Monday, May 23, 2011

Engineering Our Way to Clinical Perfection?

Put breathing tube 'A' into patient 'B'
The Disease Management Care Blog recently had the pleasure of listening to a presentation on reducing medical errors.  The speaker was dually expert in medicine (a superbly trained surgeon) and engineering (NASA).  We also had a chance to chat over lunch.  But for a "systems" approach to patient flows in emergency rooms and operating suites, he said, hospitals would be safer, better and cost-effective havens of evolving clinical perfection.

Which is why the skeptical DMCB was interested in the Health Affairs article on "How Intermountain Trimmed Health Care Costs Through Robust Quality Improvement Efforts."  Adding to the luster of "integrated delivery systems," the narrative describes how a dedicated expert team stomped out unwarranted, costly and pernicious variation in prostate, gallbladder, hip, open heart and pacemaker surgeries as well as the care of acute respiratory distress syndrome (ARDS) and "community acquired pneumonia."

After creating the requisite data systems, Intermountain discovered that, while the patients were similar, the physicians' approaches to them were not.  Despite that insight about the providers, the team was unable to discern any statistically significant outliers.  That led them to blessedly leave the individual docs alone and focus on over 1400 clinical, support, patient satisfaction and administrative "processes."  This, in turn, prompted the creation of modified guidelines and care protocols that supported higher quality and lower costs. It worked.  The authors argue this fits hand-in-glove with the Affordable Care Act, puts the docs in charge (in lieu of 'distant health insurance companies') and aligns economic incentives.

The DMCB also learned:
  • Intermountain's earliest data systems missed 35-50% of the data necessary to track the care processes described above.
  • While there are 1400 work clinical work process, 104 account for 95% of the care delivery at the bedside. Sixty are now being captured, studied and managed.
  • One guideline (the one or ARDS) required over a hundred changes to better adapt it to what was going on at the bedside.
  • It was one thing to achieve change in single clinical settings, but something else entirely to generalize them through a system made up of 23 hospitals and 160 clinics
There are no descriptions of how how Intermountain did the calculations, but they claim hip surgery costs decreased from $12,000 to $8000.  That plus other cost savings added up to $30 million, which was enough to "bend the cost curve."

Key lessons for the DMCB? 
  • The authors contrast Intermountain's systems approach with the ham fisted and statistically inept "spot the bad apples" and name-blame-and-shame-the-providers approach favored by many payors, including parts of Medicare.  The point of safety systems in planes is to make it hard for otherwise good pilots to make an error, and the same should be true in today's enlightened hospitals.
  • Nationally published "clinical guidelines" were found wanting and had to be further modified.  What's more, they had to be modified by the front line physicians.  While this could be criticized as changing the position of the goalposts, this really suggests that much of "evidence-based medicine" still may not be ready for prime-time in the trenches of patient care.  It also confirms that unless the docs are involved, it won't happen.
  • If organizing the inpatient care of rather "standard" surgical and medical conditions in hospitals is stressing information systems with dozens of "work processes" - many of which still defy measurement - think of the hubris it takes to believe that this is possible among free-range outpatients with complicated conditions like diabetes mellitus with multiple co-morbid conditions, varying insurance designs, social supports, cultural inputs, educational levels and competing priorities. 

That last point above is why the salad-fork armed DMCB pointed out to the NASA-doc that the merits of hyper-engineered systems didn't reach all into all corners of the health care system. Overconfident advocates of "disease management" made that same mistake.

We never really came to an agreement on the issue, but then again he's a surgeon.  Which reminded the DMCB of an old joke:

What's the definition of a double blind clinical trial examining the merits of competing approaches to the care of a surgical condition?  Any study involving two or more surgeons.  Ouch.

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