Heartland Health Research Institute Archives | Heartland Health Research Institute

Iowa DOT and Volvo Can Teach Medical Establishment a Thing or Two about Safety

Posted on: 11.19.19 By: David P. Lind

Before I comment about the never-ending problem of patient safety in our state and country, I want to provide kudos to the Iowa Department of Transportation (Iowa DOT) and Volvo for doing a great job of keeping vehicle drivers more safe.

Iowa Department of Transportation

When you drive on Iowa highways, particularly on our interstates, you will invariably see snarky, but clever, messages on 79 electronic message signs that may force a chuckle. You can thank the Iowa DOT and the public for these creative messages. The signs are designed to grab the driver’s attention with messages that are part of the ‘Zero Fatalities’ program the DOT launched back in 2014. The DOT promotes this program through blogs and social media. Additionally, the Iowa DOT pulls together safe driving and improved trauma care through a program called TraumaHawk.

Every Monday, the DOT messages change and relate to five driving categories such as buckle up, drive sober, stay alert, pay attention and slow down. But another statistic is commonly updated – sharing the latest number of fatalities on Iowa roads since the beginning of the year. This one always has my attention. Maybe it’s just me, but I am curious to know whether or not we have fewer fatalities.

I’m impressed that not only are the fatalities counted, but they are quickly shared with the public in ‘real time.’ According to the Iowa DOT website, a ‘fatality’ is considered “crash-related” when death occurs within 30 days (720 hours) of a crash. Complex crash investigations can delay the official fatalities report, so the numbers for the current months are preliminary and can change considerably.

Relating road fatalities with preventable medical error fatalities may sound like a stretch – but it’s not. The federal government and all 50 states have made vehicle fatalities and serious injuries a major safety priority. The design and manufacture of the vehicles we purchase are a direct result of these priorities.

Volvo’s Promise

At least one manufacturer, Volvo, has made safety it’s branded message – and market differentiator. This has been a huge success for Volvo when competing against a crowded field of car manufacturers. One of the visions listed by Volvo on its website is truly an eye opener:

No one should be seriously injured or killed in a new Volvo car by 2020.

There it is. Volvo has declared a zero tolerance for manufacturing unsafe vehicles. Quite an impressive Big Hairy Audacious Goal (special thanks to authors James Collins and Jerry Porras for coining the ‘BHAG’ term).

What About the Medical Care We Receive?

Why shouldn’t we have the same amount of commitment from the medical establishment, the federal government and all 50 states on tracking and reporting unsafe medical care? Great question, but we don’t.

Twenty years ago, the Institute of Medicine’s To Err is Human report was published, sending shock waves around the country that at least 44,000 and as many as 98,000 people die in hospitals due to preventable adverse events. The authors of this report called for developing a mandatory, nationwide system for reporting adverse events causing death or serious harm. Yet two decades later, we still have no system in place on a national basis. About two dozen states require providers to report adverse events, but these events are a narrow range of “never events,” which cover only a fraction of all harm events and errors. Iowa is not one of these states.

Tracking and reporting unsafe care boils down to disagreements on how to accurately measure patient harm. Arguments evolve around defining medical errors and avoidable harm, determining whether deaths were caused by errors or other factors, and heaven forbid, the inconvenience of having to collect this data.

Additionally, there is disagreement about the effectiveness of having healthcare staff voluntarily report adverse events or use other means, such as having automated harm surveillance tools embedded in the electronic health record (EHR). According to a 2011 Health Affairs article, voluntary reporting missed 90 percent of adverse events. It’s impossible to fix safety problems if only 10 percent of errors are observed and reported. Further, surveillance tools in EHRs can be manipulated to suit preference of results.

Apparently, ‘inconvenience’ seems to outweigh any perceived benefits of providing safer care. Seeking better measurements, however, should not hold up patient safety improvement efforts. Provider resistance to public reporting of errors is a big roadblock to making preventable medical errors a necessary reality. Unlike the Iowa DOT and Volvo initiatives, we have no ‘Zero Tolerance’ goal in eliminating preventable medical adverse events in Iowa or the U.S.

A New Relevant Role for Insurance Companies

Because the medical establishment and policymakers are unlikely to move forward to proactively improve healthcare outcomes and eliminate preventable medical errors, true payers – taxpayers, employers and their employees – must take charge. They must insist that ‘middlemen’ such as insurance companies implement initiatives, as I have outlined in my Des Moines Business Record article (2018), to proactively learn more from Iowa patients about their experiences with Iowa hospital and clinic encounters.

As an example, Wellmark can play a much greater, more relevant role – similar to the Iowa DOT and Volvo – and become the insurance company committed to the safety of their members – and not just function as a transactional player that processes claims with unknown outcomes. The premiums paid by Iowa employers and their employees should already include this ‘safety’ pledge that is not being acted upon. When you think about it, insurance companies are the stewards of our hard-earned money. We depend on them to use this money wisely.

Similar to our highways in Iowa today, imagine walking into your local hospital and seeing an electronic display showing real-time results of the ‘zero-tolerance’ program that reports preventable adverse events for that hospital. Now that would be a BHAG!

The next steps we take in Iowa will define our ethical commitment to this public health crisis.

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It’s Time for ‘Health Literacy,’ but What is It?

