Sunday, January 31, 2010
To: BIDMC Community
From:Eric Buehrens, Chief Operating Officer and Executive Vice President
Lisa Zankman, Senior Vice President, Human Resources
Subject: New Team Fund Raising for Haiti Relief
Earlier this week, our Development staff presented a check for $33,616 to Partners in Health for relief efforts in Haiti. Thanks to the almost 150 members of the BIDMC Community who donated through Grateful Nation.
It has become clear that supporting the Haitian people is going to be a long-lasting labor of love, determination and hope. The lives of our colleagues who lost family members and friends have been changed forever. Over the coming months and years, BIDMC clinicians and other relief workers will no doubt return again and again and still find so much that needs to be done.
To help with the ongoing efforts, BIDMC has been inspired by a group of medical residents, unit nurses and other staff, and their supporters who have started a little friendly competition to raise money for Haiti relief.
We’ve built a space on Grateful Nation for their efforts. In addition, anyone at BIDMC can now start a team to track fund-raising, seek other supporters and spread the competitive spirit.
To start a team, join one or support one that is already started, click here. Thank you for all your generosity.
WGBH, our public television station, is starting a new show based on the old College Bowl theme, a quiz show for high school students. It is called -- tah dah! -- High School Quiz Show.
I went with friends today for the taping of one of the segments. We arrived to find kids making posters to cheer on their school team, and we enjoyed watching the healthy competition as kids tried to answer questions in math, science, literature, history, social studies, and the like.
The show's MC is one of my former MIT students, Dhaya Lakshminarayanan. I am not quite sure what aspect of her MIT training prepared her for this career, but she is terrific in this role.
The show will be broadcast on Monday's starting on March 22, at 7:30pm.
Saturday, January 30, 2010
For generations of students and families, Chef Chang's House in Brookline has been a comfortable place for delicious Chinese food. It is informal and warm, with friendly waiters and welcoming hosts. The owners, Tony and Su-Mei Chan, have decided that three decades is enough, and the place is closing tomorrow.
I went by yesterday (twice -- lunch and dinner) for a last taste. The restaurant was packed with people wanting to do the same and to thank the family for years of service. Tony told me of a customer who had called from Tennessee to say he was flying up for one last meal and and to say goodbye. The place had meant that much to him during his college years.
There were so many customers in the last few days that they ran out of Peking duck, the house specialty. A special shipment was brought in, and they spent overnight last night roasting the ducks to have some available today. A week's worth of other supplies likewise only lasted two days. If you decide to go by, please expect to wait some time for a table.
The Chan's were genuinely surprised at the outpouring of affection. Those of us who know them are not in the least surprised.
Friday, January 29, 2010
Our Medical Executive Committee recently received a report from our Critical Care Committee. I cannot be more proud of our staff and the progress they have made to reduce harm and improve quality of care in our ICUs. I include two of the charts.
Let me translate the implications of the reduction in Ventilator Associated Pneumonia (VAP). Preventing 744 cases over three years -- at a treatment cost of about $20,000 per case -- translates into a societal savings of $14.9 million during this period.
The rate of central line infections also dropped from 4.14 to 0.52 cases per 1000 patient days between FY2003 and FY2009, a reduction of 83%.
This probably reflects lost revenue for the hospital under the fee-for-service reimbursement system. So why do we do it? First, because it is the right thing to do and saves lives.
Hundreds of lives.
On the business front, it has contributed to a reduction in length of stay in our ICUs. We were able to avoid the multi-million dollar capital cost of expanding our ICU capacity. Indeed, we were able to create capacity out of the existing facilities and improve throughput.
I hope that those who argue that global payments (i.e., capitation) are a necessary condition to create societal cost savings and improve patient care will read this. I do not deny that such a payment methodology may be worth implementing for other reasons, but there is a lot that can and should be done under the current payment system.
While the state debate goes on about cost control, why can't we get all of the hospitals in Boston to release information like this about their quality improvement efforts to provide the public and public officials with a sense of confidence that we care about these matters and are willing to be held accountable.
Then, this email arrived late this week:
we are all ok. i can't call u so i write u to tell u that's all is ok for us. so please take a good care of u.
This is a cooperative program of the Lean Enterprise Institute and Thedacare's Center for HealthcareValue. LEI and the ThedaCare Center are both 501(c)(3) non profits. This event ($500) helps fund their network and Lean promotion activities that are often offered at no cost to institutions.
Summary: This is an interactive video learning experience. You and your team will be able to view two video sessions. The first is a recorded video featuring the Strategy Deployment process in use at ThedaCare, a community health system in Wisconsin that is a leader in the application of Lean management in health care. The second is a live question and answer period with John, in which he will answer your questions about Strategy Deployment and the ThedaCare Improvement Sequence.
For example, Celebrity Diagnosis is in the Best New Medical Weblog category and Medical moments in 55 words is in the Best Literary Medical Weblog category.
As they say in Boston (or was it Chicago?) vote often and early!
Thursday, January 28, 2010
Haiti’s general hospital looks like the world’s largest battlefield MASH unit. Patients are being transported from all directions and vast numbers of wounded and recovering wait on the ground. Doctors in makeshift operating rooms are so cool and professional you’d expect them to someday be played by George Clooney and Meryl Streep.
“Sixty to seventy percent of the hospitals’ buildings have been damaged” explains Doctor David Walton, a 12 year veteran of Paul Farmer’s Partners in Health, who splits his time between Haiti and Boston. He walks us past the green open air wound care tents. He then leads us through white tents crammed with cots where post-operative care is provided to many of the poorest people in the world by a handful of the best doctors in the world, with the least amount of modern medical equipment.
