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Patient Care, Pediatrics, Public Health, Research, Stanford News

Study finds gaps in referring California’s tiniest babies to follow-up care

Study finds gaps in referring California's tiniest babies to follow-up care

preemie feet2When very fragile babies go home from the hospital after birth, they often require special follow-up care. But a new Stanford study has found that some high-risk infants aren’t receiving referrals to the follow-up care they need.

The study, which appears in the February issue of The Journal of Pediatrics, analyzed statewide data on more than 10,000 California babies born in 2010 and 2011 who were considered high risk because they had very low birth weights. Of those who survived to hospital discharge, 20 percent did not receive referrals to the state’s high-risk follow-up program.

From our press release on the research:

Babies who weigh less than 3.3 pounds at birth, nearly all of whom are born prematurely, are at risk for a variety of neurologic and developmental problems in childhood. In California, all babies with a very low birth weight who received care in a California Children’s Services-approved neonatal intensive care unit qualify for a state-supported, follow-up program that provides diagnostic assessments and services until they turn 3.

“If we cannot succeed in that first step of getting these babies referred to follow-up, we’re at a critical disconnect for what we can offer them as they grow and develop,” said Susan Hintz, MD, professor of neonatal and developmental medicine and lead author of the study.

The study analyzed which very-low-birth-weight babies were receiving referrals. Neonatal intensive care units that treated more of these babies referred a higher proportion of such patients to follow-up care, and babies with several types of medical problems were more likely than others to receive referrals. Babies whose birth weights were on the higher end of the low-weight category were less likely to get referrals, as were those of African-American and Hispanic descent.

The good news, however, is that the data was collected just after California revamped its high-risk follow-up program. Hospitals with low referral rates are already receiving feedback to help them improve, and those with high referral rates are being studied to see how their successes can be transferred to other settings. More from our release:

“We’ve already made substantial improvements in site-specific online tools and resources available to hospitals for nearly real-time feedback, and referral rates now appear to be higher than they were during 2010 and 2011,” Hintz said.

California is ahead of other states in having a comprehensive, statewide program to help high-risk infants, [she] added. “The expectation that all our high-risk infants will be referred is enormously innovative in this country,” she said.

Previously: Preemies face increased risk of death in early adulthood, Stanford study finds, NICU trauma intervention shown to benefit mothers of preemies and How Stanford researchers are working to understand the complexities of preterm birth
Photo by Jenny

Cancer, Complementary Medicine, Events, Patient Care

Knitting needles cancer while helping patients

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It may sound unusual, but knitting is one way to cope with difficult experiences, such as undergoing cancer treatment. Rhythmic and relaxing, knitting can sooth the mind and soak up the downtime that’s a big part of cancer treatment, according to Holly Gautier, RN, a nurse and director of the Cancer Supportive Care Program at Stanford.

“It’s the repetitive motion that you have with knitting… You’re focused on the stitching and your mind becomes somewhat blank – it really feels good to be making something new,” Gautier explained to me recently.

Although she administers a slew of programs – from yoga to art – Gautier said she’s particularly excited about a new knitting class, which meets weekly at the Stanford Cancer Center.  It’s free and open to all cancer patients and their families — not just those being treated at Stanford.

The class is led by a volunteer knitters, who provide supplies and teach the basic stitches. They can even accompany patients to treatment rooms to answer questions or undo an error, Gautier said. And they’re happy to put together “knitting-to-go” care packages for those who can’t stay.

While participants are welcome to work on other projects, such as scarves and hats, the class is currently making squares to create a quilt to raffle off at an upcoming benefit for the Cancer Survivorship Program. Gautier said the quilt project provides patients with an opportunity to give back – something that nearly all patients yearn to do.

Although the first session last Tuesday drew eight female patient-knitters, Gautier said she hopes other patients and caregivers, particularly men, stop by in coming weeks. More details on the Knitting with Friends program can be found here.

Previously: Knitting as ritual — with potential health benefits?, Image of the Week: Personalized brain activity scarves and A look at how helping others can be healing
Photo by meknits

Clinical Trials, Patient Care, Public Health, Research, Stanford News

Screening for diseases doesn’t necessarily save lives, study shows

Screening for diseases doesn't necessarily save lives, study shows

6143531948_a9bdfe6fb5_zIt seems like it should work: If everyone was tested for every disease, lives would be saved, right? These conditions would be spotted quickly, treated and voilà – the deadly disorder would go away.