Posted on: 01.29.19 By: David P. Lind

Let’s be honest, healthcare is complex. It affects each of us in many ways, some more than others. Despite our desires, we cannot ignore it and assume it will go away, it just won’t. Ben Franklin once wrote, “Nothing is certain except for death and taxes.” Well, let’s tack an addendum to that quote with the following: “Nothing is certain except for death, taxes and healthcare fatigue.”

Healthcare fatigue?

In its simplest form, ‘fatigue’ describes “extreme tiredness resulting from mental or physical exertion or illness.” Fatigue is found in healthcare at many different levels. We are now beginning to learn more about how medical providers – physicians, in particular – are increasingly experiencing job ‘burnout,’ a problem so alarming that a recent Harvard report is calling it a public health crisis. According to this 2018 survey, 78 percent of over 8,000 physicians polled ‘reported feeling burned out at least sometimes.’ Another recent Medscape study revealed that nearly half of 15,069 responding physicians reported they were burned out – female doctors reported at a higher rate than their male counterparts.

This horrific finding is extremely troubling for the physicians (and family members) who fight three main symptoms:

Emotional exhaustion.
Sense of depersonalization and disconnection from work.
Feeling a lack of efficiency at work.

Equally disturbing is how provider-fatigue may adversely impact patients who rely on their doctor’s clear judgement when receiving appropriate care. If one physician is battling a form of ‘burnout,’ the domino-effect on patients from that doctor becomes a multiplier effect.

Patients, for their part, must seek healthcare by using a labyrinth of passages or paths that are not often intuitive, especially when acute or chronic health conditions undermine the decision-making process. Patients have their own form of ‘healthcare fatigue.’ They must arm themselves with tools and resources needed to make informed decisions regarding preventive, routine, emergency and end-of-life care. For this to be successful, patients must become health literate.

Health literacy is about having the ability to make informed choices in any healthcare situation. Due to the complexity of the U.S. healthcare delivery system, most Americans lack the information-gathering and decision-making skills to effectively cope with today’s complexities. Jo Kline, founder of the Iowa Institute for Health Literacy, succinctly states that “The public has never been offered the health literacy tools they need. Teaching the skills of informed decision-making to those directly affected – such as 133 million Americans of all ages with chronic medical conditions – is a long-overdue first.”

If we believe our interactions with medical practitioners are a ‘monologue,’ meaning that the practitioner talks and we should only listen, we are grossly mistaken. Instead, we should be having a ‘dialogue,’ in which a healthy conversation develops between the practitioner and the patient, allowing for both sides to clearly understand what the other party is saying. Literate patients and family members must not be afraid to ask questions – and then ask more. This is, however, just one part of being health literate.

Kline explains in her recent press release, “The state of Iowa mimics what America at large is facing: aging demographics and shrinking healthcare resources. Ten thousand Baby Boomers turn 65 every day and Iowa will have an additional 158,000 seniors by 2030.” During this same time period, Kline indicates that “one-third of healthcare professionals are retiring, so the workforce will shrink and waiting times will grow – for patients of all ages.” With this inevitable challenge, being health literate is imperative for all of us.

How can employees and their family members become more health literate? A great way to start is by attending Kline’s first-in-the nation seminar on Wednesday, March 6, at the FFA Enrichment Center (DMACC Campus) in Ankeny. From this, you will discover the fundamentals of health literacy, such as reducing the risks of polypharmacy with an annual “Brown Bag Checkup” of all medications, keeping your medical history up-to-date for any new provider or emergency, and understand the vital role that palliative care can play in treating any serious illness.

Being health literate is extremely important to each one of us. We will be better equipped to recognize when, how and where to access, process and understand basic health information and services needed to make informed decisions in a particular healthcare situation.

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Patient Safety Awareness Week – Embracing the Right ‘Culture of Safety’

Posted on: 03.13.18 By: David P. Lind

Patient Safety Awareness Week began on Sunday. Therefore, it is only appropriate to commemorate this week (and all following weeks) with awareness about safe patient care among healthcare professionals and the public.

Much too often, patient safety is overshadowed by other healthcare-related issues (and agendas), such as expanding insurance coverage in state and local markets, medical and insurance mergers and acquisitions, and the opioid crisis – to name just a few. Some issues can’t be appropriately addressed soon enough (e.g. opioid epidemic), while other agendas are more about obtaining growth through acquisitions, often in the guise that more ‘value’ will be created to benefit the patient and the public. In healthcare, it appears optics is an extremely important and powerful tool.

So why is it so hard to make healthcare safer? There are many reasons, but four primary culprits stand out above all others:

Complexity of healthcare delivery system
Flawed systems are not designed to optimize patient safety
Ineffective communication contributes to patient harm
Weak incentives to push improvement processes

We all know that healthcare is complex. Much of it is due to flawed systems that are laden with unclear and distorted regulations often resulting in unintentional consequences which adversely impact patient care. Additionally, poor organizational safety cultures and communication practices compound the previous two reasons for unsafe care.

Much of the patient safety problem stems from not having a ‘business case’ to do the right thing at the right time. Business models are dependent on incentives – strong incentives – that will steer behaviors to the desired goal(s). When it gets down to it, inadequate financial incentives stunt the necessary initiatives required to spark safer patient care. Come to think of it, this is also part of human nature.

