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Emergency Medicine, Health Costs, Health Disparities, Pediatrics, Research, Stanford News

ER visits for U.S. newborns show racial disparities

ER visits for U.S. newborns show racial disparities

Haiti Earthquake“Baby’s first trip to the ER” is probably one photo that no one ever wants to put in a baby book. But a surprising number of newborns – 320,000 each year – visit an emergency department within their first month of life. For reasons that are likely a complex mix of socioeconomic and biological factors, black newborns across the U.S. are more than twice as likely to make the trip.

Henry Lee, MD, an assistant professor of pediatrics at Stanford, broke down the stats of how often newborns end up in the emergency department and looked at race, age and insurance status. In collaboration with researchers at the University of California-San Francisco, Lee analyzed data from nationwide emergency room visits collected by the National Center for Health Statistics. The study appears in the May issue of the journal Pediatric Emergency Care.

The researchers found that 14.4 percent of black babies visited the emergency department, compared to 7.7 percent of Hispanic babies and 6.7 percent of white newborns. Some trips to the ER are unavoidable, such as when a baby has an infection or isn’t gaining weight. But it’s likely that some of these visits could have been prevented.

All babies must get a checkup within several days of being born. But if the delivering doctor failed to counsel the new parents about checkups – or if the doctor missed a common problem, such as jaundice – then the new family might end up in the ER instead of at a clinic. In addition to representing a lack of continuity of care for the newborns, these visits drive up health-care costs.

Additional studies may tease apart the factors that cause black newborns to end up in the emergency room more often than other groups, and to find ways to reduce spending on health care while providing better services.

“Improving the quality of care for this higher-risk group could also help to improve disparities and outcomes as well,” Lee said.

Patricia Waldron is a science writing intern in the medical school’s Office of Communication & Public Affairs.

Previously: Decreasing demand on emergency department resources with “ankle hotline” and Speed it up: Two programs help reduce length of stay for emergency-room visitors
Photo by Olav Saltbones / Norwegian Red Cross

Health Costs, Health Policy, Podcasts, Stanford News

Considering the costs of treatment while making clinical decisions

Considering the costs of treatment while making clinical decisions

The headline of the front page New York Times article caught my attention: “Cost of Treatment May Influence Doctors.” The piece read in part:

Saying they can no longer ignore the rising prices of health care, some of the most influential medical groups in the nation are recommending that doctors weigh the costs, not just the effectiveness of treatments, as they make decisions about patient care.

The shift, little noticed outside the medical establishment but already controversial inside it, suggests that doctors are starting to redefine their roles, from being concerned exclusively about individual patients to exerting influence on how health care dollars are spent.

In reading further, I discovered that one of Stanford’s cardiologists, Paul Heidenreich, MD, was a c0-chair of the policy review that led to new guidelines from the American College of Cardiology and the American Heart Association. I thought it would be interesting to delve deeper in a 1:2:1 podcast with Heidenreich about why, as he told the Times, “we couldn’t go on just ignoring costs.” Did escalating health-care costs that are consuming GDP spur the action? Are these guidelines a threat to individual decision-making between a physician and patient? And, what role do patients have in these decisions? Shouldn’t they be included in potential key life-and-death verdicts?

I was also especially intrigued by a quote from the societies’ paper outlining the changes: “Protecting patients from financial ruin is fundamental to the precept of ‘do not harm.’ ” Hmm… a new take on the Hippocratic Oath that I’ve never considered.

Why the new guidelines?  Just consider for a moment the iconic rock lyrics of Bob Dylan. They say it all:

Come gather ’round people
Wherever you roam
And admit that the waters
Around you have grown
And accept it that soon
You’ll be drenched to the bone
If your time to you
Is worth savin’
Then you better start swimmin’
Or you’ll sink like a stone
For the times they are a-changin’

Previously: Personal essays highlight importance of cost-conscious medical decisions and Educating physicians on the cost of care

Dermatology, Health Costs, In the News, Research, Stanford News, Videos

Stanford dermatologist tackles free drug samples on NewsHour

Stanford dermatologist tackles free drug samples on NewsHour

Last week, my colleague reported on a new Stanford study showing that free drug samples lead to more expensive prescriptions. Over the weekend, dermatologist Al Lane, MD, senior author of the study, appeared on PBS NewsHour to discuss the implications of his findings. (He’s also quoted in a New York Times blog post on the research.) After mentioning that pharmaceutical companies spend more than $6 billion a year on sampling, he told NewsHour’s Hari Sreenivasan “that [this] cost eventually has to be paid by someone.” And he closes on a powerful note:

One of the focuses of our study was for the dermatologists to realize that although they think they’re helping the patients, they’re really being manipulated to write for more expensive medications with no proven benefit of those medications over the generic drugs.

Previously: Drug samples lead to more expensive prescriptions, Stanford study finds

Dermatology, Ethics, Health Costs, Research, Stanford News

Drug samples lead to more expensive prescriptions, Stanford study finds

Drug samples lead to more expensive prescriptions, Stanford study finds

drugs on money - big

It’s been years (fortunately) since I’ve needed a prescription for anything more than a simple antibiotic. But when I did, I remember I was always thankful on those occasions when my doctor offered a free sample of a medication to try before (or sometimes instead of) pulling out the prescription pad. I appreciated the chance to see if a medication would work for me, and I was happy for any opportunity to save myself (or, at times, my insurance company) a few dollars. The fact that the samples were invariably for drugs that were still on patent (known as brand name drugs or branded generics) to a particular company certainly escaped me.

Now, a study by Stanford dermatologist Al Lane, MD, highlights the dark side of such free samples, which are provided to doctors by the pharmaceutical companies who make the drugs. The research, along with an accompanying editorial, is published today in JAMA Dermatology. As Lane comments in my release on the work:

Physicians may not be aware of the cost difference between brand-name and generic drugs and patients may not realize that, by accepting samples, they could be unintentionally channeled into subsequently receiving a prescription for a more expensive medication.

Specifically, Lane and medical student Michael Hurley found that dermatologists with access to free drug samples wrote prescriptions for medications with a retail price of about twice that of prescriptions written by dermatologists without access to samples. All of the patients had the same first-time diagnosis of adult acne. The difference is nothing to sniff at – $465 for docs who accepted samples and about $200 for docs who did not. What’s more, the overall prescribing patterns of the two groups of physicians showed almost no overlap. Physicians without access to samples prescribed mainly generic drugs (83 percent of the time), whereas those with access to samples prescribed generics much less frequently (21 percent of the time). Only one drug of the top ten most commonly prescribed by physicians without access to samples even made it into the top ten list of physicians who did accept samples.

The distribution of free drug samples in this country is big business. It’s been estimated that pharmaceutical companies give away samples of medications with a retail value of about $16 billion every year. But many physicians feel the availability of samples doesn’t sway their prescribing choices, and instead feel the samples allow them more flexibility to treat their patients. Lane himself thought so, until Stanford Medicine prohibited physicians to accept samples or other industry gifts in 2006. As he explains in the release:

At one time, we at Stanford really felt that samples were a very important part of our practice. It seemed a good way to help poorer patients, who maybe couldn’t afford to pay for medications out-of-pocket, and we had the perception that this was very beneficial for patients. But the important question physicians should be asking themselves now is whether any potential, and as yet unproven, benefit in patient compliance, satisfaction or adherence is really worth the increased cost to patients and the health-care system.

Clearly Lane has had a change of heart, in part based on the data in the study. Now he’s hoping to get the word out to other physicians. He and Hurley conclude in the paper, “The negative consequences of free drug samples affect clinical practice on a national level, and policies should be in place to properly mitigate their inappropriate influence on prescribing patterns.”

Previously: Consumers’ behavior responsible for $163 billion in wasteful pharmacy-related costs and Stanford’s medical school expands its policy to limit industry access
Photo by StockMonkeys.com

Chronic Disease, Health Costs, Patient Care, Stanford News

Stanford Coordinated Care: A team approach to taming chronic illness

Stanford Coordinated Care: A team approach to taming chronic illness

team handsNearly two years ago, Stanford began an experiment in medical care, a novel way to bring down the extravagant costs of health care while improving people’s health and their experience with the system. If you ask Shelly Reynolds, RN, one of the first patients to benefit, she will tell you it’s been a wild success.

“They hold me accountable for my own health, which is great,” she told me for my recently published Inside Stanford Medicine story. “Physically and emotionally, I’m healthier than I was before.”

And the experiment is costing less, according to initial figures.

The experiment is called Stanford Coordinated Care, a clinic aimed at helping those who consume the lion’s share of health care dollars. These are patients with chronic illnesses, like diabetes or asthma, who often wind up in emergency rooms or in the hospital because their conditions aren’t being well-managed.

The clinic helps them gain control over their health through a personalized approach by a team of caregivers who are available day or night and who give them the tools and support to manage their conditions at home. It focuses on the patients’ goals and what is important to them.

“It’s easy to make a diagnosis of diabetes, but it can be hard for a person to manage day by day,” Ann Lindsay, MD, one of the clinic co-directors, commented. “We help patients in developing a plan. We support it, and we empower them along the way.”

