VA tries quality improvement approach to medical ethics

Tools to evaluate how health care facilities perform ethically are in their infancy. The VA Health Care System hopes others can benefit from its experience.

By Tanya Albert Henry
amednews.com
Originally posted May 20, 2013

How often does a physician have enough time to discuss a treatment recommendation with a patient?

Would a doctor be reluctant to raise concerns if he or she believes a colleague's clinical abilities are impaired?

How often are notes or papers with identifiable patient information left in areas where other patients, relatives or staff members might view the sensitive material?

These are just a few of the questions the National Center for Ethics in Health Care at the U.S. Dept. of Veterans Affairs is using to query its staff at the VA Health Care System. The goal is to help facilities see what they are doing well in terms of ethics and point out areas where they could be doing more.

The concept is similar to the recent push to evaluate quality of care by asking about procedural issues such as how well physicians are helping patients control hypertension or whether hospitals are keeping infection rates low.

Ethics evaluations, though, are not so common, and surveys do not tie payment to how well facilities score. However, the idea of measuring ethics as a component of quality of care is gaining momentum, and leaders in the field say its time has come.

“This is about managing ethics the same way you manage health care quality,” said Ellen Fox, MD, chief ethics in health care officer for the Veterans Health Administration. “Ethics quality is an important area that can have a dramatic effect on health care, including life-and-death decisions. … An effective ethics program promotes better patient care, better patient satisfaction, better efficiency.”

The entire story is here.

Learning From Litigation

By Joanna C. Schwartz
The New York Times - Op Ed
Originally published May 16, 2013

MUCH of the discussion over the Affordable Care Act has focused on whether it will bring down health care costs. Less attention has been paid to another goal of the act: improving patient safety. Each year tens of thousands of people die, and hundreds of thousands more are injured, as a result of medical error.

Experts agree that the best way to reduce medical error is to gather and analyze information about past errors with an eye toward improving future care. But many believe that a major barrier to doing so is the medical malpractice tort system: the threat of being sued is believed to prevent the kind of transparency necessary to identify and learn from errors when they occur.

New evidence, however, contradicts the conventional wisdom that malpractice litigation compromises the patient safety movement’s call for transparency. In fact, the opposite appears to be occurring: the openness and transparency promoted by patient safety advocates appear to be influencing hospitals’ responses to litigation risk.

I recently surveyed more than 400 people responsible for hospital risk management, claims management and quality improvement in health care centers around the country, in cooperation with the American Society of Health Care Risk Managers, and I interviewed dozens more.

The entire story is here.

There is more to end-of-life practices than euthanasia — Authors' reply

The Lancet
Volume 381, Issue 9862, Pages 202-203

Bregje Onwuteaka-Philipsen, Arianne Brinkman-Stoppelenburg, Hans van Delden, Anges van der Heide

We agree with Jan Schildmann and Eva Schildmann that the debate on end-of-life practices should not be limited to euthanasia. We also agree that increased attention to palliative care does not necessarily result in good quality end-of-life care. Our study gives an insight into end-of-life decision making and end-of-life acts, but not into the quality of end-of-life care. Additionally, what good quality end-of-life care consists of is not that straightforward. This is certainly true for palliative sedation. Although there is an increasing body of published studies on this subject, there are controversies on terminology and ethical acceptability of the practice. Guidelines are a way to try to overcome this and to improve quality of care. Yet there are many different guidelines—eg, at the institutional level and in different countries—and the premises of national guidelines can be the subject of debate. In our opinion, the role of empirical studies such as ours is to underpin the ongoing debate with information about what occurs in practice.

We declare that we have no conflicts of interest.

doi:10.1016/S0140-6736(13)60087-2

The Ups and Downs of Electronic Medical Records

By MILT FREUDENHEIM
The New York Times
Originally published October 8, 2012

The case for electronic medical records is compelling: They can make health care more efficient and less expensive, and improve the quality of care by making patients’ medical history easily accessible to all who treat them.

Small wonder that the idea has been promoted by the Obama administration, with strong bipartisan and industry support. The government has given $6.5 billion in incentives, and hospitals and doctors have spent billions more.

