The States’ Next Challenge — Securing Primary Care for Expanded Medicaid Populations

New paper in NEJM from researchers at the Department of Health Policy, George Washington University, Washington, DC.

A nice analysis. I hope to do something along these lines - related to health reform, modeling the impact under different assumptions - for my dissertation.

Will health services research determine whether health reform succeeds? - Something Not Unlike Research

Will health services research determine whether health reform succeeds?

Bill Gardner totals up the length of time necessary to do a pilot study of a health systems intervention (like a new care delivery model or physician payment program), get funding, do a larger-scale study, then publish the results: up to 10 years. Then there's a lag between the publication and the implementation by other healthcare systems. That can take another 10-15 years. Sounds similar to the lag described in the Institute of Medicine's Crossing the Quality Chasm report:

It now takes an average of 17 years for new knowledge generated by randomized controlled trails to be incorporated into practice, and even then application is highly uneven.

The lag between the introduction of a new technology or system and its widespread adoption is of great interest to me. Much of the research I've read is either coming at it from a diffusion of innovations perspective or an evidence-based medicine approach. This whole area is touchy for some doctors, and given that a third of US doctors are over 65 and older doctors tend to be slower to adopt new things, I think we need more levers to move clinicians to adopt better practices. And if that means putting them all on salary, I'd be okay with that.

Why home-based primary care is needed

A doctor posed this question in the ethics column in the New York Times magazine yesterday:

My elderly aunt became ill and phoned me, a physician, to ask if she should call an ambulance. I surmised that she was severely dehydrated. From my hospital, I took a bag of saline, IV tubing, an IV lock and a needle. An unsuspecting nurse handed me the tape that secures the needle. I gave my aunt these fluids at home, and she soon felt better, as did I: my stealing $50 worth of medical supplies saved the taxpayers more than a thousand dollars for an E.R. visit. Did I do right? E.G., NEW YORK

The ethicist, Randy Cohen, replied in part:

I should offer a word in your defense from another doctor, Paul R. Marantz, director of the Center for Public Health Sciences at Albert Einstein College of Medicine, who acknowledged that what you did was stealing, but said in an e-mail that “purloining $50 (more likely $20) worth of medical supplies while saving hundreds (more likely thousands) seems a good choice compared with the more burdensome alternative of a visit to the E.R.” I agree that those who practice medicine in imperfect institutions might — must — sometimes choose imperfect actions, but believe that your supply-room raid still fell short.

Here's a great example of a case where home-based primary care practices can make a big impact. If a system were in place that allowed for sending a primary care nurse to the woman's home, the entire ethical problem could have been avoided.

Warnings About Statins Grow Louder

Someone at Miller-McCune really doesn't like statins. Warnings About Statins Grow Louder: "New research suggests previous studies supporting widespread use of cholesterol-lowering drugs is flawed."

The research in question is a Cochrane systematic review. Here is a link to the study's abstract and "plain language summary". From the abstract:

Although reductions in all-cause mortality, composite endpoints and revascularisations were found with no excess of adverse events, there was evidence of selective reporting of outcomes, failure to report adverse events and inclusion of people with cardiovascular disease. Only limited evidence showed that primary prevention with statins may be cost effective and improve patient quality of life. Caution should be taken in prescribing statins for primary prevention among people at low cardiovascular risk.

I think what the authors are really saying is, don't prescribe pills willy-nilly unless the patient is actually at risk. Yes, prevention is worth a pound of cure and all that - but if the patient doesn't need the cure in the first place, then all you're doing is increasing the risk of side effects for no compelling reason.