Friday, September 29, 2006


Speaking of transparency (see below), the Los Angeles Times reported in June that 20 percent of U.S. transplant centers were found to be substandard, in part because of a failure to perform enough operations to ensure competency. Here is the link to that story.

In New England, only BIDMC and MGH perform over 100 kidney, liver, and pancreas transplants per year, based on data collected by the United Network for Organ Sharing, UNOS, the national organization that monitors such matters. Several other hospitals perform only two or three dozen.

If you needed a liver transplant, would you be willing to travel an hour or two to go to a transplant center that was more experienced? If insurance companies care about clinical results, shouldn't they be directing patients to those centers with more experience and better results?


margalit said...

As someone who might need a heart transplant in the not too distant future, I'd travel just about anywhere to get the best healthcare. Unfortunately, my heart disability leaves me unable to work, thus I am unable to be insured as my SSDI gives me "too much" income to be entitled to Mass Health. So I'm uninsured at use the Brigham for free care. Isn't that insane? But if I could get free care elsewhere, I would indeed travel whereever.

jacob said...

"If insurance companies care about clinical results, shouldn't they be directing patients to those centers with more experience and better results?"
maybe, but how would the other hospitals get the experience so that they can become excellent in transplanting as well?

Paul said...

A really good point, which leads to a bigger one. Maybe not all hospitals in one region should be doing all procedures. Do we really need 10 kidney transplant centers within 150 miles of Boston? There is not enough volume of patients to warrant this, and it inevitably means that some hospitals will do too few cases to be as good as they should be in this specialty. It is incredibly expensive to set up and run one of these programs, and there is no net gain to society by having 10 of them, where perhaps 5 or 6, or even 2 or 3 would do. If we care about overall costs to society -- and the quality of patient outcomes -- some limit is appropriate. Let's let the state department of public health have the authority to make this decision, based solely on the goal of achieving better quality results.

If a hospital wants to start a new program in such a highly complex area of surgery, let it be subject to a rigorous review of the matter by an independent authority. Otherwise, it will just be guided by its commercial interests to be a "full service" institution or pressured into developing a new service line to satisfy the desire of one or two of its doctors. I know this will sound strange, but hospitals sometimes need outside help so they can say "no" to new service lines.

Bwana said...

Insurance companies don't seem to care about outcomes although a long-term view would suggest that, except in cases of mortality, ensuing costs for morbidity will be higher than from a good outcome.

This is a reason to have limited centers with deep core competence in specialized procedures -- per your comment above.

I don't see much advertising on this point, but perhaps the patient database is identifiable and can be the subject of direct marketing.

Perhaps if you offered discounts to insurance companies for such referrals, it might work. I don't know about antitrust implications.

Paul said...

I don't want to offer discounts for good quality. I want to be paid more for good quality. Some insurers say this is their goal, but thus far, there is little evidence of that.

General advertising is very expensive and not really worthwhile for highly technical procedures like transplant, where there is a very small base of customers. The best advertising is when community doctors learn of the better results -- or, as noted, if the insurance companies were to use clinical outcomes to help direct patients to the places with better results.

Paul said...

Look, here is an example from Blue Cross Blue Shield of Massachusetts related to another specialty, bariatric surgery to help the morbidly obese. This shows it can be done if the will is there.

"As part of its corporate promise to put its members' health first, Blue Cross Blue Shield of Massachusetts (BCBSMA) announced that the company will adopt new quality and safety recommendations for bariatric surgery.

"These recommendations were produced in August 2004 by the Expert Panel convened by the Department of Public Health and the Betsy Lehman Center for Patient Safety and Medical Error Reduction. The Expert Panel produced evidence-based recommendations aimed at ensuring that the procedures performed in Massachusetts are as safe as possible for patients.

"After consulting with its external Physician Advisory Council, BCBSMA decided to implement a Bariatric Surgery Facility Privileging Program by January 1, 2007, based on the Expert Panel's recommendations. After that date, only facilities that have been granted bariatric surgery privileges by BCBSMA will be eligible for reimbursement for these procedures."

Patient Dave said...

I imagine we'd quickly resolve the question (how many transplant centers we need) when outcomes are posted. If a transplant provider loses 2-3x more patients because they open their doors for business before they really know what they're doing, then we consumers would avoid them - for good reason!