Not necessarily, according to a new study from a team led by Stanford epidemiologist John Ioannidis, MD, DSc, published this week in the International Journal of  Epidemiology. Here’s Ioannidis:

Screening for diseases that can lead to death typically does not prolong life substantially; a few screening tests may avert some deaths caused by the disease being screened, but even then it is difficult to document an improvement in overall survival.

Ioannidis and his team examined whether screening prevents death in 19 diseases with 39 screening tests, looking at evidence from randomized controlled trials and from meta-analyses combining the results of the trials. Patients were asymptomatic when tested.

In their meta-analysis, the researchers found that mortality from the disease dropped in these cases: ultrasound for abdominal aortic aneurysm in men, mammographyfor breast cancer, and fecal occult blood test and flexible sigmoidoscopy for colorectal cancer. But no other tests reduced the number of deaths caused by the disease in meta-analyses.

What gives?

The test might not be able to detect accurately enough early stages of the disease, or there might not be life-saving treatments available, Ioannidis and colleagues write.

Ioannidis acknowledges that screening might ward off other ill-effects of disease aside from death. But in general, few screening tests among the many new ones being proposed are subjected to a randomized controlled trial before they are introduced, Ioannidis said.

“This is unfortunate. All screening tests should be evaluated with rigorous randomized controlled trials. I see no alternative to prove that they are worth being adopted in large populations,” he told me.

This work follows another recently published paper, in which Ioannidis and colleagues argue that screening all baby boomers for hepatitis C isn’t necessarily beneficial.

Previously: To screen or not to screen for hepatitis C, Bad news for pill poppers? Little clear evidence for Vitamin D efficiency, says Stanford’s John Ioannidis, John Ioannidis, MD: Research’s researcher and Screening could slash number of breast cancer cases
Photo by david_jones

Health and Fitness, Patient Care, SMS Unplugged, Technology

“Nudges” in health: Lessons from a fitness tracker on how to motivate patients

“Nudges” in health: Lessons from a fitness tracker on how to motivate patients

SMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

fitness trackerIt was 11:47 PM. That meant that I had 13 minutes to reach my pre-set goal of  “activity” that the fitness tracker on my wrist had been registering throughout the day. If I met the goal I would get a “trophy” on the accompanying app. I probably looked pretty funny bouncing around my living room doing a squat here and a sit-up there, punching a pretend opponent, and running in place. But I made it minutes before midnight. If I hadn’t – well, then I would have just blamed the piece of technology on my arm for not working.

The tracker was a gift from my cousin Steve. Steve is impressively fit; he runs marathons, tackles obstacle courses, and races road bikes. A few years back at Christmas dinner, Steve challenged me to a pull-up contest – I was super hyped and ready for it until, well, I lost. Every holiday season since then, I’ve spent the weeks prior to heading home logging extra push-ups, pull-ups, and bicep curls just in case a re-match comes up. Without knowing it, Steve inspired me to get active. Now, with blinking lights and status reminders, the fitness tracker he gave me does so more frequently, more annoyingly, but in a way, more enjoyably and effectively.

The fitness band on my wrist doesn’t tell me to go to the gym or go for a run. The periodic updates on how far I am from my pre-set goal, however, “nudge” me to get up during a commercial and do a set of push-ups, to get out for a walk, or to take the stairs. I’ve even turned to running in place or a set of body squats whenever I find myself yawning to make sure I get enough points.

In the past, I’ve been good about working out, even doing stretches of two-a-day gym trips. But this doesn’t last very long as I use the busy “medical school” schedule as an excuse. After getting the fitness tracker, it’s been a string of random, spontaneous, and unstructured “work outs” throughout the day. While I may not have achieved Mr. America status, I’ve felt good about meeting my daily goal and racking up “trophies.” It’s even become a bit of a game to see how high I can actually make my numbers go. I’m competing against myself. This may sound weird, but at least I know my opponent and understand what I’m up against, right?

Wearing the fitness band reminded me of the concept of nudges. Nudges, as discussed by Richard Thaler, PhD, and Cass Sunstein, JD, describe how a person can be steered toward making a particular decision without hard instruction. An individual encounters small pushes towards doing something that is desired of them, unaware that they’re being led in that direction. Commercial companies have mastered this in form of advertising, making us feel as if we “need” their product. This fitness band has me thinking that I’m playing a game; the soreness in my legs and looser fitting clothes would indicate that I’m working out.

