Comments on: Practice Pattern Variation http://www.letstalkhealthcare.org/transparency/practice-pattern-variation/ Sat, 22 Nov 2008 04:46:54 +0000 http://wordpress.org/?v=2.5.1 By: bev M.D. http://www.letstalkhealthcare.org/transparency/practice-pattern-variation/#comment-5579 bev M.D. Mon, 07 Jul 2008 13:25:15 +0000 http://www.letstalkhealthcare.org/transparency/practice-pattern-variation/#comment-5579 Charlie; Yes, I think there is no question that doctors are trained to heal and therefore it is difficult to sit back and do nothing - once the code is called. As a practical matter, if the patient is a DNR a code shouldn't have been called in the first place. This is usually a nursing issue and once again, they err on the side of caution unless the patient or family has made it crystal clear they really do mean DNR. It's a difficult issue. I think having a palliative medicine service can help this issue, but I would defer to those with more experience than me on that part of it. Charlie;

Yes, I think there is no question that doctors are trained to heal and therefore it is difficult to sit back and do nothing - once the code is called. As a practical matter, if the patient is a DNR a code shouldn’t have been called in the first place. This is usually a nursing issue and once again, they err on the side of caution unless the patient or family has made it crystal clear they really do mean DNR. It’s a difficult issue. I think having a palliative medicine service can help this issue, but I would defer to those with more experience than me on that part of it.

]]> By: Charlie Baker http://www.letstalkhealthcare.org/transparency/practice-pattern-variation/#comment-5565 Charlie Baker Fri, 04 Jul 2008 19:12:30 +0000 http://www.letstalkhealthcare.org/transparency/practice-pattern-variation/#comment-5565 Bev - great post and a great set of insights. I'd be interested in your thoughts on whether or not medical professionals also feel under some obligation to "do something" for patients under duress. I've had many conversations with friends of mine who are clinicians about this issue, and find, more often than not, that they tend to lean, intrinsically, in the "do" direction, all other things being equal. I presume this is based on their line of work and their training. In other words, it's hard for caregivers to start with a presumption against delivering care - even if that might be the patient's preferred approach. Bev - great post and a great set of insights. I’d be interested in your thoughts on whether or not medical professionals also feel under some obligation to “do something” for patients under duress. I’ve had many conversations with friends of mine who are clinicians about this issue, and find, more often than not, that they tend to lean, intrinsically, in the “do” direction, all other things being equal. I presume this is based on their line of work and their training. In other words, it’s hard for caregivers to start with a presumption against delivering care - even if that might be the patient’s preferred approach.

]]> By: bev M.D. http://www.letstalkhealthcare.org/transparency/practice-pattern-variation/#comment-5562 bev M.D. Thu, 03 Jul 2008 15:44:39 +0000 http://www.letstalkhealthcare.org/transparency/practice-pattern-variation/#comment-5562 The non-honoring of DNR orders has much of its origin in two factors: lack of immediate availability of the DNR order when the patient is discovered in arrest, and fear of malpractice suits. Although the hospitals try to make DNR orders obvious in patient rooms, it can be seen as kind of insensitive to post them on the door or in other prominent places. No one has time to check the chart before calling the code, and often the code team does not work on the floor and doesn\\\'t know the patient. These are not excuses since they are remediable, just explanations. Also, often family members are not in agreement over DNR orders. I just wanted to point these features out to allay any ideas that DNR orders are deliberately ignored for no reason. The non-honoring of DNR orders has much of its origin in two factors: lack of immediate availability of the DNR order when the patient is discovered in arrest, and fear of malpractice suits. Although the hospitals try to make DNR orders obvious in patient rooms, it can be seen as kind of insensitive to post them on the door or in other prominent places. No one has time to check the chart before calling the code, and often the code team does not work on the floor and doesn\\\’t know the patient. These are not excuses since they are remediable, just explanations. Also, often family members are not in agreement over DNR orders. I just wanted to point these features out to allay any ideas that DNR orders are deliberately ignored for no reason.

]]> By: Charlie Baker http://www.letstalkhealthcare.org/transparency/practice-pattern-variation/#comment-5543 Charlie Baker Tue, 01 Jul 2008 15:26:44 +0000 http://www.letstalkhealthcare.org/transparency/practice-pattern-variation/#comment-5543 Barry - don't disagree with living wills and advance directives are a good idea, but would point out that somebody like RAND studied how often DNR orders are not honored by health care providers, and the percent was something like 50. In other words, about half the time, providers didn't honor the DNR orders issued by their patients. We have a very long way to go on this one. Hospice care is an unlimited benefit in all HPHC policies, for the reasons you outline above. Not true, I don't think, for Medicare. At least not yet. Barry - don’t disagree with living wills and advance directives are a good idea, but would point out that somebody like RAND studied how often DNR orders are not honored by health care providers, and the percent was something like 50. In other words, about half the time, providers didn’t honor the DNR orders issued by their patients. We have a very long way to go on this one.

Hospice care is an unlimited benefit in all HPHC policies, for the reasons you outline above. Not true, I don’t think, for Medicare. At least not yet.

]]> By: Barry Carol http://www.letstalkhealthcare.org/transparency/practice-pattern-variation/#comment-5527 Barry Carol Fri, 27 Jun 2008 09:06:32 +0000 http://www.letstalkhealthcare.org/transparency/practice-pattern-variation/#comment-5527 Since Bellevue in NYC, with a large number of salaried doctors, still scored in the 60th percentile while the Mayo Clinic was in the 28th percentile, it suggests that the general practice pattern culture in NYC is considerably more aggressive than it is in Minnesota. Other things equal, one would also expect generally more aggressive treatment in teaching hospitals than in a community setting because the teaching hospitals have the capability to do more plus their need to educate the next generation of doctors provides an additional incentive to sometimes do things for the educational value even if it may not help the patient but (hopefully) won’t cause harm either. My two conclusions from the fact that practice patterns vary widely in the U.S., especially with respect to end of life care are: (1) it is important for patients to execute living wills and advance directives, for family care givers to know where they are, and to make sure the hospital has it and includes it in the patient’s chart and (2) every hospital of any size should employ salaried palliative care specialists who can explain the options available to patients and families in end of life situations. Insurance company case managers, for their part, should do their best to make sure this happens and insurance companies themselves should reimburse palliative care specialists adequately even if Medicare doesn’t. I think it would be in their economic interest to do so. Since Bellevue in NYC, with a large number of salaried doctors, still scored in the 60th percentile while the Mayo Clinic was in the 28th percentile, it suggests that the general practice pattern culture in NYC is considerably more aggressive than it is in Minnesota. Other things equal, one would also expect generally more aggressive treatment in teaching hospitals than in a community setting because the teaching hospitals have the capability to do more plus their need to educate the next generation of doctors provides an additional incentive to sometimes do things for the educational value even if it may not help the patient but (hopefully) won’t cause harm either.

My two conclusions from the fact that practice patterns vary widely in the U.S., especially with respect to end of life care are: (1) it is important for patients to execute living wills and advance directives, for family care givers to know where they are, and to make sure the hospital has it and includes it in the patient’s chart and (2) every hospital of any size should employ salaried palliative care specialists who can explain the options available to patients and families in end of life situations. Insurance company case managers, for their part, should do their best to make sure this happens and insurance companies themselves should reimburse palliative care specialists adequately even if Medicare doesn’t. I think it would be in their economic interest to do so.

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