The financial wallop of surviving a heart attack

Surviving a heart attack comes with a considerable price tag to patients as well as to their employers.

In a new study presented this week at the American Heart Association’s Scientific Sessions 2012, researchers tallied up the direct and indirect costs of treating a heart attack and other forms of acute coronary syndrome.

Here’s what they found:

- The  average person had $8,170 in health care costs, including out-of-pocket expenses. Although most of the money was spent on hospitalization and medical care, a sizable chunk – $625 – was for pharmacy costs.

- Workers lost 60.2 days of work in the short term and 397 days of work in the longer term.

- The cost to employers of losing the worker’s productivity was $7,943 per claim for short-term disability and $52,473 per claim for long-term disability.

- Hospitalization accounted for three out of every four dollars spent annually on acute coronary syndrome.

What makes this study somewhat unusual is that it focuses almost exclusively on working-age adults under age 65, a population that accounts for just under half (47 percent, to be exact) of all coronary patients yet often is statistically lumped in with older people.

The researchers conducted their analysis using data from Integrated Benefits Institutes’ Health and Productivity Benchmarking Databases and IMS Lifelink. They looked at medical, pharmacy and short-term and long-term disability claims to calculate both the direct and indirect costs for more than 37,000 employees and their dependents from 2007 to 2010. About three-fourths were men, and 95 percent were under age 65.

There’s much that the analysis doesn’t tell us, of course. Women were underrepresented, and it would be interesting to know how they fare. Is it more costly for women to be treated for a heart attack, and do they sustain more or fewer disability-related costs? What about younger heart attack survivors – those under age 55, for instance?

It’s also notoriously difficult to reckon up the emotional cost, both to patients and to their families, during the immediate crisis and lingering aftermath.

But it’s clear from the American Heart Association report that having a heart attack comes with a price that’s steeper than many of us realize.

I was curious to know how the cost of treating a heart attack stacks up against other situations – for instance, cancer or traumatic injury. According to a statistical comparison developed by the National Heart, Lung and Blood Institute (you’ll have to scroll down to the bottom of the linked page to find it), cardiovascular disease accounts for the greatest share, far and away, of annual health care costs in the U.S. It outstripped even cancer and diabetes.

Not every heart attack can be prevented. It’s thought that a large percentage of heart attacks are avoidable, however, and many of the most common risk factors – smoking, sedentary lifestyle, elevated blood pressure and/or cholesterol levels that are poorly controlled – can be modified.

If the impact of a heart attack on their overall health is too hazy or theoretical to motivate people, perhaps the practical implications for their wallet might send a stronger message about the value of doing what they can to reduce their risk.

What price for peace of mind?

The patient is eight years out from treatment for breast cancer and is doing well, but four times a year she insists on a blood test to check her inflammation levels.

The test is pointless and has nothing to do with cancer or its possible recurrence. But what happens when the patient makes the request to the doctor?

“To my shame, I must admit, I order it every time,” writes her oncologist, Dr. James Salwitz (if you haven’t yet discovered his excellent blog, Sunrise Rounds, head over there and check it out).

The test may provide temporary reassurance for the patient. At $18, it isn’t expensive, and it’s considerably less harmful or invasive than other tests. But all the same, it’s useless, and it prompts Dr. Salwitz to ask: What can health care do to stem the practice of tests, procedures and other interventions that have no real benefit to the patient?

He writes:

Medicine is full of better-known examples of useless and wasteful testing. PSA and CA125 cancer markers that fail as screening tests. Analysis indicates they cause more harm than benefit. MRIs for muscular back pain, which will go away by itself. Unneeded EKGs, stress tests and cardiac catheterizations, instead of thoughtful conservative medical management. CT scans often take the place of sound clinical analysis and judgment. A 15-year study of 30.9 million radiology imaging exams published recently shows a tripling in the last 15 years.