This hospital is a microcosm of many issues converging in Haiti today: the challenge of coordinating individuals from numerous institutions, the lack of basic infrastructure, the heartbreak of so many children left to survive on their own and in the street, the resilience of the Haitian people who are playing a major role in their own recovery. Mostly it underscores the need for taking a long view and making an almost unimaginably long term commitment.
For example, one of the unique and terrible legacies of this disaster will be the large number of people who needed to have limbs amputated. Many were lying quietly on cots after surgery, between 12 and 20 to a tent, some sutured but not bandaged. Some were soon to be released, but of course not to their home which no longer exists, but to the sidewalk or a tent city erected in parks and on hillsides across Port au Prince.
The day after visiting I called former U.S. Senator Bob Kerrey, who lost his leg in Vietnam, had nearly a dozen surgeries, and eventually returned there to help establish prosthetic clinics. I used to be his chief-of-staff and knew how well he understood the need. This is what he explained: “Making prosthetics is not complicated, but there is artistry involved. A five year old girl that needs to be fit for prosthesis will need to be fit for another when she’s seven, and again when she’s 12, and then every six months for awhile. She’ll need prosthetic services for the rest of her life.
“In the US that would cost at least $15,000 a person, but it can be done less expensively in Haiti and elsewhere. We wouldn’t have enough expertise here in the U.S. to ship to Haiti even if we wanted to. What we need to do is build training centers for prosthetic technicians so we can help kids but also employ Haitians.” Kerrey offered to chair a national committee to bring such expertise and resources to Haiti.
When we returned to the air field in Port au Prince to head back home, helicopters of all sizes were touching town and taking off as quickly as commuters getting their morning coffee at a McDonald’s drive through window. Relief workers from different organizations were shouting over the noise of the engines, introducing themselves, helping each other load or unload. Some who’d been since right after the quake were hitching flights that might somehow get them home from Haiti, like weary refugees looking for letters of transit to leave Humphrey Bogart’s Casablanca.
The longer we traveled through Haiti over the last couple of days, the more Timberland’s Jeff Swartz and I found ourselves feeling this paradox. Everything we saw reinforced how blessed we were in our comfortable lives and why we should never want for more.
But at the same time it was impossible to not keep adding to the list of people we wished we were or want to be when we grow up: the soldier from the U.S. Army’s 82nd Airborne who carried a woman in his own arms from the street into the general hospital because there was no stretcher and no time; the 35 year old doctor from Grand Rapids who left for Haiti a week ago on two hours notice and ran a hospital 10 miles outside of Port au Prince where he had nothing but farm tools to perform everything from amputations to delivering a baby; the mother of three who opened her home to us in the hills high above Port au Prince and had more than a dozen people she’d never met until that evening sleeping on her floors and in the bed she and her husband gave up. They are the kind of people who are not only making Haiti better, but us better too.
Heartbreak and heroes never seem to be too far from one another in this world. Each has their own way of seeming to appear out of nowhere. We saw both at every turn on this journey. Thank you for the commitment to what we do at Share Our Strength that enables us to support and sustain such heroes whether in Haiti or here at home.
Wednesday, January 27, 2010
Dear President Levy and Dr. Hurst,
As part of a multidisciplinary multihospital team, I had the honor and privilege to work alongside one of BIDMC's outstanding nursing professionals as part of the first wave of Partners in Health medical response to the earthquake relief in Haiti. As a trauma nurse, Judy was invaluable as she courageously worked under the most austere environment to provide care to the impoverished who suffered open fractures, compartment syndrome, and sepsis. Equipped with little more than a stethoscope, some drugs, and an indomitable spirit, Judy provided indefatigable care to countless patients in the postoperative recovery unit.
Her greatest gift to her patients was her compassion. One selfless act stands out among many. One of our patients had blood sugars that were so high that they were unmeasurable on the glucometer. There was no insulin available. Judy gave the patient her own insulin. With nursing professionals like Judy, it was a privilege to serve the people of Haiti.
Selwyn O. Rogers, Jr, MD, MPH
Then pillbox has an embedded cellular phone that can send reminders by phone call, text message, or email. It also has lights that blink and sound alerts that beep. You can program it to send reminders in any or all of these formats -- but not just to the patient. The reminders can also go to a trusted family member and/or the provider. These can be easily programmed on the company website. You load up a month's worth of medications, and on you go. Or, if you forget to load up the medicines, you can have an alert about that.
As an example, here's the simulated email it sent me:
This is an alert from MedMinder. You are receiving this alert because you are listed in the system as a patient or caregiver who should be notified of this event. The system reported the following event on 1/27/2010 12:17:45 PM (EST):
Reminder: The patient has not yet removed the Wednesday Noon medication cup.
Eran and his folks are in the midst of trials with physicians and patients with hypertension and also post-surgical patients who need protracted doses of medication. They are looking for other interested provider groups.
Meanwhile, a number of us in the provider community have submitted written testimony. In the absence of news coverage of those comments, I offer mine for your review and thoughts. As you will note, it is within the power of the state government to take steps right now that could help "bend the cost curve," but it has been unwilling to date to exercise that authority.
Mr. Kevin Beagan
Division of Insurance
One South Station
Boston, MA 02110
Dear Mr. Beagan:
On behalf of our physicians, nurses, volunteer Boards of Directors and Trustees, and the entire Beth Israel Deaconess Medical Center (BIDMC) community, I want to thank you for the opportunity to submit written comments to the Division. I understand that your goal is to examine the reasons for significant increases in small business health insurance premiums and to explore how we -- policy makers, hospitals, health insurers, physician practices, community health centers, employers, employees, consumers and others -- can work together to address these rising premiums.