Unfortunately, in healthcare, it appears to be less about ‘doing the right thing’ and more about having appropriate incentives that will create the ‘business case’ of providing safe care to patients. This mentality must change.

After publishing ‘Iowans’ Views on Medical Errors,’ I created a number of Fact Sheets that address some takeaway thoughts for patients, employers and healthcare providers. These printable documents are found in the right sidebar on this HHRI webpage. Given the importance of this week, I would like to briefly address one particular Fact Sheet, ‘8 Strategies for Hospitals and Clinics to Prevent Medical Errors.’

I clearly realize that healthcare administrators will likely scoff at my ‘attempt’ to help them reform themselves, after all, they have been doing this reformation work for years, if not decades. But it seems to me – and many national medical experts included – patient safety begins with having a legitimate culture of safety at each medical establishment. And, it begins in the boardroom on down to each department in the organization. From this embedded culture, all other safety strategies can successfully follow.

My strategies, in no particular order – follow ‘culture of safety:’

Embrace a culture of safety
Treat staff burnout as an organizational priority
Adopt a structure to improve patient handoffs
Develop and nurture a patient and family-led advisory council
Be vigilant about reducing infections
Work to avoid diagnostic errors
To avoid medication errors, find opportunities to include pharmacists
Electronic health records systems must be interoperable

In 2017, the American College of Healthcare Executives and the Institute for Healthcare Improvement/National Patient Safety Foundation published an excellent resource to address this critical strategy for delivering safe care: “Leading a Culture of Safety: A Blueprint for Success.”

Patients experience medical errors not because doctors and hospitals wish to do them harm. Rather, unsafe care occurs because the systems and cultures of medicine influence medical providers to make decisions that don’t produce the best clinical results. It’s really quite simple. What patients want and need – coordinated and compassionate care that is affordable and safe – must align with the ‘business case’ of those who are paid to deliver it.

A ‘culture of safety’ should not just be a slogan in advertisements, but rather, THE reason healthcare organizations exist.

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Making Sense of the ‘Iowa Patient Safety Study©’

Posted on: 01.17.18 By: David P. Lind

Confronting problems we have in healthcare today and fulfilling our vision for the future begins with having the courage and willingness to do the ‘right thing.’ Too often, however, doing the ‘right thing’ runs contrary to how we are incentivized to perform. As we know, incentives drive behaviors – both good and bad.

In his book, “Mistreated: Why We Think We’re Getting Good Healthcare and Why We’re Usually Wrong,” Dr. Robert Pearl appropriately wrote: “The design of our healthcare system – how it’s structured, reimbursed, technologically supported, and led – determines how the people in it will behave.” This sentence clearly articulates the inherent problems found in a haphazardly-designed system that now comprises almost one-fifth of the U.S. economy.

I have learned a great deal from our recent “Iowans’ Views on Medical Errors – Iowa Patient Safety Study^©.” Five large takeaways from this study include:

Nearly one-in-five Iowa adult patients experienced medical errors in the past five years, either for themselves or for someone close to them.
When a medical error occurs, six-in-10 Iowa patients are not notified of the error by the responsible healthcare provider.
Most Iowans who experienced medical errors desire to report the error because they want to prevent the same error from happening to someone else. This runs contrary to conventional belief that patients desire to report medical errors primarily to receive compensation for the harm they received.
Iowans strongly feel that medical errors must not be hidden from the public and should be reported, both to the patient and to an appropriate regulatory agency.
Iowans believe medical errors are mostly caused by overworked staff, lack-of-care coordination and poor communication.

Reading between the lines on many of the survey findings, here are some of my general thoughts on what we can learn from this report:

Medical errors are a national public health crisis, and Iowa is certainly not immune from this persistent epidemic.
Making healthcare safer is difficult largely because healthcare organizations operate in a very complex healthcare system. They use a myriad of inoperable electronic health-record systems that are not fundamentally equipped to allow for effective communication between providers. Most importantly, strong incentives to push appropriate patient care in the right direction is sorely lacking. Because of this, delivering efficient and safe healthcare appears to be more problematic than putting a man or woman on the moon.
Surveyed Iowans are not necessarily blaming individual workers who devote their worklife to the medical profession, but rather, they tend to believe that well-meaning medical professionals are trapped in a subpar delivery system.
The patient ‘perspective’ must be actively pursued to measure the outcomes of the care they receive, and this experience can help reveal the prevalence of medical errors. The future of healthcare will be determined as much or more by patients as by physicians.
Zero-tolerance of preventable medical errors should be the norm, rather than exception – Most everyone knows that this problem is happening, but little has been done to determine the extent of this problem and how to make it unacceptable in the future. When errors occur, provider care systems are largely silent on this topic, often failing to share prompt, open disclosure and a full apology to harmed patients. This primarily happens because providers wish to avoid the possibility of malpractice lawsuits and maintain a pristine public reputation. Patients, on the other hand, have reasonable expectations that are woefully unmet after an error occurs. They likely feel thrust into a confrontational situation while still being in a fragile state of health. In short, if we don’t demand safe care, they don’t supply it. In 2017, commercial passenger airlines had zero deaths due to accidents…because that industry has a zero-tolerance approach to preventable errors. The medical industry can learn greatly from other industries.
Organizational culture is critical to the success of delivering safe care. The environment in which medical staff work – such as hospitals and clinics – can provide the necessary organizational culture to ensure the healthcare delivered is as error-free as humanly possible. Medical staff should not be afraid to report medical errors when they do occur. Safety improvement initiatives will only succeed when leadership, safety culture programs, fundamental communication practices, commitment to transparency and patient engagement are fully-aligned with the objective of greater patient safety.

