Telestroke

It's been a long time since my last post. I apologize for the long period of quiet. Between studying for the MCATs and applying to medical school, my free time has come in bits and pieces.

I thought that I would mention an encouraging trend that I've seen in the world of stroke care. For a while now, there has been a big buzz surrounding the potential for telemedicine to improve access to care in a cost efficient manner. In the last few months, however, my colleagues and I have had multiple requests for information on telestroke technology.

Nationally, there is an acute shortage of neurologists willing to take 24/7 stroke call. The theory is that a large tertiary care facility may be able to help address this shortage by adopting a telestroke system that allows the facilitiy's neurologists to perform emergent consultations for less advanced community hospitals or critical access hospitals in the surrounding area.

There are still a lot of regulatory and cost issues to consider, but I hope that this movement continues to strengthen. There are many facilities - Saint Luke's Hospital in Kansas City, MGH, UPMC, Atlantic Health, Medical College of Georgia - that have developed impressive regional stroke networks using telestroke technology. These networks have excellent clinical outcomes and deliver neurological care to a much wider market.

How to incentivize hospitals?

Let's say you are the head of the Centers for Medicare and Medicaid Services (CMS) in the United States and are trying to answer a simple question: how should CMS incentivize U.S. hospitals? In an ideal world, hospitals that provide superior clinical care while minimizing costs should be optimally rewarded. The problem is, of course, that those two goals - good care for cheap - are often at odds. So we're back to our original question:

How should a government that pays for healthcare (for at least a sub-set of its citizens) incentivize hospitals?

From a cost perspective, it's a fairly simple question. You provide a set payment to a hospital for a set service and allow the free market to work its magic. Hospitals that keep their own costs lower than the government's payment make a profit and hospitals that do not control costs lose money. I'm going to call this the cost reduction handle. By constantly squeezing payment rates for various healthcare services, the government incentivizes hospitals on cost controls.

But what happens if a hospital swings entirely from the cost reduction handle at the expense of clinical quality? Ethical concerns aside, it is not hard to imagine that hospitals who provide inferior care may end up having lower costs and therefore higher profits than hospitals who provide superior care. As a result, the government needs to establish some type of quality improvement handle to incentivize hospitals on clinical quality. If a government can establish a mechanism for continuously monitoring clinical care within hospitals and punishing under-performers, it can incentivize clinical quality.

Here-in lies the rub. Measuring clinical quality is notoriously difficult. What metrics should we use to compare clinical quality in the care of ischemic stroke? Once we have decided which metrics to use, how do we develop the infrastructure to compare outcomes across U.S. hospitals? The systems simply don't yet exist.

In an ideal world, hospitals would be stretched between the cost reduction handle and quality improvement handle so that at no point could they sacrifice clinical care for cost controls or cost controls for clinical care.

Sometimes It's Good To Steal

Given my interests in health system performance, I was drawn to this New York Times article highlighting how the Swiss and Dutch Health Systems - as hybrid private-public models for universal heatlhcare insurance - are in vogue among U.S. politicians. Other than to briefly note that citizens in these two European countries are forced to purchase their own health insurance at the risk of penalty, the article is light on the details.

It's still unclear to me whether these health systems are in the press because they are effective (from a quality and cost perspective) or because they are politically feasible in a United States political environment that is increasingly looking towards universal health insurance but that is also wary of single-payer models of universal coverage. Nonetheless an interesting article and something I'm going to read up on before my next post.

A Nursing Shortage

In 2005 the health division of the OECD - a best practices research group for the world's wealthy countries - published a working paper entitled Tackling Nurse Shortages in OECD Countries. The authors - Steven Simoens, Mike Villeneuve and Jeremy Hurst - take a diagnostic look at nursing shortages in multiple nations and take a stab at identifying best practices employed by nations to either increase the number of nurses entering the workforce or reduce the number of nurses exiting the workforce.

It's an illuminating read. From a macro-economic policy perspective, it will open your eyes to how little we know about the factors that affect nursing recruitment and retention. And this is despite the fact that nurses represent the single largest employee group in the hospital environment. I am always fascinated by the things we learn from our peers and this paper highlights several putative best practices employed in socialized healthcare systems.

Among the highlights. In Ireland, the government set up the Nursing Careers Center in 1998 to promote and market nursing as a career. In Canada, the national health system has introduced various flexible scheduling and family care initiatives to improve job satisfaction among nurses and aid in retention. Yet, it is surprising how little hard data we have on these measures. What initiatives are most effective at recruiting and retaining nurses? What initiative are most cost effective?

Technology in Public Health

With our first world country bias, we tend to view advancements in medical technologies through the lens of capital technology. We measure clinical advancement in 64-slice CT scanners, intraoperative imaging suites and innovative radiation therapy delivery platforms.

However, we tend to forget that for the vast majority of human beings - people without access to clean water and nutrition - medical innovation can come in more basic forms. Scientists at Proctor & Gamble, in collaboration with the U.S. Center for Disease Control (CDC) have made amazing advancements in water purification technology. Though it emerged more than a year ago, the PUR water filtration technology is worth highlighting for its ingenuity and potential to improve access to clean water in developing countries. The size of a sugar packet, a PUR packet costs less than seven cents and can purify up to 10 liters of pathogen-laced water. Given that pathogen-acquired diarrhea is a leading worldwide killer of children under the age of five and that contaminated drinking water is a prime cause, any improvement in access to purified drinking water will dramatically reduce childhood mortality in the developing world.

It's easy to forget that, for the vast majority of this planet's inhabitants, access to basic needs is a necessary pre-requisite to improving public health. First, the clean water and reliable food source. Then, the 64-slice CT scanners.

More Transparency, This Time By the MHA

The Massachusetts Hospital Association recently posted data on the number of patient falls per 1,000 inpatient days and various other measures of clinical outcomes for heart attack, heart failure and pneumonia care. It's an admirable move and more evidence that full clinical transparency, if not here, is at least gathering steam.

The more transparency there is in hospital outcomes, the easier it will be for hospitals to identify negative and positive deviants. At the very least, such information will help hospital administrators identify areas for improvement. And, if you believe that the age of consumerism in healthcare is already here, perhaps such information will allow consumers to apply strong market pressure to under-performing institutions.

Choosing a Specialty

Yesterday I was speaking to a friend of mine who will be entering medical school in the fall. When I asked him what specialties interested him, our conversation shifted towards a discussion of the relative advantages and disadvantages of the different medical specialties.

Why become a neurologist? Why become a dermatologist?

Presumably medical students - as any other consumer of goods or services - respond to market incentives. Certain specialties involve more patient contact, others are better compensated and still others have better qualities of life. In making their decision, medical students must weigh personal interests against debt loads, training times, expected financial rewards and quality of life.

Neurosurgeons, though well compensated, have lengthy residencies. Although they train for less time, neurologists are relatively poorly compensated and often participate in grueling call schedules. Simply on a financial basis, it is not surprising that medical students graduating with over $200,000 in debt gravitate towards higher-compensating specialties and avoid residencies in lower-compensating fields like family medicine and pediatrics.

As an outsider, it's easy to forget that both monetary and non-monetary incentives are highly likely to influence the medical specialty, region and city that a medical student selects.