Pioneering Ideas

Can a Reduction in Hospital Acquired Infections Cut Health Care Costs?

There is no denying that hospital acquired infections (HAIs) are an expensive drain on the system and impact the lives of an estimated 1.7 million hospital patients a year – killing nearly 99,000 annually. Is it possible that simply instituting best practices in infection control can substantially reduce these infections and save the nation’s healthcare system billions of dollars a year?  Yes, according to an article in last week’s Roll Call by Ramanan Laxminarayan of the Extending the Cure initiative, a Pioneer grantee, and Ed Septimus from HCA Healthcare System.  Laxminarayan and Septimus propose several ideas and incentives, which they believe will reduce the rate of resistant HAIs and control the rise of antibiotic resistance. 

Are hospital acquired infections really the low hanging fruit that will benefit patients and cut health care costs?  Check out the article and then come back here and let us know what you think.   

 

Mix of things to check out

A bunch of things caught my eye today that may be of interest.  First, given that the Games for Health conference kicks off today and I have to sit it out this year, I was especially glad to see this article in the Syracuse Post-Standard.  It profiles one of our Health Games Research grantees, Cornell University, which has given middle-schoolers iPhones loaded with a game designed to encourage healthier eating choices.  The way they do it is pretty clever, though...the kids take care of their own virtual pet and snap photos of their food selections, which are sent to the Cornell research team.  When indicated, the virtual pet will prompt the kids to consider, say, trading in their chips for a yogurt next time.  It's more of a fun interaction than preaching, as the article points out, and it goes wherever the kids go.  I like that it shows how health is playing out apart from health care settings and encounters, and how games and game technologies may provide ways to deliver health messages to kids in ways that are so much more up their alley, and potentially so much more effective.

Second, Steve Downs and John Lumpkin blogged on June 1 on "Catalyzing an App Store for EHRs," which our friends at the Health Care Blog were kind enough to re-post.  A great conversation has kicked up around this - read the comments and add your own thoughts.

Finally, Project HealthDesign received 145 new proposals last week in response to its Round 2 CFP. National Program Director Patti Brennan talks about the breadth of ideas and wide range of observations of daily living that teams proposed - they'll be working together with patients managing multiple chronic diseases to capture and analyze health data generated in the course of daily life and test how it can be integrated in to clinical care workflows.

The Need to Disrupt the Patient Gown: New Research, New Thinking

The efforts of Pioneer grantee North Carolina State University to redesign the current hospital gown are featured on the front page of today’s Wall Street Journal.  Congratulations to Blan Godfrey, Traci May Lamar and the NCSU team – it’s great to see prototype designs emerging from their comprehensive research to determine the needs, constraints and priorities of players up and down the hospital gown supply and demand chains.

 

The article takes a light touch with the subject matter.  True, most everyone hates the gown because it’s an unmitigated fashion disaster…ugly, flimsy, see-through, ill-fitting, inconvenient, hard to tie or fasten, and often thoroughly humiliating in its, er, exposure.  I’ve searched for who is buzzing about this story so far, and it’s been highlighted on the (presumably official, but who knows) Twitter stream of French fashion house Givenchy – I’m thinking this is an RWJF first.

 

But this project was always designed to go deeper, and there’s a real vision and potential for change in health and health care that motivated Pioneer’s decision to support this work.  Indeed, it’s interesting to think about it in the wake of Clay Christensen’s visit last week.  The current patient garment is a classic, ubiquitous example of a job that is not getting done for patients or, as the NCSU research shows, care providers either.

 

Between the survey research and focus group findings at the heart of this project, we’ve learned some interesting things about the gown, how people feel about it, and its impact on care.  The upshot is that it’s never been about just looks: 

• 87% of caregivers felt the current gown sometimes interferes w/ administering IVs, catheters, feeding tubes or other devices. 

• 88% responded that the gown sometimes or always affects the emotional wellbeing of patients.  66% thought it sometimes or always affected patients’ physical well-being.

• 74% of nurses are involved in the gowning process; patients are not comfortable with how to put the gown on when confronted with it, so that even if they’re not seriously ill or impaired, they typically ask nurses for help.

• Some patients confessed that they may limit their mobility becaused they are concerned about being overly exposed in areas outside of their hospital rooms – people don’t just lie in bed anymore to get well. 

• Patients tend to use a second gown as a robe to cover them from the back, which effectively doubles the cost and time of collecting, laundering and stocking gowns.

• There is the perception that nicer, more dignified gowns may help patients feel better emotionally and be more active, boosting their prospects for and pace of physical healing and recovery.  Patients are struck by their loss of dignity and control in the hospital experience..."If I have this gown, I’m really sick.”

