Author: Laura Landro

A program at the University of California San Diego known as PACE –- for Physician Assessment and Clinical Education — is being used by a growing number of hospitals and state medical boards to assess the competency of troubled doctors, according to an article in today’s WSJ special report on Innovations in Health Care.

The program is one of the few to tackle a thorny problem in health care: how to ensure that doctors remain competent to practice once they have their medical license. The Federation of State Medical Boards, which co-administers the basic licensing test for physicians, has been weighing the issue for years.

In 2003, the group convened a special committee on MOL –- for “Maintenance of Licensure” — to study the role of state medical boards in developing processes to evaluate whether a physician has maintained the “competence and qualifications necessary for licensure on an ongoing basis,” according to a spokesman for the federation. In 2008, it adopted five principles to help guide future policy, and then launched another effort to analyze the idea further. A report summarizing those findings is due to be presented for discussion next week at the board’s annual meeting.

But skeptics say there are a number of barriers, not least of which is financing and questions about whether boards have authority to start such programs or need legislation to do so. William Norcross, who runs the PACE program at UCSD, tells the Health Blog that each state would have to create educational programs for doctors or subcontract with another group to handle the job, and then monitor the programs for quality and ensure that doctors participate.

“This would throw a large new burden on the state medical board at a time when state medical boards are already overwhelmed with work,” Dr. Norcross says. However, he adds, maintenance of licensure programs are “the right thing to do.”

Some experts believe a more likely way to improve doctor quality sooner is a program from the American Board of Medical Specialties to re-certify doctors in 24 specialties. While state medical boards confer medical licenses that allow a doctor to practice, board certification is considered the gold standard to assure that doctors have top skills and qualifications in their specialty.

Studies show that board-certified physicians provide improved quality of patient care and better clinical outcomes than those physicians without board certification. Instead of being certified once in a lifetime or once every six to 10 years, physicians would voluntarily commit to being evaluated in six areas of competency on a more regular basis; the medical boards are each working on programs for their specific specialty.

Lucian Leape, a Harvard university professor and patient safety expert, says the certification program could force hospitals “to be more rigorous in evaluating doctors regularly, and doing something about the deficiencies they find.” He adds: “I am not at all optimistic that the state licensing boards will do it.”

Image: iStockphoto

A number of groups are offering financial aid to cancer patients who can’t cover the costs of treatment, including many who have inadequate health insurance, as I write in the Informed Patient column today.

An estimated 25 million patients are considered underinsured in the U.S — meaning that they have health policies that don’t cover all of their medical needs and leave them struggling with high out-of-pocket cots. And many of their health policies include high deductibles, which can send patients scrambling for aid in the early part of the year before the deductible is met.

Julie Reynes, president of the Patient Access Network, which provides help to patients who can’t meet co-payments for their medications, tells the Health Blog that the group had a “deluge” of requests for help in January and February, but didn’t have adequate funds to help everyone.

The non-profit is one of five major groups that provide such assistance, along with several other disease-specific groups that help patients with cancer co-payments such as the Leukemia and Lymphoma Society. Unless the patient has already incurred the expense, the payments usually go directly to providers, physicians or suppliers of the medications.

A large portion of the funding for co-payment programs is provided by pharmaceutical makers, but as donors, the companies have no say over how the funds are used or which products are used by patients. However, any donations can be directed to a specific disease fund.

Patients can visit the group’s Web site to see which disease funds have monies available. For example, for pancreatic cancer patients, applications for new and renewal patients are being accepted, and grants of as much as $7,500 are allocated immediately. But there’s no funding available at present for colorectal cancer in the program.

Patients who meet eligibility criteria can still be approved and placed on a waiting list and receive assistance once funding becomes available. But Ms. Reynes says one reason for posting the status of the funds is to discourage patients from wasting their time when there isn’t any money to help.

The Patient Access Network Web site also provides links to other groups that provide co-payment help, including the Healthwell Foundation and Patient Services Inc.

Photo: iStockphoto

Despite mounting evidence of the health risks in unpasteurized milk, raw milk advocates continue to tout its alleged benefits, dismissing warnings about bacterial contaminants that can sicken or even kill adults and children, as I write in the Informed Patient column today.

