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Cowboy docs, insufficient opiate addiction treatment, overuse in India: RightCare Weekly

August 7, 2014

The RightCare Weekly is a newsletter that helps you stay on top of important news in the ongoing quest to move the U.S. health care system toward delivering the right care to all patients. We’ll bring you the most important stories, news articles, and opinion pieces of the week, along with our interpretation of why they’re important for patients, doctors, and communities.

 

  • Jonathan Skinner, an economics professor ​at Dartmouth​, has written extensively about the variation in healthcare delivery in the U.S​. This week, he’s interviewed on WBUR’s CommonHealth blog about “cowboy doctors” who are responsible for much of that variation. A new paper finds that 17 percent of total variation in U.S. healthcare spending – nearly $500 billion – can be attributed to physician beliefs unsupported by clinical evidence.

 

  • Austin Frakt writes in The Upshot about the challenges of widespread opioid addiction: Treatment for addiction to these painkillers is highly cost-effective, both for the health care system (by preventing expensive ED visits, hospital admissions and transmission of HIV) and for society as a whole (by reducing crime and helping addicts stay productive). But efforts to reduce opioid addiction have focused mostly on restricting access to the painkillers, instead of treating the drug dependency. One of the most important drivers of the under-treatment of opioid dependence is the cultural attitude toward addiction.

“Culturally, there’s a temptation to view dependency as a result of poor lifestyle choices, not as a chronic disease, and to view maintenance treatment as merely substituting one addiction for another. This is akin to viewing chronic insulin use as a mere substitute for chronic diabetes.” 

 

  • Dr. Mikkael Sekeres writes a powerful story for the New York Times’ Well Blog, which captures the difficulty of communicating with patients and understanding their wishes when they seem to be acting irrationally. In the piece, his eagerness to treat his patient effectively limited his ability to understand her point of view. He notes, “I felt like I failed her because, for all the time I knew her, I never could figure out her wishes, her goals, to determine if the treatment I was prescribing was what she really wanted.”

 

  • As much as we discuss overuse in the U.S. healthcare system, the issue isn’t limited to this country. The World Bank’s India health team recently convened a meeting to discuss the growing overuse problem in that country, at which Dr. Vikas Saini, president of Lown Institute, challenged the gathered policymakers to create a system that will, as Dr Bernard Lown put it, “do as much as possible for the patient, and as little as possible to the patient.”

 

  • Jason Millman of the Washington Post describes a “medical arms race” in healthcare, where hospitals invest in new technologies to keep up with competitors and attract higher-paying patients. A recent study on surgical robots shows that hospitals are more likely to invest in a surgical robot if a neighboring hospital has one. However, surgical robots, while expensive, have not been shown to prevent complications any better than traditional surgeries. The study’s authors argue that the use of new medical technology is driven, at least in part, by competition with neighboring hospitals rather than a mission to provide the best care.

 

  • Laura Landro of the Wall Street Journal says that “In Treatment, There Can Be Too Much of a Good Thing.” When treatment for hypertension or diabetes focuses too much on hitting numerical targets, and not enough on the specific risks faced by a particular patient, patients can end up more harmed by the treatment than helped. Instead of over-controlling indicators like blood pressure, treatment should be based on shared decision-making to help patients choose the treatment that best meet their needs.

 

  • Last month, Paula Span wrote a story for the New York Times on efforts to wean seniors off of sleeping pills. This week, she published a follow-up piece further describing the risks of overusing these drugs. Span writes that geriatricians have been concerned for several years about the use of sedative-hypnotics for the treatment of insomnia in older adults. Attributing the high rate of prescriptions for these drugs to the relative ease of writing a script, Span writes that there are better alternatives, like establishing a regular sleep schedule and practicing relaxation techniques. But it takes longer to see results from these alternatives. According to the physicians Span interviewed, these drugs should only be used when changes in sleep habits and cognitive behavioral therapy have been unsuccessful.

 

  • Prior authorization required” may not be saving money the way insurers had hoped. According to Danielle Ofri in the New York Times, explaining to insurers why a patient might need a costlier medication consumes huge amounts of time – in one study, around 20 hours a week in a typical practice. The article also highlights the challenges of designing systems that prevent inappropriate treatment without getting in the way of needed care. That is the importance of cultural, rather than technical, solutions to overuse.

 

  • The Robert Wood Johnson Foundation highlighted our Young Innovator Grants program this week. Emmy Ganos writes that “Young innovators are well-positioned to reshape the environments in which they are working, and encourage a culture in which the idea of ‘more is better’ refers to caring and commitment, not to unneeded tests and procedures.” See our website for more information, watch an archived version of the webinar, or apply here.

 

  • Improving the quality of life for terminally ill patients at one Central France hospital is taking on a new dimension: Partaking in the new wine bar. The Local reports that doctors at CHU Clermont-Ferrand Hospital hope to restore “longing, taste and desire” to patients with the new program aimed at those undergoing treatments and their loved ones. The bar offers champagne and whiskey, too. While hospitals in the U.S. might not be calling sommeliers yet, the wine bar is a creative example of making care for seriously ill patients a little more humane.

 

We invite you to share your thoughts. Weigh in by email at comments@LownInstitute.org, or Twitter at @LownInstitute.

The Right Care Weekly is made possible through the generous support of the Robert Wood Johnson Foundation.

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