But as health care providers adopt electronic records, the challenges have proved daunting, with a potential for mix-ups and confusion that can be frustrating, costly and even dangerous.

Some doctors complain that the electronic systems are clunky and time-consuming, designed more for bureaucrats than physicians. Last month, for example, the public health system in Contra Costa County in California slowed to a crawl under a new information-technology system.

The entire story is here.

Outpatient Care of Young People After Emergency Treatment of Deliberate Self-Harm

By Dennis Thompson
MedicineNet.com
Originally published on May 25, 2012


Doctors have long known that some kids suffering severe emotional turmoil find relief in physical pain -- cutting or burning or sticking themselves with pins to achieve a form of release.

But researchers now are questioning whether enough is being done to reach out to these young people and help them before they do themselves irreparable damage.

One study this year found that six of every 10 adolescents who went to an emergency room for treatment after harming themselves were released without receiving a mental health assessment or any follow-up mental health care. The findings were reported in the February issue of the Journal of the American Academy of Child & Adolescent Psychiatry.

Here is a link to the summary of this article.

The original research is below.

by Jeffrey Bridge, Steven Marcus, and Mark Olfson

Journal of the American Academy of Child & Adolescent Psychiatry
Volume 51, Issue 2 , Pages 213-222.e1, February 2012

Objective

Little is known about the mental health care received by young people after an episode of deliberate self-harm. This study examined predictors of emergency department (ED) discharge, mental health assessments in the ED, and follow-up outpatient mental health care for Medicaid-covered youth with deliberate self-harm.

Method

A retrospective longitudinal cohort analysis was conducted of national 2006 Medicaid claims data supplemented with the Area Resource File and a Substance Abuse and Mental Health Services Administration Medicaid policy survey of state policy characteristics focusing on ED treatment episodes by youth 10 to 19 years old for deliberate self-harm (n = 3,241). Rates and adjusted risk ratios (ARR) of discharge to the community, mental health assessments in the ED, and outpatient visits during the 30 days after the ED visit were assessed.

Results

Most patients (72.9%) were discharged to the community. Discharge was inversely related to recent psychiatric hospitalization (ARR 0.75, 99% confidence interval [CI] 0.63–0.90). Thirty-nine percent of discharged patients received a mental health assessment in the ED and a roughly similar percentage (43.0%) received follow-up outpatient mental health care. Follow-up mental health care was directly related to recent outpatient (ARR 2.58, 99% CI 2.27–2.94) and inpatient (ARR 1.33, 99% CI 1.14–1.56) mental health care and inversely related to Hispanic ethnicity (ARR 0.78, 99% CI 0.64–0.95) and residence in a county with medium-to-high poverty rates (ARR 0.84, 99% CI 0.73–0.97).

Conclusions

A substantial proportion of young Medicaid beneficiaries who present to EDs with deliberate self-harm are discharged to the community and do not receive emergency mental health assessments or follow-up outpatient mental health care.

Psychiatric Patients Languish In Emergency Rooms

By Eric Whitney
Colorado Public Radio in conjunction with Kaiser Health News
Originally published May 31, 2012

Last fall Kathy Partridge got a phone call from a local emergency room, telling her that her daughter, Jessie Glasscock, was there -- and was OK. Glasscock had gone missing overnight.  She was away at college, and had a history of manic episodes. Police had found her in a dumpster and brought her to the ER for her own safety.  It was a huge relief for her mother – but she was completely surprised by what happened next.

"It sort of seemed like, well, they'll stabilize her, help her get back on her meds and she'll pick up her pieces. Instead, I went down to this emergency room and just found her by herself, basically locked in a closet," Partridge said. 

The "closet" was actually an exam room, but Partridge explains it was small, windowless, and the only furniture was a stainless steel bed.  Her daughter waited there, wearing nothing but a hospital gown, without treatment or a decent meal for 24 hours.  Partridge was shocked to learn there was no place for her daughter to get treatment.  "There was not a single psychiatric bed to release her in in the entire state of Colorado," she says.

