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‘Dr. Abscess’ and Why Surgeon Scorecard Matters

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Stephen Engelberg writes in ProPublica:

We’ve had a remarkable response in the two weeks since we published Surgeon Scorecard. The online database has been viewed more than 1.3 million times by people looking up doctors. Surgeons and others pored over the intricacies of the data and methodology. Some praised it as a long overdue, transformative in the data and what they viewed as flaws in the analysis.

Perhaps the most striking response, though, came from one of our readers, the husband of a nursing supervisor at a medical/surgical unit in a respected Southwestern hospital.

“When my mother required gallbladder surgery, my wife specifically ensured that a certain surgeon wasn’t on call for the procedure,” he wrote. “While I was at the hospital visiting my wife, I mentioned casually to two of her coworkers (separately) that my mother was upstairs awaiting surgery. Both nurses asked cautiously who was on call and when they found out it was Dr. [redacted] … they breathed a sigh of relief.”

That doctor that hospital insiders protected their loved ones from? The nurses called him “Dr. Abscess.”

For decades, the shortcomings of the nation’s Dr. Abscesses have been an open secret among health care providers, hidden from patients but readily apparent to those with access to the operating room or a hospital’s gossip mill.

The author of this email, whose name we’re omitting for obvious reasons, asked his wife to rate the surgeons she assisted every day, and compared her thoughts to what we reported in Surgeon Scorecard. “I randomized the names as I listed them to her, and she hadn’t read about the Scorecard and didn’t know anything about the results. She simply told me her choice for the best and worst and was right across the board.’’

Dr. Abscess? He had the highest complication rate of any doctor operating at the hospital.

Surgeon Scorecard marks ProPublica’s first attempt to make data available about surgeons. Like any first attempt, version 1.0 can be improved, and we plan to do so in the coming months.

But it’s worth noting that some of the most frequently cited concerns reflect basic misunderstandings about how Surgeon Scorecard works. I’d like to address some those questions in detail.

There aren’t enough data to learn anything useful about individual surgeons.

Many critics have noted that Surgeon Scorecard draws only on records of procedures paid for by Medicare’s fee-for-service program. “I can’t reiterate enough the paucity of the data that is analyzed,’’ Dr. Jeffrey Parks, a general surgeon in Solon, Ohio, wrote in one typical critique.

In fact, study after study of the nation’s health care system by some of academe’s most prestigious scholars draws on similar data from Medicare. Medical research is typically done using far smaller groups to represent even larger populations. Even in large clinical trials, new drugs are tested on a few thousand people who serve as stand-ins for all 320 million Americans.

Overall, Surgeon Scorecard looked at 2.3 million surgical procedures and rated nearly 17,000 doctors. The complication rates we’ve computed for surgeons have been adjusted to control for each patient’s age and health, and the differences among the hospitals where they work. For each doctor, the rate is reported in a range called a confidence interval.

The width of a surgeon’s interval can vary depending on how much information is in our data about him or her. Surgeons who do a large number of Medicare operations requiring overnight stays will have a narrower interval that hones in more precisely on their true performance. Surgeons who’ve done fewer operations have a wider range. Our critics have said this means we can’t know anything about how they compare to peers.

It would be great if every surgeon did thousands of operations. That would make differences between surgeons more clear cut. But patients have to choose now based on the procedures actually performed. The complication rates we report are the most likely based on what we can know. They give a strong signal that some surgeons perform better than others, even if the differences aren’t always as conclusive as some might like.

You can read the calculations that support that finding here.

Parks and other general surgeons have raised a reasonable question about gall bladder removals, one of the eight elective procedures we studied. Because of the way Medicare compiles billing records, our data only includes patients whose operation required an overnight hospital stay. Many doctors also perform this procedure on an outpatient basis.

There is no question that patients would know more if we could publish complication rates that include the outpatient procedures. We are now trying to obtain the records needed to do this.

Counting readmissions to the hospital and deaths is not a fair way to track surgeon performance since Medicare data does not say who precisely was at fault. . .

Continue reading.

Written by LeisureGuy

28 July 2015 at 10:04 am

Posted in Healthcare, Medical

Religious issues flock to US Supreme Court

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Linda Greenhouse has a very interesting column on what a mess the Roberts Court has created with its Hobby Lobby decision. From her column:

. . .  At issue are the options the Obama administration has made available to a category of employers deemed “religious nonprofit organizations” that object to including birth control in their employee health plans. These groups differ from “religious employers,” a category essentially limited to churches, which are deemed exempt under the Affordable Care Act regulations. Rather, these are religiously affiliated nonprofits such as colleges, seminaries and religious orders like the Little Sisters of the Poor, which runs nursing homes and describes itself as an equal-opportunity employer in its hiring practices for lay staff members. These nonprofits do have to provide contraception coverage unless they accept the administration’s offer to opt out of the requirement by passing the legal obligation on to their insurance carriers.

