Unrestrained restraints in the ICU, community needs in the ED, and 1000-fold price variation: RightCare Weekly
August 21, 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.
Ravi Parikh, a resident in internal medicine and primary care, writes about hospitals’ use of physical restraints in The Atlantic this week. Wrist and ankle belts, vests, and mitts are often used to restrain patients who may disrupt a lifesaving therapy, like an IV or breathing tube. However, evidence suggests that using restraints may not decrease the risk of harm for patients, and their use can make anxiety worse, lead to serious complications like delirium, falls, and breathing problems, and increase the risk of death. While new devices like shields around IVs are being developed to make restraints less necessary, Parikh suggests there are other, more patient-centered options for reducing use of restraints: hospital rooms can be rearranged with mobility aids to help patients with risks of falling, and caregivers can devote more time to talking with disoriented patients to calm them down.
Leana Wen, MD, writes for KevinMD of the challenges of caring for her patients when so many of the issues they face are deeply rooted in the communities in which they live. As an emergency physician, Dr. Wen sees many patients whose ailments could easily have been prevented before they became emergencies. She writes, “We need to recognize that health does not exist in a vacuum, that it is intimately tied to issues such as literacy, employment, transportation, crime, and poverty. An MRI here, a prescription there – these are Band-Aids, not lasting solutions.”
Last week we wrote about a piece by Aaron Carroll, MD on the lessons of low-tech solutions for the American health care system. This week, Amy Yee, in the New York Times Opinionator, discusses another low-tech solution, this one involving the global community. Oral Rehydration Solution (ORS), a simple water-salt-sugar drink first formulated in Bangladesh, has emerged as an incredibly effective treatment for diarrhea-related dehydration. The Bangladesh Rural Advancement Committee is now training residents to make the solution at home. As a result, diarrhea accounted for only two percent of deaths of children under age 5 between 2007 and 2011. Between 1988 and 1993, diarrhea accounted for around a fifth of early childhood deaths.
As many as half of those with a 75% chance of dying within nine years are still screened for cancers that are unlikely to kill them in that time frame. A paper in the current issue of JAMA Internal Medicine reports that cancer screening is common in people with short life expectancies, even though they are unlikely to benefit. The screening may be appropriate for some of those people, depending on their preferences, but it can also be harmful – especially if screening tests find false positives or provoke unnecessary follow-up testing or treatment.
High insurance deductibles and copayments are driving patients to ask their physicians two important questions: “What will this procedure cost? Do I really need it?” In Modern Healthcare, Melanie Evans finds that many doctors welcome such queries because they lead to discussions on how to prevent illness, minimize complications and avoid unnecessary care. But doctors also believe that too much cost sensitivity could harm patients who skip needed treatments. Additionally, such conversations may raise uncomfortable financial issues for doctors about whether they are providing care in the most cost-effective way.
The charge for one patient’s blood cholesterol test at a California hospital was more than $10,000 – while at another, the bill was a mere $10. The wide disparity in listed charges for routine blood tests was exposed in a study of charges for services performed at California hospitals in 2011, published in the August issue of BMJ Open. In a piece last week in Kaiser Health News, the paper’s lead author, Renee Hsia, MD, remarks that while our healthcare system needs to be more marketplace-driven, the charging and payment systems “are irrational.” They also make it harder for patients to make wise choices.
Lois Snyder Sulmasy and Steven Weinberger of the American College of Physicians take on defensive medicine in the Cleveland Clinic Journal of Medicine, arguing that although many clinical guidelines discourage overuse, they are often ignored by doctors who are fearful of lawsuits and believe performing more testing or treatment will protect them. The authors suggest that instead of ordering extra tests to demonstrate they have exhausted every medical option for their patient, clear and compassionate communication may be the best defense against malpractice suits.
A Bloomberg View editorial notes that American taxpayers are continuing to provide billions of dollars in funding to the teaching hospitals that train young physicians – but the government exercises no control over what kind of doctors are trained. The editorial argues that the program should be replaced with something that’s more targeted to meeting the country’s healthcare needs. We would suggest a program that produces fewer specialists, and more physicians committed to providing primary care in underserved and rural areas.
As Sandeep Jauhar, MD, writes for the New York Times Well blog this week, it takes time and practice for doctors to get good at their work, and during that learning curve, patients can be at higher risk for bad outcomes from mistakes. Physicians can’t learn without practicing on patients, but in many cases, patients might be safer or more comfortable with experienced clinicians. Additionally, hospitals that frequently perform certain procedures tend to have better safety records, so Dr. Jauhar suggests “regionalizing” some procedures and not spreading technology for new procedures to every hospital. That might mean patients travel farther from home—worth it, if error rates decrease and incentives to overbuild expensive equipment and to attract lucrative patients are minimized.