Posts Tagged ‘United States’

How can you know your child's in a good PICU? — assessing quality of care

September 20, 2008  |  General  |  No Comments

There are about 400 PICUs in the United States. It is hard to know the exact number because, although several organizations have proposed standards, these facilities are self-identified. So a hospital is free to designate a place as a PICU and paint the letters on the door to it. How can you tell if your child is in a good one? Of course you can use the general reputation of a hospital to decide — a recognized children’s hospital will most likely have a good one — but are there any reliable measures of quality?

The question of quality of care (and the related one of getting good value for our healthcare dollars) should revolve around outcomes — how did the patients fare? After all, that’s the bottom line. However, that question can be difficult to answer, and the reason for that difficulty relates to our essential humanity — we are all unique. Thus the same treatment applied to different persons, even if they have the same disease, can yield different results, because no two individuals truly have the “same” disease — it expresses itself differently in each of us. Still, we can’t use this uniqueness to dodge the issue; clearly, some things work and some things don’t, and some facilities do them better than others. How can we sort them out?

A huge issue for outcomes research is case-mix. That is, the only way to compare how one PICU does with another is if the patient populations are nearly exactly the same. If they aren’t, it’s not a fair comparison. We generally can compare very large PICUs with each other because they care for so many children that small case-mix differences wash out. But that may not be not true for smaller ones, and even among the large ones there are differences in the sort of children they serve.

Since outcome research is so hard, what is often done is to use a proxy for it, something called a process marker. The notion is that one can monitor how a hospital is following a recommended process, such as standard procedures for immunizations. If the hospital is doing well at that, by assumption it probably is doing well at other things. But that is an assumption, although there is research to support it. You can find examples of this here and here, at the National Quality Measures Clearinghouse.

One of the most rigorous outcome measurement programs is in the area of organ transplantation. This is because the organization that regulates how precious organs are used demands that all hospitals submit reports of how well their patients are doing. You can even read and compare these for yourself here. There are still problems of case-mix, since hospitals vary in choosing precisely what patients they will transplant, but overall the system gives great transparency to what is happening to patients.

So back to the original question: how can you know a PICU is a good one? If you dig (and have the time), you can find out how well a hospital does with complicated, planned procedures like organ transplants or heart surgery. But most children land in a PICU from some acute, unplanned condition. In that case all a parent can realistically do is check the credentials of the facility (such as here) and of the doctors (such as here and here). One day we will have more, since both the public and those who pay the medical bills — insurance companies and governmental agencies — are rightly demanding it.

How can you know your child’s in a good PICU? — assessing quality of care

September 20, 2008  |  General  |  No Comments

There are about 400 PICUs in the United States. It is hard to know the exact number because, although several organizations have proposed standards, these facilities are self-identified. So a hospital is free to designate a place as a PICU and paint the letters on the door to it. How can you tell if your child is in a good one? Of course you can use the general reputation of a hospital to decide — a recognized children’s hospital will most likely have a good one — but are there any reliable measures of quality?

The question of quality of care (and the related one of getting good value for our healthcare dollars) should revolve around outcomes — how did the patients fare? After all, that’s the bottom line. However, that question can be difficult to answer, and the reason for that difficulty relates to our essential humanity — we are all unique. Thus the same treatment applied to different persons, even if they have the same disease, can yield different results, because no two individuals truly have the “same” disease — it expresses itself differently in each of us. Still, we can’t use this uniqueness to dodge the issue; clearly, some things work and some things don’t, and some facilities do them better than others. How can we sort them out?

A huge issue for outcomes research is case-mix. That is, the only way to compare how one PICU does with another is if the patient populations are nearly exactly the same. If they aren’t, it’s not a fair comparison. We generally can compare very large PICUs with each other because they care for so many children that small case-mix differences wash out. But that may not be not true for smaller ones, and even among the large ones there are differences in the sort of children they serve.

Since outcome research is so hard, what is often done is to use a proxy for it, something called a process marker. The notion is that one can monitor how a hospital is following a recommended process, such as standard procedures for immunizations. If the hospital is doing well at that, by assumption it probably is doing well at other things. But that is an assumption, although there is research to support it. You can find examples of this here and here, at the National Quality Measures Clearinghouse.

One of the most rigorous outcome measurement programs is in the area of organ transplantation. This is because the organization that regulates how precious organs are used demands that all hospitals submit reports of how well their patients are doing. You can even read and compare these for yourself here. There are still problems of case-mix, since hospitals vary in choosing precisely what patients they will transplant, but overall the system gives great transparency to what is happening to patients.

So back to the original question: how can you know a PICU is a good one? If you dig (and have the time), you can find out how well a hospital does with complicated, planned procedures like organ transplants or heart surgery. But most children land in a PICU from some acute, unplanned condition. In that case all a parent can realistically do is check the credentials of the facility (such as here) and of the doctors (such as here and here). One day we will have more, since both the public and those who pay the medical bills — insurance companies and governmental agencies — are rightly demanding it.

