May 13, 2006
Communication Found Lacking in OR
The Times published an interesting piece this week about an article that recently appeared in the Annals of Surgery and the Journal of The American College of Surgeons. Here's the gist of it:
The researchers surveyed more than 2,100 surgeons, anesthesiologists and nurses about operating room communications. Their views — and the divergence among them — may shed light on how some surgical mistakes happen.
When the participants were asked to "describe the quality of communication and collaboration you have experienced" with other members of operating teams, surgeons were given the lowest rating for teamwork. Their worst assessment was from nurses, the group that got the highest rating. . . .
Many operating room mistakes, like sponges left in patients or the wrong body part being operated on, could be avoided through better communication, the researchers said. But this can mean getting over barriers of class, race, gender and even general outlook.
Afterward, the researchers spoke with participants and found that "nurses often describe good collaboration as having their input respected, and physicians often describe good collaboration as having nurses who anticipate their needs and follow instructions."
May 12, 2006
Allocating Scarce Resources: Avian Flu Vaccine
The avian flu virus hasn't yet managed to mutate into a form that can be efficiently transmitted from person to person, and we don't yet have a vaccine (since we don't know the precise form of virus we will be dealing with), but the experts all say that preparedness is the key to survival, and that includes getting straight on the ethical dimensions of preparedness. So along come Ezekial Emanuel and his co-author, Alan Wertheimer -- both of the Department of Clinical Bioethics, The Clinical Center (NIH) -- with a provocative suggestion for allocating inevitably scarce vaccine:
Science 12 May 2006: Vol. 312. no. 5775, pp. 854 - 855
Policy Forum, PUBLIC HEALTH: Who Should Get Influenza Vaccine When Not All Can?
The potential threat of pandemic influenza is staggering: 1.9 million deaths, 90 million people sick, and nearly 10 million people hospitalized, with almost 1.5 million requiring intensive-care units (ICUs) in the United States. The National Vaccine Advisory Committee (NVAC) and the Advisory Committee on Immunization Policy (ACIP) have jointly recommended a prioritization scheme that places vaccine workers, health-care providers, and the ill elderly at the top, and healthy people aged 2 to 64 at the very bottom, even under embalmers. The primary goal informing the recommendation was to "decrease health impacts including severe morbidity and death"; a secondary goal was minimizing societal and economic impacts. As the NVAC and ACIP acknowledge, such important policy decisions require broad national discussion. In this spirit, we believe an alternative ethical framework should be considered.
The alternative ethical framework: After front-line healthcare workers and vaccine production and distribution workers, preference goes generally to younger people over older, with a slight additional preference for key government leaders; public health, military, police, and fire workers; utility and transportation workers; telecommunications and IT workers; and funeral directors. Their rationale is complex and subtle and well worth reading. For those without access to Science, the Chicago Sun-Times has a pretty good article on this, as does Ceci Connelly at the Washington Post. [tm]
May 11, 2006
Harvard Study: 40% of Med Mal Claims Baseless
As reported by AP/Yahoo, the New England Journal of Medicine today published an article by researchers at the Harvard Public Health School that concludes that 40% of med mal cases are meritless: either there was no injury or there was no evidence of negligence. Here's the abstract:
Background In the current debate over tort reform, critics of the medical malpractice system charge that frivolous litigation — claims that lack evidence of injury, substandard care, or both — is common and costly.
Methods Trained physicians reviewed a random sample of 1452 closed malpractice claims from five liability insurers to determine whether a medical injury had occurred and, if so, whether it was due to medical error. We analyzed the prevalence, characteristics, litigation outcomes, and costs of claims that lacked evidence of error.
Results For 3 percent of the claims, there were no verifiable medical injuries, and 37 percent did not involve errors. Most of the claims that were not associated with errors (370 of 515 [72 percent]) or injuries (31 of 37 [84 percent]) did not result in compensation; most that involved injuries due to error did (653 of 889 [73 percent]). Payment of claims not involving errors occurred less frequently than did the converse form of inaccuracy — nonpayment of claims associated with errors. When claims not involving errors were compensated, payments were significantly lower on average than were payments for claims involving errors ($313,205 vs. $521,560, P=0.004). Overall, claims not involving errors accounted for 13 to 16 percent of the system's total monetary costs. For every dollar spent on compensation, 54 cents went to administrative expenses (including those involving lawyers, experts, and courts). Claims involving errors accounted for 78 percent of total administrative costs.
Conclusions Claims that lack evidence of error are not uncommon, but most are denied compensation. The vast majority of expenditures go toward litigation over errors and payment of them. The overhead costs of malpractice litigation are exorbitant.
How do these data fit into the larger debate about whether there is a malpractice crisis, or whether federal tort reform is needed to stem the tide of frivolous lawsuits that are bleeding the system dry? The answer depends on which side of the fence you're on. Here (from the AP story) are some reactions:
- "[T]he American Medical Association, which favors caps on malpractice awards, called the study proof that a substantial number of meritless claims continue to slip through the cracks, 'clogging the courts' and forcing doctors to waste time defending them, association board member Dr. Cecil Wilson said in a statement."
- "Chris Mather, a spokeswoman for the Association of Trial Lawyers for America, said the study was biased because data was taken from insurers, which sometimes are the defendants in malpractice suits."
- "George Annas, a Boston University bioethicist who had no role in the study, said he was not surprised by the findings. Many personal injury attorneys receive a contingency fee — meaning they get paid only if they win — and will not go to court with a baseless lawsuit, Annas said. 'There's really no motivation to bring a frivolous lawsuit,' he said. 'It's not worth their time and effort.'"
Forty percent sounds like a ridiculously high percentage of meritless cases, now matter what Prof. Annas says. And although the system seems to be doing a pretty good job of weeding these bad cases out without payment, the cost of defending the suits to the point of dismissal or defendant's judgment needs to be reckoned (which the article does), as well as the emotional cost to the individual defendants. Worth reading . . . [tm]
May 9, 2006
Off-Label Prescription Practices
The Archives of Internal Medicine has an interesting study of off-label prescribing practices (abstract) this week, and Monday's "All Things Considered" on NPR had a good story on the study. [tm]
May 8, 2006
CDC to Recommend Routine HIV Testing
According to news reports (AP/MyWay), the CDC is poised to recommend that HIV testing be automatically included in standard blood workups for all patient between the ages of 13 and 64 years. The Center's recommendations include eliminating pre-test counseling and offering post-test counseling only in the event the patient tests positive. [tm]
May 7, 2006
Projected Date of Medicare Trust Fund's Insolvency Moved Up
The Medicare Hospital Insurance Trust Fund will become insolvent in 2018, based on current cost and population trends, two years earlier than predicted last year, according to the Social Security and Medicare trustees annual report. Inside the Beltway, the response to this news seems to split along (gasp!) party lines, with Republicans calling for cuts in benefits and Democratic party leaders speculating whether the report is a GOP scare tactic designed to drum up support for the President's going-nowhere-fast program to reform Social Security. Joseph Antos at the American Enterprise Institute has a very helpful analysis of the concept of "insolvency" as it applies to the two Medicare trust funds, in the course of which he basically says we should ignore the trustee's estimate of the year the Medicare HI Trust Fund won't be able to meet its obligations.