My experience with the fitness tracker has reminded me of the importance in framing conversations with patients. We often resort to telling patients, “You should work out and eat healthy – if you don’t you’ll get this or that disease.” It’s easy to frame things in the negative and use scare tactics. But rather than give constant reminders of what they aren’t doing, conversations with patients should contain nudges of encouragement. Nudges such as aligning goals with patient priorities, setting check-in time-points, and incorporating social networks for accountability. If we could do for chronic-disease management what the fitness band tries to do for working out, our patients might have an easier time.

Moises Gallegos is a fourth-year medical student. He’ll be going into emergency medicine, and he’s interested in public-health topics such as health education, health promotion and global health.

Photo by Vernon Chan

Big data, In the News, Patient Care, Pediatrics, Stanford News

Examining the potential of big data to transform health care

Examining the potential of big data to transform health care

Updated 1-6-15: The piece also aired this week on NPR’s All Things Considered.

***

9-29-14: Back in 2011, rheumatologist Jennifer Frankovich, MD, and colleagues at Lucile Packard Children’s Hospital Stanford used aggregate patient data from electronic medical records in making a difficult and quick decision in the care of a 13-year-old girl with a rare disease.

Today on San Francisco’s KQED, Frankovich discusses the unusual case and the potential of big data to transform the practice of medicine. Stanford systems-medicine chief Atul Butte, MD, PhD, also weighed in on the topic in the segment by saying, “The idea here is [that] the scientific method itself is growing obsolete.” More from the piece:

Big data is more than medical records and environmental data, Butte says. It could (or already does) include the results of every clinical trial that’s ever been done, every lab test, Google search, tweet. The data from your fitBit.

Eventually, the challenge won’t be finding the data, it’ll be figuring out how to organize it all. “I think the computational side of this is, let’s try to connect everything to everything,” Butte says.

Frankovich agrees with Butte, noting that developing systems to accurately interpret genetic, medical or other health metrics is key if such practices are going to become the standard model of care.

Previously: How efforts to mine electronic health records influence clinical care, NIH Director: “Big Data should inspire us”, Chief technology officer of the United States to speak at Big Data in Biomedicine conference and A new view of patient data: Using electronic medical records to guide treatment

In the News, Patient Care, Pediatrics, Stanford News

Fifty-plus years of Sunshine: Long-time Stanford neonatologist discusses his career

Fifty-plus years of Sunshine: Long-time Stanford neonatologist discusses his career

sunshineWith a name like Dr. Sunshine, parents should know their premature babies are in good hands. On yesterday’s Forum, neonatologist Philip Sunshine, MD, discussed the fifty-plus years he’s been caring for preemies. At 84, he’s still at it, working 30 hours in a step-down nursery at Lucile Packard Children’s Hospital Stanford. (He jokingly told host Michael Krasny, “I do all the stuff the young people don’t want to do.”)

During the hour, Sunshine, a 2015 “Legends of Neonatology” honoree, talked about the changing field of neonatology, including his views on the ever-growing popularity of home births (“Home deliveries are for pizzas only,” he quipped, referencing a pin his former classmate always wore). He also read e-mails and took calls from listeners – many of whom thanked him for saving their children’s lives (30,000 and counting).

Previously: Eightysomething “neonatology superhero” still at itA pioneer of modern-day neonatology and Neonatologist celebrates 50 years of preemie care
Photo courtesy of Lucile Packard Children’s Hospital Stanford

Health Costs, Health Policy, Patient Care, Research

Medicare payment reform shown to cut costs and improve patient care

Medicare payment reform shown to cut costs and improve patient care

PT got Margie practicing on crutches, including going up and down a step.A few years back, the Centers for Medicare and Medicaid Services (CMS) made a straightforward change: No longer would it pay for easily preventable conditions that develop in the hospital. A care-team fails to help ambulate a patient following a hip or knee surgery and the patient develops deep-vein thrombosis? Unfortunate for the patient and unfortunate for the hospita, which now has to absorb the cost of that care.

It seems obvious, yet slightly disturbing, that this approach would be successful. In my idealized worldview, all patients are treated the same, regardless of who’s picking up the tab.

But when you change the financial incentives, change happens. Stanford health economist Jay Bhattacharya, MD, PhD, and health economist Risha Gidwani,DrPH, who is affiliated with the VA and Stanford, found the prevalence of two preventable conditions – deep-vein thrombosis and pulmonary embolisms – for patients with a recent hip or knee surgery dropped after Medicare stopped paying. The study was published today in the Journal of General Internal Medicine.