Under pre-existing regulations that the Obama administration fine-tuned in the aftermath of the Hobby Lobby decision, all these organizations have to do to qualify for the exemption is to ask for it, by filling out a two-page form, or even more simply by sending a letter to the Department of Health and Human Services declaring that they have a religious objection to paying for birth control. At that point, their obligation ceases and the coverage has to be provided by the organizations’ insurance carrier or, in the case of a self-insured plan, by the third-party administrator, without any financial involvement by the organization.

Dozens of these organizations promptly filed suit claiming that they couldn’t possibly fill out the form or sign the letter because to do so would make them complicit in the ultimate choice their employees might make to use birth control.

It’s important to understand the difference between these cases and the lawsuit by Hobby Lobby’s owners. As a for-profit company, Hobby Lobby had no accommodation available. It had either to provide the coverage or pay a huge fine. In fact, the court’s majority opinion, written by JusticeSamuel A. Alito Jr., strongly suggested that the problem, as the majority saw it, could be solved if only the administration would offer Hobby Lobby the same choice it was giving the religious nonprofits. Justice Alito wrote that the Department of Health and Human Services “itself has demonstrated that it has at its disposal an approach that is less restrictive than requiring employers to fund contraceptive methods that violate their religious beliefs.” In a footnote, he added: “The less restrictive approach we describe accommodates the religious beliefs asserted in these cases.” Justice Anthony M. Kennedy, who provided the fifth vote to the majority, wrote in a concurring opinion that the accommodation as described “does not impinge on the plaintiffs’ religious beliefs.”

The Hobby Lobby case had not been argued on this basis, and Justice Alito noted that the court was not deciding whether such an accommodation would suffice “for purposes of all religious claims.” To that extent, the statements were nonbinding “dicta,” not part of the holding. But they have had a powerful influence in the lower courts. Cases challenging the adequacy of the accommodation as applied to religious nonprofits have now made their way through six of the 12 federal appellate circuits. Remarkably, every court has rejected the religious claims.

Not all the decisions have been unanimous; there have been dissenting opinions by individual judges, a fact that may lead the Supreme Court to accept one or more of the pending appeals despite the absence of the “conflict in the circuits” that the court usually waits for. But, notably, judges across the ideological spectrum have ruled for the government. One of the country’s most conservative federal judges, Jerry E. Smith, wrote the opinion last month for a unanimous panel of one of the country’s most conservative courts, the United States Court of Appeals for the Fifth Circuit.

The Supreme Court’s Hobby Lobby decision “is of no help to the plaintiffs’ position,” Judge Smith wrote in East Texas Baptist University v. Burwell.The reason, he explained, was “not just that there are more links in the causal chain here than in Hobby Lobby.” Rather, it was that “what the regulations require of the plaintiffs here has nothing to do with providing contraceptives.”

It’s worth quoting Judge Smith at some length, including his reference to the Religious Freedom Restoration Act, the federal law under which the Hobby Lobby case and the current cases were brought:

“The plaintiffs urge that the accommodation uses their plans as vehicles for payments for contraceptives. But that is just what the regulations prohibit. Once the plaintiffs apply for the accommodation, the insurers may not include contraceptive coverage in the plans. The insurers and third-party administrators may not impose any direct or indirect costs for contraceptives on the plaintiffs; they may not send materials about contraceptives together with plan materials; in fact, they must send plan participants a notice explaining that the plaintiffs do not administer or fund contraceptives. The payments for contraceptives are completely independent of the plans. . . The acts that violate their faith are the acts of the government, insurers, and third-party administrators, but R.F.R.A. does not entitle them to block third parties from engaging in conduct with which they disagree.”

And of course, the choices and the rights of third parties, in this instance, the female employees, are the whole point. It is not only that female employees, and not their bosses, make the choice to use birth control. It is that the employers’ religious objections, if honored, would cause these third parties actual harm — harm that would be avoided if the employers simply signed the form or sent the letter. The extreme to which the plaintiffs’ refusal takes their “complicity” argument is what the appeals courts have found so alarming. The organizations don’t want to pay for birth control and they don’t want anyone else to pay for it either.

