First Do No Harm

As we’ve seen in some recent high profile deaths reported by the U.S. media, physicians can play an important role in reducing the skyrocketing prescription drug death epidemic. On January 13, 2012 the U.S. Centers for Disease Control (CDC) reported in the Morbidity and Mortality Weekly Report  almost 27,000 people died in the United States died as a result  unintentional drug overdose.  This translates to 1 death every 19 minutes across the U.S.  And it’s not just a U.S. problem. Prescription drug abuse is the fastest growing drug problem across North America, and it’s not just in big cities, in small rural and remote parts of Canada it is a silent epidemic that is ripping apart whole communities. This dramatic increase in the unintentional drug overdose death rate is fueled largely by prescription opioid analgesics. Since 2003, prescription opioid analgesics deaths have been double that for the illegal drugs heroin and cocaine combined. And the prescription drug death rate is only the tip of the iceberg. It also drives up the utilization costs for many health services. For every unintentional overdose death from opioid analgesics, 9 people seek treatment for substance abuse, 35 visit emergency departments, 161 report dependence, and 461 report recreational or non-medical uses of opioid analgesics. Do the math, this is a costly epidemic in more ways than one. Physicians have an vital role to play in both practice and in leading the call for a research-based public policy strategy that targets those at greatest risk.

Rate of unintentional drug overdose deaths per 100,000 population — United States, 1970–2007 Source: National Vital Statistics System

 

 

Healthcare Reform For Dummies

Treat healthcare as a high-tech industry (image by Danilo Rizzuti)

1.     Move routine specialty services such as endoscopies out of hospitals

2.      Create focused factories of care independent from hospitals to improve access, throughput and quality

3.      Use technology to improve productivity, for example email to arrange for referrals, appointments and routine prescription renewals

4.      Encourage grassroots, provider-based innovations

5.      Facilitate mergers and acquisitions of health service organizations

6.      Modernize the way health services are funded to reward new ways of delivering services, in different ways; have funds follow the patient

7.      Restore choice as a dimension of quality

For more ideas on Fiscal Accountability and The Transformation of Canada’s Healthcare System see the report Shifting Gears from The Mowat Centre and the School of Public Policy and Governance at the University of Toronto.

The Forgotten Ones

Life is short the art is long (image by Vlado)

End of life care is difficult to really talk about in the abstract, that is separate from the care needs of the individual children, teenagers, adults or senior citizens needlessly suffering in their final days and hours. The lack of coordinated care for this stage of life stands in stark contrast to the excellent standards of care generally achieved for example in obstetrical care across the country. For sure there are pockets of excellence in palliative care and many dedicated people doing what they can to provide care and relief.

The roots of neglect lay in the origins of Medicare. End of life standards of care are very different today from when Medicare was first established. Originally established to provide coverage for hospital and physician care, Medicare did not envision the exponential growth in medical technology and the ability to offer many more options for treatment to prolong life, to enable many people to live longer with chronic disease, so that many more will require end of life care. It should come as no surprise then that an end-of-life care strategy is desperately needed across Canada. One that is person-centred, family-focused and community-based, and one that addresses suicide prevention and abuse.  Societies are going to need to find creative ways to reallocate limited funds to make home care, long-term care, and palliative care consistently insured services under Medicare and to define a commitment to make excellence in palliative care an achievable, measureable goal.

More Efficient Care

Follow the money (image by Master isolated images)

A recent poll conducted by Environics Research published in Health Edition reports that Canadians think inefficiency is the source Medicare’s woes.

Of those surveyed 62 per cent think inefficient management is the root problem while 30 per cent think it is insufficient funding. This is a shift from a 2002 poll when Canadians were almost equally divided on the issue: 41 per cent citing inefficiency and 44 per cent citing lack of funding.

Canadians have a strong preference for the government-funded Medicare program while interest in private health care options remains consistently low.

So here’s the question: is public opinion based on knowledge, experience, or media reporting?

Improve Health Save Money

GAI could save millions and improve health (image by graur codrin)

Could innovation in population health be found in a little known Manitoba pilot project from the 1970s? Few people know about the amazing social experiment conducted in Dauphin Manitoba between 1974 and 1979 called Mincome. The pilot project quietly shut down and there was no real evaluation—until now.  Evelyn Forget a researcher at the University of Manitoba published her results in Canadian Public Policy in 2011. Using routine administrative data she documented an 8.5 percent reduction in hospitalization rates for participants in the pilot project relative to controls.  These results were particularly relevant for accidents and injuries and mental health conditions. Her analysis also found that participants had fewer doctor visits, especially for mental health issue, and more young people continued past grade 12 in school. Her study found no increase in fertility rates, family dissolution rates, or birth outcomes. The study concludes a relatively modest guaranteed annual income (GAI) can improve population health with potentially significant health savings. With the rising cost of health care, an aging population and the need to reduce the size of government, could real health innovation be buried in a little known social experiment? Maybe it’s time this innovative idea had some serious consideration.