Thought leader and author Frank Sonnenberg describes trust quite succinctly, “Trust is like blood pressure. It’s silent, vital to good health, and if abused it can be deadly.” To have an efficient and effective healthcare delivery system, trust will be required at all levels and by all participants. This means that, at their most vulnerable time, patients should not be taken advantage of by those who are given this trust – especially when medical errors occur.

If we can put a man on the moon in 1969 using technology dated 50 years ago, why can’t preventable medical errors be tracked and mostly eliminated today? We must first have the moral will to succeed, and then design and install correct incentives to ensure the desired behaviors and outcomes.

The re-design of our healthcare system requires the grit we used when launching a rocket to the moon. In healthcare, however, its more about human (and organizational) behavior than rocket science.

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New Survey: Nearly One-in-Five Iowa Patients Experience Medical Errors

Posted on: 01.08.18 By: David P. Lind

Clive, Iowa – January 8, 2018 – Although a vast majority of Iowans have positive experiences with the healthcare system in Iowa, nearly one-in-five Iowa adults (18.8 percent) report having experienced a medical error either personally or with someone close to them where they were very familiar with the care that person received, during the past five years.

This finding comes from a new Iowa survey released today by Heartland Health Research Institute of Clive, Iowa. The first of its kind in Iowa, this statewide survey was conducted from May 11 to June 6, 2017. A total of 1,010 Iowa adults age 18 and over took part.

To download a FREE copy of the Study, click here…

Of the 18.8% of Iowans who experienced an error, 60 percent were not told by the responsible healthcare provider that an error had occurred. The survey finds that hospitals are the most frequent site of medical errors (59 percent), while 30 percent of errors occurred in the doctor’s office or clinic, four percent in nursing homes and seven percent at some other location.

Other notable survey findings regarding Iowans who reported an experience with medical errors in the past five years include:

The most common type of medical error cited by Iowans were mistakes made during a test, surgery or treatment (60 percent), while over half (55 percent) said the error was due to a misdiagnosis.

Ninety percent of those experiencing a medical error, either personally or with someone close to them, believe the medical error was preventable.
When experiencing a medical error, six-in-10 Iowans believe a serious health consequence resulted and nearly one-third reported that serious financial consequences had resulted from the medical mishap.
Sixty-two percent of those who experienced a medical error reported the error, while one-third did not report the error. Almost two-thirds of those who did not report said they simply didn’t think reporting the error would do any good.
Almost nine-in-10 Iowans who reported the medical error did so because they wanted to prevent the same error from happening to someone else. Only 25 percent reported the error because they desired to receive compensation for the harm.

Other key highlights for all Iowans surveyed, whether they experienced a medical error or not, include:

When asked if medical errors were a problem in Iowa, 26 percent of all Iowans surveyed believe medical errors are a “Very serious” or “Somewhat serious” problem, and 11 percent perceive medical errors to be “Not too serious.” Almost half believe that medical errors are not a problem.

To assess perceived progress in eliminating medical errors during the past five years, about a quarter of Iowans (24 percent) believe there are fewer errors today than five years ago, whereas 18 percent believe there are more errors now. About one-third of Iowans (32 percent) felt the frequency of errors has not changed in five years.
Many Iowans generally believe that a high percentage of medical errors can be prevented, and are primarily caused by overworked medical staff, lack of care coordination and poor communication.
Ninety-three percent of Iowans at least somewhat agree the public should have access to medical error information for each hospital and doctor.

Eighty percent of Iowans “Strongly agree” that Iowa hospitals should be required to report all medical errors to a state agency, and 74 percent “Strongly agree” that Iowa doctors should be required to report all medical errors to a state agency.
Nearly nine-of-10 Iowans “Strongly agree” that providers should be required to tell patients of any medical error.

Sixty-one percent of Iowans who have not experienced a medical error are likely to believe their personal doctor would tell them if a medical error occurred, yet only 41 percent of Iowans with a medical error history believe this is true.

“The prevalence of medical errors in our country remains a public health crisis, and the findings of this study clearly demonstrate that Iowa is not immune from this serious problem. Iowans strongly feel that medical errors must not be hidden from the public and should be reported, both to the harmed patient and to an appropriate regulatory agency,” says David P. Lind, President of Heartland Health Research Institute. “Quality of healthcare will only improve when leadership, organizational culture and patient engagement are fully aligned. When seeking healthcare, patients deserve truthful, timely, and transparent information about medical errors.”