The United States Court of Appeals for the 10th Circuit had this to say in a decision last week, Little Sisters of the Poor v. Burwell: “Plaintiffs sincerely oppose contraception, but their religious objection cannot hamstring government efforts to ensure that plan participants and beneficiaries receive the coverage to which they are entitled.”

The Religious Freedom Restoration Act, the court said, “does not prevent the government from reassigning obligations after an objector opts out simply because the objector strongly opposes the ultimate goal of the generally applicable law. Plaintiffs’ complicity argument therefore fails. Opting out would eliminate their complicity with the mandate and require only routine and minimal administrative paperwork, and they are not substantially burdened by the government’s subsequent efforts to deliver contraceptive coverage in their stead.”

Writing in The National Catholic Reporter last week, Michael Sean Winters, author of a blog on the publication’s website called Distinctly Catholic, praised the 10th Circuit decision, saying: “If you think the form used to object to participation is itself a form of participation, I am not sure how we, as a nation, can ever carve out religious exemptions.”

Evidently, the religious groups pressing this litigation would rather keep fighting than declare victory. . .

Read the whole thing.

Written by LeisureGuy

23 July 2015 at 9:41 am

The observer effect on surgeon performance

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The idea of grading surgeons, given lower marks whose work produces more post-surgery complications or results in more deaths, seems simple and, on the face of it, valid. But we are familiar with how the presence of an observer can affect the thing observed and change its behavior. Sandeep Jauhar discusses in the NY Times some adverse effects of ranking surgeons:

ONE summer day 14 years ago, when I was a new cardiology fellow, my colleagues and I were discussing the case of an elderly man with worsening chest pains who had been transferred to our hospital to have coronary bypass surgery. We studied the information in his file: On an angiogram, his coronary arteries looked like sausage links, sectioned off by tight blockages. He had diabetes, high blood pressure and poor kidney function, and in the past he had suffered a heart attack and a stroke. Could the surgeons safely operate?

In most cases, surgeons have to actually see a patient to determine whether the benefits of surgery outweigh the risks. But in this case, a senior surgeon, on the basis of the file alone, said the patient was too “high risk.” The reason he gave was that state agencies monitoring surgical outcomes would penalize him for a bad result. He was referring to surgical “report cards,” a quality-improvement program that began in New York State in the early 1990s and has since spread to many other states.

The purpose of these report cards was to improve cardiac surgery by tracking surgical outcomes, sharing the results with hospitals and the public, and when necessary, placing surgeons or surgical programs on probation. The idea was that surgeons who did not measure up to their colleagues would be forced to improve.

But the report cards backfired. They often penalized surgeons, like the senior surgeon at my hospital, who were aggressive about treating very sick patients and thus incurred higher mortality rates. When the statistics were publicized, some talented surgeons with higher-than-expected mortality statistics lost their operating privileges, while others, whose risk aversion had earned them lower-than-predicted rates, used the report cards to promote their services in advertisements.

This was an insult that the senior surgeon at my hospital could no longer countenance. “The so-called best surgeons are only doing the most straightforward cases,” he said disdainfully.

Research since then has largely supported his claim. . .

Continue reading.

In effect, the operation of a grading/ranking system creates perverse incentives that lead to lower quality medical care.

Written by LeisureGuy

22 July 2015 at 10:21 am

Posted in Healthcare, Medical

Good analysis by Aaron Carroll in discussing just how medical is cannbis?

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It’s a valid question, I think. His column in the NY Times begins:

It is becoming easier to get marijuana, legally. In the last 20 years or so, 23 states, as well as the District of Columbia, have passed laws that make it legal to use marijuana for medical treatments. So have some countries, like Austria, Canada, Finland, Germany, Israel and Spain.

Advocates believe that this has allowed many with intractable medical problems to receive a safe and effective therapy. Opponents argue that these benefits are overblown, and that advocates ignore the harms of marijuana. Mostly, opponents say that the real objective of medical marijuana is to make it easier for people to obtain it for recreational purposes.

Both sides have a point. Research exists, however, that can help clarify what we do and don’t know about medical marijuana.

A recent systematic review published in The Journal of the American Medical Association looked at all randomized controlled trials of cannabis or cannabinoids to treat medical conditions. They found 79 trials involving more than 6,400 participants. A lot of the trials did show some improvements in symptoms, but most of those did not achieve statistical significance. Some did, however.

