Anything you can do, I can do better

A very important article appeared today in the newspaper that I regularly read. Let me immediately say that I still do subscribe  to a physical (vs virtual) newspaper. Personally, I would stop my subscription and simply read everything online. But the powers that be in my household much prefer a physical newspaper, especially on the weekend. Long ago, I learned the secret to all happiness – “pick your battles”. So our subscription continues to run.

The article I read spoke to a marvelous new service that is being provided by the Israeli Ministry of Health. The Ministry of Health published a comparison between hospitals based on a whole range of parameters. The purpose of this comparison is to identify hospitals that are more and less successful at complying with various standards of care.

This kind of information is critical to the future of the entire practice of medicine. It is only when patients will have full and complete access to such comparative statistics that market forces will drive all hospitals to achieve better and better outcomes. Despite my socialist leanings, I am totally in favor of market competition. My perspective is that health care should be a basic right of any citizen and should never lead to the bankruptcy of any citizen, just because that individual had the poor luck of getting sick [even if it was by his or her own hand]. At the same time, I am fully aware of the fact that market competition is really the only way to drive people to achieve better outputs.

The four indicators that were used to compare amongst hospitals were as follows:

  1. Speedy percutaneous angioplasty i.e. opening blocked heart vessels using a catheter and balloon [and possibly stent]
  2. Providing aspirin at the time of discharge of the patient who suffered an MI
  3. Speedy management of patients with a fracture of their hip
  4. Provision of antibiotics prior to abdominal surgery

One of the generally surprising [but not surprising to me] findings was that the quality of care was not necessarily better in the bigger hospitals or the hospitals in the center of the country. Considering the long standing debate about providing better care in the periphery of the country, these statistics are critical to the discussion.

To maximize the comparisons, the four parameters noted above were investigated in detail. For example, the study did not just look at the overall average time between arrival to the hospital and the beginning of inserting the balloon into the heart vessels. The study also looked at the effect of day of the week and time of day on these values. With this information, a patient could literally scan a page of statistics and decide, based on distance to the hospital, time of day and day of the week, where the best place is to go for their heart condition or fractured hip. I really cannot overstate how important and game changing this data is.

In a previous blog post, I stated that comparing hospitals based on outcomes can be very difficult. When comparing outcomes, one has to spend a significant amount of time in matching the clinical backgrounds of patients amongst different hospitals. If an individual wishes to know where to have their appendectomy, that individual would have to find patients who matched his or her general health and then compare these patients’ outcomes amongst the different hospitals. So let’s say that the person seeking health care is on chemotherapy for lung cancer. This patient  would need to be able to say that the rate of success with appendectomy specifically for patients on chemotherapy for lung cancer is “X%”  in hospital A and “Y%” in hospital B. If the value of X is greater than Y, then the patient would choose to have the surgery in hospital A.

The problem with this approach is that it requires a significant amount of work to find patients who match the person who is trying to make the decision about where to have their healthcare provided. As I’ve stated in the past, there is a better option which is likely more effective at identifying the better healthcare service.

A great deal of clinical research is designed to identify best practice. For example, as noted above, the faster that a patient is transferred to the angiography room in order to have a cardiac vessel ballooned open, the better the results. If the patient is treated within one to two hours of the beginning of chest pain & signs of an MI on the EKG, the outcomes are far better than if the patient is treated many hours after the beginning of symptoms. The standard of care that has been shown to generate the best results is a speedy angiography. A great deal of work has been done in clinical settings to reduce “time to balloon”. One method involves direct transfer of an incoming patient to the angiography suite, bypassing the emergency room entirely. There are of course protocols for doing this, but the results of implementing these protocols directly manifests as improved outcomes.

Given that there are many such standards of care published for a whole variety of conditions, one can legitimately identify a better health care service based on compliance with all standards of care. Imagine that one hospital has a 90% handwashing rate amongst its staff versus a second hospital that has a 20% handwashing rate. I do not need to do a new study to show that the first hospital will have better outcomes. The extremely powerful effect of washing hands has been shown in multiple previous studies. Therefore, I can declare that the first hospital is a better hospital simply because it complies with the handwashing standard of care.

In the comparison noted in the newspaper article, some hospitals measured very highly in one standard of care but poorly in another. Therefore, major hospitals were not necessarily better than smaller peripheral hospitals. The only question that should be asked is whether any given hospital complies with every standard of care. More so, any hospital that does not comply with standards of care is performing at a substandard level. The Ministry of Health needs to publish more and more of such statistics and comparisons to literally shame every underperforming hospital into improving their compliance with protocols.

From a medicolegal point of view, this data is extremely important. If the patient claims that he or she suffered due to malpractice, and the hospital in question has been shown not to comply with the standard of care for reducing operation related infections, then there is a far greater likelihood that a judge will find in favor of the patient. On the other hand, if the hospital can demonstrate statistics that show a high compliance rate with all protocols, a judge will tend to give the hospital the benefit of the doubt.

This is the future of medical quality assurance. Measuring compliance with protocols is far easier than measuring outcomes and then comparing groups of patients based on outcomes. It is my great hope that this is the first of a regular publication of such statistics, and that over time, every procedure and operation that is done in a hospital will have to submit its compliance rate to protocols. It truly is hard to overstate the revolutionary effect that this kind of statistical analysis will have on quality of care.

It is critical to remember that there is no way to gather all of this information without maximizing the use of various technologies for collecting all types of clinical data. Sensors that are distributed on the patient, in the examining room, in the corridors of the hospital, and in every procedure and operating theater will provide a constant flow of clinically important information about the status of the patient, as well as adherence to protocol.

For example, when a doctor orders an x-ray, data from all of these sensors will indicate how quickly the patient has been taken to x-ray and how quickly the patient has been returned. For patients who are in a deteriorated state of health, the turnaround time for x-rays should be kept to a minimum. The various sensors I just noted above can provide this value for turnaround time. One can then compare this value amongst hospitals. I think it is clear from this one example that a whole suite of new software will be necessary to collect all of this data and then analyze it and deliver the results to the appropriate individuals, professionals and government offices.

There are still many physicians who bemoan the computerization of the entire clinical experience. To be very blunt, I truly do not understand these doctors’ perspective. It is my impression that increased computerization, and thereby the increased quantification of clinical practice, will only improve the quality of care and literally save lives. And improving quality of care is why people become doctors.

Thanks for listening

About the Author
Dr. Nahum Kovalski received his bachelor's of science in computer science and his medical degree in Canada. He came to Israel in 1991 and married his wife of 22 years in 1992. He has 3 amazing children and has lived in Jerusalem since making Aliyah. Dr. Kovalski was with TEREM Emergency Medical Services for 21 years until June of 2014, and is now a private consultant on medicine and technology.
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