The safe transport of critically ill and injured children

July 3, 2008  |  General  |  No Comments

Critically ill or injured children often develop their problems far from where they need to be in order to get the care they need. A common scenario is for a child to be brought initially to a facility such as a general community hospital, where they are stabilized and receive initial therapy. Following this, however, they often need transport to a larger facility with specialized resources, such as a children’s hospital. To get there they need to ride in an ambulance, an airplane, or a helicopter. Are there risks to that? Unfortunately, although the risks are small, they are real. A recent collision of medical evacuation helicopters in Arizona, one of nine such mishaps thus far this year, has the National Transportation Safety Board concerned.

How common are accidents with pediatric transports? A 2002 survey of all pediatric transport teams in the United States asked if they had suffered any accidents in the preceding five years — 42% of the teams had. These included 9 aircraft crashes and 57 ambulance accidents. To judge transport risk, of course, we need to know a key piece of information — the total number of transports — and this number is unknown. We do know that there were about 150 pediatric transport teams in the country at the time, and a typical team does around a hundred transports each year. Thus I calculate the accident risk to be somewhere around 0.05-0.1%. This isn’t a big number, but it does indicate a real risk.

Fifteen years ago I founded and subsequently ran for nearly a decade a pediatric transport program, during which time I made quite a few flights in both fixed-wing aircraft and in helicopters. I quickly learned how difficult that work environment can be for the medical team. Our team suffered one accident, the result of engine malfunction with our helicopter; fortunately, no one was injured, but the incident underscored for all of us the risks of the process. (I don’t do that any more, but I continue to be a member of the Transport Section of the American Academy of Pediatrics.)

From a patient-care perspective, the main advantage of helicopter transport versus ground ambulance is speed (fixed-wing aircraft transports are a bit separate, being typically used for long-range transports over hundreds of miles). Speed is especially important for severe trauma cases. The principal disadvantage of a helicopter, compared to an ambulance, is that the former is a very difficult environment in which to work; it is noisy, cramped, and often buffeted about in the air.

In spite of the risks of transport, specially-trained pediatric transport teams are an important component of all regionalized pediatric critical care systems. If your child’s doctor recommends this for your child, the slight risk of the trip is far outweighed by the benefits of getting your child to the people best equipped to care for her.

It's official: rising health care costs are killing us

November 11, 2007  |  General  |  No Comments

If they’re not exactly killing us, they will eventually kill the economy. Everyone knows that health care costs are rising, generally much faster than the inflation rate. Many reasons are given for this, including such things as increased costs for medications, the cost of litigation (this one is influenced by whether or not you think there is a “malpractice crisis”), the aging of our population, and the built-in inefficiencies of the insurance industry. Whatever the reasons, though, a recent and telling study by the Congressional Budget Office lays out what most of us already knew: “The long-term fiscal balance of the United States will be determined primarily by the future rate of growth of health care costs . . . .”

We simply cannot sustain a rate of health care spending that is rising faster than the cost of anything else in the economy. In a way, we are victims of our own success in devising new medicines and treatments. But if nothing changes the CBO predicts that by the year 2050 health care would consume 20% of the national economy, a proportion which today is that of the entire federal budget. Clearly, something has to give. What will it be?

The only way I can see for this mess to get fixed is for everyone to agree there is a huge problem that is nobody’s entire fault — it is consumer demand that has largly driven the whole thing. We did it. So we have to dampen that demand in some way. How to do this? I fear ultimately it will come with draconian and inevitably soulless bureaucratic rules. But is doesn’t have to be that way. Each of us has the power to realize that when we demand a new medical service that hasn’t really been shown to work any better than cheaper ones, and when we insist on services shown to be of only marginal benefit, we are robbing from everyone else, especially our children who will be left with the bills. Equally important, when we demand expensive care for ailments that we largely caused in ourselves we are doing the same thing.

We are all a community. We need to solve this problem as a community.

It’s official: rising health care costs are killing us

November 11, 2007  |  General  |  No Comments

If they’re not exactly killing us, they will eventually kill the economy. Everyone knows that health care costs are rising, generally much faster than the inflation rate. Many reasons are given for this, including such things as increased costs for medications, the cost of litigation (this one is influenced by whether or not you think there is a “malpractice crisis”), the aging of our population, and the built-in inefficiencies of the insurance industry. Whatever the reasons, though, a recent and telling study by the Congressional Budget Office lays out what most of us already knew: “The long-term fiscal balance of the United States will be determined primarily by the future rate of growth of health care costs . . . .”

We simply cannot sustain a rate of health care spending that is rising faster than the cost of anything else in the economy. In a way, we are victims of our own success in devising new medicines and treatments. But if nothing changes the CBO predicts that by the year 2050 health care would consume 20% of the national economy, a proportion which today is that of the entire federal budget. Clearly, something has to give. What will it be?

The only way I can see for this mess to get fixed is for everyone to agree there is a huge problem that is nobody’s entire fault — it is consumer demand that has largly driven the whole thing. We did it. So we have to dampen that demand in some way. How to do this? I fear ultimately it will come with draconian and inevitably soulless bureaucratic rules. But is doesn’t have to be that way. Each of us has the power to realize that when we demand a new medical service that hasn’t really been shown to work any better than cheaper ones, and when we insist on services shown to be of only marginal benefit, we are robbing from everyone else, especially our children who will be left with the bills. Equally important, when we demand expensive care for ailments that we largely caused in ourselves we are doing the same thing.

We are all a community. We need to solve this problem as a community.