These unneeded tests do more than waste dollars. If a test is not necessary and has no medical benefit, it can only cause harm. The test itself can cause problems such as excess radiation exposure, allergic reactions and discomfort. In addition, tests find false positive results, which lead to further useless testing or unneeded treatment.

It’s been rather remarkable to witness the pulling-away from excess tests and treatment that has taken place in American medicine in the past few years. There’s a growing recognition that there’s such a thing as too much intervention and that intervention is not automatically good for patients.

Moreover, we’re becoming more willing to talk openly about the tradeoff of benefit vs. harm. Not all that long ago, it was considered heresy to even suggest that women in their 40s didn’t absolutely need a mammogram every single year. The thinking on this is beginning to change as the evidence accumulates of mammography’s limited benefits for younger, low-risk women, and it’s showing up in patient decisions; a recent study by the Mayo Clinic found a 6 percent decline last year in the number of 40-something women who opted to have a mammogram.

It’s easy to oversimplify this issue, and indeed, it’s not always as straightforward as it seems. Interventions sometimes don’t look useless until they’re viewed afterwards through the retrospectoscope. At the time, in the heat of battle, they may seem necessary and justified. Nor do patients fit neatly into little diagnostic boxes; what may be unnecessary for one might make sense for someone else.

There’s a larger question, though, that we sometimes fail to ask: If something is medically useless, does it still have value if it gives the patient (and perhaps the clinician as well) some peace of mind?

To many patients, this is no small thing. It’s an emotional need that’s not easily met by science-based rational discussion about the studies and the actual evidence for the pros and cons. Unfortunately it’s also often abetted by consumer marketing that plays up the peace-of-mind aspect of certain tests while remaining silent about the limited benefit, the possible risk and the clinical complexity that may be part of the larger picture. The message can be sent that it’s OK as long as it provides the patient with some reassurance, and who’s to say this is entirely wrong?

Should clinicians be tougher about just saying no, then? It may be easier to give in, but does this constitute quality care? An interesting ethics case by the Virtual Mentor program of the American Medical Association explores some of the issues that make this so challenging: the responsibility of the physician to make recommendations and decisions that are clinically appropriate, the importance of respecting the patient’s autonomy and values, the balance between patient preferences and wise use of limited health care resources.

You could argue that patients should be allowed to obtain unnecessary care as long as they pay for it themselves, but does this really address the larger question of resources? Regardless of who’s paying the bill, unnecessary care comes with a cost. The blood test requested by Dr. Salwitz’s patient, for instance, likely would involve the use of equipment such as a disposable needle and lab supplies, staff time to draw the blood, analyze the sample, record the results, report them to the doctor and patient, enter them in the medical record and generate a bill (and I may have skipped a few steps).

Yet it’s not always easy to make this case to patients when what they’re really looking for is that elusive creature known as peace of mind.

Dr. Salwitz writes that he’ll be seeing his patient again soon and will try once again to persuade her that the test she’s asking for has no medical benefit for her. “I will try to replace this test crutch with knowledge, reassurance and hope,” he writes. “Maybe it will help us to understand each other a little better.”

Avoiding the doctor’s office

Somewhere in the midst of the national conversation about health care costs and effective, evidence-based care, Americans started going to the doctor less often.

Surveys and reports have been trickling in for at least three years, documenting a persistent decline in the number of office visits and the slowest spending growth on office-based physician services since 1960.

Just how pervasive this trend has become was summed up last week by American Medical News, which reviewed several studies and found one thing in common: Patients are staying away from the doctor’s office because they’re afraid of being saddled with a large bill.

From the article:

Even two years after the official end of the recession, the studies report patients struggling to handle medical bills, or fearing they won’t be able to handle them. Physicians might not notice the decline on a day-to-day basis – perhaps it’s one or two fewer patients a day – but the numbers add up over time.

The evidence goes contrary to the popular belief that most Americans seek medical care for anything and everything and are spending the health care system into oblivion.