The entire story is here.

Court Upends 9-Year Fight on Housing Mentally Ill

By Mosi Secret

The New York Times

Originally published April 6, 2012

A federal appeals court, ruling on procedural grounds, struck down on Friday a judge’s order that New York State transfer thousands of mentally ill adults in New York City from institutional group homes into their own homes and apartments. In doing so, the court brought a nine-year legal battle to an abrupt end without resolving the underlying issues of how the state cares for such patients.

Though the lower court judge had ruled the current system violated federal law by warehousing people with mental illness in far more restrictive conditions than necessary, the appellate panel said the nonprofit organization that began the litigation, Disability Advocates, did not have legal standing to sue.

The panel, comprising three judges of the United States Court of Appeals for the Second Circuit, acknowledged that its decision essentially reset the long-running battle to its starting point.

The entire story is here.

Inviting Patients to Read Their Doctors' Notes

Patients and Doctors Look Ahead

Patient and Physician Surveys

Original Research: Improving Patient Care

Annals of Internal Medicine

By Jan Walker, RN, MBA; Suzanne G. Leveille, PhD, RN; Long Ngo, PhD; Elisabeth Vodicka, BA; Jonathan D. Darer, MD, MPH; Shireesha Dhanireddy, MD; Joann G. Elmore, MD, MPH; Henry J. Feldman, MD; Marc J. Lichtenfeld, PhD; Natalia Oster, MPH; James D. Ralston, MD, MPH; Stephen E. Ross, MD; and Tom Delbanco, MD

Abstract

Background: Little is known about what primary care physicians (PCPs) and patients would expect if patients were invited to read their doctors' office notes.

Objective: To explore attitudes toward potential benefits or harms if PCPs offered patients ready access to visit notes.

Design: The PCPs and patients completed surveys before joining a voluntary program that provided electronic links to doctors' notes.

Setting: Primary care practices in 3 U.S. states.

Participants: Participating and nonparticipating PCPs and adult patients at primary care practices in Massachusetts, Pennsylvania, and Washington.

Measurements: Doctors' and patients' attitudes toward and expectations of open visit notes, their ideas about the potential benefits and risks, and demographic characteristics.

Results: 110 of 114 participating PCPs (96%), 63 of 140 nonparticipating PCPs (45%), and 37 856 of 90 203 patients (42%) completed surveys. Overall, 69% to 81% of participating PCPs across the 3 sites and 92% to 97% of patients thought open visit notes were a good idea, compared with 16% to 33% of nonparticipating PCPs. Similarly, participating PCPs and patients generally agreed with statements about potential benefits of open visit notes, whereas nonparticipating PCPs were less likely to agree. Among participating PCPs, 74% to 92% anticipated improved communication and patient education, in contrast to 45% to 67% of nonparticipating PCPs. More than one half of participating PCPs (50% to 58%) and most nonparticipating PCPs (88% to 92%) expected that open visit notes would result in greater worry among patients; far fewer patients concurred (12% to 16%). Thirty-six percent to 50% of participating PCPs and 83% to 84% of nonparticipating PCPs anticipated more patient questions between visits. Few PCPs (0% to 33%) anticipated increased risk for lawsuits. Patient enthusiasm extended across age, education, and health status, and 22% anticipated sharing visit notes with others, including other doctors.

Limitations: Access to electronic patient portals is not widespread, and participation was limited to patients using such portals. Response rates were higher among participating PCPs than nonparticipating PCPs; many participating PCPs had small patient panels.

Conclusion: Among PCPs, opinions about open visit notes varied widely in terms of predicting the effect on their practices and benefits for patients. In contrast, patients expressed considerable enthusiasm and few fears, anticipating both improved understanding and more involvement in care. Sharing visit notes has broad implications for quality of care, privacy, and shared accountability.

Primary Funding Source: The Robert Wood Johnson Foundation's Pioneer Portfolio, Drane Family Fund, and Koplow Charitable Foundation.

The entire story is here.

Thanks to Ken Pope for this story.