Monthly Archives: October 2012

Weighing the risks and benefits: what health policy can learn from clinical medicine

A few months back, we admitted a patient we’ll call Mr. Jones to the hospital for a severe gastrointestinal bleed.  We had discharged him two weeks earlier after he had come in with a heart attack and made sure he was on aspirin to prevent future cardiac events.  He dutifully took his aspirin and on the day of the readmission, had a massive bleed.  He made it to the hospital barely alive and an endoscopy in the ICU showed an active bleeding gastric ulcer.  For Mr. Jones, the gastrointestinal bleed, likely brought on by the aspirin, was an “unintended consequence” that almost killed him. Yet no one questioned whether we should have given him aspirin in the first place.  I felt terrible about what had happened but found solace in knowing that while for some patients the risks of aspirin are worse than the benefits, for the general population of people like Mr. Jones, the benefits are clearly worth the side-effects.

We do risk-benefit analyses every day in clinical care, knowing that for some patients, the benefits will be outweighed by the harm.  We try to be thoughtful about who might be hurt or not, but most of the time, we just can’t predict.  So, when the benefits appear to outweigh the risks, we move forward and try to learn from cases like Mr. Jones.

While this kind of risk-benefit analysis is common in clinical practice, it’s unfortunately not how we discuss health policy interventions.  No policy intervention is ever without risks, and it is rare that a new policy will have no side-effects at all.  Yet, every time policymakers put in a new initiative, they sell it as a panacea. Critics, upon finding an unintended consequence, then declare the whole thing a failure.

An excellent example of this is health information technology, a topic that I have blogged about in the past (here and here).  Proponents only talk about its benefits, allowing critics to highlight every shortcoming and failure.  Thank goodness I don’t have to deal with proponents and critics like that every time I consider prescribing aspirin to my patients.

From this backdrop comes an important new JAMA study by Dr. Karen Joynt (on which I was senior author).  We examined what happens to patients with an acute myocardial infarction in states that have public reporting of outcomes for patients undergoing percutaneous coronary intervention (PCI, better known as angioplasty and stenting).  Three states have instituted mandatory public reporting of outcomes for this procedure.

Proponents of public reporting argue that transparency will motivate poor performers to improve and provide information that consumers can use to choose the best providers. However, it was not without controversy.  The critics voiced concern that public reporting would lead to denial of care for the sickest patients because doing so could make physicians’ mortality statistics look worse.  Whether public reporting leads to better care, unintended consequences, or both is an empirical question – a question our research team wanted to answer.

So what was the punch line?  We found that public reporting was associated with reduced access to PCI for patients who had a heart attack.  Stated simply, in states with public reporting of angioplasty outcomes, heart attack patients were less likely to receive this life-saving procedure.  This was especially true among the sickest patients (the ones who probably benefit the most).  Even more concerning, there was a trend towards higher mortality for heart attack patients in public reporting states, presumably because they were less likely to receive this life saving therapy (this effect was small and not consistently statistically significant).  This was clearly an unintended consequence, and a bad one at that.

Transparency – making outcomes public so patients have access to information – clearly has its upsides as well.  There’s evidence that public reporting of PCI has led to lower procedure complication rates, presumably because providers are being more careful.  There’s evidence from cardiac surgery that public reporting pushed some of the worst performing surgeons to stop doing surgery altogether.  While difficult to measure, making the healthcare system more transparent to patients has its own benefits in terms of increased trust.

The lesson to draw from our paper in JAMA is that no policy, no matter how well intentioned, is without side effects.  Our job is to think about how to minimize those side effects.  We could improve risk-adjustment methods so that cardiologists get more credit for performing PCI on the sickest patients.  We could carve out some exceptions from public reporting, as Massachusetts has been trying to do, as a response to this kind of data.  Or, ultimately, we can hope that over time, physicians get used to public reporting and simply do what is right for their patients.

When aspirin was first tested in heart attack patients nearly two decades ago, large randomized, controlled trials were conducted, giving us precise estimates of both the benefits and harm.  We could make thoughtful clinical decisions about whether it was worth it or not and in whom.  Most health policy interventions are not tested rigorously before they are implemented.  That’s why we need robust health policy research after policies go into effect.  We need these studies not to discover whether there are any unintended consequences – there usually are – but rather, to quantify the benefit and the downsides so that we as a society can make thoughtful decisions about whether the policies are worth it or not.  Despite the fact that Mr. Jones had a horrible complication from aspirin, I will continue to prescribe it to my heart attack patients.  Despite the fact that transparency seems to reduce access to PCI for critically ill patients, I will continue to advocate for it in healthcare.  The question we now need to ask is how can we do it in ways that lets us maximize the benefit and minimize the harm.

Safdarjung Hospital: Volume and efficiency but little time for quality

I visited Safdarjung Hospital in New Delhi today – an institution with  1,531 beds and 145% occupancy rate.  Yes, 145%.  You do the math.  A lot of bed sharing and asking families to bring in cots.  It’s right across the street from the All India Institute of Medical Sciences (AIIMS), the premier public healthcare institution in India.  While both AIIMS and Safdarjung are run by the federal government, only AIIMS is renowned for famous specialists, world class facilities, and an international reputation to boot.  Safdarjung doesn’t suffer such burdens – its specialists are not well known, facilities are dilapidated, and you probably have never heard of it.