From our press release on the work:

When CMS stopped paying for treating deep-vein thromboses and pulmonary embolisms, the incidence of those conditions after hip or knee replacement surgery dropped 35 percent in the Medicare population, Gidwani said. In the younger, non-Medicare population, the incidence of these two conditions increased, although they also decreased in the patients over age 65 who had private insurers. There are more than 1 million hip or knee replacements performed in the United States each year, and over 60 percent of them are paid for by Medicare.

“We have a win-win,” Gidwani told me. “We have patients who are avoiding adverse events while Medicare saves money.”

Previously: Beyond Berwick brouhaha: Medicare chief another step to health-care reform, Experts discuss high costs of health-care — and what it will take to change the system and Competition keeps health-care costs low, Stanford study finds
Photo by Dave & Margie Hill

Patient Care, Public Health, Research, Science

Finding cures for the most challenging diseases

640px-Drawing_Test_tubes_different_colorsThe recent Ebola outbreak and the subsequent race to find a vaccine and other treatment options has brought the topic of drug development back in the public spotlight. But despite the millions of dollars spent on these efforts and the technological advances in biomedical sciences in the last 20 years or so, the process is still time-consuming and prone to failure. A recent feature story from National Journal (which also appears on The Atlantic’s website today) describes the work of several scientists trying to find cures or treatments for some of the most challenging diseases, from infectious diseases, like AIDS and Ebola, to chronic diseases such as Alzheimer’s.

The first disease the article highlights is a rare disorder called progeria, which causes young children to age prematurely. Recent breakthroughs in treatment have come from a team led by Francis Collins, MD, PhD, who is more famous for leading the Human Genome Project and now serves as director for the National Institutes of Health. Collins worked briefly on progeria early in his career and the combination of Collins’s work and genomics made it possible for his team to crack the genetic secret of the rare disease: that it was caused by a single genetic mutation. That finding led to a treatment that extended the lives of patients with progeria by several years. But it also points to some of the overwhelming challenges of chasing down cures and treatments:

The doctors and scientists hunting for new cures and treatments work in a constant state of tension. They operate in a tremendously high-stakes environment, pouring years of their lives into research as the people who inspire them continue to suffer and even die. Drug hunters face failure after failure, almost never followed by success. Decades of work flame out. Promising ideas turn into dead ends. For every 10,000 compounds they explore, scientists wind up with just one drug approved by the Food and Drug Administration. Even when medical science moves as fast as it can—and today, it’s moving faster than ever before—it’s still an agonizingly slow process.

“As much as we say that failure is part of what we do—if you’re not failing, you’re probably not doing science that’s very interesting—it still hurts,” Collins says. “It is frustrating, because you want to come up with the answer. You want to save lives. That’s what we all get into this medical research area to try to achieve, and yet the challenges are immense. And we make progress, oftentimes, in very small baby steps, even though what we’re hoping for are big leaps.”

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Emergency Medicine, Medical Education, Patient Care, SMS Unplugged

Role reversal: How I went from med student to ED patient in under two minutes

Role reversal: How I went from med student to ED patient in under two minutes

SMS (“Stanford Medical School”) Unplugged is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

emergency sign - smallAs part of the second-year clinical skills course, each member of my class is required to complete two 8-hour Emergency Department (ED) shifts. I had my first ED shift last week, and when I walked in, I introduced myself as a second-year medical student who needed to practice IV placements, EKGs, and any other procedures that happened to come my way. Three hours later, when I walked out of the ED, staff knew me not as a medical student, but as a recently discharged patient, grasping paperwork with my official diagnosis: “syncope and collapse.”

It was 30 minutes into my ED shift, while I was watching a pelvic exam (ironic, given my post a couple weeks ago), when I began to feel a little dizzy. I’ve fainted twice before – once in high school after getting my blood drawn, and once when watching a C-section at a clinic in India – so I recognized the signs: feeling a little hot, starting to see black dots, slightly swaying. I tried to fight off the sensation by breathing slowly, but I could tell it wasn’t working. At the earliest possible opportunity, I turned to the attending in the room, saying, “Is it okay if I leave? I’m feeling lightheaded.”