In one of the studies cited by American Medical News, the Centers for Medicare and Medicaid Services found that national spending on health care increased by 3.8 percent in 2009 and 3.9 percent in 2010. This was the lowest in years, and reflects slowdowns in almost every category, from office visits to prescription drugs to hospital procedures.

The decline in office visits isn’t just among the uninsured; it also includes those with health insurance. What’s particularly worrisome, according to a Commonwealth Fund study issued late last year, is that many of the individuals avoiding the doctor’s office are sicker and might not be receiving needed care.

I was interested to learn recently that the we’re-all-spending-less-on-health-care trend apparently isn’t confined to the human species. The American Pet Products Association reported this month that spending on veterinary services in the U.S. is growing only in the single digits and is projected to slow in 2012.

It’s not hard to draw the obvious conclusion: The recession has taken an enormous toll on people’s financial security and they’re attempting to cut costs wherever they can.

I suspect there’s more going on here than simple economics, however, and a recent column at The Health Care Blog more or less reinforces this. In a piece titled “It’s NOT the Economy, Stupid!”, J.D. Kleinke of the American Enterprise Institute writes that health care spending “has been cooling, slowly and steadily, since 2002.”

Oops! Turns out the recession has had nothing to do with a 10-year trend – one driven not by government inaction and then the recession and threat of “ObamaCare” – but by slow, steady, cumulative improvements in medical care and, as importantly, by the introduction of marketplace disciplines into the demand for and purchase of that health care.

Kleinke also posits that what we’re seeing is “health care simply self-correcting, slowly and tediously, nearly a decade after the failure of the great managed care experiment of the 1990s.”

He makes a number of compelling points. I’m not convinced, though, that “marketplace disciplines” are solely responsible for what’s happening. More Americans are uninsured, probably because of increasingly unaffordable premiums and deductibles, the recession or both, and people who are uninsured generally are slower to seek care. I’m also sensing a growing backlash among people who feel health care in the U.S. has become too aggressive and who are becoming more outspoken about the need for a “less is more” approach.

Or maybe what’s really happening is what a Health Care Blog commenter described as “a tired, bloated industry running out of gas.”

Either way, some caution is called for. The decline in physician office visits could be good if it means medical practices are being more efficient about when and how often patients need to be seen, and patients are thinking twice about the necessity of the visit. But it could be not so good if it means people are avoiding or delaying necessary care – and possibly incurring higher costs for problems that are allowed to escalate into something worse.

In health care, cost and utilization are closely intertwined. It’s hard to change one without changing the other. Ideally, there should be a point of equilibrium, but we haven’t found this yet and may not ever reach it. In the meantime, lower cost and utilization do not automatically equate to a healthier population. This seems to be a case of being careful what you wish for.

Getting personal about the cost of care

Health care is very personal, and this includes the financial aspects of how we pay for care.

Costs of Care, a nonprofit organization dedicated to raising the level of awareness about medical decisions and how they affect what the patient pays, has announced the finalists in its second annual essay contest – and I can’t wait to read the entries.

There’s the story of Renee Lux, a patient from Connecticut who received an unnecessary CT scan for neck pain and ended up being branded with a pre-existing condition that caused her health insurance premiums to go up.

There’s Melody Chung of California, whose mother underwent a barrage of diagnostic tests for fleeting chest pain and was charged an unexpectedly high bill.

There’s Molly Kantor, a medical student in Massachusetts who helped treat heart failure on a $100 budget by avoiding an unnecessary hospital admission.

Winners of the essay contest will be announced in mid-January. Entries will appear on the Costs of Care blog throughout 2012.

This is the second year Costs of Care has sponsored the national essay contest. More than 100 entries were submitted from across the U.S. The distinguished panel of judges includes C. Everett Koop, former U.S. Surgeon General; Peter Orszag, former White House budget director; Jennifer Granholm, former governor of Michigan; women’s health advocate Dr. Susan Love; and Alan Garber, Harvard University provost and health economist.