It's hard to think that a manager would decide to hang out a shingle for a new service, knowing that they're likely to lose more people than an alternate provider. But perhaps they don't actually have access to that data, themselves.

It's axiomatic in business that you get what you measure (presuming people can see the numbers). 20 years ago the airline industry was committing horrible abuses in cancelling or delaying flights. Rules were added requiring that they publish their outcomes (their on-time percentage). Consumers started avoiding flights that were never on time, and that became a factor in the daily decisions of people operating the airlines.

If transplant outcome data is posted, then a new provider would have STRONG incentive not to open their doors until they really know what they're doing. That's how the system should work. Good idea.

Paul said...

Blue Cross Blue Shield took this action after the state DPH got involved in bariatric surgery after several people died in very public cases. (Bariatric surgery always carries a somewhat high risk of death, in part, because of the weight of the person being operated on.) But whether they led the charge or joined in with the state doesn't matter. They saw a problem and acted. Mortality and morbidity from transplant cases might not be so visible to the public, but it is serious enough to warrant action, too.

Paul said...

And here is an example of the kind of thing you can do when you have a larger program. One of our staff, Jim Rodrigue, Ph.D., just received an NIH grant to study how intervention to improve people's quality of life can affect the effectiveness of a kidney transplant.

Please forgive the jargon, but here is the summary of the grant:

"Project Summary: Despite known quality of life (QOL) deficits associated with end-stage renal disease (ESRD), there have been very few attempts to develop strategies to improve QOL in adults with ESRD awaiting renal transplantation. The long-term goal of this research program is to better understand how QOL can be enhanced, to identify the mechanisms underlying QOL changes, to identify which patients benefit most from QOL intervention, and to determine whether QOL benefits can extend beyond transplantation. The objective of this application is to determine the effectiveness, feasibility and applicability of Quality of Life Therapy (QOLT) in treating adults with ESRD awaiting renal transplantation. In a recent small, single-center clinical trial, we demonstrated that QOLT can improve QOL, psychological functioning, and social intimacy in patients awaiting lung transplantation. This application seeks to examine whether this intervention can be effectively adapted and implemented with adults with ESRD who are awaiting renal transplantation. The central hypothesis is that by targeting improvements in specific life domains, QOLT yields significant clinical benefits in QOL, psychological functioning, and the patient-caregiver relationship. This hypothesis will be tested by pursuing three specific aims: 1) Determine the effectiveness of QOLT; 2) Examine the differential effectiveness of QOLT by race (White, African American); and 3) Assess the feasibility of a multisite R01 application. Under the first aim, adults with ESRD awaiting renal transplantation will be randomized to receive QOLT, Supportive Therapy (ST), or Standard Care (SC). Primary outcomes will be changes in QOL, psychological functioning, and social intimacy at 1 and 12 weeks post-treatment. Under the second aim, the relationship between race and intervention outcomes will be closely examined. Under the third aim, attrition rates, reasons for attrition, therapist adherence to treatment protocols, and participant satisfaction ratings will be gathered to assess the need for protocol changes prior to developing a larger, multisite clinical trial R01 application. This study is innovative because it is among the first to evaluate a theoretically-driven psychological intervention to specifically improve QOL in the context of ESRD and renal transplantation. The proposed research is significant because it is expected to advance and expand understanding of how QOL can be improved in patients with ESRD. Relevance to Public Health: This is an important and under-investigated area. With very long waiting times to renal transplantation and the burdens associated with dialysis, effective QOL interventions can be used to improve the quality of well-being for all patients who are otherwise medically disabled and awaiting transplantation. These benefits have the potential to extend the QOL outcomes otherwise derived from transplantation alone."

Maxine said...

I have long thought about this and wondered why there were so many doing the same things. In fact, I wish the insurance companies would get over this network business and let people go where the expertise is. I am not interested in letting another facility gain experience on me. For example, if I had diabetes, I want to go to Joslin, they are the best. if heaven forbid I needed a transplant, I would definitely head to BIDMC. But how are you at hip or knee replacement - the Baptist claims expertise there. I think we live where the best is, we should all be able to choose it. However wouldn't this mean a whole different set up for hospitals.