I am grateful to the Division for posing this question directly. Our ability to address these issues will have profound implications for the Commonwealth’s job growth and economic future as well as the sustainability of providing universal access to health care coverage in Massachusetts.
We have been pleased over the last year to have worked with many stakeholders on key components of this effort, including our hospital colleagues in Massachusetts and throughout the country, the Massachusetts Special Commission on the Health Care Payment System, policy makers, Legislative leaders, and others.
I have four major sets of recommendations and observations to share with you, based on the eight years I have served as President and Chief Executive Officer of BIDMC:
Make Quality and Transparency Count. There is simply no substitute for transparency of data on the quality and safety of patient care. Thus far, this information is of limited use by consumers and purchasers, although that is likely to change over time. In the meantime, and perhaps more importantly, the value of transparency is as a management and process improvement tool. As I said in an article in Business Week in September of 2007:
There are often misconceptions as people talk about "transparency" in the health-care field. They say the main societal value is to provide information so patients can make decisions about which hospital to visit for a given diagnosis or treatment. As for hospitals, people believe the main strategic value of transparency is to create a competitive advantage vis-à-vis other hospitals in the same city or region. Both these impressions are misguided.
Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.
At BIDMC, we have been publishing quality information for several years. During this same period, we have steadily improved our performance. We know that we are saving hundreds of lives and millions of dollars in health care costs as a result of the quality and safety initiatives we have carried out. An indication of our institutional commitment to this direction is that the governing bodies of our hospital -- the Board of Directors and Board of Trustees -- took audacious votes last year to eliminate all preventable harm at BIDMC by 2012 and to be transparent about our progress and results. This information is published quarterly on our website at www.bidmc.org.
Improve Public Payer Reimbursement and Rationalize Payment for all Health Care Services. Levels of public reimbursement are a contributing factor to higher-than-necessary private insurance premiums. Medicaid, Medicare, and the Health Safety Net Trust Fund reimburse hospitals – on average -- at significantly below the cost of providing care. These payment inequities are particularly acute for services to some of our most vulnerable patients, such as for inpatient mental health care. Because of this, we are forced to identify alternative revenue sources to cover our operating costs. One such source is our reimbursement from private insurers. The overall reimbursement we receive from private health insurers ultimately subsidizes our losses from public payer contracts that fail to cover our costs. State budget reductions for academic medical centers over the last two fiscal years have had a sustained, significant negative impact on our fiscal health. But these two years have been different only in degree, not in direction. For years, public payer losses have also damaged our ability to keep up with the capital investments needed to maintain our facilities on an annual and long-term basis.
In addition, for many key services that are central to our non-profit mission, private health insurer reimbursement also fails to cover our costs. This means we are forced to invest in higher cost services that command higher reimbursements and cross-subsidize services for which we are drastically underpaid. The Division should work with health insurers and other stakeholders on strategies to improve public payer reimbursement, rationalize payment for health care services, and eliminate the need for cross-subsidization.
Correct Market Dysfunctions. We have to acknowledge that the manner in which reimbursement rates are established in this state is not related to the quality of medical service provided. Instead, market power seems to be the predominant factor in the rate-setting environment. Thus, we have the odd result that, for example, the reimbursement rate for the very same colonoscopy performed on exactly the same type of patient will vary by large percentages depending in which contracting network a doctor happens to be situated. I will tell you frankly that BIDMC and our physician contracting organization, BIDPO, is sometimes a beneficiary of this process. At other times, we are put at a competitive disadvantage. In both cases, this is a result counter to sound public policy.
There are two solutions to this problem. The first would be to return to a rate-setting environment, in which the Commonwealth would establish the reimbursement rates for each insurance company and each provider organization. I personally would not have a problem with such an approach, in that health care can viewed as a “utility-like” function, in which reliance on competitive forces is unlikely to produce economic efficiency and equity.
Short of rate-setting, I believe the Commonwealth should use its existing authority to make reimbursement contracts public. Allowing sunshine to reach the current reimbursement arrangements would provide moral and political pressure from subscribers, public officials, and the public on the insurance companies to equalize payments across provider groups. I believe this would result in rate-setting methodologies that are more tied to the quality of service provided.
Embrace Innovation in Health Care Delivery with Accountability to Consumers. At BIDMC, we recently teamed up with the state’s largest physician group practice, Atrius Health, to establish a new model for health care delivery in the Commonwealth. We are using shared electronic medical records to improve our efforts to provide the right care at the right time in the appropriate setting. We have also embarked on a robust agenda for quality improvement and cost-efficiency strategies. Our collaboration will be built around a strong emphasis on primary care, and a continuum of care from the ambulatory setting to the hospital and beyond. Among our strategies:
Putting primary care at the center of patient’s care;
Ensuring that physicians work together as a team with nurses, technicians and other allied health professionals;
Enhancing and further integrating electronic medical records;
Advancing health equity and ensuring a diverse, culturally competent interdisciplinary workforce;
Preventing and reducing medical errors and being transparent about results;
Improving the efficiency of health care delivery by continuous process improvement as exemplified by the LEAN methodology; and
Empowering patient involvement in the design of the health care delivery system through advisory councils, secret shoppers, patient satisfaction surveys, and other mechanisms.
We are confident that these innovative strategies – put into practice – will have a meaningful impact on quality, access and the cost of health care in Massachusetts.