The situation bedevils public-health officials and food-safety experts. “We know raw milk is hazardous, but we don’t know what it is that drives people to consume it anyway,” says Jeffrey LeJeune, a microbiologist and researcher at the Food Animal Health Research Program at Ohio State University. Dr. LeJeune is conducting a study with funding from the USDA to learn more about how consumers make judgments about milk safety.

“There are tacit webs of belief that drive behavior, and everyone acts in what they believe to be a rational way,” Dr. LeJeune says. “We need to learn more about where they seek information, and how they decide to reject or accept it.”

One problem, he says, is that physicians often have gaps in their knowledge and therefore don’t warn patients about the risks. Farmers who sell raw milk also may not be aware of the scientific data about risks. And for consumers who decide to research the issue online, typing “raw milk” into Google returns mostly links to sites run by raw milk advocates.

Such sites attempt to debunk scientific evidence presented by the CDC and the FDA, offering up reams of data allegedly showing the benefits of raw milk. Some raw milk advocates also claim that pasteurization is harmful and destroys milk’s vitamins and minerals (false, according to Dr. LeJeune, the CDC and FDA) and that raw milk contains natural enzymes that kill bacteria on their own (also false, according to the experts).

In a 2009 paper in the journal Clinical Infectious Diseases on the continued public-health threat of unpasteurized milk, Dr. LeJeune noted that dangerous bacteria can be carried by healthy animals, so a nice local farm with well cared-for animals doesn’t guarantee safety. And even in the cleanest dairy environment, where milk is properly chilled after harvesting, the risk of contamination from bacteria can’t be fully eliminated.

So why do people drink raw milk? Christine Chessen, a San Francisco mother of three who has become an activist in efforts to loosen regulations on raw milk in California, says after she and her children began drinking raw milk, they got through the winter without colds or flu.

“If I hadn’t seen such a difference in my own family I wouldn’t have believed it,” says Ms. Chessen. In states where raw milk sales are illegal, the FDA ban on interstate shipments of raw milk “is forcing moms like me to get their milk on the black market or go across state lines in middle of night,” she says.

But Dr. LeJeune tells the Health Blog that mothers may be less inclined to feed raw milk to their kids if they could see the damage the more serious bacterial infections from E. coli 0157 or campylobacter can cause. “It can shut down the kidneys and even kill a three-year-old,” he says. And for survivors, ” there can be really severe consequences for the long term.”

Image: iStockphoto

iVillage, one of the largest Web sites for women, is hoping to capitalize on a female penchant for seeking help online for health concerns or questions — especially those they are too embarrassed to discuss with anyone else.

iVillage launched a new health portal today, as part of a redesign of its site started last fall. General Electric has agreed to sponsor the launch as part of its Healthymagination initiative, a six-year, $3 billion program that has as one of its goals to get more health information in consumer’s hands. (GE has agreed to sell a controlling stake in iVillage parent NBC/Universal to Comcast.)

Nearly half of 1,342 women who responded to a recent Harris Interactive poll conducted for iVillage said they’d go online first to research a health question, close to double the number that said they’d go to the doctor first. Anonymous peer networking and sharing common experiences is what drives women online for health matters, the poll found, with four out of give women saying there are reasons to feel uncomfortable when discussing health concerns or questions with friends or family members.

There are scads of online health sites out there already, but iVillage is hoping its existing popularity will give it the new portal an edge with women, Executive Vice President Jodi Kahn tells the Health Blog. With about 30 million unique visitors per month, iVillage has hundreds of health-themed community message boards on topics ranging from weight loss to kids’ nutrition to breast cancer to birth control.

The site will add new content from the Cleveland Clinic and health news provider Healthwise, and offer new bells and whistles such as a dozen digital tools. Among them: “The Care Circle,” which creates customized health profiles, interactive personalized health assessments, a drug lookup, a symptom checker, an alternative treatment finder and fitness and calorie trackers.

Health-care organizations are dealing with the thorny issue of how to handle doctors, nurses and other professionals who make mistakes that harm patients, as I write the Informed Patient column today.