In the intense, ongoing national conversation about the cost of health care, it’s easy for individual stories to become lost in a sea of statistics and arguments. The personal stories are a reminder that this issue is more than academic; it’s about real lives and real people. Watch this space for the announcement of the essay contest winners next month.

Taking our medicine

Apparently even the promise of no co-payments isn’t enough to entice some patients to take their medication.

For those who missed it yesterday, a new study reported that when a group of heart attack survivors was offered prescription medication fully covered by their health plan, fewer than half took the drugs. In fact, the researchers struggled to even get enough people signed up to take part in the study.

Coverage by the Associated Press produced what surely must be the health care quote of the month, from one of the researchers who was involved in the study: “My God, we gave these people the medicines for free and only half took it.”

A quick summary: The study involved 5,855 adults who had recently been hospitalized with a heart attack and who had been prescribed one or more medications afterwards to lower their risk of another cardiac event. About half of them were prescribed preventive medications with no out-of-pocket costs; the rest were given prescriptions with the usual co-pay. At the end of one year, fewer than half of the patients overall were actually filling their prescriptions – and there were only minor differences in the adherence rate between those who had a co-pay and those who didn’t.

So what is up with that? Are patients so unwilling to comply with taking their prescribed medication that they can’t even be motivated by free drugs?

That’s certainly one way to interpret this study. But I suspect there’s more going on here than a straightforward case of collective noncompliance.

Adhering to a medication regimen involves multiple, interrelated steps. For starters, patients have to buy into the notion that they need medication and that it will somehow benefit them. They have to fill the prescription at the pharmacy. They have to remember to take the drugs each day, and take them correctly. They have to remember to get refills. They might have to deal with unwanted side effects. Adherence can go off the rails at any one of these critical points.

Although it’s often assumed that cost is a major influence on whether patients get their prescriptions filled, the NEJM study suggests that it perhaps isn’t as important as other factors – and that if clinicians want to devise effective strategies to encourage adherence, they need to do more than address the money angle.

I’m aware of at least one study that found a surprisingly basic reason for why some patients don’t take their medication: They simply don’t like the idea of taking a lot of pills each day.

It would be interesting to know the extent to which psychology might be contributing to medication non-adherence. The patients in the NEJM study had all recently had a heart attack. On average, they were 53 years old. Among at least some of them, perhaps their vision of themselves was that they were mostly healthy. Perhaps they weren’t emotionally ready yet to accept that their health had changed or that they were going to need medication for the rest of their life.

On top of this, there are strong American cultural attitudes about aging and infirmity. We tend to regard disease as a burden on society and often blame the sick for “not taking better care of themselves.” Should we be surprised when people resist taking prescription medication because, consciously or not, they don’t want to be perceived as one of those sick, costly individuals?

The study in the New England Journal of Medicine did reinforce that when patients stuck with their medication regimen, they were less likely to have a second cardiovascular event. Overall, health care costs for these people also were somewhat lower. The savings weren’t huge but then again, it often can take years to see a measurable payoff from this kind of health intervention, and the study wasn’t designed to track long-term results.

Did the elimination of co-pays help some patients more than others? It’s probably safe to assume that it did, at least among those for whom cost was the main barrier. For other folks, though, it’s clearly going to take more than this to raise the adherence rate. A better understanding of both the practical and emotional issues involved might be a good place to start.

Getting personal about the cost of care

Even being a doctor doesn’t necessarily make you immune to hassles about health care costs, as Dr. Jeffrey Rice, chief executive of Health Care Blue Book, described recently at the Costs of Care blog.

Dr. Rice’s 12-year-old son needed to undergo relatively minor surgery on his leg. The family had a high-deductible health plan and wanted to know in advance what it would cost.

Dr. Rice explains:

I called the hospital to request a price for the surgery and they said they couldn’t really tell me. They offered to send the procedure codes to an external reviewer who would provide a general idea of the anticipated charges. Three days later the answer came back at $37,000. I reiterated that I had high deductible insurance and needed to know the actual price they would bill me after an insurance adjustment to the network fee schedule.

