One primary care doctor, David Ives, the medical director of Affiliated Physicians Group, the largest group of private doctors that admits patients to Beth Israel, reacted to the price of a nasal endoscopy and said he thinks the procedure is used too often when a physical exam would suffice.
This comment angered many Ear, Nose and Throat specialists who say the development and use of this scope is one of the most important diagnostic tools in their field in recent history. Before filing the story, I searched for medical literature comparing either the cost effectiveness or the outcomes of a nasal endoscopy vs. a physical exam. I didn’t find anything. I did not call a representative of the American Academy of Otolaryngology for their views on nasal endoscopy. We offer that now.
Wendy Stern is the chair elect of the Public Relations committee for the American Academy of Otolaryngology/Head and Neck Surgery, a former president of the Massachusetts Society of Otolaryngology. Dr. Stern says nasal endoscopy allows the physician to look for signs of bacterial infection, structural changes, polyps or tumors that would not be visible without this tool.
Not using it, “could be harmful or even deadly in the event a patient had cancer,” says Stern. Using the scope appropriately “often helps reduce the need for antibiotics or other unnecessary medication,” continues Stern and can “reduce overall medical costs and the costs of sick days and time out of work.” Continue reading
Beth Israel Deaconess Medical Center
A one-page list of 56 common medical tests and procedures could shake up the way doctors deliver care at Beth Israel Deaconess Medical Center. Why? Because there’s a price next to each item.
Such lists are very unusual. Most doctors have no idea what they are spending when they order care for patients — and finding out is an eye-opening experience.
“I didn’t realize that the prices were as high as they actually were, although I knew that there were some pretty extreme examples,” said David Ives, a primary care doctor and the medical director of Affiliated Physicians Group, the largest group of private doctors that admits patients to Beth Israel.
“One [price] that really pissed me off,” Ives said, “was that when you send someone to an ear, nose and throat [specialist], something like 80 to 90 percent of the time they get a flexible scope of their sinuses.”
Ives says using this flexible cord with chip camera is rarely better than having the doctor look up a patient’s nose or down their throat, but it costs 10 times more than the physical exam.
“It’s just done because the technology is there,” Ives continued, throwing up his hands. “Is there value added for that? And I thought, probably not. And that might someday dissuade me from referring to someone who does a lot of those.”
Ives acknowledges that some ear, nose and throat specialists would disagree and argue that the scope is a valuable test. But raising that disagreement is part of the point of the price list. Phil Triffletti, another primary care doctor at Beth Israel, says that as health care costs continue to rise, physicians need to talk to each other about which tests or procedures are worth the money. Continue reading
Asthma can be terrifying. One minute you’re breathing, the next, you’re gasping for air. I’ll never forget my little brother, chest heaving, rushed to the emergency room during middle-of-the-night attacks.
But despite its dramatic and objectively physical nature, asthma is also a disease with an element of subjectivity.
That point is elegantly underscored in a new study just published in The New England Journal of Medicine. Harvard Medical School investigators found that when asthma patients were treated with the medication albuterol, their lung function improved significantly compared to those given placebo, or fake, treatments. However, and here’s the rub, when the same patients were asked to report how they were feeling — a subjective measure — placebo treatments turned out to be as effective as real medicine in helping to relieve asthma symptoms and alleviate patients’ discomfort.
Indeed, the placebo effect seemed to be on full display here: whether patients were on albuterol, the placebo inhaler or undergoing sham acupuncture (which feels real, but in fact uses trick needles that don’t penetrate the skin) they all reported significant symptomatic improvement compared to little improvement among patients who got no treatment at all.
The takeaway, researchers agree, is that there’s something therapeutic about the act of treatment itself, the ritual of care and the reassuring bond between doctor and patient that makes people feel better, whether or not their treatment includes pills or drugs with an active ingredient. Continue reading
New research suggests that when a doctor (as opposed to a business manager) runs a hospital, it may help improve patient care and boost quality overall.
The New York Times reports:
The findings, published in the journal Social Science & Medicine, are based on a review of 300 top-ranked American hospitals in the specialties of cancer, digestive disorders and heart surgery. Amanda Goodall, a senior researcher at the Institute for the Study of Labor in Bonn, Germany, tracked the professional background of each hospital’s chief executive and then compared the performance of physician-run hospitals with that of hospitals overseen by someone with a nonmedical background.
The study found that overall hospital quality scores were about 25 percent higher when doctors ran the hospital, compared with other hospitals. For cancer care, doctor-run hospitals posted scores 33 percent higher.
Dr. Goodall said the finding was consistent with her research in other fields, which has shown, among other things, that research universities perform better when led by outstanding scholars and that basketball teams perform better when led by former top players.
All of this begs the local question: Should the new chief of Beth Israel Deaconess Medical Center be a doctor? Continue reading
The Boston Globe reports here:
The Lahey Clinic and Beth Israel Deaconess Medical Center, two respected academic medical centers, are the latest Massachusetts hospitals to open merger discussions.
