Category: Quality & Safety

Third Meeting of UofL Hospital Operations Review Committee.

Finally some real data.

On April 5, the Ad Hoc Operations review committee of University Medical Center, Inc. (UMC) met for the third time. This was the first meeting in which substantive analysis was presented by the consultants of Dixon Hughes Goodman. Unfortunately, Committee attendance continues to dwindle. Only five of the 10 committee members attended, one of those by telephone. In the peanut public gallery were myself, reporter Patrick Howington, and someone from Brown-Forman. One additional meeting before a final meeting on May 9 is planned.

The entirety of the meeting was a PowerPoint presentation by the consultants with only a few questions and comments from committee members. No handouts were presented as the material was said to be a work in progress. I could not help but suspect there was also some desire that the information not be disseminated. Indeed, most of the data presented must have been disappointing to the University. In any event, I photographed the projected slides and they are available here.

Senior consultant Craig Anderson, Sr. gave an update on the status of the project and lead his team of two additional people through a brief review of the challenges facing all academic medical centers (AMCs), some themes and observations from initial interviews with Hospital and University personnel, and some initial data addressing four of the hypotheses to be tested: lack of physician alignment, quality of clinical care and operations, payer environment, and facility constraints. Continue reading “Third Meeting of UofL Hospital Operations Review Committee.”

The Cardiac Gloves Come Off!

Why is your heart the punching bag?

My cardiologist is just as good as yours.

On the way to my gym on Shelbyville Rd., I noticed a billboard advertising Baptist Health’s cardiology service.  It advises me that “some of the best cardiologists around don’t practice downtown.”  This, of course, is true.  The ad is an obvious riposte to some of the advertisements of downtown hospitals, one of which advised that for your best chance of surviving a heart attack, you should take the next exit.  If corporations are people, it is now getting personal!

It’s hard not to notice that our area hospitals advertise their cardiac services heavily.  Each one is said be the better for you, and amazingly, many can produce reports from external review organizations appearing to back up their assertions.  What is distinctly lacking, in my opinion, is objective evidence in the promotional material to support claims of excellence.  For most of the Fall and Spring of 2008-09, I drove several times a week past the sign (and the exit) on Interstate 65 that promised my best chance of surviving a heart attack.  I wondered on what basis the hospital could make such a claim.  When I learned that Medicare’s Hospital Compare was then calculating risk-adjusted mortality following heart attack, I had to check it out.  In fact, not only did the advertising hospital not have the best survival rate in the city, it had the lowest.  Nevertheless, the sign stayed up for many months.  Today the mortality rates have evened out, but is all such advertising so much puffery?  How are we to know?

Why are cardiology patients fought over?

It is not a state secret why cardiology, cancer, orthopedics, or neurosurgery are advertised so heavily by hospitals. These are among hospitals’ most profitable services. My former hospital lobbyist colleagues were quite open in admitting that cardiology services are overpaid by Medicare and other insurance companies.  According to the bank robber Willie Sutton’s law of medicine, that’s where the money is. I will say more about this in another post because an absence of profitable services is relevant to the financial difficulties of Louisville’s University Hospital.  In my opinion, the other downtown hospitals have helped to keep University Hospital in its place.

The Baptist billboard is clever, and reminds me of the series of billboard ads for hotdogs and whiskey also containing witty one-liners that we all chuckle at.  I would not be surprised if the same advertising agency was responsible for some of the medical ads as well. That is, a very depressing thought however.  At a time when food and dietary supplements are marketed as though they were medicines, medicine is marketed as though it was soap powder.  Are we really that gullible or so easy to manipulate?  I have already told you how I feel about the quality and ethics of some of these advertising campaigns.  If you believe everything you see and hear, you will be badly served. Continue reading “The Cardiac Gloves Come Off!”

Exaggeration, Unethical, or Just Plain Despicable?

Today’s Courier-Journal reported on a legislative hearing in Frankfort concerning the struggling implementation of our new Medicaid Managed Care companies in Kentucky. The focus was on slow payments to providers and difficulties arising from having to interact with the systems of three different providers, although there were apparently also problems in obtaining timely authorizations for treatment or prescriptions. None of this should have been completely unexpected given the relative speed at which rather drastic changes were made to the Medicaid program of Kentucky. Most of the state just went from unbridled fee-for-service care to the more closely supervised system we call managed care. I am certainly not surprised! What is more important is how this vital healthcare system reacts and repairs itself. Time will tell.

What did surprise and more-than-disappoint me was the report of the behavior of an unnamed psychiatrist in Kentucky who is said to have refused to continue to treat two of his current patients who are children because “he has not been paid since Nov 1.” Why is this not abandonment and a cause for disciplinary action by the Medical Licensure Board, or if there are any damages, in a civil court? My friends in the Medical Licensure Board, what does it take for you to investigate this accusation? You may consider this a complaint. The safety of two children is in jeopardy, or the good image of physicians has been sacrificed to make a better story for our legislators. Either alternative begs for clarification and resolution. Reports like this, when true, make me ashamed on behalf of my profession. Continue reading “Exaggeration, Unethical, or Just Plain Despicable?”

On Excellent Medical Reporting

In an earlier entry, I was critical of what I call the “press release” variety of medical reporting in which the news report is based heavily or entirely on a press release by individuals or institutions who have a financial or other vested interest in shaping the presentation.  In many, if not the majority, of these the difference between informing and marketing is not discernible to me.  It is therefore only fair to give credit for what I think is an example of excellent medical reporting. As described below, I was also impressed at the value added to conventional newspaper reporting by its associated Internet capabilities. The article provides an example of the pre-publication embargo system used by some major medical journals with what I think are both positive and negative implications.

The Article and Report.
On Tuesday, February 8, New York Times reporter Denise Grady published an article, “Lymph Node Study Shakes Pillar of Breast Cancer Care.” My sometimes faulty memory tells me I saw her article Monday evening on the New York Times website. The article Ms. Grady reported on was officially published in the February 9 issue of JAMA, the Journal of the American Medical Association: “Axillary Dissection vs No Axillary Dissection in Woman With Invasive Breast Cancer and Sentinel Node Metastasis, ” by Armando E. Giuliano and coauthors; vol. 305:569, 2011. I received my personal copy of the Journal on Wednesday the 9th.

I spent over two hours studying this seven page paper. It was heavy going for me and would have been largely impenetrable to a layperson. It goes against my grain to be paternal, but there is no way for a layperson to understand the significance of the research or how it might relate to them without help. In fact, even I needed some help to put things in perspective, and I confess some of that help came from Denise Grady.

To summarize the paper in an obscenely brief manner, 891 women with breast cancer that had already metastasized as far as the lower lymph nodes in her axilla (armpit) were randomized to 2 different treatment plans. Half the women went on to what was then the standard treatment of extensive removal of all the lymph nodes in their axilla. The other half had no additional surgery beyond the biopsy of the low sentinel node that showed the metastatic cancer. All of the women had a lumpectomy and radiation to the breast, and almost all had additional adjuvant or prophylactic chemotherapy. The patients were followed for as long as eight years. There was no difference in the survival or cancer recurrence rate in either group. Continue reading “On Excellent Medical Reporting”