About the Survey

The Iowa Patient Safety Study – Iowans’ Views on Medical Errors^© was conducted from May 11 to June 6, 2017. Results are based on a representative sample of 1,010 Iowa adults age 18+. Interviews were completed using telephone-based data collection, with 451 completed interviews on numbers called using random digit dialing of landlines with Iowa’s area codes. In addition, 559 interviews were completed using cell phones. For the overall sample, the results are accurate to within plus or minus 3.1 percent, at a 95 percent confidence level. The study methods used permit the results to provide estimates of all Iowa adults. Data Point Research, Inc. (DPR) provided the interviewing, statistical analysis and mathematical basis for the study. Funding for this study came from David P. Lind, as President of Heartland Health Research Institute and was undertaken as a public service, with no financial, political, professional, personal or other bias inherent therein. A full report is available at HHRI.net.

About Heartland Health Research Institute

Heartland Health Research Institute (HHRI) is an independent, nonpartisan and nonprofit research organization based in Clive, Iowa. HHRI is organized as a public benefit 501(c)(3) corporation that conducts research and analysis on a broad spectrum of healthcare issues. Topics specifically focus on the patient’s perspective – measuring their confidence and trust in the healthcare system today and into the future. To learn more about HHRI, visit HHRI.net.

About Data Point Research, Inc.

Data Point Research (DPR) is an independent full-service research organization dedicated to improving the lives of others. DPR provides precise, neutral, detailed, and easy-to-read analysis for clients. Founded in 1997, DPR collects, analyzes, and provides clients with the information needed to make solid, well-informed decisions in the areas of social policy, health, and employee benefits.

Many Iowans have suffered medical errors, and most weren’t told, poll finds (Des Moines Register, January 8, 2018)

To download a FREE copy of the Study, click here…

Why Health ‘Autonomist?’

Posted on: 05.30.17 By: David P. Lind

Words do matter.

A recent survey of 500 consumers located in six southwest states were asked about their sentiments regarding healthcare advertising and marketing. One big takeaway? The three most effective words that healthcare organizations should use when marketing their services to the public are:

Knowledgeable
Trustworthy
Cost-Effective

Other similar words, such as “expert,” “helpful” and “innovative” ranked considerably lower. Researchers concluded, “Clearly, nuance [in messaging] matters.” Crafting advertising language in any type of business or industry is important for a few key reasons: Inform, promote and, most importantly, sell.

Unfortunately, in healthcare, when it comes to decision-making tools on pricing of procedures and having the best clinical outcomes on specific local providers, the public generally operates in a ‘black box.’ Instead, we are forced to rely on other factors that serve as guardrails when seeking effective and appropriate medical care, such as provider reputation (justified or not), word of mouth, provider participation in insurance networks, trust (again, justified or not), and the aforementioned, advertising.

The general public is bombarded with countless health-related topics and sources. How can Americans decide what ‘position’ to accept as gospel or reject as hogwash? The convergence between truth and fiction can become so difficult to decipher, especially when documented facts are baked in with half-truths. Former New York Senator, Daniel Patrick Moynihan, perhaps put it best when it came to sharing the truth: “Everyone is entitled to his own opinion, but not his own facts.”

Individuals, organizations and industries are entitled to share their views, but when these views are dangerously lauded to be factual, a fine-line is often crossed that is intended to mislead the public. One of the first things I do when reading an article, study or advertisement is to learn about the author (or source). Which organization(s) does he/she/they represent, and how might they be compensated? I know, it seems a bit anal-retentive, but it actually serves as a good, informal reality check to expose the fox guarding the hen house. As we all know, the fox may appear to have the chicken’s best interest in mind, but in reality, he is looking for his next supper – at the chicken’s expense.

Recently, I was asked by a media outlet to participate in a public discussion about healthcare issues facing Iowa and the U.S. Although unable to attend this event, I was reminded that my role was important because “I had no dog in the fight.” This meant that I had no predisposition to protect a particular industry or take a sacred position on any given issue. Just tell it like it is. I took this to be a high compliment.

Because I write separate blog posts for two websites, David P. Lind Benchmark and Heartland Health Research Institute (HHRI), I have decided to assign a particular name to my HHRI blogpost – “The Health Autonomist.”

Autonomist: The independence to share one’s thoughts and to have the freedom from external control or influence.

Autonomist comes from ‘autonomy,’ a refreshing word having the independence to share one’s thoughts or actions without tilting the windmill. Autonomy is also about having freedom from external control or influence. When I write about various topics on health, healthcare and health insurance, I try very hard to look at different perspectives that may most likely challenge conventional wisdom. Readers need to understand that there are few simple, concrete answers to these complex, mosaic issues.

When writing a blog, my intent is to not influence the reader, but rather, provide a different perspective, using factual information based from credible sources. So, should you believe everything I write? Simply put, “No.” In fact, if you have feasible information that refutes my posts, I invite your comments. When it comes to discussing health, healthcare and health insurance, it is critical to have a community dialogue rather a one-person monologue. Please remember, I am merely trying to seek the truth, as it is buried somewhere under mainstream thought and practice.

The word ‘autonomist’ matters to me. I hope it also matters to you!

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Diet Soda – A Correlation to Stroke and Dementia

Posted on: 05.09.17 By: David P. Lind

Every day we learn of new study results that admonish us to consume more (or avoid) foods and beverages to keep us both safe and healthy. Some reports conflict with one another, causing us to become even more confused about our daily dietary decisions.

For a number of years, sugar-sweetened soda had been associated with obesity, diabetes, poorer memory and small overall brain volumes. Over time, sugary soda was no longer the ‘beverage of choice’ for some. It was substituted for a seemingly more palatable option – diet soda, a sugar-free, calorie-free carbonated water with artificial-sweetened versions.