I spent several hours walking around, talking to lots of physicians, visiting ICUs and cath labs.  I visited the outpatient department where 7,000 people show up every day, many lining up the night before, to get a ticket by 11 a.m., when registration closes and those who haven’t gotten a ticket are out of luck.  In the ER, there was a line of between 50 and 100 people waiting to get rabies shots.  This is the hospital where every poor person in Delhi unfortunate enough to get a dog bite is sent.  They have the rabies serum.  Most other public hospitals do not.

Safdarjung has “efficiency” baked in.  In a typical year, they do 800 cardiac surgeries, 2,000 angioplasties, 3,000 echocardiograms, and 100,000 EKGs.  They see tens of thousands of patients in the cardiology clinic.  They have 4 (yes, four) full-time cardiologists on staff.  The rest of the work is done by medical residents, who call when they get into trouble.  Brigham and Women’s Hospital, which probably doesn’t have one quarter the volume of this place, has 140 cardiologists.  The patients at Safdarjung pay essentially nothing.  Even their medications are free.  For those who are not extremely poor (and I doubt there are many non-poor patients who go to Safdarjung), you do have to pay for your own devices.  Need a stent?  Bare metal ones cost $200 to $1000.  Drug eluting stents are $1500 to $2500.  You get to decide which one you want.  They have a chart with pictures and prices that looks a lot like a dinner menu.

What is remarkable about Safdarjung, though, is not its bustling hallways and jam-packed ER.  It’s how well it seems to work.  I visited a large ICU with lots of patients on ventilators, and a single medical resident running the place.  During the time we talked, he scanned the room and gave out orders. Everything seemed under control.  If you believe in the data on the volume-outcome relationship (and you should), it’s clear why this place claims to have terrific outcomes. They very well might.  Yet, as I walked around with the chief of cardiology, I asked him about their cardiac surgery mortality rates.  He assured me mortality was low, “comparable to international standards” (whatever that is).  I pushed him – he said very few patients died after procedures.  When I pushed a little more, he got annoyed, wondering if I was accusing him of running a poor quality hospital.  I backed off.

This is a place that seems to have no time for data.  At each step, I asked if they tracked outcomes.  They didn’t.  They know the latest evidence.  They could easily tell you all the studies that underpin the Hospital Compare quality measures and assured me they did all of those things “always”.  Patients always got antibiotics quickly.  Thrombolysis or primary PCI was never delayed.  No one went home without a beta-blocker.  Yet, several clinicians seemed to grow tired when I asked gently if they tracked their data.  They didn’t.

Safdarjung hospital is a marvel.  It has huge volumes and clinicians who are clearly both incredibly talented and dedicated.  If I were a guessing person, I’d say it probably achieves 80% of the quality of U.S. hospitals at 10% of the cost.  However, while I’m confident on the cost, I’m guessing on the quality.  For some procedures, they probably do better than the average U.S. hospital.  The upside of working in a country where high volume is easy to achieve. Of course, Safdarjung does it with none of the creature comforts we’d want in a hospital (think 145% occupancy rate and patients having to double up).  In the cardiac unit, there’s one monitor for every two patients, and they switch off depending on who is sicker at any given moment.  In the U.S., we obsess if it’s OK for a patient to take off their cardiac monitor for 10 minutes to take a shower.  This is how Safdarjung does so much with so little.  Their clinicians “cut corners” we are not willing to cut.  Its not clear to me that they are practicing worse medicine than I am.  The corners they cut are often of little or no clinical consequence.

Safdarjung is not a place that would score very highly on “quality culture” surveys.  It’s focused on efficiency in a way that few places are, and it probably has no choice but to prioritize this (think 7000 outpatient visits and 400 inpatient hospitalizations every day).  It’s overwhelming.  But, if Safdarjung could put in real metrics for clinical quality, pick some low hanging fruit (a simple EHR would be really helpful) and stop assuming good patient outcomes, it could change the culture of clinical care in India and probably surpass a majority of U.S. hospitals on safety and effectiveness.  Adding private rooms and some decent food would still leave it 85% cheaper than the average U.S. hospital. At what price point would Americans be willing to travel to India for their hip surgery?  I suspect Safdarjung wouldn’t be their destination (it’s too busy caring for the poor to invest in medical tourism).  But, there are lots of hospitals like it in Delhi – high volume centers with an appetite for new technologies and the creature comforts we would want.  Their problem is that they neither reliably measure quality nor make its improvement a priority.  Therefore, we’re left assuming “international standards”.  If there is anything we’ve learned from looking at quality in the U.S., it’s that hospitals across the street from each other can have profoundly different outcomes.  There is, unfortunately, still no international standard.

Safdarjung is an amazing place:  a high volume, efficiency-driven institution that seems to deliver pretty good care.  If it could just sprinkle in some quality measurement and make quality improvement a routine part of how it delivers care, it would likely have a profound effect on how hospital care is delivered across India and beyond.  Who knows, it might even have something to teach U.S. hospitals.