I hope that the foregoing comments are helpful, and I would be glad to discuss these with you in the future.
Very truly yours,
Paul F. Levy
Our understanding is that Geisinger CEO Glenn Steele will be nominated as the next Administrator of the Centers for Medicare and Medicaid Services.
A colleague writes:
The President is planning on mentioning him in the State of the Union address and formally offer him to the Congress later this week or early next week.Glenn, who runs the Geisinger Health System, would certainly be very qualified for this post.
Click here if you cannot view the video.
Tuesday, January 26, 2010
Monday, January 25, 2010
Thank you everyone. We are all fine. No time to txt much.
Things here working. Coming off critical triage mode but masses of work to do. Essentially started putting people back together again. You can't imagine the emotion that creates. Morale soared yesterday as patients were coming out of OR fixed. Then 2 deaths during evening rounds, one massive PE and one medically sick baby. The reality of poverty and what's happened here hits you again.
Understand the USS Comfort is working. Had contact and heard evac helos flying. Hoping for first evac today for ICU (young woman has tetanus). Reinforcements here essentially enough to run hospital and teach local staff. Don't need more staff now after second PIH (Partners in Health) team from California arrived. Had major problem with arriving Docs etc in uncoordinated groups who want to work. Good will has to be organised.
Port au Prince still sounds very bad. Damage there terrible. Found cracks in tile in our OR Floor after aftershock and had to stop work 2 days ago. But checked by US structural engineers sent by PIH and all OK. Damage clearly old on reflection.
Have mesher but urgently need skin graft knife and blades. Electric dermatome best as no air power and will need lots of big grafts. Old hand knife will be difficult. Mark/Jeanette can you help? Thank you for tourniquet already saved life. Country will need thousands of vacs.
Coordination around the place is nightmare and have problem with patients. With infected open fractures that are not reconstructable, refusing surgery in case they need amputation. They are just frightened and know there is no limb fitting service. Heard of same problem all over. Families take them away for second opinion which will be the same. Next phase needs limb fitting/prosthetics please! James Toussiant joined us yesterday (our Haitian ortho resident). Gem of a guy solving many problems immediately, but the amputation problem is still real despite the communication. Hoping to do 20 cases today in 2 rooms but also have enough staff to do dressings under sedation on wards! Kindness in care as well.
First wave expecting to be done by Saturday. Will need different team ortho/plastic surgery, nursing PT and lots of admin. Community will need lots of trained nurses. Specifically need loads of Haitian/American nurses and doctors to bridge the gap. So fortunate to have had some.
Robin and Mary, thank you so much for all the work you have been doing at home. You can't imagine how much it means.
Sunday, January 24, 2010
Meanwhile, though, the patterns left in the dunes provide a beautiful display of the layers of glacial till, clay, and other materials that comprise them. More details follow below.
Friday, January 22, 2010
The question of how the dulcimer, or yangqin, arrived in China is a mystery. There are three theories noted in Wikipedia, which I excerpt here.
One theory is that the yangqin came into contact with the Chinese through the Silk Road. The Silk Route stretches almost 5,000 miles reaching from China to the Middle East, including Iran (Persia). The Iranian santur, a dulcimer, has existed since ancient times. If any dulcimer was to influence China by land, it is likely to be this instrument. It is somewhat smaller in size, is same in shape, and is also played using two wooden mallets.
Here's the second theory. During the 16th century, the Age of Exploration in Europe reached its climax, and soon trade was established between China and Europe. Portuguese trading in Chinese waters began in the 1500s. Music historians report that the salterio, a hammered dulcimer, was played in Portugal, Spain, and Italy during this period. Thus, it is possible that the yangqin originated when the Portuguese, the English or the Dutch brought a dulcimer player to China who performed for locals.
The final theory that some music scholars support is the theory that the yangqin was developed within China itself, devoid of all foreign influence. These historians state two possible explanations for the instruments native origin. One is that the yangqin is a development from an ancient string instrument called zhu. The other is that the yangqin originated from Yangzhou, China itself.
Click here if you cannot view the video.
Thursday, January 21, 2010
Our Team Names in no order.
Additional help from others who just arrived!
Grace Deveny RN MPH, international health program manager, MGH
Henry Salzarulo MD, anaesthesia, Seneca SC
Malcolm Smith MD, Ortho Trauma, Partners/MGH
Selwyn Rodgers MD, Gen/trauma surg, BWH
Denise Lauria RN, OR nurse, MGH
Nathaly Arredondo RN ERG, trauma nurse Lakeland Regional Medical Center, FL
Giliane Joseph MD, General internal medicine, Albert Einstein NY
Sachita Shah MD, ED doc Rhode Island Hospital, Providence RI
Kieth Antonangeli ST, MGHOR
Akshay Dalal MD, anaesthesia, MGH
George Dyer MD, Ortho Trauma, Partners/BWH& VA
Judy Wagoner RN., Trauma/surg nurse, BIDMC
Heather Bedlion RN, Cardiac step down, BWH.
Sergeline Lucien RN, Oncology nurse, BWH
Sarah Marsh Partners in Health, Women's Health
And expecting James Troussant Harvard, combined Ortho program, MGH resident (also Haitian) and others today.
Summary diary for today: Had a small disturbance this am when limited visitors at gate to reduce numbers of people in the hospital. As you may expect a lot of care of given by families. Settled when interpreter and I explained to crowd. Was really only shouting pushing and a few fists and was improving when I got there. Completely calm since, have asked DC for UN security to maintain safety but feel ok.