However, a 2013 National Center for Biotechnology Information (NCBI) study revealed that both sugar-sweetened and artificially sweetened beverages were linked to an increased risk of developing Type 2 Diabetes. Another study, after adjusting for common factors that contribute to weight gain such as dieting, exercising change or diabetes status, showed that those who drank artificially-sweetened drinks have a 47 percent higher increase in Body Mass Index than those who did not.

A study released in the May journal of Stroke concluded that “artificially-sweetened soft drink consumption was associated with a higher risk of stroke and dementia.” It found that those who drank at least one artificially-sweetened drink a day were 2.96 times as likely to have an ischemic stroke and 2.89 times as likely to be diagnosed with dementia due to Alzheimer’s Disease. The research, however, emphasized that it did not show causation to these diseases, only a correlation. This study’s takeaway is this: Diet sodas may not necessarily be a healthier alternative to sugar-sweetened beverages.

Iowa Healthiest State Initiative

I serve as a committee member on the Iowa Healthiest State Initiative (HSI), a statewide program whose mission is “To improve the physical, social and emotional well-being of Iowans.” As the name suggests, the goal of HSI is to ultimately “become the healthiest state in the nation.” Our workgroup is currently assessing many different healthy measurement metrics – including dietary behaviors – that will gauge the progress Iowans make when living active and healthy lifestyles. One key dietary measurement objective that we will likely pursue is decreasing the number of Iowans who consume sugar-sweetened beverages on a daily basis. As with all objectives, the idea is not to have prescriptive “Do’s” and “Don’ts” for Iowans. The goal is to gently nudge behaviors that will encourage positive outcomes for the individual’s physical and emotional well-being.

This most recent study provides yet another reason to temper our thirst for sugar- and artificially-sweetened beverages. Other healthier options to these sugar-sweetened beverages? According to The Nutrition Source from the Harvard T.H. Chan School of Public Health, drink more water, tea or coffee (with little or no sugar), limit milk and dairy products (1-2 servings/day) and just one small glass of juice each day. Again, these are merely suggestions.

More about the Healthiest State Initiative, version 2.0, in future blogs!

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Malpractice Caps Won’t Protect Harmed Patients

Posted on: 04.04.17 By: David P. Lind

Medical-malpractice reform bills currently moving forward in both the Iowa House and Senate (SF 465) attempt to place a $250,000 cap on non-economic damages, such as “pain, suffering, inconvenience, physical impairment or mental anguish.” The push to limit non-economic damages comes from the provider community, which includes doctors and hospitals.

Both sides of malpractice reform offer persuasive arguments on the merits of these reforms. Injured individuals and their lawyers argue against malpractice reform, saying patients won’t be protected against negligent providers. Because of errors, healthcare costs are higher. Botched care requiring fixes often happens without patient knowledge and involves additional patient and insurance payments. The social and economic costs of medical errors are also enormous.

Doctors and hospitals, on the other hand, usually push for reform, saying it will protect patients from having to pay the high costs of malpractice insurance and help curtail defensive medicine practices – presumably through lower health insurance premiums – and perhaps increase accessibility to some healthcare services.

Interestingly, a recent report from personal finance website, WalletHub, indicated that Iowa is the best state for doctors to practice medicine, when comparing 14 different relevant metrics, and Iowa is the fifth least-expensive state for annual malpractice liability insurance.

But here’s the fundamental question that gets lost: Will capping non-economic damages provide the necessary incentives for providers to alter their practices enough to eliminate avoidable medical errors? This should be the most critical question regarding malpractice reform being debated in Iowa and elsewhere. Unfortunately, the Iowa bills fail to address this issue.

Patients expect to be safe when they receive healthcare from the providers they trust. Yet, solid evidence suggests this trust is routinely violated. We’ve made relatively little progress in reducing preventable medical errors since 1999, the year the Institute of Medicine released their book, ‘To Err is Human.’ In the last year, using national estimates on preventable medical errors, my organization extrapolated that a mid-range estimate that 85,000 patients are harmed in Iowa hospitals yearly due to preventable medical errors. This number does not include harm occurring in physician clinics, outpatient surgery centers, nursing homes and other care locations.

I don’t represent trial lawyers nor healthcare providers and I have become rather apostate regarding political parties. In my opinion, tort reform should be about reducing medical errors – the root cause of why we have malpractice issues in the first place. By working toward the elimination of the root cause – medical errors – malpractice and its negative side effects will also disappear. This more logical approach will benefit patients, providers and our overall healthcare system. Adopting safe care practices would substantially reduce the costs of botched-care fixes and defensive medicine – in addition to enhancing the quality of life for patients and their caregivers.

As the Iowa bills demonstrate, we continue to seek ‘quick fixes’ that gnaw at the edges of the problem. But these laws seldom address the core reasons of why many medical errors happen. Medical errors are, unfortunately, a fact of life. But many are avoidable. In our healthcare world, we have well-meaning and very capable caregivers. Too often, however, we also have broken organizational cultures that inadequately address patient safety protocols and burned-out physicians and staff who are required to “produce” at unsustainable levels. Any meaningful reform must begin at the healthcare organization level, ensuring we all receive appropriate and safe care. Organizations providing impactful interventions to help promote safe cultures of care can greatly improve safe care practices.

