held accountable for developing and testing the systems, but also is imbued with authority to demand compliance from the participating institutions. In the US, on the other hand, the responsibility for disaster planning is divided between the CDC, Homeland Security and the department of Health and Human Services, and none of these bodies monitors preparedness and surge capacity on the ground, leaving the hospitals themselves to take them on individually and voluntarily.

Turning now to the NEJM Perspectives piece by David Cutler, a grim, albeit not unfamiliar, picture of the US hospitals emerges: ¼ of all US hospitals operate in the red, with another 11% making a less than 2% annual profit margin. In the current financial situation Medicare and Medicaid increases don’t have a snowball’s chance in hell, and private third-party payers are steadily negotiating lower reimbursements. Of direct relevance to disaster planning, emergency departments are seeing 30% more visits than they did two decades ago, and among urban centers, those most likely to be affected by a mass casualty event, two-thirds operate at or over capacity. How does one prepare in this context?

Back to Israel. Three points are critical in the Israeli preparedness plan. First, they have a concrete blueprint for de-clogging the EDs, the central point for efficient and effective management of the sick. Do we? Second, Peleg and Kellermann also remind us that centralized coordination, so well designed and executed in Israel, is possible there partly because of universal access to healthcare: hospitals do not have the incentive to see insured clients over engaging in potentially less lucrative mass casualty care. Not so here. Finally, communication and collaboration between healthcare institutions are key to the success of preparedness efforts. In the US competition precludes such collaboration.

Let’s add the threat of H1N1 to this mix. Now, I am not a catastrophist, and I do not want to be perceived as Chicken Little of the 2009 flu season. I recognize that so far this flu seems by and large to cause less severe disease than its seasonal counterpart. What I am also appreciating is that this flu is highly contagious, so, despite a relatively low frequency of complications, their volume may be vast. These predictions are based on what we know so far, and, while they may not come true, we need to be moving as if they were certainty. If we do not, and they come true, we will be caught with our pants down and suffer more than just a red face. Yet no one is at the wheel coordinating a response to this likely event. If the EDs are operating at or over capacity and have no contingency plans, how do we expect them to provide adequate care this fall? If hospitals are having to let go of essential personnel due to financial difficulties, how can we expect them to care for 30-60% more patients coming through their doors with the flu? Although the Federal Government has allocated funding for institutional preparedness, no one has overseen its implementation and the math is not adding up.

The situation poses an obvious conflict between our collective need to be prepared and our societal fear of centralization, exacerbated by the healthcare system’s financial ruin. Further, our culture of individualism is driving absurdly self-centered discussions without any regard to the reality or application of wisdom to the upcoming potential disaster: not everyone will get everything. In fact, even if we had the will to implement a preparedness schema akin to Israel’s getting all of our ducks in a row, rationing during a pandemic would be mandatory. What will things be like when tough choices have to be made under the pressure of a chaotic situation, choices that we as a society are ignoring now, when there is time to approach them rationally? Why are we engaging in hysterical lies about government-sanctioned euthanasia instead of discussing this challenging and rapidly approaching reality?

Today in New Hampshire Obama appealed to our civility and common sense as a nation in our discourse on healthcare reform. We need to heed this message, turn away from demagoguery and focus on developing a roadmap for realistic scenarios of 5 patients competing for one ICU bed, of our EDs clogged with a relentless influx of casualties from H1N1, and of having to make end-of-life choices for our critically ill grandma because asking her about her preferences when she was well would have amounted to a Nazi execution.

Both, the JAMA and the NEJM papers offer solutions to the US problem of healthcare capacity and preparedness. These solutions require time and a culture shift. But time is short, and culture change before the fall is unlikely. Yet this is a teachable moment in which we need leadership. Mainstream media should lead this conversation without attention to their ratings and in more than sound bites. Treat us, the citizens, like intelligent adults, and we will rise to the challenge; treat us like spoiled children, and we will miss this narrowing window of opportunity.