Argentinian UN military stopped for short visit then left promising to come back, did not. No more trouble. Lots of people but calm. Have been offered help from Congressman Capuano's office in DC. Sounds wonderful, hopefully can get supplies in to local soccer field by air. Expecting Akshay, our second anaesthetist tonight and James our own Hatian ortho resident with more MGH nurses to fly tomorrow Thank you Jeannette and everyone in Boston.
Medicine Sans Frontiers team visited today as did American coordinating nurse from somewhere nearby. Neither providing any help but supportive. It sounds the same elsewhere but many not getting it going as well. Working very well as a team ourselves, so impressed with these people. Have raided local warehouse for stores, found lots of unopened aid boxes, some gloves, drapes, etc but will need surgical supplies soon. Discovered the only blood tests we can do is a crit and cross match. No facilities to do electrolytes. Problem with rhabdo patients so watching urine colour and volume pushing fluid and diagnosing acidosis clinically. No iv bicarb so took advice and sent someone to buy baking soda to give orally not sure. Can someone ask our renal guys about renal protection in this situation?
Done 16 cases so far through 1 room in 3 days operating and 1 more to do tonight. Mainly massive soft tissue crush, including BK's AK's and hip disartic in basically MASH conditions all surgical patients improving. 3 deaths, 2 in ED mins after arrival and today a 24yr male with thigh buttock and leg compartment syndrome a week old. Died from rhabdo today just about the right time after injury. Have about 60 waiting most with wounds and open fx.
Had to operate for a short time with head lights when power cut this evening. Thank you Mary and LL Bean. Finally about to do our first laparotomy as have Selwyn* (BWH trauma surgeon) with us but being delayed by C section just happened, our anaesthetist helped baby looks fine. Life really just goes on.
*My note: I assume this is Dr. Selwyn Rogers at Brigham and Women's Hospital. Apologies if wrong.
Wednesday, January 20, 2010
Aftershock this morning at 6.1 just west of Port au Prince. Apparently minimal damage as all that could fall down went down with the big one.
BIDMC is ready to field a new team but we are still waiting for the specifics from the field. At present we have over 90 volunteers, most of whom have been oriented, inoculated, and if they go, provided with the needed supplies and gear.
David Callaway is at a hospital in Jimini, just over the border in the Dominican Republic. He is completing the needs assessment and formulating what our next response should be. He is working closely with the Dominican government who supports our project to work out of the border hospital. There is a short note from him this morning below and we are waiting for a more detailed communication later today. We think this may be the best and most likely place for us to engage.
No further call in the last 2 days for volunteers from Partners in Health although they have said they expect needing staff soon.
We are in contact with the D-mat teams out of Worcester, anticipate that they may soon need help, and they are aware of our support.
We are reaching out to the Israelis who we have heard may soon be needing more personnel to see if they would be interested in working with us.
We have partnered with Denver Health who has 60 volunteers and is willing to have us coordinate for them.
We have made contact with Caritas who reportedly is helping to staff the ship Hope and is tied in with the Order of Malta. They are aware of our resources and will reach out to us with any needs.
From: Callaway,David W. (BIDMC - Emergency Medicine) Limited access but have longer one to send. DR has disaster management needs. good ED medical needs as they just have rotating surgeons, no ED style system. we are trying to set one up. limited viz on haiti- i sent a team member yesterday and she is coming back today.
I did hear from Dan Nadworny last evening via texting.... Over all, he is doing ok - he said it is the most traumatic scene he has ever witnessed. He is set up in a soccer field, with his IMSURT team of MDs and RNs...working in medical tents - the field is protected by armed Marines as there are many people trying to steal antibiotics and pain medication from the tents. He said on average they are doing about 5 OR cases in his tent alone per day. He is hoping to connect with Dave Callaway there - I asked him for a more detailed update for communications, but this is all he could text. His signal is not good - so we are getting spotty messages from him. I told him all of us are thinking about him and praying for his safe return.
Following up on yesterday's data about practice variation with regard to endoscopies, here is another presentation from Blue Cross Blue Shield of MA regarding treatment of hypertension.
Here's the technical explanation, provided by a colleague at BCBS:
Two medicines -- ACE-inhibitors and Arbs (Angiotensin receptor blockers) are clinically interchangeable.* ACE-inhibitors cost substantially less than Arbs. The very high rate of Arb use (23% on average) is a good example of unexplained practice variation.
We see a wide spread in cost of treatment between the lowest quartile and the top quartile. A significant component of that, 30%, is accountable to the drug cost. And over 40% of the doctors have a use of Arbs that is above the network average.
And now look below at one particular 12-doctor primary care group, where the use of Arbs ranges from 13% to 55% and where three-quarters of the group are above the network average.
I recognize that the data don't tell us everything, but they suggest areas for inquiry. Let's beware, though, of demanding more and more analysis and data before reaching the conclusion that there is no underlying problem of practice variation.
In a comment below, I quote Paul Batalden from a seminar I attended months ago:
Measurement is a reductive act. We measure an aspect of a phenomenon. We often start with one or a few measures. A "natural" reaction is to want a more representative picture of the phenomenon -- hence a "breeder reactor" for measurement.
His point, I think, is that you have to start somewhere and see what you can learn, but if you think you are ever going to satisfy all of the data needs that definitively prove something, you will never reach that point of certainty.
*There is one minor caveat: A small percent of the population has a sensitivity to ACE-inhibitors, such that they develop an annoying (though benign) cough. Most docs suggest that could be about 10 to no-more-than 15% of a patient population. So Arb would need to be used on that small group.
Tuesday, January 19, 2010
From Cange, Central Plateau
We arrived at Cange, in the Central Plateau, the heart of operations for Partners In Health/Zamni Lasante, yesterday. As we expected, things are incredibly busy. People are still arriving from Port au Prince. Those who have been fortunate enough to survive their injuries this long are now running into complications of wound infections, some of which have turned septic, and venous blood clots (from immobility and trauma). Patients have completely filled the hospital and we have set up makeshift wards in a nearby church and school. We have surgical and non surgical personnel working tirelessly. We are doing lots of wound evaluation, injury stabilization, and post-op care. We are planning to get the more complicated surgery cases out to the MERCY ship when it arrives in Port au Prince, hopefully tomorrow. We are also assisting in provision of acute care issues for the other, non-trauma patients on the wards here.
Patients are dazed. The disruption to their families and lives is beyond description. Many of our injured patients are not mobile, have few resources, have no home to return to, and many have lost their entire families. We care for their wounds. We listen. We grieve with them.
And yet amidst this darkness, there are rays of hope. Today a one day old baby girl was brought in, after being born on the streets of Port-au-Prince with clubbed feet. Her mother suffered lower extremity fractures in the quake and couldn't really move, but labored successfully, lying adjacent to the rubble of her home. The parents were so worried about the child that the baby’s father made his way to Cange with the child because he knew he could find care here. The baby will be casted and staff here will be shown how to recast her as she grows.
The Haitian medical staff of Partners In Health/Zamni Lasante and survivors of the quake are working with unimaginable valor and dedication, as many of them have lost several or most members of their family. And yet they remain here, working tirelessly to provide care for others. They are the true heroes. Those of us fortunate enough to be here to contribute to the immediate relief efforts labor by their side with complete humility. We are in awe of their strength, compassion and dedication.
That there is some variation in practice patterns among physicians, even for comparable patient populations, is inevitable. That its range is so wide is not, as often noted by Brent James. To the extent variation is not based on scientific evidence, it presents an impediment to process improvement that could reduce overuse and underuse in the delivery of medical care, or the amount of harm caused to patients. Why? Without some standardization, it is impossible to have a baseline against which to collect evidence as to the effect of proposed process improvement measures.
With help from friends at Blue Cross Blue Shield of MA, I offer an example. The issue here is the percentage of times that physicians choose to endoscopically examine and conduct a biopsy on patients with GERD, gastroesophageal reflux disease, which often presents as heartburn.
The top chart shows how the average cost per episode varies among the four quartiles of all cases. Note a variation of almost 100% in costs between the bottom and top quartiles. As noted by BCBS, the procedure cost is the single most important source of variation.
The second chart shows the variation, doctor by doctor, for use of endoscopies with biopsies. The charts shows that 74 of the 331 gastroenterologists have a significantly higher than average use of this procedure.
The question that follows is whether this degree of variation is accounted for by the variation within the patient population. That is, if one were applying standards of evidence-based medicine, would the distribution look like this? Or, is the distribution skewed by habit and predisposition of doctors? Is it influenced by a fee-for-service payment regime that encourages more procedures than are necessary? Are some doctors more fearful of malpractice suits and engaging in defensive medicine?
I often hear doctors say, when they are presented with these kinds of data, that "my patients are different," and that the data don't prove anything. But that assertion usually has no quantitative support.
BCBS is providing a valuable service in sharing these data with the hospitals in Massachusetts. The BIDMC data indicate that our doctors, like all others, vary within and across practice groups in management of the conditions at hand. We are finding this to be a useful tool in evaluating our practice patterns, both within our own practices and in comparison to others. In the face of these kinds of numbers, it is important to ask the questions.
Monday, January 18, 2010
Thank you…thank you for all the support you showed to me and BIDMC community during Friday's prayer service for Haiti. I wanted to share some news with you.
I'm happy (overjoyed, elated, through the moon, jumping for joy and every emotion in between) to say that late Saturday night I was able to finally speak and locate my missing family members (two brothers, niece and nephew) who all said that they were doing well, considering the chaos that is happening around them. Both my parents are from Haiti and I have several family members who were directly effect by Tuesday's devastating quake. It's been an emotional roller coaster, the not knowing was torture, but the continued support that I received from colleagues and friends kept me sane and hopeful - I'm truly grateful.
I ask that you continue to keep the people of Haiti in your prayers, because we have a long road ahead of us. Again, thanks!
Sunday, January 17, 2010
From: Kelly,Sean P. (BIDMC - Medical Education)
Sent: Sunday, January 17, 2010 12:06 PM
To: Cherry,Robert (BIDMC Vice President - Support Services)
Cc: Pyne,William (BIDMC - Support Services); Wolfe,Richard E.
(Chief, BIDMC Emergency Medicine); Callaway,David W. (BIDMC -
Subject: Medical supplies for Haiti
I am one of the ER docs going to Haiti tomorrow am with Dave Callaway.
Can you give me a call on my cell at 617 ***-**** to talk about
supplies for us to take with us? Here is a preliminary list of items
and we can go through quantities in greater detail on phone. As you
know our major mission this time out is not deliver of goods or care
on a large scale but we would still like to bring highest impact
stuff that we can carry and load into a car or van.
Gloves 20 boxes mostly medium-sized some large and two small
Sterile gloves various sizes mostly 7.0, 7.5, 6.5 and 8 Gowns
Sterile drapes Betadine 4 bottles Scrubs 20 Some saline Alcohol
wipes (500 cc or 1000cc bags NS for iv fluid - a couple boxes) IV
tubing, setup, supplies ( enought for 100-200 setups?) Angiocaths
(sizes 16,18, 20, and 22) approx 250?
