NEJM Highlights Feb 2016: metrics for all, ROI perversion, less memory loss, the value of a kinder gentler residency

By

Defining success in health care

A perspective advertising yeoman’s work of the International Consortium for Health Outcomes Measurement (ICHOM) which has defined specific metrics for dozens of diseases for which there are no widely accepted standards defined so far. If followed broadly, this will greatly facilitate performance comparisons across systems, improvement of processes of care delivery, and the implementation of value based contracting. Standardizing Patient Outcomes Measurement (free access)

 

Public health gets no respect

A lament on how population health interventions tend to be beholden to positive ROI standards (i.e. will we save money by keeping at risk patients out of the hospital), whereas other interventions, (e.g. a chemotherapy for cancer) are simply held to a (often tenuous) lower standard of positive value for a patient. One wonders what ICHOM metrics (see above) are going to solve that. Asymmetric Thinking about Return on Investment (free access)

 

Adjusted rates of dementia seem to be decreasing

From its inception in 1949, the 5000+ cohort of the Framingham heart study and their progeny continue to yield powerful indications of health trends – starting from the association of smoking with heart disease in the 60s, to now, information on the rate of dementia in the elderly. The finding that in this group, age- and education-adjusted rate of dementia decreased by about 40% over the last 30 years provides additional evidence for similar observations that have been made elsewhere. As to what is responsible for this decrease, nobody is sure – but leading the list would be better treatments for cardiovascular disease (after all, the brain is exquisitely dependent on its blood supply), and potentially decreased life-long exposure to toxins, either airborne (e.g. lead, or particulates), or in the food supply.  However, as management of key causes of mortality continues to improve, the need for therapies for Alzheimer’s and other neurological diseases will grow to ensure that we achieve Michael Kinsley’s goal of “death before dementia”. Incidence of Dementia over Three Decades in the Framingham Heart Study; Is Dementia in Decline? Historical Trends and Future Trajectories (subscriber access)

 

Should residency be boot camp?

Post-graduate medical training in the US has long been a brutal endeavor characterized by extremely long hours. In the 2000s a series of reforms were put in place to ensure that residents’ duty hours and days on duty would be bound by limits thought to be reasonable – with a key motivating argument around patient and physician safety.  However, because of the shortened shifts, an opposing argument has been made that increasing the number of patient hand-offs can lead to worse outcomes. In the end, a study in which surgical residency programs were randomized to “flexible hours” (e.g. can go more than 28 hours in a shift) or standard policy (limits on shifts) showed no difference either in patient outcomes, or on resident well-being.  What does this mean? Simply, that within a range, working hours are a smaller factor in resident happiness and effectiveness.   I would guess that instead, the atmosphere of residency program is key (residents have a term for particularly abusive programs: “malignant”). But independent of the specific context, this study is interesting because it focuses on how physicians work rather than what they do to the patients – an area where there is a lot more lore than evidence.  National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training; Surgical Resident Duty-Hour Rules — Weighing the New Evidence; Leaping without Looking — Duty Hours, Autonomy, and the Risks of Research and Practice (free access)

 

The New England Journal of Medicine is a premier weekly medical journal covering many topics of interest to the health sector. In this monthly series we offer a brief overview of highlights that might be of interest to our clients and others.

Tags: