Trendspotter: Safety Procedures Known to Save Lives Are Not Being Used

By Ken Terry

Safety and quality checklists can save lives in hospitals, as a new British Medical Journal study reiterates. Yet only a fraction of U.S. hospitals are using the World Health Organization (WHO) surgical safety checklist, which was introduced here 15 months ago. And the Leapfrog Group, a public-private consortium that presses for quality improvement in hospitals, has found that a minority of hospitals adhere to nationally endorsed process measures that have been shown to reduce mortality.

Interestingly, the checklist approach does not require electronic health records. Both the WHO surgical safety checklist and the “care bundle” approach used in three London hospitals rely on paper documentation. So, while there are indications that EHR use can save lives, much can be done even without information technology.

In the BMJ study, the care bundle method—which requires doctors to check off certain treatment steps—was associated with a major drop in patient deaths. While there were 255 fewer deaths in these hospitals during the study year than in the previous 12 months, 174 of those were related to the 13 targeted diagnoses. Despite a 5.7 percent increase in admissions, the mortality rate fell 14.5 percent. Both the drop in overall deaths and the decreased mortality among patients with the targeted conditions were statistically significant.
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The eight checklists addressed these diagnoses: peritonitis and intestinal abscess, senility and organic mental disorders, pleurisy pneumothorax pulmonary collapse, aspiration pneumonitis food/vomitus, skin and subcutaneous tissue infections, acute bronchitis, urinary tract infections, acute cerebrovascular disease, other gastrointestinal disorders, septicemia (except in labor), pneumonia, chronic obstructive pulmonary disease and bronchiectasis, and congestive heart failure (non-hypertensive).

The clinical areas covered by the checklists, which were introduced in April 2007, included central venous catheter/line sepsis, diarrhea and vomiting, stroke, ventilator acquired pneumonia, methicillin resistant Staphylococcus aureus infections, heart failure, surgical site infections, and chronic obstructive pulmonary disease.

Nearly 700 hospitals were using the WHO surgical safety checklist a year ago, and 300 more had committed to trying it, but there have been no updates since then from the Institute for Healthcare Improvement, which is spearheading the checklist campaign. The WHO checklist goes beyond the Joint Commission’s patient and site identification requirements by ensuring that everything is ready for an operation, that everybody on the team knows the safety procedures, and that there’s good communication among team members. A multinational WHO study showed the use of the checklist decreased mortality by nearly half. While it’s expected to have a much smaller impact in the U.S., where surgical mortality is fairly low, it could have a marked impact on reducing complications.

The Leapfrog survey, using 2008 data, found that relatively small percentages of U.S. hospitals were adhering to evidence-based guidelines that are known to save lives. Among the areas where compliance was poor: heart bypass surgery (43 percent), angioplasty (35 percent), high-risk deliveries (32 percent), pancreatic resection (23 percent), bariatric surgery (16 percent), esophagectomy (15 percent), aortic valve replacement (7 percent), and aortic abdominal aneurysm repair (5 percet). Moreover, 65 percent of Leapfrog’s participating hospitals lacked policies to prevent common hospital-acquired infections.

Now, it’s possible that the evidence is poor for some of the surgical protocols, and reducing infection rates poses a number of challenges, both human and technical. But physicians and hospitals that aim to be accountable and form “accountable care organizations” owe us all a better effort to improve patient safety. There’s no excuse for not trying to save lives when we know how to do it.

Trendspotter: Do We Want Hospitals to Run Health Care?

By Ken Terry

Major changes in the healthcare delivery system are coming, and they will affect every physician. The question is whether those changes will have the effect we all want or whether they will lead to unintended consequences that we don’t want.

Back in the 1990s, during the debate over the Clinton plan and in the period following its rejection, hospitals and physicians began preparing for what they assumed was going to be a massive shift to prepaid managed care. While that never happened, many physicians joined larger single-specialty and multispecialty groups, and hospitals purchased many practices, some of which they later returned to their owners. Something similar is happening now as hospitals snap up practices right and left in anticipation of a reform-driven shift to various types of financial risk. According to one estimate, around half of the doctors in the country are already working for hospitals, and there are some markets where hardly any private practices still exist.

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Some experts believe that the fragmentation of our delivery system is responsible for much of our out-of-control spending and the poor quality of care, especially at the primary level. In that view, the disorganization of American medicine, coupled with fee for service and overspecialization, encourages redundant, wasteful, and even harmful care. But I question whether hospitals and healthcare systems are the right agents to reduce this fragmentation by employing more and more physicians.

The problem with the hospital-centric view of the world is that it’s all about hospitals. Whether for-profit or not-for-profit, hospitals seek to maximize their revenues, their market share, and their competitive advantage. In that sense, they’re very much like corporations in any other field. When they employ physicians, they’re thinking about the value of each doctor’s admissions – about $1.5 million per year, on average – and whether they want their competitors to get those referrals. They may also be considering how a particular physician or group can help sustain or grow existing or new service lines and feed new imaging equipment.

Having hospitals run a revamped, better-organized system creates other issues as well. One is related to the mal-distribution of specialists, which is endemic across the country. Some communities are saturated with specialists, while other communities have very few or no specialists in certain key fields. As hospitals control an increasing percentage of physicians, some facilities will not be able to provide certain kinds of care, because the competing hospital in town has locked up all of the specialists who are capable of providing those services.

There is much validity in the concept of “accountable care organizations”--combinations of hospitals and doctors that can provide particular services or types of services for a budgeted payment, with the ability to share in cost savings. ACO supporters say that these organizations might be “virtual” organizations that tie together independent practices and hospitals through information technology. Unfortunately, however, one outcome of the move toward ACOs and payment bundling—both goals of the reform legislation—might be the growth of hospital power in many communities. And I don’t think we should place responsibility for the future of healthcare in the self-interested hands of hospitals.

I’m not predicting that this is the only possible result of current trends. We’re also facing the influx of millions of newly insured patients in 2014, and it’s clear that there won’t be enough primary-care physicians to care for them. That will be true even if every primary-care doctor in the country is working for a hospital by then. So we’re going to see an increasing emphasis on community health centers, which have received a steep increase in funding from the Obama Administration. Those clinics, which now care mostly for poor patients who have little money, will soon be seeing more middle-class patients—just as retail clinics do. So they will be competing with hospitals, but I don’t see them ever having the same power and influence that the healthcare systems do.

What we need now is for policymakers to give some serious thought to the long-term implications of the trends that are now being set in motion. It’s always easier to make course corrections along the way than to deal with unintended consequences later on.

Trendspotter: Where Hospitalist Communications Fall Short

By Ken Terry


One of the persistent problems in our healthcare system is the communication gap between inpatient and outpatient care. The increasing use of electronic health records hasn’t really resolved this problem, because, unless ambulatory-care physicians are using the same EHR that their hospital is, comprehensive information about a patient’s inpatient care is still hard to obtain in a timely manner. Discharge summaries are supposed to contain this data, but they often arrive too late to be helpful; and even if a primary-care doctor receives this document soon after a patient’s discharge, it may be missing key information.

A recent study in the Journal of General Internal Medicine found that tests pending at discharge were mentioned in only a quarter of discharge summaries and that only 13 percent of the summaries stated what those tests were. “We already know that outpatient providers aren’t very good at following up on pending tests documented in the discharge summary,” commented Dr. Martin Were of the Regenstrief Institute, the study’s author, in an article about the study’s findings. “Imagine how much worse the follow-up is when pending tests aren’t even documented.” Were added that the growing use of hospitalists and the tendency to discharge sick patients faster make the situation even more alarming.

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The discontinuity of care between hospitalists and outpatient physicians has been mentioned in a number of studies. Internist Robert Wachter of the University of California San Francisco, one of the hospital movement’s leaders, told me a few years ago that good hospitalists believe it is essential to contact referring doctors when one of their patients is discharged. “They ‘get’ that sending the patient back to the primary-care physician without the right information and without a phone call is a bad thing to do, both for the patient and in terms of the program’s credibility,” he said. But he admitted that some hospitalists in some programs are not very good about calling outpatient physicians; they might have a nurse or house doctor do it.

Even if the hospitalist does call the primary care doctor, he or she might not mention a pending test. The hospitalist might think it’s more important to focus on the most relevant issues in a brief call. There are also reasons why pending tests might not be documented in a discharge summary, Were points out. For example, multiple consultants order tests at different stages during a hospitalization. To find out which were pending, the hospitalist might have to pull information from several different hospital systems. Of course, that would not be the case in a hospital with a computerized physician order entry system—but only about 15 percent of hospitals have CPOE.

Even if hospitalists are aware of all pending tests, Were notes, they must distinguish between which are important enough to include in a discharge summary. Outpatient physicians will be annoyed if they are prompted to follow up unnecessarily on tests such as kidney function or CBC tests if the results had been normal throughout a patient’s hospitalization.

Another major issue is confusion over who has responsibility for following up on pending tests in the hospital, Were notes. Even if a primary-care physician knows about a pending test, he or she may feel that the inpatient physician should follow up. Hospitalists, on the other hand, may believe that, after a patient is discharged, the outpatient physician is responsible for all aspects of that patient’s care. But if a pending test is not documented, Were believes, it should be the responsibility of the hospitalist to follow up on it.

Blogger Kevin Pho observes, “Some hospitals have post-discharge clinics where hospitalists do the follow-up themselves, but that’s not commonplace. We clearly have a ways to go in bridging the communication gap between hospitalist and outpatient physician.”

This is an area that deserves much more attention, especially given the shockingly high readmission rate of Medicare patients. Part of the solution is to give hospitalists better tools and incentives for communicating all key inpatient data to primary care physicians, whether on the phone or in the discharge summary. In addition, as we build electronic health record systems in hospitals and physician offices, national health IT policy should prioritize the creation of electronic connectivity between inpatient and outpatient care settings.