It seems that there are certain things in medicine that we do because they’ve always been done that way; such is the case with the patient gown.  It’s become institutionalized as part of the status quo and has gone unchallenged for decades.  It seems so simple and obvious to change the gown and bring it in line with 21st-century care requirements and patient needs and preferences – however, if it were that simple, it would have happened.  As NCSU’s Traci May Lamar states in the article, "We thought that it would be a much easier problem to tackle."

Update: Positive Deviance & MRSA Reductions on NYT Lede Blog

Kevin Sack interviewed the CDC's John Jernigan about the effects of the Plexus Institute's positive deviance MRSA prevention partnership and wrote a post on the New York Times "Lede" blog.  Check it out and comment away, either there or on Pioneering Ideas.   

CDC: Positive Deviance Helps Reduce MRSA Infections

We've written several times before here on the blog about MRSA (methicillin-resistant Staphylococcus aureus) infections, their impact on lives and on hospitals, and the Pioneer-funded work of the Plexus Institute to explore "positive deviance" as a method to cut a hospital's MRSA infection rate. 

This past Saturday, at a special late-breaker session during the Society for Healthcare Epidemiology of America's 19th Annual Scientific Meeting, RWJF and Plexus announced the results of a study conducted by the Centers for Disease Control and Prevention (CDC) of whether the positive deviance approach does, in fact, work on MRSA.

We were thrilled to see that the answer is a resounding yes: significant reductions in MRSA incidence ranging from 26 to 62 percent at participating hospitals.  You can read more about the study and its results here.

And because a picture is worth a thousand words, you might also want to see how CBS News reported the story on Sunday night: 

Guest Bloggers: the Drug Box Meets the FDA

A few weeks ago, Al Shar told us about the work of Lisa Schwartz, Steve Woloshin and Gilbert Welch on a simpler way to communicate information about prescription drugs in direct-to-consumer advertising. Recently, the researchers met with the FDA to discuss their work, and then provided us with this report:

"The drug box was very positively received at the FDA's Risk Communication Advisory Committee meeting (February 27, 2009).  We described the history of the drug box (it was inspired by the FDA nutrition facts box), reviewed four studies demonstrating that consumers want, understand, and are influenced by drug efficacy and side-effect data, and summarized our pilot work to date with the FDA (funded by the RWJ Pioneer program).

We made the following recommendations to the committee:

1. FDA should start producing drug facts boxes as part of the review process for  new drugs now - either in a stand-alone form or as part of other CMI efforts.
2. Consumers want and understand data on drug efficacy and side-effects as presented in drug facts boxes.
3. No one is better positioned than FDA reviewers to write boxes.
4. Drug facts boxes are an effective way for FDA to ensure that it communicates what it knows about drugs to the public.

Following several hours of discussion, the committee voted unanimously that 'FDA should adopt the Drug Facts Box format as its standard' in communicating essential information about prescription drugs. While the vote was extremely gratifying for us, the committee's recommendations are not binding.  At this point we simply do not know how the FDA will respond.  And we may not know for some time:  many important policy decisions will be on hold until the new FDA Commissioner is named."

Our thanks to Lisa, Steve and Gilbert for this update.  We'll keep you posted on future developments.

Could a Virtual Nurse or Doctor Be Your Future Facebook Best Friend?

Microsoft and their partner Intel have an understandable interest in promoting new computing fields. So the recent reference to a Jetsons-style future with a virtual personal assistant, named Laura, coming out of Microsoft makes sense – Laura can tailor responses and decisions to your personal situation and visual presentation.

 

The challenge for Laura gaining a significant following in the long run may be the number of people any of us can have a meaningful relationship with. As estimated by the Anthropologist Robin Dunbar, humans can have about 150 connections in a stable social network. Recent analysis of Facebook data by Cameron Marlow reinforces the hypothesis, along with the observation that the number of friends a person frequently interacts with is typically quite small. At the upper end, when you go much beyond the 150, the cognitive limits of our species become a constraint. Now all this is far from precise, but the main point is that we do have limits, and preferences among possible types of friends. So what kind of person might make the list?

 

How about one that knows your health history, routine behaviors, and likes and dislikes. One who you can trust unconditionally, who could give you advice about how you could make your life more fulfilling, more healthful? In short, how about someone with the qualities that we often wish our nurses and doctors had? Could Laura be your future doctor or nurse and make it into your Dunbar 150? Might Laura be your best friend in 2020?

When Simple Works

Good health information ideas that work don’t have to be complex, use lots of technology and be hard for the user to understand. That’s the way I read the article “Communicating Drug Benefits and Harms With a Drug Facts Box: Two Randomized Trials” by Lisa M. Schwartz, MD, MS; Steven Woloshin, MD, MS; and H. Gilbert Welch, MD, MPH that appeared in the newest issue of the Annals of Internal Medicine. If you don’t want to read the whole thing, USA Today ran a good summary of the study outcomes.