But getting to the bottom of medical errors can be a challenge, since hospitals often keep the details under wraps, and malpractice settlements may put gag orders on all involved.

The latest issue of the Joint Commission Journal on Quality and Patient Safety provides a rare look at the anatomy of one of the most devastating medical errors of the last decade: the death in 2006 of a pregnant teen, Jasmine Gant. She died at St. Mary’s Hospital in Wisconsin, after nurse Julie Thao, intending to administer penicillin, instead hooked up a look-alike bag of anesthetic –- meant to be delivered later by epidural route only –- through Ms. Gant’s IV. The nurse was later dismissed and charged with negligence by the state.

The issue also contains three editorial looking at the broader issue of how medical personnel who make mistakes are treated, including pieces by Harvard University health-policy professor Lucian Leape, systems expert Sydney Dekker and Charles Denham, who co-chairs a National Quality Forum committee on safe practices in care.

St. Mary’s, which settled a malpractice case brought by the family for a reported $1.9 million, invited the nonprofit Institute for Safe Medication Practices to conduct an independent “root cause analyses” –- a process to identify the factors leading to the error. The paper is worth reading for its insights into the case, but Judy Smetzer, a nurse and vice president of ISMP who led the study, tells the Health Blog the aim in identifying the factors on all sides leading to the error was also to provide lessons that could be used by other providers.

After outlining both safety violations made by the nurse and flaws in the hospital system that contributed to the mishap, for example, the report provides a number of general recommendations that could be used in any hospital where medication mistakes are a danger because of look-alike packaging or a chaotic environment.

For example, hospitals should use different shaped or sized containers to differentiate IV medications from epidurals, or provide epidurals only in syringe form, to be administered by syringe pump. Another strategy: apply big warning stickers on both sides of an epidural bag and over the access port used to spike the bag.

And to avoid confusion and distraction medications should be prepared in a quiet zone, not at the bedside, explaining the importance as a safety move to patients and family.

Image: iStockphoto

A nationwide push is underway to lower radiation exposure from CT scans, amid growing concern about the risks of cancer linked to the high-powered imaging technology, as I write in the Informed Patient column today.

While much of the focus is on adult CT scanning, between 5% and 10% of the approximately 70 million CT scans performed each year are administered to children, who are at higher risk because of their smaller size and the longer life expectancy. The Society for Pediatric Radiology is sponsoring an “Image Gently” campaign to promote use of the smallest amount of radiation possible during an imaging study. The group also is urging radiologists to take other precautions, including covering areas of the such as reproductive organs, and to consider alternative tests such as ultrasound.

Take head injuries. The CDC estimates that 435,000 children under 14 visit emergency rooms every year to be evaluated for traumatic brain injury, but not all head trauma results in a TBI –- the severity of a brain injury may range from mild, causing brief change in mental status or consciousness, to severe, causing permanent symptoms and irreversible damage.

Emergency department physicians at the University of California Davis Children’s Hospital recently developed guidelines for doctors, based on a study that found a substantial percentage of children who get CT scans after apparently minor head trauma don’t need them, and as a result are put at increased risk of cancer due to radiation exposure.

The study, published last fall in the Lancet, evaluated records of more than 42,000 children from 25 medical centers using data from the Pediatric Emergency Care Applied Research Network and found that one in five over the age of 2 and nearly one quarter of those under 2 who received CT scans following head trauma didn’t need them because they were at very low risk of developing serious brain injury compared with the cancer risks of the radiation dose.

Study lead author Nathan Kupperman, chairman of emergency medicine and a professor of pediatrics at UC Davis, tells the Health Blog that guidelines can help identify children who wouldn’t need a CT Scan, including kids who show normal mental status, with no palpable scalp swelling or skull fracture, and are showing normal behavior according to a parent. To validate the rules, the researchers applied them to data from a second group of 8,600 children; in more than 99.9% of cases they accurately predicted kids who weren’t diagnosed with serious brain injuries.

Dr. Kupperman says that for children whose risks are determined to be low or intermediate, he would engage parents in the decision-making process and explain the risks of radiation. The hard part, he says, is getting doctors to use evidence-based prediction rules in making the call on a CT scan.