Dermabond (how many could we take of the smallest kind?) Wound care
supplies like sterile bandages Some wound closure materials like
sutures (4-0, 5-0, and 6-0 nylons and something absorbable)
Irrigation supplies (xirowet caps and bowls) Bandaids (bunch of
boxes) Other bandages like tegaderm and xeroform etc.
From: Cherry,Robert (BIDMC Vice President - Support Services)
Sent: Sunday, January 17, 2010 1:04 PM
To: Hopkins,John J. (BIDMC - Material Logistics)
Subject: FW: Medical supplies for Haiti
This is the list requested by Dr Kelly. Can you review this, and
send me the list of what you are sending [through PIH]. Of course, if we can add
these items that would be great, but we can not short the hospital.
Sunday, January 17, 2010 2:17 PM
The courier is here now. I am going to load the van with him and
then go to the east to load some more.
After that Dr Sean Kelly will be arriving here in his own car. I
will try and supply him with goods also. When he is gone I will
begin to put a list together of the inventory of items taken based
on handwritten list of item numbers I have here.
It will take a while to do this.
Sunday, January 17, 2010 3:12 PM
Thanks for doing this on a Sunday afternoon. I assume Dr. Kelly is
going to get goods for the others docs flying out tomorrow as well.
Let me know if you run into any complications.
Sunday, January 17, 2010 5:38 PM
Dr Kelly was here and I believe he was very pleased with the
supplies we got for him. We checked off nearly all of what he needed
and he couldn't carry anymore. We also filled the PIH van until
there was no more space, again with very relevant supplies of the
same kind. I will convert my handwritten list of item numbers
dontated to the Haitian project into a proper list of what we issued
today and will email it to you but I will leave that until tomorrow
afternoon as it will take quite a while in itself to do this.
Have a good weekend.
Sunday, Jan 17, 2010, at 6:18 PM
That is fantastic. i appreciate you taking care of this on your day
off. You should feel great about helping our docs and the people of
Haiti. Enjoy the rest of the weekend.
Sunday, January 17, 2010 9:08 PM
I agree. Thanks to all. You rose above and beyond the call of duty.
Thank you for giving us these life saving supplies.
John and Carl did a fantastic job of getting us what we needed on
short notice on a holiday weekend.
We will do our best to put this stuff to good use.
A friend writes: "Israel, a nation of 7.5 million people, has sent a team of 220 people that include medical personnel and will establish the largest field hospital in Haiti, treating up to 5000 people a day, an experienced search and rescue team and medical supplies. As in previous earthquake disasters, such as in Gujarat India in 2001 and in Turkey, in the bombings in Kenya, Israel has been one of the most generous givers of aid and assistance."
The major media outlets are quick to publish stories when Israel is accused of disproportionate use of force in other situations. Their failure to do so when it offers a disproportionate humanitarian response is disheartening.
Saturday, January 16, 2010
Here is our latest staff memo on the issue (with emails and phone numbers omitted or amended in the text to prevent web-based spamming from this blog post).
To: BIDMC Community
- 4 kiosks with international phone lines and computers/internet access reserved for Haitian emergency use only
- 2 additional computer kiosks
- 6 international telephone lines
- 4 computers
Pastoral Care, Social Work and Employee Relations – To reach these services, call the page operator to page the Administrative Clinical Supervisor: from inside BIDMC, dial 123 and select pager #*****, or from outside BIDMC dial (617) ***-**** and select pager #*****
Employee Assistance Program – 1-800-***-**** (available 24 hours a day)
Friday, January 15, 2010
[T]he White House on Thursday broke the last major logjam blocking enactment of far-reaching health-care legislation, cutting a deal with organized labor on how to tax high-cost insurance policies.
The agreement, forged in a marathon negotiating session that included White House officials and seven prominent labor leaders, would exempt union members from a proposed surtax on expensive insurance plans until 2018, five years after the legislation would take effect.
This is extraordinary. If passed, the bill would establish different rates of taxation for citizens depending on whether they are members of a union. I know that we have established classes of citizens based on income. But I do not know of any example in which tax rates are based on membership in a bargaining collective.
So, to my attorney readers out there, would this pass Constitutional muster if it were brought before the Supreme Court?
If you are looking for a simple summary or explanation for what goes on in Israel, you will be disappointed. Israel is a land of complexities.
This little country has a political system that is incomprehensible to Americans. Here, we vote for candidates, whether for the legislative or executive positions. There, they vote for a political party. No names of people appear on the ballot. Since no party wins a majority in the parliament, every government is a coalition. The prime minister’s job must be to hold the coalition together, or the government ends and a new election is held. In the USA, if a President loses the majority in Congress, he remains as President for the rest of the term and continues to decide on foreign policy and on the execution of the laws.
Israel remains surrounded by countries and political movements that refuse to acknowledge its right to exist and that are dedicated to destroying it. Because of the country’s small size and the location of its neighbors, there is essentially no geographic buffer zone to protect it. It responds to this situation by investing in a strong security force but also by initiating counter-terrorist operations. When it does so, it is criticized by many in the world community. That same world community remains essentially silent when other countries attack their neighbors or minorities within their borders.
Israel is criticized for holding on to territory seized after wars of aggression against it. Those territories help provide security. There is an expectation among many that it should be required to return that territory, although it is hard to think of other countries that have been held to this standard following wars of aggression against them -- much less those countries that have acquired territory as a result of their own aggression.