The hospital next referred me to my insurance company. The insurance company referred me to their PPO network. The PPO network said that they could not reveal the prices until after the case was performed.

Health care consumers are often criticized for not thinking about the cost before seeking care. But when doing your homework involves negotiating an obstacle course worthy of the Green Berets, it’s not hard to see why many people give up after encountering the first few barriers – or worse yet, don’t even try.

Luckily Dr. Rice was persistent. He decided to ask the surgeon if the procedure could be done at an independent ambulatory surgical center. The answer was yes. “One phone call and 10 minutes later I have the exact price for his surgery – $1,515,” Dr. Rice wrote. “My son had his surgery and is doing well. We got a fair price because we demanded more of the system.”

Stories like these are a real-life example of how cost intersects with the care patients receive and how challenging it can be to link the two in a meaningful way.

Costs of Care, a nonprofit organization based in Massachusetts, is looking for stories about the cost of care for its second annual essay contest.

Consumers and providers are invited to submit personal anecdotes illustrating how cost awareness led to high-value care and/or cost savings, or how a lack of cost awareness led to an unexpectedly high bill or difficulty figuring out what a test or treatment would cost.

Four $1,000 prizes will be awarded to the winners. The contest deadline is Tuesday, Nov. 15. Finalists will be announced Dec. 15; the winners will be announced Jan. 15. Click here to read more about the contest rules and how to submit an entry. And watch this space for contest updates and links to the winning entries.

For what it’s worth, I don’t buy the argument that it’s too difficult for health organizations to give patients an estimate ahead of time for what their care will cost. Here in Willmar, Minn., Rice Memorial Hospital has been doing this for the past year with the help of a software tool called CarePricer. By all accounts, it’s quite accurate, even taking into account how much of the patient’s deductible has already been met for the year. I’ve heard anecdotally from hospital staff that in a few cases, patients have decided to delay elective surgery after learning what their out-of-pocket costs would be. It takes work to put this kind of process into place but clearly it can be done, and done successfully.

Risky business

As I sat in a corner of the waiting room and perused the consent form, alarming words and phrases leaped out at me. “We cannot guarantee…” ”… rare complications…” ”… risk of death…”

It made me seriously wonder if I was making a mistake by subjecting my cat to anesthesia in order to have her teeth cleaned.

In the end, the risk seemed small and not enough to outweigh the benefits. But just the same, I handed her over to the veterinary tech with a pang of misgiving. Even a small risk doesn’t mean there’s no risk at all. If complications are going to happen, who says it won’t happen to you?

When you get right down to it, much of health care decision-making involves a series of calculated risks, a complex set of tradeoffs. This treatment for that benefit. This medication for a reduction in the chances of having a heart attack. These antibiotics, and the side effects that go with them, in exchange for getting rid of a bacterial infection. This conservative watch-and-wait approach vs. prompt and possibly unnecessary (and expensive) intervention. This risky surgery in hopes of saving the patient’s life.

Yet how we perceive risk vs. benefit often tends to be highly subjective. What some people view as reasonable might be viewed by others as too aggressive or perhaps not aggressive enough.

I’m eagerly waiting to get my mitts on Dr. Jerome Groopman’s latest book, “Your Medical Mind.” Co-written with Dr. Pamela Hartzband, it’s subtitled “How to Decide What Is Right for You” and explores how our beliefs, values and past experiences help shape the health care choices we make. (A review of the book appeared last weekend in the New York Times.)

Are you a minimalist who prefers to avoid procedures and pills unless they’re totally, absolutely necessary? Or do you believe in seeking out the latest technology or treatment that science can offer?

People can be unconsciously swayed by factors they might not even recognize – pharmaceutical marketing that plays up the effectiveness of a new drug, for instance, or a relative’s previous frightening experience with a surgical procedure that went awry. Over the years I’ve had other cats who had to be lightly anesthetized for a dental cleaning. They emerged a little bit woozy but were safe and sound and soon recovered. This helped reinforce that it was an acceptable risk to take. My perception might have been entirely different if I’d had the experience of losing a cat who stopped breathing under sedation.

We are not, in fact, entirely rational in how we assess our health risks. Via MinnPost, I came across an article from Discover magazine that delves into the conflict between our gut and our brain. Author Jason Daley describes how we fear rare threats while downplaying risks that are far more real:

A whole industry has boomed around conquering the fear of flying, but while we down beta-blockers in coach, praying not to be one of the 48 average annual airline casualties, we typically give little thought to driving to the grocery store, even though there are more than 30,000 automobile fatalities each year.

One of Daley’s points seems especially valid in the current health care environment: We tend to gravitate toward that which confirms the optimistic beliefs we already hold.

For an example of this, look no further than screening for prostate cancer. The screening is common, it’s widely thought by the lay public and many doctors to be beneficial in catching prostate cancer in its early stages, and the belief is that it saves lives. But when you look closer, it turns out that, statistically speaking, the survival benefit isn’t particularly strong. Furthermore, aggressive screening has led to overtreatment, side effects and complications among men who could equally well have taken a watch-and-wait approach – or skipped the screening altogether.

When we’ve long held the belief that prostate cancer screening saves lives, however, it’s a hard pill to swallow that this isn’t the intervention we thought it was.

There’s sure to be a storm of controversy this week when the U.S. Preventive Services Task Force formally issues a new recommendation against routine annual prostate cancer screening for older men. In fact, the controversy has already begun with salvoes fired here, here and here. It’s all very reminiscent of a similar firestorm two years ago when the USPSTF recommended against routine mammograms for women in their 40s, saying there wasn’t enough evidence to support that routine screening saves lives and that mammograms for women in this age group should be made after weighing the pros and cons with their doctor.

Life would be easier if health care decisions were straightforward: Yes, this intervention will help; no, this prescription won’t help. Emotions, values and individual health history, coupled with the actual evidence (or lack thereof), make for a complicated tangle of factors to consider. We seem to slowly be coming to a realization, though, that overtreatment is as undesirable as undertreatment, and that some risks pay off while others may not. Making health-related decisions is a risky business that deserves to be approached with as much rationality as we can muster.

Scrimping on health care

More Americans are skipping doctor visits and scrimping on prescription drugs to save money, a new survey has found.

The survey, released today by the Consumer Reports National Research Center, found that the percentage of people who reported cutting corners on their health care rose from 39 percent to 48 percent over the past three years. The poll was conducted this past June and involved a representative sample of 1,200 adults.

The findings reinforce what many observers have been saying all along: Consumers are pressured by health care costs and some of them are opting to delay or forego care, perhaps unwisely.

- 21 percent of the survey participants said they had delayed seeing a doctor because of the cost.

- 16 percent didn’t fill a prescription.

- 12 percent skipped a scheduled dose without first discussing it with their doctor or pharmacist. (The poll unfortunately wasn’t designed to examine whether those who reported skimping on care ended up with health consequences down the road.)

- Survey respondents in lower income brackets were more likely to cut corners than those who earned more.

- Although generic drugs are cheaper than name-brand versions and their use is widespread, 41 percent of the respondents said their doctor only sometimes – or never – recommended a generic. The survey also uncovered misconceptions about generic drugs; nearly 40 percent of the participants expressed concerns about the safety and effectiveness of generic drugs, suggesting a need for more education on this front.

- In most cases, the cost of prescription drugs was not discussed during the visit with the doctor. Two-thirds of the survey respondents didn’t know what their medication would cost until they picked it up at the pharmacy.

- The majority of those surveyed said they were concerned about the influence of the drug industry on physicians’ likelihood to issue prescriptions – but it appears patients also can be swayed by drug advertising. Eighteen percent of the respondents said they had asked their doctor to prescribe a drug they saw advertised, and the majority of the time they received it.