Photo: Bloomberg News

Sepsis and pneumonia, two infections that can often be prevented with tight infection control practices in hospitals, killed 48,000 patients and added $8.1 billion to heath care costs in 2006 alone, according to a study published today in the Archives of Internal Medicine.

Researchers analyzed 69 million discharge records from hospitals in 40 states between 1998 and 2006; the length of stay and mortality rates for the infections didn’t change substantially over time, the study found, and high infection rates persist.

The news, principal investigator Ramanan Laxminarayan tells the Health Blog, is that the study for the first time links about half of all infection deaths directly to infections acquired in the hospital in the course of care.

While the Centers for Disease Control and Prevention estimates there are 1.7 million hospital infections and 99,000 associated deaths each year, he says, those numbers don’t calculate deaths caused by, rather than merely associated with infections patients get in the hospital. The CDC figures also are based on voluntary reports by hospitals, whereas the new study is based on data about patient diagnosis, hospital treatment and exposure to infections prior to hospital admission.

While in many cases sepsis and pneumonia could have been avoided with better infection control in hospitals, Laxminarayan says, one issue is getting the financing to set up infection control programs. “Even when physicians are gung-ho to do something about infection control, they may not have buy-in from hospital administrators,” he says. “They may still ask why do you need $500,000 if it isn’t going to do anything for the bottom line?”

While Medicare has announced its decision to cease paying hospitals for some of the care made necessary by “preventable complications” such as infections, penalties may not be enough to incentivize better infection control if hospitals knowingly misclassify infections to avoid penalties, or if problems documenting the infections prevent adequate enforcement, the study notes.

The study was funded by the Robert Wood Johnson Foundation as part of Extending the Cure, a project examining antibiotic resistance. The project is based at the Washington think-tank Resources for the Future, where Laxminarayan is a senior fellow.

Accompanying the study is an editorial co-authored by Johns Hopkins Hospital safety guru Peter Pronovost, creator of one of the checklists used by hospitals to prevent infections. While he says the estimates in the study may have some “systematic errors” in calculating costs and mortality, “they suggest a substantial opportunity to reduce patient harm.”

Photo: iStockphoto

With new food-safety legislation making its way through Congress, safety advocates are hoping the FDA will soon have sweeping new powers to protect the nation’s food supply, as I write in the Informed Patient column today.

But in the debate over how to make food safer, it can be tough for consumers to figure out what’s safe to eat. Take a study released earlier this month by Consumers Union, which analyzed 208 samples of bagged, pre-washed salad, and reported finding “indicator organisms” –- bacteria found in the digestive tracts of humans, animals and the environment. The study authors say those bacteria indicate the potential for the presence of more dangerous bacteria, but none of the dangerous bacteria were found in the salad packages tested.

A spokeswoman for the Produce Marketing Association, which represents the fresh fruit and vegetable industry, says the study found no evidence of public health risk. And while cautious consumers might decide to re-wash the bagged salad to be on the safe side, she recommends against it: a scientific panel that studied the issue in 2007 warned that re-washing ready-to-eat, packaged leafy greens introduces a risk of cross-contamination of other surfaces in the unlikley event that harmful bacteria is present.

Likewise, a number of dairy producers and consumers are strongly advocating consumption of raw milk, on the grounds that it is more nutritious, better tasting and no more harmful than pasteurized milk, which is heated to kill bacteria. But its sale is illegal in many states, and the FDA warns that raw milk can harbor dangerous microorganisms that can pose serious health risks, such as E. coli and listeria.

The Health Blog asked food-safety specialist Sam Beattie at Iowa University about both issues. While he says bagged salad should be considered safe to eat because of steps taken by processors to test for pathogens, he suggests using products furthest from the expiration date on the package and avoiding bags whose contents look wet or wilted.

When it comes to raw milk, however, he recommends against it. “I can’t think of a more unsafe food,” he says. His advice: steer clear of unpasteurized dairy products in general.

Image: iStockphoto

New risk calculators from the American College of Surgeons aim to help evaluate individual patients’ risks of complications and death from surgical procedures, as I write in my column today.