Dr. Howard Grant, president of Lahey in Burlington, recently proposed that the two institutions join forces — though both sides said the discussions are preliminary.
Now for some grains of salt:
Grant’s vision, according to a hospital source, is to form a parent corporation with its own chief executive to oversee a fully integrated health care system that includes the two teaching hospitals as well as a half-dozen community hospitals.
Hartman downplayed the proposal, saying that Grant is “talking to everybody. Dr. Grant has talked to almost every single teaching hospital in the state and talked to the majority of hospitals in our service area.”
Beth Israel Deaconess spokesman Jerry Berger echoed those remarks. “We talk to lots of people about lots of things in this economy and climate and with the changes in health care,” he said.
You hear about it happening to gymnasts and runners, dancers and anorexics. A woman’s — or girl’s — body fat gets so low that she stops having periods; her reproductive cycle shuts down.
You can imagine how evolution may have worked it this way. In ancient times, if conditions were so bad that you were down to skin and bones, that was not the time to try to feed a baby. But in modern times, women with extremely low body fat may face unwanted infertility, and they have been found to be at higher risk for osteoporosis.
Today, researchers report that leptin — a hormone famed for its role in appetite and obesity — is a key to that loss of menstruation, known as “hypothalamic amenorrhea,” and that giving women synthetic leptin can restore their reproductive function and possibly protect their bones.
The paper’s lead author, Dr. Sharon H. Chou of Beth Israel Deaconess Medical Center, summed up the findings:
Women with hypothalamic amenorrhea, or loss of menstrual periods from excessive exercise, excessive stress, or decreased food intake, have additional neuroendocrine abnormalities and experience bone loss. These women also are found to have low leptin levels, which can be seen as a marker of energy stores. This study shows that replecement of leptin in these women restores menstrual periods, corrects some of the neuroendocrine abnormalities, and may improve bone loss.
And this from a Beth Israel press release:
The findings are reported on-line in the Proceedings of the National Academy of Sciences (PNAS), the week of April 4.
“This condition accounts for over 30 percent of all cases of amenorrhea in women of reproductive age, and is an important problem for which we didn’t have a good solution,” explains senior author Christos Mantzoros, MD, Dsc, Director of the Human Nutrition Unit at BIDMC and Professor of Medicine at Harvard Medical School.
“Our findings now prove beyond any doubt that leptin is the missing link in women with significantly diminished body fat, and that this, in turn, results in numerous hormonal abnormalities.” Without leptin, he explains, menstrual periods cease, the body becomes chronically energy-deprived and women experience bone loss and an increased risk of bone fractures. Continue reading
An analysis of mortality data for the fiscal year ending Sept. 30, 2009, showed that 13 of 93 patients who underwent the procedure died. Beth Israel Deaconess’s mortality rate — after adjusting for how ill the patients were — was 5.82 percent, compared with 5.12 percent for hospitals statewide, according to state public health officials.
The hospital’s mortality rate for the 1,039 non-emergency cardiac catheterization patients in 2009 was average.
Doctors at the hospital said their internal investigation, as well as a review by a top cardiologist from Brigham and Women’s Hospital, found that no patients died as a result of complications of emergency heart catheterizations, or from post-surgical care. And since 2009, hospital executives said, the death rate has fallen among patients who undergo the emergency procedure to remove blockages from their coronary arteries.
Beth Israel says the state didn’t account fully enough for how sick the patients were; the state questions whether some patients might have been too sick for the procedure, and says that issue will be examined.
The hospital sent around this internal email:
To: BIDMC Community
From: Donald Cutlip, MD
Kenneth Sands, MD
Senior Vice President,
Silverman Institute for Health Care Quality and Safety
Subject: State Releases Data on Cardiac Treatment Outcomes
The Massachusetts Department of Public Health (DPH) report for statewide post-procedure mortality data for coronary artery bypass surgery and coronary angioplasty (also called percutaneous coronary intervention, or PCI) for FY2009 was released today. We are writing to let you know that BIDMC’s mortality rate among one small group of PCI patients will be identified as being higher than expected.
We take this matter very seriously and have looked at all of the data carefully. After a detailed examination of each of the cases in question, we have found no evidence that any patient died as a result of a complication during the angioplasty procedure itself or as a result of post-procedure care. Rather, we believe that the deaths were due to serious underlying medical conditions. However, to be certain that nothing was overlooked in our internal assessment, we enlisted Dr. David Williams from Brigham and Women’s Hospital to conduct an independent evaluation of these cases, and his conclusions are supportive of our internal review. We will follow this up with a second independent review of our program by the American Medical Foundation.
The DPH findings related only to a small group of patients with the most serious forms of heart disease, including certain types of heart attack and many patients with cardiac arrest or shock (a condition in which the heart is severely weakened and is unable to maintain blood pressure). During the year being reported (October 1, 2008 through September 30, 2009) this group represented less than 10 percent of all patients undergoing PCI at BIDMC. The finding of higher mortality is based on 13 deaths occurring in this population.