Misguided malpractice reform can actually exacerbate rather than eliminate medical errors. Placing caps on damages, economic or otherwise, insulates the medical community from high monetary awards, yet offers little, if any, incentives for healthcare organizations to establish clear and genuine protocols to ensure a culture of safety. The right incentives matter, especially when it comes to the safe care we trust we’ll receive.

Isn’t it time for provider organizations to adopt a culture of safety, rather than seek malpractice caps that do nothing to protect us as patients?

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Another Estimation on Hospital-Related Deaths Due to Medical Errors

Posted on: 02.21.17 By: David P. Lind

Just one year ago (February 2016), Heartland Health Research Institute (HHRI) published a series of white papers, ‘Silently Harmed – Hospital Medical Errors in the Heartland.’ ‘Silently Harmed’ was intended to demonstrate what the national estimated preventable adverse events (PAEs) may mean to Iowa and six states contiguous to Iowa. Using a handful of U.S. studies that evaluated preventable mortalities, HHRI settled on approximately 250,000 patients dying annually in U.S. hospitals due to preventable mistakes.

Just two months after ‘Silently Harmed’ was published, The Leapfrog Group estimated over 206,000 avoidable deaths occur in hospitals annually. A month later in May, a report released by Makary and Daniel estimated preventable deaths in U.S. hospitals to be greater than 250,000, similar to the HHRI estimate. The Makary-Daniel report made national headlines by suggesting “medical errors are the third leading cause of death in the United States.”

Another report has now been released in the March 2017 edition of the Journal of Patient Safety suggesting that “approximately 200,000 preventable hospital-related deaths each year in the United States is not unreasonable.” This report is authored by Kavanagh, Saman, Bartel and Westerman.

Unfortunately, there are no systematic protocols in place within our hospitals that mandate reporting medical errors. To date, all studies that address the mortality in U.S. hospitals due to medical errors are simply projections that are based on small sample sizes of hospitals and patients. The provider community, armed with their own under-reported data on medical errors, can only argue that these estimates are much too high. The fact is that much of the literature suggests that these estimations are conservative and underestimated.

What I found to be most interesting in the recent report by Kavanagh et. al include the following:

Patient Perspective – Any insinuation from the medical community that preventable medical errors should be discounted due to patient age, health or life choices are baseless. If a terminal patient dies prematurely due to a medical error, this is still an unacceptable occurrence. As the article correctly states, “Medicine does not have the moral authority to discount or disregard days, weeks, or months of life.”

Voluntary and Non-Audited Reporting – Voluntary and non-audited reporting mechanisms greatly under-report adverse events, preventable harm and fatalities. “The 2010 Office of Inspector General Report found diagnostic codes ‘absent or inaccurate’ in seven of eleven Medicare hospital-acquired conditions, and in 93 percent of the time, incident reports were not submitted.” In fact, “since 2005, an average of less than 1000 sentinel events have been voluntarily reported to The Joint Commission per year from the hospitals that have undergone their accreditation process…Officials at The Joint Commission estimate that less than 0.1% of events have been reported.”

Cultural of Safety – Having a ‘culture of safety’ serves as the hospital’s foundation from which to build new internal systems and policies that prevent patients from being harmed. “What ties the occurrence of preventable adverse events and mortality together is the willingness and determination of facilities to adopt a culture of safety and invest in patient safety. The adoption of preventive protocols is further hindered by the United States’ fragmented, nonuniform healthcare systems composed of facilities with differing philosophies and administrative structure.”

Put Your Money Where Your Mouth Is – Some in the healthcare industry ignore current studies on medical harm and believe we must wait for more perfect data before it can be shared with the public. “The onus should not be on consumers but on the healthcare industry to generate comprehensive data to demonstrate that their product is safe.”

One example on just how grossly under-reported adverse events are in our hospitals, just look at a recent article in the Minneapolis Startribune. The article indicated that Minnesota hospitals reported only 336 ‘adverse events’ during the last year, including operations on the wrong body parts and disabling medication errors. The report included four adverse events that resulted in deaths — three from patient falls and one from a medication error — and 106 that led to severe injuries. This type of reporting runs contrary to national reports on adverse events in U.S. hospitals. In May 2016, the Agency fo Healthcare Research and Quality stated, “According to the most recent data, nearly 4 million adverse events occurred in U.S. hospitals in 2013…we can project that about 170,000 people died in 2014 as a results of an adverse event or medical error.” This estimate is for Medicare-eligible patients only. Based on 585,000 hospitalizations in Minnesota in 2012, HHRI estimated that roughly 146,000 patients are seriously harmed in Minnesota each year, while over 4,200 patients are fatally harmed annually.

Creative reporting of such important metrics continues to be allowable in this country.

Most agree that we need better data to avoid further speculation of this epidemic. Playing horseshoes and hand grenades to determine the number of patients harmed is no longer good enough. After all, if we don’t know the extent of the problem, how can we determine whether the new delivery and payment systems will solve it?