I barely waited to hear her response before I bolted out of the room and found the closest stool to sit on. Bad call. The stool had no back to it, and next thing I knew, I was on the ground. When I opened my eyes, there were at least five  nurses around me, one whom matter-of-factly said, “Honey, you just became a patient.” Another nurse quietly slipped my hospital badge off my jacket, returning two minutes later with a medical bracelet that she fastened around my wrist.

My memory of those early moments is a little shaky, but I do remember saying over and over again, “I’m so sorry, I’m so sorry.” I felt awful that I had come to the ED to learn from the patients, physicians, and staff – without being a burden – but had ended up being another patient for whom they had to provide care. The nurses and attendings immediately normalized the situation, telling me repeatedly that this is a common occurrence in the ED and that many of them had had this happen to them as well. Their assurances made me feel so much better.

The efficiency of the events that followed totally impressed me. The nurse helping me to the bed did the fastest history on me I’ve ever heard, all while hooking me up to a BP cuff and a pulse oximeter. Did I have allergies? (Nope.) Did I  have diabetes? (Nope.) When was the last time I ate? (That morning). Any other medical conditions that I’m being treated for? (Nope.) Any family history of cardiac conditions? (Nope.)

The attending who was with me when I initially felt lightheaded came in at that point and asked, “Has this happened to you before?” and when I told her about the C-section, joked, “ObGyn probably isn’t your favorite thing, huh?” She then laid out the plan for what would happen next: an EKG, a glucose stick, and a blood test, to check for cardiac abnormalities, low blood sugar, and anemia, respectively. Within 30 minutes, all three of these had been done, and I even got a bonus ultrasound thrown in by someone who was practicing recognizing cardiac pathology (not that I had any). Noticing my scrubs and med student badge, this person took the time to show me each ultrasound image, pointing out the various heart chambers, valves, and the location where my IVC entered my right atrium.

By 2 PM, my tests were all back, everything was normal, and I was able to laugh about the entire situation: Somehow, I had come into the ED hoping to practice blood draws and EKGs but came out having them done to me instead. Just another day in the life of a med student.

Hamsika Chandrasekar is a second-year student at Stanford’s medical school. She has an interest in medical education and pediatrics.

Photo by zoomar

 

Health Costs, Health Policy, Patient Care, Research

Spotting stellar primary care practices, Stanford study identifies 10 practices that lead to excellence

Spotting stellar primary care practices, Stanford study identifies 10 practices that lead to excellence

crutches-538883_1280Many of us know first-hand that expensive, substandard health care abounds in America. The problem has been analyzed and bemoaned, measured and critiqued. Solutions, bright spots and success stories are less abundant—in fact they are downright rare. That’s why recent findings from a partnership between Stanford’s Clinical Excellence Research Center and the Peterson Center on Healthcare, a new organization that aims to improve health care in the United States, are so exciting. Bucking current theories, researchers found that independent, primary care medical practices can provide superior care while saving money. And, they identified 10 principles these practices embrace, which distinguish them from their peers.

I had the chance to speak with CERC Director Arnold Milstein, MD, about the Stanford-based project:

What exactly did you do?

We examined the performance of more than 15,000 primary care practices looking for “positive outliers” or practices that provide excellent care at a lower cost. This is the first  systematic comparison of its kind and we weren’t sure we’d be able to discern any differences. But we did. We found a substantial difference in measures of quality and the total annual amount of health care spending between sites. Then, we arranged for  observers (independent physicians) to visit these offices to understand what was different about care delivery at sites associated with less spending and high quality scores.  They discovered 10 distinguishing features of successful health-care practices that were present much more frequently in these positive outlier practices than in other offices. There are some major differences in how they deliver care.

What were some these features? Did any surprise you?

About two-thirds align with current national initiatives such as Choosing Wisely and the Patient Centered Medical Home, but about one-third are new ideas.

The 10 features are not abstract ideas, they are tangible and therefore more easily transferable. For example, the higher-performing sites are ‘always on’ — patients can reach the care team quickly 24/7. I use the word ‘care teams’ because I’m not referring to physicians only. These teams include nurses, nurse practitioners, medical assistants and/or office managers, developed  to the highest of their abilities. These teams often treat conditions in a gray zone between primary care and specialist care. They follow up with their patients when a case is referred to a specialist. They check in with patients to ensure they are able to follow self-care recommendations.  Their work station is shared, so they can learn from each other. These teams adhere to systems to deliver care — choosing individual tests and treatments carefully. Distribution of revenues among physicians is not  solely based on service volume. Finally, these practices invest much less in office rent and costly testing hardware.

 

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