What can patients do to ensure they’re spending wisely on prescription medications? Consumer Reports offers some advice: If you’re concerned about the cost, bring it up with the doctor, especially if it involves a medication you’ll need to take long term. In many cases you might be able to substitute with a generic. Pharmacies also can help with discounts, or help connect you with programs that offer lower-cost prescription medications.

The Consumer Reports survey doesn’t let clinicians off the hook either, noting that they need to be more aware of the financial impact of their decisions. Some studies in fact suggest that nine out of every 10 health care dollars spent in the United States is ultimately determined by health care providers rather than by patients.

Although this survey underscores how cost-conscious many people are when it comes to health care, it makes another point that’s subtle but important: When consumers pay more out of pocket for health care, it might force them to think twice before spending the money but it doesn’t guarantee they’ll be smarter or more well-informed, or that they’ll make better choices. Furthermore, what looks like a short-term cost saving could turn out to be more expensive in the long run, particularly if people are skipping medications they truly need. If the Consumer Reports poll is any indication, there’s still considerable work to be done on how we approach the entire monster issue of health care costs.

A toxic place to work?

Talk about ironic: A new survey suggests that many hospital employees don’t practice what they preach when it comes to staying healthy.

The survey, conducted by the Thomson Reuters consulting group and released this week, found that health care spending for hospital workers was 10 percent greater than for the U.S. workforce as a whole. Hospital employees also were more likely to have chronic medical conditions such as asthma, diabetes, high blood pressure and congestive heart failure.

The report is based on an analysis of health care costs and utilization by 1.1 million hospital employees and their dependents who had employer-based coverage.

I’m not sure what to think of these findings. Are people who work in hospitals really less healthy than everyone else? Or is the real issue that hospitals often are stressful, unhealthy places for people to work?

I once spent a day shadowing a registered nurse. She was on her feet almost all day and barely even had time for lunch.

Multiple studies have documented the occupational stress nurses face every day and the toll it takes on them. Many observers believe the stress is only increasing as the work load intensifies, putting nurses at greater risk of burnout and chronic disease.

But it’s not just nurses who work in stressful conditions. It would be hard to find a hospital employee anywhere these days, from the kitchen to the intensive care unit, who isn’t feeling the pressure to do more with less, to be more efficient and deliver safe, quality services while reimbursement continues to be ratcheted down.

Despite a mounting body of evidence that 12-hour and rotating shifts are associated with fatigue, decreased physical and mental functioning and even lower life expectancy, these schedules are still commonplace at many U.S. hospitals.

Fast meals, often grabbed on the go from a vending machine, can become the norm during a busy day. Even eating in a hospital cafeteria isn’t necessarily the better option, especially when menus are designed to appeal to visitors rather than the workers who eat there every day.

Put it all together and it should no longer be surprising that hospital employees statistically comprise one of the least healthy occupational groups.

When the University of Michigan tackled an initiative in 2002 to develop a wellness program at Allegiance Health in Jackson, Mich., the researchers’ baseline assessment found some of the unhealthiest workers they’d ever seen. Only half of the employees who underwent the assessment were considered low risk; 19 percent were classified high risk.

All of this is to say that it’s usually not enough to tell people they should shape up. The environment must support this as well.

I had the opportunity recently to visit with a couple of local employers about some of the changes they’ve adopted to encourage better food choices and more physical activity among their workforce during the work day. They haven’t been draconian about it; employees can still get a candy bar from the vending machine if they’re really craving a Milky Way. But both these organizations – Affiliated Community Medical Centers and West Central Industries – have become more intentional in their policies and practices: smaller portions for catered meals, more low-fat entrees and fresh fruit and vegetables in the cafeteria, fewer high-calorie snacks in the vending machines, walking programs that encourage employees to log some exercise time each day.