Old And Older

CIHI report points to needed changes (image by graur codrin)

Our friends over at the Canadian Institute for Health Information (CIHI) say the Medicare insurance system needs to address gaps in the continuity of seniors’ care. The aging population will hit Canada faster than many other countries, and the number of people over 65 is expected to double to 25 per cent of the population by 2036.

So far the impact of an aging population on health costs has remained fairly stable, the report says seniors are frequent users of Medicare and cost more than any other segment of the population. At present seniors (over 65) account for only 14 per cent of the population, but they use 40 per cent of hospital services and account for approximately 45 per cent of all provincial and territorial government health spending.

A number of ideas are put forward in the report to help alleviate the cost pressures and provide better care for seniors. Clearly, improving the integration of care across the continuum, more focus on primary and secondary prevention measures, making efficient use of new technologies, and better use of information on seniors’ medical conditions.

Integration of care is key and can make a big difference. In Australia the use of a care facilitator was able to reduce seniors’ emergency department visits by 21 per cent and hospital admissions by 28 per cent. In Canada, according to CIHI, one in every 11 emergency department visits by seniors is for a chronic condition that can potentially be managed at home or elsewhere in the community. However, less than half of seniors are able to get a same- or next-day appointment with a family doctor, and more than a third wait a week or more.

Medication safety is another area where well-integrated seniors’ care could help. The report says almost two out of three seniors in 2009 took five or more prescription drugs, with close to a quarter taking ten or more, increasing the potential for very serious drug interactions.

In an era of slashing Medicare budgets innovations such as these could improve elder care and save money. However, slashing budgets without targeted investment in key areas such as those noted in the CIHI report could have the unintended consequence of increasing Medicare costs, drive up costs of emergency and acute care and ultimately drive the percentage of GDP spent on health care to a staggering new high.

A Closer Look At Patient Safety

Patient safety needs another look (image by Simon Howden)

Most people don’t think about the risks of being admitted to a hospital. In some countries, and some hospitals the risks are greater than others. The Canadian Institutes for Health Information (CIHI) released a report Learning from the Best: Benchmarking Canada’s Health System,  an analysis of international data by the Organization for Economic Cooperation and Development (OECD) on how its member countries have fared regarding access to quality health care.

In the OECD study (see: www.oecd.org/dataoecd/13/0/49084244.pdf) Canada is in the top 25 per cent for avoidable hospital admissions for conditions such as asthma and some other chronic conditions. Canada ranks third for five-year breast cancer survival rates, and is above average for colorectal cancer survival.

But CIHI said Canada has some of the highest rates among 17 reporting countries for accidental puncture, and for foreign bodies left in during surgical procedures. It also has among the highest rates of obstetrical injury of 20 countries. In July 2011, the World Health Organization (WHO) reported Canada has among the highest rates of health care-associated infections in major developed countries. These issues are directly related to how health care providers perform their jobs and the working environments in which they work. Is the future of patient safety better health human resources management and better working conditions? It’s work a closer look.

Hair Raising Matter

Hare of another kind (by FreeDigitalPhotos.net)

It’s Saturday and time for a hair cut for sure but there are different schools of thought. Do I get the Number 2 Buzz or just a trim? There are implications to either one: if you get the Number 2 you’ll be back in a month, on the other hand if you get a trim and continue to let your hair grow long you can get away for another 6 to 8 weeks. People do have opinions about other people’s hair. One becomes a topic of conversation. Maybe even a subject of pity, all because you make a decision to get a haircut, or not. So will it be a left brain or a right brain decision today?