There are more journalists in Jerusalem than in any other city in the world, save three. Every aspect of Israeli society is laid bare for the world to see. In contrast, its neighbors strongly control the access of their countries to the media.
As David Brooks noted in the New York Times this week, Israel has an exceptional concentration of scientists, engineers, and other people who have created a vibrant economy. They thrive because of an entrepreneurial environment and freedom of expression. And yet, there are areas of poverty and hunger in parts of the country, social inequalities, and other such problems that face every democracy in the world.
The Holocaust during the Nazi regime is often given as the reason for establishing a Jewish homeland in the Middle East; but the Zionist movement existed well before that, and there were Jews who had returned to the area decades earlier. This is the ancestral home for this faith. The region, though, is also the homeland for others. This leads to the final contradiction:
The creation of a Palestinian state is an existential requirement for the future of Israel as a Jewish state. But, the creation of a Palestinian state which has a credo of denying Israel’s right to be a Jewish state is an existential threat to the future of Israel. Resolution of that contradiction is the job facing this country and the world community.
If I had any doubt about Israeli policy before our visit, it would relate to this fence. After all, it brings back memories of other fences and walls created for other purposes. For my generation, the Berlin Wall is the one most etched in our minds, and we associate it with a totalitarian regime.
But things are different in the Middle East. For several years, Israel found itself attacked by suicide bombers and others who were entering the country from the Palestinian areas. Their task was to kill civilians and to do so in a brutal and terrorizing fashion.
Here’s where you need to understand the real estate situation. Israel is roughly the size of New Jersey. East Jerusalem is literally across the street from Jerusalem. Other parts of the West Bank are closer than your daily commute to work. A terrorist, therefore, can easily walk or drive from one part of the country to another.
The Israeli government decided to construct a physical barrier to control and slow the passage of people from one area to the other. They closely screen people going through the gates between the two in an attempt to deter and catch possible terrorists. Clearly, this creates an inconvenience and, as you see, a visual and aesthetic barrier between sections of the city and sections of the country.
Lawsuits against the fence and against the particular location of many segments were brought to the Israeli Supreme Court. That there is an expectation of such a judicial review is a statement in itself about the legal rights of all people living in Israel and already distinguishes this structure from those like the Berlin Wall. The Court issued a decision allowing the structure, saying that the security needs of the population had to be weighed against the other concerns raised by the plaintiffs. However, the Court required the government to provide a substantive basis for the choice of the fence’s route. After reviewing many dozens of complaints, it found that only a few had to be configured to reflect local concerns.
On the overall merits of the issue: The fence has been successful in eliminating terrorist attacks against the Israelis where it has been in place. For those of us living elsewhere, it might remain an uncomfortable sight, but it is hard to argue with its success.
Thursday, January 14, 2010
As we we fly over and out of Jerusalem, you can clearly see the old city, with the Western Wall and the Temple Mount (minute 1:40). A monastery is visible just north of the city at minute 2:25, built into a narrow canyon.
A memorable moment is when you are flying several hundred feet above the river valley and the altimeter says sea level! There are lots of irrigated acres of crops (3:00).
The ruins you see at minute 3:15 of the video (and in the photo above) are Roman (including the amphitheater and cardo) near Beit She'an, built on the site of an even older Greek city called Scythopolis. Nearby are the mountains of Gilboa, made famous in the Bible during the reign of Saul.
As you approach the Sea of Galilee, you will see the city of Tiberias (3:30) on its coast. This is near the site of the story of Jesus feeding the multitudes.
If you cannot view the video, click here.
Just outside of the wall of the old city of Jerusalem is an area known as the City of David. This is thought to be the site of the early Jewish kingdom, from biblical times. But as is often the case, there are many layers. Here is a video of an area known as the Shiloach Pool. Two centuries ago, it was the site of a large mikvah, or ritual bath, from which people would traverse along a protected stairway to the Temple just up the hill. When the Temple was destroyed in 70AD, things went into disuse and were eventually buried underneath the following developments of the city.
Now, under the auspices of the City of David ("Ir David") Foundation, the old buildings are being uncovered. The video is the story of the newly discovered passageway. That's the stairway to the right, characterized by a double step separated by a flat section all the way up.
If you cannot view the video, click here.
After visiting the Israeli school just outside of Gaza, we met with Major General Yoav Galant. Depending on your perspective, he is either a hero or villain. Things are like that in the Middle East. Very view people do not have a strong opinion. (Full disclosure: I put him in the first category.)
General Galant is in charge of the Israeli Southern Command and was responsible for coordinating Operation Cast Lead in Gaza in mid-2009. This series of attacks was carried out in response to over 8000 rockets from Gaza being launched on Israeli civilian areas over four-year period.
I recognize that people will disagree over the merits of Israeli and Palestinian political and negotiating positions, but I think most people would agree that it is the responsibility of a nation to protect its citizens from these kinds of attacks. The difficulty in this situation is that rockets are launched and war materiel is stored in an urban setting. Indeed, the military installations in Gaza are often in the very same buildings as residential, education, or health care institutions.
Much has been written on this operation, pro and con, with lots of descriptions. General Galant made a very persuasive case that it was carried out in a way to minimize harm to noncombatants. He also made the case that the invasion was necessary to disrupt and disarm the Palestinians, who were accumulating rockets with longer fly ranges, which would be able to get beyond the rural villages and reach larger population centers.
Since the operation, the number of rockets being launched towards Israeli communities has been reduced by 95%. "The area is quiet," reports the General.