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Time to Move Upstream and ‘Invest’ in our Health

Posted on: 11.21.16 By: David P. Lind

Authors: David P. Lind and Yogesh Shah, MD, MPH

Employer-sponsored health premiums in Iowa have increased 215 percent since 1999. This growth, however, appears tame when compared to health insurance plans sold in the individual market. We’ve grown so accustomed to rising health costs that it has become the ‘new normal’ with no apparent silver bullet in sight to remedy the core problems. Healthcare costs continue to outpace general inflation, typically by two-to-three fold. We live with constant anxiety about paying more for our healthcare – whether through taxes, premiums, deductibles and/or other out-of-pocket expenditures.

With the advent of a new Trump administration geared to repeal many Obamacare components, all sorts of health insurance “solutions” will be debated. Ideas to make coverage more competitive include selling policies across state lines, pushing for health savings accounts, and relying on other tax incentives to perform magic. However well-intentioned, belief that the insurance component will somehow fix our cost problem is wishful thinking.

The major source of this problem is our unhealthy population. “Upstream” environmental factors greatly impact our “downstream” health. for all of us. Upstream factors are many – primarily poor nutrition, inadequate housing and education, and low incomes – all considered to be social determinants of our health.

To meaningfully address healthcare costs in Iowa and nationally, we must be willing to consider new approaches and develop a mindset that transcends party politics. This may sound counterintuitive, but to reign in ever-increasing healthcare costs and enhance better population health, we should explore new solutions ‘upstream’ to invest in our collective health and well-being. This is not about implementing ‘socialized medicine.’ It’s about using our limited resources more wisely on key determinants of overall health that can ultimately improve health and control healthcare costs.

Healthcare Spending

In 2014, we spent 17.5 percent of our economy on healthcare, reaching $3 trillion annually. By comparison, in 1960, we spent only five percent on healthcare. One disturbing estimate by the Institute of Medicine shows about one-third of our healthcare spending – or $1 trillion – is widely considered wasted spending, money that can be better invested elsewhere.

Should healthcare costs dominate such a large segment of our economy? If so, shouldn’t we be healthier than other nations based on what we spend? On a per capita basis, the U.S. performs poorly on many key health indicators. For example, our country has lower birth weight, higher maternal and infant mortality, as well as higher incidents of injuries, obesity, diabetes, heart disease, chronic lung disease, disability rates, mental illness and, surprisingly, shorter life expectancy. In addition, we have more drug-related deaths than other industrialized countries.

With these in mind, one would think that most comparable countries must be outspending the U.S. on healthcare services. The facts are quite the opposite. In 2009, our country spent 16.3 percent of its gross domestic product (GDP) on healthcare, about six percentage points higher than the average 10.3 percent spent by 10 other industrialized countries. Yet, our growing appetite for more healthcare spending results in poorer health outcomes. This is both puzzling and frustrating – for policymakers, taxpayers, employers and their employees.

Social Services (Community Health) Spending

Instead of focusing on how to pay for healthcare – a perpetually-growing segment of our economy – we should re-direct our limited resources to impact basic social determinants of health, such as targeting education, housing, nutrition and poverty. Unlike healthcare, U.S. public spending on social services falls far below other developed nations. In 2009, the U.S. spent 9.1 percent of its GDP for aggregate social services versus the average of 15.8 percent spent by all 10 other wealthy countries.

When combined, U.S. healthcare and social services spending ranks in the middle of the pack of peer countries, with a disproportionately higher amount spent on healthcare than on social services.

The U.S. is the only wealthy country where healthcare spending accounts for a greater share of GDP than social services spending – an “imbalance” our country has embraced. Over decades, we’ve allowed soaring healthcare costs to smother the necessary investments we must make to improve our community health. In other words, our country inefficiently relies on medical care and insurance to address problems that we fail to address upstream, at their source. An insightful reference on this subject comes from a book written by Elizabeth H. Bradley and Lauren A. Taylor – The American Health Care Paradox…Why Spending More is Getting Us Less.

What can we learn from this?

High healthcare spending in the U.S. has far-reaching economic consequences, such as wage stagnation, personal bankruptcy and budget deficits. Extensive evidence suggests that making the right investments in social well-being substantially improves population health outcomes downstream. For example, housing vouchers, home energy assistance and the availability of supermarkets in low-income areas are known to reduce obesity, diabetes and nutritional risk in children. In addition, availability of prenatal and infant nutritional assistance is associated with reduced infant mortality.

Realistically, the American culture has had little appetite for becoming more ‘socialized’ in tackling upstream problems, relying instead on the national ideology that spending more on healthcare will solve our health woes and improve health outcomes. But for meaningful change to occur, balancing healthcare with social determinant strategies must emerge both nationally and locally here in Iowa. The Iowa Healthiest State Initiative, a nonpartisan, nonprofit organization, is just one example of attempting to improve the physical, social and emotional well-being of our Iowa communities. This initiative is a good start, but other bold private and public initiatives need to be undertaken for real positive change to occur in healthcare outcomes.

Investing in our health upstream makes a great deal of sense. Spending for the ‘right’ community measures that impact health will provide better health outcomes for Iowa and our country. Such expenditures will take time to translate into positive health outcomes but we need to start investing now. The result may be cost-shifting from inefficient healthcare spending to re-allocating funds for social determinants that matter most, such as nutrition, adequate housing and education. By doing so, we will make our communities and state both healthier and more productive.

Controlling health costs and improving population health – we cannot have one without the other.