Air Canada Wins Worst Service In The Civilized World Award

Okay, this wasn’t the story for today; at least it wasn’t supposed to be. My red-eye flight on Air Canada flight 156 from Vancouver to Toronto was delayed. It wasn’t delayed for weather, or mechanical problems, things that just happen and hapless travelers simply put up with. Oh, no, no, no, this 45-minute delay in departure was so passengers on a later flight whose plane’s toilet didn’t work could be accommodated on our flight. Of course that 45-minute delay meant that the 25 people on my flight who were making the same connection as I was were now not going to make their connection for their next flight. Instead of delaying our connecting flight a few minutes, which would have been fair, Air Canada cancels my seat and all of my travel companions seats on our connecting flight.  When we land in Toronto we are all summarily advised like newly arrived refuges that we must see the gate agent to have our connections revised. When I turn on my cell phone after landing, I get a text message from Air Canada (which costs me money) telling me my connecting flight has been cancelled and the message tells me what I must do like some obedient prisoner/customer. Instead of a real person meeting with me and apologizing for the delay, perhaps arranging for a nice foot massage or something (dream on), the impersonal text message orders me to take a flight to Montreal immediately.  I am ordered to get on the plane right away or I’ll miss the flight and it will be my fault if I miss it. In Montreal I am told to catch another plane that will finally take me home, but I’ll have to get the boarding pass and find what gate from someone else. Assuming of course I make that flight which appears very tight too.  So this is what I think is going on. Air Canada believes its providing good customer service by having a computer, not a person, revise my itinerary. Now, let’s remember, we selected our flights with great care, carefully considering all the options before we booked our flights online with Air Canada. And I paid top dollar for the privilege of being treated as a commodity. So how does Air Canada get away with telling me what to do? Who decides one plane gets held for one set of passengers and not for another? I now see the attraction of private jets. I get it Mr. Branson, I really do.

Driving quality service

The Day Health Innovation Died

Health innovation needs to be rescued (image by digitalart)

Was anyone paying attention on January 17, 2012 when the Canadian Premiers announced a Health Care Innovation Working Group? The communiqué joyously announced, “While acknowledging that Canada’s provinces and territories are pursuing innovation in their own jurisdictions, Premiers recognize that more can be done together.” The Press Release goes on to say they will provide their “first report” in July in Halifax. Okay, this is the Ides of February and what is it they’re actually working on? BC Premier Christy Clark is quoted as saying: “The message we want to send is that we are working together to innovate and provide better care for seniors and all Canadians.” Uh, huh, this certainly sounds good, and it would really be a first, because historically the provinces haven’t been able to agree on anything when it comes to health care. Every jurisdiction has different services covered by Medicare, some include home care and long-term care while others don’t; some cover “catastrophic” drugs, others don’t, and they all compete with each other for health care providers that contribute to rising costs and dwindling services.

Right now they are working on these “innovations”:

1. “Scope of practice: examining the scope of practice of health care providers and teams in order to better meet patient and population needs in a safe, competent and cost effective manner.

2. Human resources management: address health human resource challenges and explore more coordinated management to address competition across health systems.

3. Clinical practice guidelines: accelerating the development and adoption of best clinical and surgical practice guidelines so that all Canadians benefit from up-to-date practices.”

They tried for years to “work together” on scope of practices issues when really governments gave that one over to the professions many, many years ago. It would take legislative changes in all provinces and territories at the same time to make that one work. Oh, oh, looks like another committee will be announced. The same goes with health human resource management; the Martin federal Liberal government got sucked into spending millions on that one over the past 8 years and many provinces ramped up medical and nursing school spots already; lots of reports, research, meetings, new organizations and money spent but where is the fix for a generation? So just how are the provinces going to address competition across the country when the richer provinces materially contribute to the competition? The last priority on clinical practice guidelines is the best joke of all. Who picked that one, a health policy grad student? One only has to look at the Cochrane Collaboration database to see the evidence of how poorly clinical practice guidelines are used, notwithstanding the plethora of conflicting guidelines, and guidelines based on biased industry funded research. The last time I was involved with guideline development the cost PER guideline was approximately $500,000; that was more than a dozen years ago, so I’d say double figure that now. Do the Premiers want to get into that business?

The economic playing field is hardly level across the country driving government realities and priorities. I suspect Premiers east of Ontario are digging into the Drummond report right now, and what Drummond has to say about health innovation is that more drastic changes are needed right now—big time. As the old salts in Newfoundland and Labrador would say, “the arse is out of ‘er buys.”

Six weeks into the year, those three priorities the Premiers announced in January are looking awfully dower and very road weary—hardly Steve Jobs’ idea of innovation. The thing is Mr. and Ms. Premier innovation comes with risk.  There’s nothing risky in duct taping the status quo around platitudes and committee-speak bailing wire. Is genuine innovation lurking somewhere between the lines of the Drummond report’s recommendations? Are visionary leadership and the courage to tell the truth to the public the real innovations needed to transform health policy? If truth is the first victim of war, as Churchill said, could it also be the neglected stepchild of health innovation? Or are the Premiers just blowing smoke, and it’s really just all about getting elected?