 

The idea is fairly simple: replace the brief summary page that accompanies print advertisements for prescription drugs with a “drug facts box,” a table that quantifies outcomes with and without the drug. The idea is similar to the nutrition information that is standard on foods sold in supermarkets. The article discussed two trials, a symptom drug box trial using direct to-consumer ads for a histamine-2 blocker and a proton-pump inhibitor to treat heartburn, and a prevention drug box trial using direct-to-consumer ads for a statin and clopidogrel to prevent cardiovascular events. Since the pharmaceutical industry spent more than $5 billion on these ads in 2007 – more than twice the total U.S. Food and Drug Administration (FDA) budget – finding a way to help inform consumers is important.

 

The results were impressive. In the symptom drug box trial, 70% of the drug box group and 8% of the control group correctly identified the PPI as being “a lot more effective” than the histamine-2 blocker (P 0.001). In the prevention drug box trial, 72% of the drug box group and 9% of the control group correctly quantified the benefit of the statin. (See left for a sample).

Last August Pioneer helped fund a collaboration between this research team and the FDA in the development of 10 prototype boxes. Unfortunately, right now the FDA seems absorbed with, once again, studying the “best” way to work. Sometimes striving for perfection impedes actions that can have a positive effect right now. This might be one of those times.

Is the country ready for health reform?

Health reform seems to be on everyone’s mind these days – and why not? Our system doesn’t deliver great value overall, it is inequitable, and the economic crisis promises to make it much worse unless we can do something about it.

I came across two views of health reform Sunday – one by David Leonhardt and the other by Janet Rae-Dupree – both in the New York Times. Leonhardt placed health reform in the context of big picture economic strategy over decades; Rae-Dupree brought the lens of disruptive innovation to health reform. Leonhardt singles out health because it is such a daunting fiscal problem, even in the context of the worldwide economic crisis. The future unfinanced obligations under Medicare plus a distinctly inefficient system makes the future price tag of health reform bigger than the estimated bailout. That is not what most people have in mind when they think of health reform – they think of more people having insurance coverage and improving the care people get.

Rae-Dupree applies Clayton Christiansen’s concept of disruptive innovation to health care, drawing on his book The Innovator’s Prescription, and holds out this pathway for getting beyond the current gridlock of inefficiencies. She describes promising examples, some based on emerging scientific discoveries that point the way.

Both views underscore the need for fundamental changes. But I can’t escape the feeling that much of the country isn’t really prepared for the consequences of health reform that would address some of the basic problems with our system. Disruptive innovations replace existing business models, they would change the way care is delivered – when, who, how, where, costs, and perhaps even our very conception of health-improving services. Health reform may have to combine these two views, addressing the looming budget challenge and encouraging disruptive innovations. Figuring out what the country will do about future Medicare obligations may just require a system that fosters the benefits that disruptive innovations can bring. It will certainly test the country’s resolve to improve health through reform at a time when all of us will be called upon to sacrifice.

Where's the revolution?

In Sunday’s Washington Post, Health Reporter David Brown wrote a very interesting thought piece, We All Want Longer, Healthier Lives. But It's Going to Cost Us. He outlines the “steady, predictable, relentless growth” we’ve seen in health care costs since the end of World War II. He says the time of cheap innovations that can produce the longer, healthier lives we all desire—clean water, vaccines, antibiotics—is past. Citing work by David Cutler at Harvard, he writes, “In the 1970s, it took $46,870 to add a year to the life expectancy of 65-year-olds. By the 1990s, it cost $145,000.” The next gains, Brown suggests, will come at even greater price.

There are some things we could do to shift the curve down, to save some money. Bringing down administrative costs, for instance. Or prevention, thought he notes prevention hasn’t been demonstrated to be any cheaper in the long run. Ultimately, though, on our current path, “We are on a collision course between our wish to live longer, healthier lives and our capacity to pay for that wish.”

Unless…

Brown suggests the current collision course sounds similar to that proposed by English Parson Thomas Malthus in the 18th century. Malthus published "An Essay on the Principle of Population as It Affects the Future Improvement of Society,” in which he projected a point in time where population growth would outstrip food production capacity. His analysis made a lot of people nervous.

But there were two things Malthus failed to imagine: “The first was that scientific agriculture would eventually double, triple and quintuple crop yields,” Brown writes. “The second was that when industrialization pulled huge numbers of people out of poverty, infant mortality fell, women became more educated, and the value of their labor rose. The net result was a huge decline in birth rates. This is known as the "demographic transition," and virtually every region of the planet has gone through it.”

We need a similar revolution in healthcare to avoid the collision between our desires for long and healthy lives and what those lives will cost, Brown says. Where it will come from, he doesn’t know.

So: Where will that revolution come from? Advances in genomics? Proteomics and diagnostics? New business models ala Clayton Christensen’s recent book, The Innovator’s Prescription? Any and all thoughts welcome.