The clinic is the brainchild of Arnold Milstein, MD, a professor of medicine at Stanford and nationally known health care innovator. He developed a model, called the “ambulatory caring ICU,” which was tested successfully in several major pilot sites around the country. He wanted to bring the model to Stanford and recruited the husband-and-wife team of Alan Glaseroff, MD, now a professor of medicine at Stanford, and Lindsay, who had led one of the sites in California’s Humboldt County.

The clinic now has more than 200 patients, all employees and their families at Stanford University and Stanford Hospital & Clinics. Glaseroff calculates that among the first 27 patients treated in the first six months of the clinic’s opening in May 2012, it saved about $420,000, a 39 percent decline in costs from the previous six months, when patients were receiving care elsewhere. He said the numbers are still small and that research is under way to determine if the model is effective in reducing costs, improving outcomes and promoting patient satisfaction.

Initial findings show patient satisfaction at 100 percent. Reynolds is a good example: Working with Lindsay, she has developed a plan to effectively manage her asthma and her back pain and keep her out of the emergency room. She no longer feels like “a number” in the health care system and says having support from Lindsay has made all the difference: “For the first time in a long time,” she told me, “I felt that someone was looking out for me, advocating for me. It was such a relief.”

Previously: Focusing on the whole person to treat chronic disease – and cut costs, At-home program aimed at helping patients with chronic illness and Innovative Stanford clinic to support chronic care patients
Photo (modified from original) by bibendum84

Emergency Medicine, Health Costs, Research, Technology

Can sharing patient records among hospitals eliminate duplicate tests and cut costs?

566748316_7b72d5b777A recent analysis of the impact of health information exchanges, which allow health-care providers to share patient records electronically and securely, shows the systems hold promise for reducing health costs and unnecessary care in emergency departments.

For the study (subscription required), University of Michigan researchers examined information on hospital health information exchange participation and affiliation from the Health Information Management Systems Society’s annual survey as well as data the  California and Florida state emergency department databases from 2007 through 2010. Both states were early adopters of health information exchanges. According to a university release:

The findings show that the use of repeat CT scans, chest X-rays and ultrasound scans was significantly lower when patients had both their emergency visits at two unaffiliated hospitals that took part in a [health information exchange]. The data come from two large states that were among the early adopters of [health information exchanges]: California and Florida.

Patients were 59 percent less likely to have a redundant CT scan, 44 percent less likely to get a duplicate ultrasound, and 67 percent less likely to have a repeated chest X-ray when both their emergency visits were at hospitals that shared information across an [health information exchange].

More research is needed to determine the value of health information exchanges on patient care and health-care costs. But in order to conduct future analysis, said study authors, more states need to report relevant data to the Healthcare Cost and Utilization Project system  to allow researchers to view the activity of individual patients across their different medical encounters, while preserving patient privacy.

Previously: Experts brainstorm ways to safely reduce health-care costs, U.S. Olympic team switches to electronic health records and A new view of patient data: Using electronic medical records to guide treatment
Photo by Tabitha Kaylee Hawk

Health Costs, Health Policy, In the News

Is “Big Med” the future of health care?

The current special issue of the Journal of the American Medical Association takes the history and vitals of the U.S. health-care system’s finances. And, as NPR’s Shots blog reports, experts conclude that the cost of “drugs, hospital stays, doctors and bureaucracy” – rather than the number of diagnostic tests ordered or the size of the aging Baby Boomer population – accounts for over 90 percent of spending increases on health care since 2000.

What’s the prognosis? Maybe the large and concentrated market power of “Big Med,” says the Shots piece, borrowing the term from a JAMA analysis. But, like big airlines, the consolidation of services into fewer large bodies could produce better efficiency and safety while leading to a loss of quality in the consumer experience.

Previously: Making health care better and more affordableThe history of U.S. health care in about 1,000 words, An expert’s historical view of health care costs, Stanford expert urges physicians to take the high road in slowing health care spending and Does the Affordable Care Act address our health-cost problem?

Health Costs, Medicine and Society, Orthopedics, Research

How much for those healthy knees?

How much for those healthy knees?

hurt kneeWhat’s the cost of healthy, functional knees for life? Priceless, you might say, especially if yours feel achy or injured. But rehabilitation after a major injury, such as an anterior cruciate ligament (ACL), can be expensive, and results after surgery vary.

A recent study published in the Journal of Bone and Joint Surgery has examined the cost-effectiveness and quality-of-life impact of surgery to repair an ACL tear in relation to the price of the procedure, versus rehabilitation without surgery. Researchers found the average lifetime societal benefit of having ACL reconstruction surgery to be $50,000 per patient – or $10.1 billion across the U.S., which reports approximately 200,000 ACL tears annually.