Studies to date have shown mixed results on the benefits of employee health initiatives. The payoff – healthier workers and lower health care costs – generally isn’t immediate; in fact, costs can rise in the short term as issues such as high blood pressure are identified and treated. Corporate wellness initiatives seem to work best when they target the workforce as a whole, not just those who are deemed at risk. They can also be counterproductive if workplace hazards and other environmental barriers aren’t dealt with first.

The lesson here, it seems, is that wellness doesn’t begin and end at home. If we want hospital workers to be healthier, part of the solution will have to come from their employers.

Photo: Wikimedia Commons

Rethinking hospital readmissions

There’s long been a belief that hospital readmissions are largely preventable, and that if a patient is readmitted after an earlier hospital stay, it’s a sign of lower-quality care. In recent years, hospitals in the U.S. and elsewhere have poured untold amounts of time and resources into lowering their readmission rates.

A new study from Canada has come along to challenge this thinking. The study, which appeared this week in the Canadian Medical Association Journal, analyzes emergency readmissions among 4,800 patients at 11 hospitals in Ontario and concludes that only about one in five could have been prevented.

Moreover, the researchers learned that the number of readmissions may be lower than previously thought. In this particular study, 13.5 percent of patients in the sample group had an urgent, unplanned readmission within six months after a hospital stay.

One study doesn’t make a trend. For one thing, the analysis didn’t include patients who were readmitted after being discharged to a nursing home and who may have been older, more frail and more vulnerable. For another, the determination of whether an admission was avoidable was to some extent subjective.

But it certainly calls into question the widespread belief, especially among health policy folks, that readmissions are a reliable indicator of whether a hospital is “good.” It also challenges the assumption that readmissions can be avoided if only hospitals work diligently and hard enough.

Among the many nuggets of information in the Canadian study: The majority of patients who had an urgent readmission were more likely to have chronic or serious health conditions and a history of previous hospital admissions than the sample group as a whole.

There appeared to be multiple reasons why these patients had to be readmitted. Case reviewers found that some readmissions were obviously avoidable but others were less clear-cut. Errors in patient management were among the most common factors. So were surgery-related complications and medication-related issues. Some patients were readmitted because they developed a hospital-associated infection, others because there was a diagnostic error during their initial hospital stay.

One point worth noting: Readmissions that were deemed preventable mostly occurred within a few days after the patient left the hospital. This could suggest many things – for instance, that this subset of patients was perhaps simply more sick to begin with, or not quite ready yet to be sent home.

Another crucial point: The case reviewers couldn’t always clearly determine whether a readmission was truly avoidable and often needed more information before classifying it as preventable or not.

Dr. Carl van Walraven, a clinical epidemiologist at the Ottawa Hospital Research Institute and lead author of the study, told the Ottawa Citizen, “Not all urgent readmissions are avoidable, despite the care that is provided. This means that a lot of them are caused by a patient’s condition, or other factors that are not treatable or modifiable.”

The use of metrics, or statistically measurable indicators of hospital care, is widespread in the industry. Increasingly, the federal government, payors and quality assurance organizations are tieing metrics to how much hospitals are paid – more money for hospitals who meet the standard, less for those that don’t. But what if the metrics are based on faulty assumptions, i.e. that most unplanned readmissions are avoidable?

If anything, this study seems to underscore how difficult it is to define and measure quality in health care. Can every pressure ulcer be prevented? Perhaps not, although the most serious pressure ulcers are probably avoidable and the goal should be to make them a very rare occurrence. Much more can be done to lower the rate of hospital-acquired infections but it may not be possible to get down to zero.

This isn’t to say that high-quality hospital care doesn’t matter, because it does. But hospitals deal with sick human beings in all their infinite variety and the results aren’t always standard or predictable. The risk with metrics is that they can reduce the definition of quality to “that which can be measured” instead of the complex, nuanced, many-faceted creature that seems to be emerging the more we study it.

Photo: Wikimedia Commons