Medical marijuana was associated with some pretty impressive improvements in complete resolution of nausea and vomiting due tochemotherapy (47 percent of those using it versus 20 percent of controls). It also increased the number of people who had resolution of pain (37 percent up from 31 percent). It was shown to reduce pain ratings by about half a point on a 10-point scale, and to reduce spasticity in multiple sclerosis or paraplegia in a similar manner.

Those aren’t insignificant results and they are supported by other studies that have confirmed that marijuana and cannabinoids can help withrefractory pain. But most researchers stress that they should be consideredonly when other therapies have failed.

There’s a little bit of evidence that marijuana might help with anxiety disorders and with sleep. . .

Continue reading.

And so on. And he rightly points out the malign effects of a common prescription drug replaced by marijuana: opioid painkillers, which as he notes have plenty of problems (overdoses, addictions) of their own. Using marijuana in lieu of the painkillers could avoid harm—and, according to evidence, it does indeed reduce harm in that are. In other words, we must consider all the effects of alternative treatments (such as opioid painkillers), rather than considering only the good effects: opioid painkillers come with a high overall cost—including the literal cost:  a patient using opioid painkillers cannot simply grow his own rather than buying prescriptions.

Moreover, alcohol is a very dangerous drug (overdoses, addiction, injuries up to and including death to self and others due to being actively inebriated: all well documented), and quite often the use of marijuana displaces the use of alcohol, another instance of harm avoidance and, given the medical dangers of alcohol (cirrhosis of the liver, for one), certainly should be considered in the context of marijuana’s overall contribution to medicine and healthcare. And Carroll also addresses that issue in another column.

Written by LeisureGuy

20 July 2015 at 11:08 am

Risking Your Health for Your Politics

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It’s interesting that the GOP leaders’ bad-mouthing of the Affordable Care Act has indeed worked to prevent many Republicans from signing up. Seth Masket looks at the phenomenon in Pacific Standard:

One of the big public health stories over the past few years has been the sharp decline in the number of uninsured Americans since the implementation of the Affordable Care Act. This decline has not been even across the United States population, though. We know that poorer people, African Americans, Latinos, and other demographic subgroups have benefited more rapidly from this act than others. But it also turns out that there’s a partisan component: Democrats are benefiting more than Republicans.

As Michael Tesler reported at the Monkey Cage last week, the percent of uninsured who are Democrats has essentially been cut in half over the past two years, while the percent of uninsured who are Republicans has barely budged. One might just dismiss this as a feature of demographics: Democrats tend to be poorer than Republicans and to live in states that have more aggressively adopted health exchanges. Yes, that’s true, but Tesler actually controls for all sorts of demographic factors, including race, income, and state of residence, and still finds a large partisan effect. What’s going on here?

One possible explanation is that Republicans are constitutionally less inclined to seek out a public service until they desperately need it. That would be consistent with some of the anecdotes we’ve seen about people who were opposed to Obamacare on ideological grounds but enrolled in it when a medical crisis hit their family. And conversely, Democrats may be constitutionally more comfortable with signing up for a government service. These differences, that is, may simply reflect the general attitudes of liberals and conservatives toward actions by the government and toward collective action in general.

Even if the government is not involved, after all, insurance is all about pooled money and calculated risk. When you buy health insurance as a healthy person (and if you expect to be healthy much of your life), you accept that a good deal of the money you put in will go to benefit other people. Republicans might simply be more likely to see this as a scam, while Democrats view it as a social responsibility.

Healthgraph
(Source: Michael Tesler/The Washington Post)

But another related explanation for the partisan differences in health insurance enrollments just has to be . . .

Continue reading.

Written by LeisureGuy

20 July 2015 at 10:02 am

Posted in GOP, Government, Healthcare

What schizophrenia is not

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Really, at this point a new name would be better—isolated personality disorder, or the like. Michael Byrne explains at Motherboard:

What schizophrenia is not: A state of being multiple contradictory things at once.

Feel free to chase the etymology of “schizo” all the way to its Greek origins as a prefix meaning roughly “split” or “divided.” And feel free to argue that said roots justify a billion hacky music writers calling songs and albums and bands “schizo” when what they really mean is “different things together.” (Which they will continue to do because they will continue to not have anything better to say than “this song or album or artist has ‘different things together.'”) Send me your dictionary links and examples of historical usages of the non-psychiatric definition of schizo and schism. What about schizocarp and schizogenesis? Surely psychiatry can’t take away my ancient Greek-derived deprecated slang?