We are pleased that this DPH report found no concerns about post-procedure mortality among a much larger group of less ill patients receiving PCI at BIDMC (more than 90 percent of patients undergoing angioplasty.) Furthermore, a report from the Federal Center for Medicare & Medicaid Services (CMS) showed that for all Medicare patients who received care for heart attacks at BIDMC between July 2006 and June 2009, the risk of mortality was lower than the national average; in fact, BIDMC was ranked in the top 3 percent of hospitals.
BIDMC’s Interventional Cardiology Service is among the best in the world and is consistently one of the two highest-volume centers in Boston. Our Division fully supports public reporting and transparency regarding patient outcomes, and members of our interventional cardiology staff serve prominent local and national roles in this area. We will continue our efforts to make certain that outcomes reports are informative for improving the quality of care for all patients, including those who are critically ill and may benefit from potentially life-saving treatments, which will never be completely risk free.
The Boston Globe reports here that outgoing Beth Israel Deaconess Medical Center chief and prominent blogger Paul Levy will receive up to $1.6 million — about two years’ salary — in severance in a “negotiated departure.” Sounds a little different from Paul Levy’s blog description of realizing as he biked through some North African mountains that running a hospital just wasn’t floating his boat anymore.
The Globe’s Liz Kowalczyk reports:
“The Board concluded that this agreement was in the best interest of the medical center and the people it serves …” board chairman Stephen Kay wrote in an e-mail to the hospital community this afternoon. “Just under two years before Paul’s contract would have expired, the Board of Directors has agreed with Paul on a negotiated departure.”
The e-mail suggests a more complicated scenario behind Levy’s departure than he and Kay described Jan. 7, the day Levy announced his resignation. At the time, Kay had said, “Paul wanted a change, there’s nothing more to it.”
In an e-mail to the Globe today, Kay elaborated on how the decision unfolded, after the board had completed Levy’s first comprehensive job evaluation. Kay said that when Levy returned from a vacation to Morocco, “I updated him on questions that had been raised about his level of engagement and I told him that recent performance reviews had been mixed.”
He “raised the question of whether it would be better for BIDMC if he stepped down,” Kay continued. “Initially, his suggestion took me off guard but soon I calculated that the medical center might be better served with a leader who did not take as a burden the day to day challenges of a ‘post turn-around’ institution.”
Did the scandal around Paul Levy’s relationship with a young mentee play a role in the decision by the hospital or its chief? Whether it did or not, that relationship is playing a role in the opprobrium heaped on the outgoing chief by some commenters on boston.com. But there are also defenders like this one:
Paul Levy has done more for BIDMC than most of you ignorant mutton heads have ever done in your careers. First, he reversed the hospital’s financial spiral. This was followed by him successfully navigating through our most recent recession by collaborating with all of the hospital employees to minimize job loss by temporarily reducing raises, vacation time, etc. Once the hospital’s finances stabilized, he returned all of the previous benefits lost as promised. By accounts of those that have worked in proximity to this man, he is an empathetic leader that strives for the good of the whole. Yes he made a mistake/err in judgment, but the ridiculous demonization of this man that positively affected so many people is disheartening.
Veronica Turner, the executive vice president of the state’s largest health care union, 1199SEIU, issued a statement saying in part: “The board should immediately rescind this agreement and return the money to the public charity of the hospital. Every year, BIDMC receives massive amounts of scarce public dollars.”
The payout “demonstrates Levy’s past statements about his departure as completely non-transparent, even duplicitous, and shows his willingness to take scarce public dollars for his own personal gain.”
CommonHealth note: Dear readers — We linked to this post by Paul Levy on Kevin MD today, but it has been called to our attention that it is actually an old piece, and was originally posted this summer. (Dr. Kevin Pho, aka, Kevin MD, explains why the post was up today: “I regularly post articles on my Twitter stream to reach back into my archives. They are with the is.gd link. New articles have links shortened with the goo.gl link,” he wrote in an email.
Still, we should have clarified the original date of the piece. So please accept our apologies. (For Levy’s current posts, see his new blog, Not Running A Hospital.)
Readers, what do you think? Please comment below. Meanwhile, here are responses from Paul Levy’s own blog, Running A Hospital:
David Harlow (of Healthblawg fame) said…
Best of luck in your future endeavors.
Your work at BIDMC (including this nice little blog of yours) has certainly shaken things up — in a good way — both at BIDMC and in the local and national arenas.
I hope to see you on the road.
good riddance. This hospital needs someone who brings it to a first rate patient care but also first rate research and education center. What you have ignored. Also, a place that discrimination is a thing of past.
Bob Coughlin said…
You turned the organization around. You are truly an amazing person. Thank you for your contributions and leadership in the healthcare industry. We owe you a great deal of gratitute and thanks.