But access to the calculators, which will cover 20 different types of surgery eventually, is limited to about 250 hospitals in the American College of Surgeon’s National Surgical Quality Improvement Program, known as NSQUIP. Adapted from a program used to monitor and improve surgical quality in Veterans Health Administration hospitals, the program was launched in the non-VA hospitals in 2005, and has had marked success in reducing mortality rates and complication rates, according to a September 2009 study in the Annals of Surgery.

So why aren’t more hospitals using it?

Clifford Ko, a colorectal surgeon at the University of California, Los Angeles, and director of research and optimal patient care for the American College of Surgeons, tells the Health Blog that NSQUIP was initially designed for large community hospitals and academic medical centers — and its $35,000 annual fee to participate is a barrier for some institutions. The college is working on a pilot to offer lower-cost participation to smaller and rural hospitals which perform fewer types of surgeries and don’t need to collect as much data, “but still want to participate and evaluate their own quality.”

The American College of Surgeons is also partnering with the Florida Hospital Association to launch a modified version of NSQIP to focus on just four quality measures: surgical site infection, urinary tract infection, colorectal outcomes and elderly surgery outcomes.

NSQUIP gathers data on 140 different factors ranging from pre-operative risks to 30-day surgical outcomes, and uses 40 different quality measures. Dr. Ko says that unlike some quality improvement programs that use data from billing claims, NSQUIP measures outcomes, and thus can provide a more reliable picture of success rates, complications and mortality .

One draw is that hospitals can use data from the quality improvement program to compare their performance against a national benchmark, and tell patients, for example, whether their complication rates are lower than the national average. Henry Pitt, a surgeon who is chief quality officer of Indiana University Hospital in Indianapolis, says participation in NSQUIP helped his hospital identify and tackle a problem with infections in surgeries to remove all or part of the pancreas and other digestive organs for patients with pancreatic cancer and tumors.

By focusing on preventive measures such as the use of antibiotics and monitoring patient wounds, the hospital has reduced infection rates steadily, Dr. Pitt says. He uses the risk calculator to help patients understand the potential complications of long and arduous pancreatic surgical procedures, which carry special risks for surgical site infections—but he is also able to reassure them that his hospital infection rates are now below national averages for the procedures.

Photo: iStockphoto

With growing concern about the risk of disease transmission through donated organs and tissues, federal health experts have delivered up a sobering picture of wide gaps in patient safety, as I write in my Informed Patient column today.

Their 100-page report, “Biovigilance in the United States: Efforts to Bridge a Critical Gap in Patient Safety and Donor Health, ” ordered up by the federal Dept. of Health and Human Services’ advisory committee on blood safety and availability, was quietly made public last month on the group’s Web site. The findings were hashed over at a recent two-day meeting where transplant experts and federal safety experts went over the challenges the U.S. faces in coordinating the patchwork of regulations and voluntary programs that govern blood, organ and tissue transplants. Transcripts of that meeting also were posted late last week.

With most of the focus in Washington on health care reform these days, it hasn’t been easy to get attention for patient safety issues – but for anyone concerned about safety risks, particularly in organ transplants, both the report and the transcripts are worth plowing through. The report recommends the creation of a national biovigilance network to centralize blood, organ and tissue safety monitoring, including a system to detect infections in donors, track their organs and tissues, and prevent the transmission of additional infections.

At the meeting, where medical experts discussed balancing the availability of organs with the need to screen out diseased organs and tissues and inform patients of risks, the committee also heard pleas for better screening and testing procedures from the wives of two men who died after receiving a transplants.

Shirin Platt’s husband Peter contracted a parasite through a donated kidney; Pam Alesescu’s husband Ken contracted a fungal infection that may have been transmitted by a donated aortic valve, and later died. Alesescu told the committee she realizes it is “probably next to impossible to treat and evaluate human-derived resources for every type of fungal, bacterial, or viral contamination and that doing so can become cumbersome and costly.” But, she added, “We owe it to donors’ families and to the patients who receive these precious gifts” to make sure that patient safety “is always in the forefront.”