Psychological or Physical

Perhaps I shouldn't be, but I am constantly surprised by the links that are uncovered between psychological and physiological health. Today the Associated Press reported on a recently published study in which individuals in bad personal relationships had a significantly greater risk of heart disease than individuals in good personal relationships. While this study certainly doesn't prove causation (merely correlation), it is indicative of both the basic challenges of medical research in humans and the greater challenge of disseminating research findings to the lay public.

Commenting on the results of the study, one expert noted "it is still not clear what to recommend. Do we tell people who have negative relationships to get therapy? They may have other reasons to do so, but I see no basis for them doing so only to avoid a heart attack." Ending a bad marriage is not necessarily the answer either, he said, given evidence that being unmarried also could be a risk.

When even the experts appear at a loss, how is the public supposed to internalize the health ramifications of a clinical study?

Networking Hospitals to Improve Care

For better or for worse, we Americans live in a country that is generally suspicious of anything that smells even remotely of government interference in free markets. With that in mind, I came across an interesting article in the Wall Street Journal discussing how state governments are passing laws mandating a multi-tiered system for hospitals providing trauma care.

What is the problem that these laws attempt to address? To be blunt, you wouldn't want to be a trauma patient at a rural community hospital that lacks the staff, technology or care protocols to optimally treat your injuries. However, in many states there are few regulations mandating transfer protocols for severe cases.

In brief, these state laws attempt to address this problem by differentiating hospitals' trauma capabilities and ensuring that the most serious trauma cases get routed to the most advanced trauma center as rapidly as possible. If a patient arrives at a rural hospital with serious injuries, they are immediately transferred by ambulance or helicopter to the nearest level I trauma center.

There is an interesting ethical question here. If patients in states with trauma networks have substantially better outcomes than trauma patients in states without trauma networks, isn't there an ethical mandate to create these trauma networks in other states as well? And if the networks improve outcomes for trauma, might networks for other medical needs also improve outcomes? There is already evidence to suggest that stroke networks founded on the same clinical principles as trauma networks - rapid patient transfer to the best equipped hospitals - improve patient outcomes.

It will be interesting to watch if these trauma networks continue to proliferate among the states and serve as models for other clinical pathologies. There are certainly many hurdles left to clear - a distrust of government interference, resistance from hospitals and regulatory challenges in enforcement, to say the least.

How Does Innovation Spread?

In a word, slowly. Our colleagues in the field of psychology tell us that human beings are incredibly resistant to change. But what about in the healthcare industry where innovation is expected and even demanded of physicians and hospitals? Thousands of clinical studies are published every year and based just on the sheer volume of clinical literature, one might assume that medicine is universally dynamic, infused with an ethical mandate to roll-out innovations as rapidly as possible. But even if we assume that a true innovation in clinical care has been identified, historical experiences suggest that the healthcare industry is as resistant to change - if not more so - than other industries.

Caused by blood clots in the brain's blood vessels, ischemic stroke is a leading cause of death and disability in the United States. Prior to the mid-1990s, there were no effective treatments for ischemic stroke. Although ischemic stroke patients arriving at the hospital would receive supportive medical care, there were no known pharmaceutical or surgical interventions proven to lyse or remove the blood clot. However, in 1996, on the strength of a study published in the New England Journal of Medicine, the FDA approved the intravenous delivery of the clot-busting tissue plasminogen activator (tPA) as the first treatment for acute ischemic stroke.

The first true therapy for ischemic stroke had been approved, the optimists sat back and waited for a dramatic spike in the use of tPA and a concomitant improvement in clinical outcomes.

However, despite tPA's FDA approval and a rash of subsequent studies confirming the drug's clinical efficacy for treating ischemic stroke, the use of tPA remained surprisingly low. Even today, only 1-5 percent of ischemic stroke patients nationally receive tPA. The reasons are many. First, to be eligible for tPA, patients must present to the hospital within three hours of stroke onset. Second, there are a host of physiological contraindications to tPA that disqualify many patients. Yet, even among patients who are eligible for tPA, the national treatment rates range from 15-20 percent.

Why aren't more eligible ischemic stroke patients receiving tPA? Innovation spreads slowly.

Transparency

NetDoc recently combined data on hospital quality outcomes - as reported by hospitals to the Department of Health & Human Services - with Google Maps to provide a diagnostic snapshot of hospital quality. In grading each individual hospital, the tool combines data on heart attacks, heart failure, pneumonia, surgical infection prevention to create an overall "clinical quality metric" for each hospital.

This website is just one more indicator of the slow shift towards transparency in the U.S. healthcare system. Information is the mediator of free market competition and an increase in transparency in hospital performance will play an important role in improving overall quality of care. Patients will be able to make more informed decisions about providers and hospitals will emulate positive deviants in the market to improve outcomes and stay competitive.

Measuring Things

I recently read Better: A Surgeon's Notes on Performance, a wonderful collection of essays penned by Atul Gawande, a general surgeon and frequent contributor to The New Yorker. I was struck by one passage in particular:

"Regardless of what one ultimately does in medicine - or outside of medicine for that matter - one should be a scientist in this world . In the simplest terms, this means one should count something. The clinician might count the number of patients who develop a particular complication from treatment - or just how many are actually seen on time and how many are made to wait."

How can a hospital improve clinical outcomes without first understanding how its outcomes compare to outcomes at peer institutions? The larger argument is that in any given endeavor - medicine, baseball, farming - there are positive deviants that, by definition, outperform the average. Just as some baseball players consistently bat above the league average, some physicians and some hospitals consistently create superior clinical outcomes. In the case of hospitals, how much could they improve the quality of care delivered if they could identify and emulate positive clinical deviants among other hospitals? Why is the Mayo Clinic more successful at treating pituitary tumors than 95 percent of other U.S. hospitals? What are they doing right?

At the Organization for Economic Cooperation and Development (OECD), a sort of best-practices organization for the world's developed nations, researchers are developing a comprehensive set of healthcare quality indicators that will eventually allow policy makers to compare clinical performance across healthcare systems. The development of metrics for the assessment of clinical quality - breast cancer survival rates, stroke 30-day mortality rates and colorectal cancer screening rates - will help answer important questions. What does the French healthcare system do better than the Spanish healthcare system? Why does it do it better?

I think they're great questions and will hold important lessons for individual institutions and systems.