This price includes not only money that would have been spent on rehabilitation and future injury repair, but also comparative lost wages and disability payments after surgery versus non-surgical rehabilitation. It also considers the patient’s ability to live with high function, low levels of pain and minimal risk of developing knee osteoarthritis.

From the study:

In the short to intermediate term, ACL reconstruction was both less costly (a cost reduction of $4503) and more effective (a [quality-adjusted life years - QALY] gain of 0.18) compared with rehabilitation. In the long term, the mean lifetime cost to society for a typical patient undergoing ACL reconstruction was $38,121 compared with $88,538 for rehabilitation. ACL reconstruction resulted in a mean incremental cost savings of $50,417 while providing an incremental QALY gain of 0.72 compared with rehabilitation. Effectiveness gains were driven by the higher probability of an unstable knee and associated lower utility in the rehabilitation group. Results were most sensitive to the rate of knee instability after initial rehabilitation.

Previously: Study shows men, rather than women, may be more prone to ACL injuries, Stanford study shows protein bath may rev up sluggish bone-forming cells andIron-supplement-slurping stem cells can be transplanted, then tracked to make sure they’re making new knees
Via Medical News Today
Photo by Carolyn Tiry

Chronic Disease, Health Costs, In the News, Patient Care, Stanford News

Focusing on the whole person to treat chronic disease – and cut costs

Focusing on the whole person to treat chronic disease - and cut costs

Yesterday’s Marketplace on NPR offered a look at the new – and cost-effective – way some doctors are treating chronic illness. Among those featured in the segment was Alan Glaseroff, MD, co-director of Stanford Coordinated Care:

“[Our] work begins by asking the question, ‘Why wouldn’t a person with a chronic condition do everything in their power to live long and feel well?’” he says. “And generally there is sort of a subtext, ‘What is wrong with this person, they are not listening to me.’”

At his clinic, Glaseroff sees 160 privately insured patients, who racked up $58,000 a year, on average, in medical bills before he began treating them.

Glaseroff directs his team to focus first on what matters to a patient like dancing at his daughter’s wedding, for instance. Then they deal with the fact that the patient is diabetic and smokes three packs a day.

Glaseroff says his approach has helped shave 20 percent off his patient’s medical costs. He says if the model succeeds in other states, “It will be a huge step forward.”

Previously: Innovative Stanford clinic to support chronic care patients

Health Costs, Health Disparities, Public Health, Rural Health

“Mountain Dew mouth” rots teeth, costs taxpayers

"Mountain Dew mouth" rots teeth, costs taxpayers

1527462651_903a291406“Blecch! Ew! Sheesh! I’ll take a crab juice,” replied a thirsty Homer Simpson to a vendor’s alternative offer of Mountain Dew. I side with Homer on most issues, including this one. But whatever you think of the taste, you’d be hard-pressed to argue in favor of the soft drink’s nutritional value.

Soda has a bad reputation for being high in empty calories that contribute to some of the nation’s public-health problems, such as obesity and diabetes. NPR’s The Salt blog reports today on a phenomenon widespread in Appalachia of rotting teeth owing to frequent consumption of soda. The incidence is called “Mountain Dew mouth” – “after the region’s favorite drink,” which was invented in Tennessee, the piece notes.

Public-health advocates point out a burden of cost imposed by the Dew, which can be acquired with food stamps (now called the Supplemental Nutrition Assistance Program). Greater access to the drink and limited availability of dental care contribute to “Mountain Dew mouth,” which is reinforced by cultural issues in the area.

From the piece:

Many people don’t trust the well water in their homes because of pollution concerns and probably drink more soda because of it, [Priscilla Harris, JD, an associate professor at the Appalachian College of Law], says. She’s received a grant from the Robert Wood Johnson Foundation to study the problem.

And there’s another reason why soda mouth is so pervasive in Appalachia, Harris says: the region’s distinct culture of sipping soda constantly throughout the day. Singer adds, “Here in West Virginia, you see people carrying around bottles of Mountain Dew all the time — even at a public health conference.”

The article reports statistics about the region’s rate of tooth decay as 26 percent for pre-schoolers, and tooth extraction because of decay or erosion as 15 percent for 18- to 24-year-olds. In West Virginia, Centers for Disease Control and Prevention numbers show 67 percent of residents age 65 and over having lost six or more teeth from tooth decay or gum disease.

Previously: Sugar intake, diabetes and kids: Q&A with a pediatric obesity expert and Dental health a major problem for many
Photo by uberculture

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