No—no it can’t. But understand that by calling the new Kanye West track a“schizophrenic monster” or that Kate Nash album “thrillingly schizophrenic” or some Eminem verse “full schizo Slim Shady mode” you do nothing but hurt and obfuscate. Your misuse of “schizo” and “schizoid” and schizophrenic has only the effect of perpetuating misinformation and stigmatization. And for what?

A shitty metaphor.

A survey conducted in 2007 found that about a third of total uses of “schizophrenic” in the US press involved the metaphorical two-things-at-once slang definition rather a reference to what schizophrenia actually is (or what it is to be schizophrenic). In the German press, that share jumped to nearly 60 percent. And among music reviews, my own unscientific research suggests that the percentage of metaphorical misuse is pretty much 100 percent.

The “schiz” in schizophrenia indeed derives from schism, but not in the classic modern interpretation of cleaving between two oppositional concepts. The schism of schizophrenia is detachment—schizophrenia is very broadly characterized by an inability to correctly interpret sensory input and, in some part, to make sense of the real-world. This has a lot of seemingly disparate manifestations—delusions, hallucinations, extreme social detachment and self-isolation—but it’s basically like being forced to live in the world one step removed. This is the schism.

Patrick House, a neuroscientist at Stanford University, got this exactly right a couple of years ago in a piece for Slate called “Schizophrenic Is the New Retarded.” “The metaphorical use of schizophrenic suggests a rapid and unexpected switch from one extreme state to another, something like an embattled other self breaking through and taking over,” he wrote. “But schizophrenia is not some unexpected polarity, nor is it a disease of fugue-like dissonance or a Jekyll-and-Hyde struggle for control.”

If the whole Jekyll-and-Hyde psychiatric fiction corresponds to anything, it’d be multiple-personality disorder or dissociative identity disorder, a diagnosis thatremains (justifiably) controversial. Schizophrenia is really nothing like that—in the canonical sense, it’s a disease of disordered thinking, a partial inability to separate the signals of the everyday lived world from its noise. If anything, it’s more like being trapped in personality solitary confinement than it is sharing different personalities. A profound and profoundly disabling unrelatability.

Of course, schizophrenia is hardly alone in this problem. See also: Oh I’m just so OCD about my Gmail inbox or I’m just so bipolar! I like junk food and vegetables. Or whatever. These are like the classic tools of cheap hyperbole. . .

Continue reading.

Written by LeisureGuy

18 July 2015 at 9:37 am

Posted in Mental Health, Writing

Kale: Too much of a good thing is bad

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I just learned that the cruciferous vegetables (kale, cabbage, broccoli, brussels sprouts, collards, bok choy) are contraindicated for those who suffer from hypothyroidism, a condition that often develops in women over 40. Flaxseed is also to be avoided. Foods good for those with that condition are seaweed (e.g., seaweed salads, which I love), brazil nuts, macadamia nuts, and hazelnuts, fish, and others.

Tom Philpott has an interesting article in Mother Jones on the dangers of eating large amounts of kale daily: thallium poisoning, such as “Chronic fatigue. Skin and hair issues. Arrhythmias and other neurological disorders. Foggy thinking. Gluten sensitivity and other digestive troubles.” But this is for people who eat a lot of kale—e.g., using a juicer to make a daily glass of kale juice. (I avoid juicing in any case: why avoid the fiber?)

Jennifer Berman also has a column in the NY Times (from 1/1/2014) about the dangers and effects of overindulging in kale:

. . . Imagine my shock, then, at my last physical, when my doctor told me I had hypothyroidism, common in women over 40. When I got home I looked up the condition on the Internet and found a list of foods to avoid. Kale, which I juiced every morning, tops the list, followed by broccoli, cauliflower, cabbage, Brussels sprouts and collard greens — the cruciferous vegetables I consumed in large quantities because they are thought to prevent cancer, which runs in my family. And flax — as in the seeds — high in omega 3’s, that I sprinkled on cereal and blended in strawberry almond milk smoothies. Also forbidden: almonds and strawberries, not to mention soy, peaches, peanuts, corn, radishes, rutabaga and spinach. . . .

Continue reading.

If you find yourself eating a lot of any food, it’s probably a good idea to search for common side-effects or contraindications. Eating a good variety whole foods (not concentrating them by juicing) is a good and conservative approach.

UPDATE: An interesting note from TYD: “Cooking breaks down the goitrogenic compounds and thus it is only the vegetables in raw form that should be avoided by people on synthetic thyroid hormones.”

Written by LeisureGuy

17 July 2015 at 12:10 pm

Posted in Food, Health, Medical, Science

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