the Natural Condition

Health Affairs released a report yesterday (March 10th) that outlined trends in American Emergency Department wait-times between 1997 and 2004. They considered three overlapping cases: all patients (18 and older), patients with ‘emergent’ conditions as indicated by triage staff (should be seen within 15 minutes), and patients with an eventual diagnosis of acute myocardial infarction — heart attack. On the whole, the median wait time to see an ED physician increased 36%. While wait times for ‘all patients’ and ‘emergent patients’ increased by about 40% per year (22 to 30 minutes, and 10 to 14 minutes, respectively), the change in the ‘AMI patient’ wait time dwarfed them both:

During the 7 years examined, the median wait time for patients eventually diagnosed with AMI increased by 150%, from 12 minutes in 1997 to 20 minutes in 2004. That is truly shocking news. Cardiogenic-shocking news, to be precise (pardon the pun).

In the decade from 1994 to 2004, total ED visits increased by about 18% (from 93 million to 110 million, annually). Emergency Department closures — as many as 12% during the decade — compounded the boom in visits. “Other likely contributors include inpatient bed shortages leading to bottlenecks in the ED; increasing uninsurance; population aging; shortages of staffing, space, and interpreters; and difficulties assuring non-ED follow-up care.” The sum of which totaled to a crucial deferral of care in the neediest patients. The authors of the paper raise the important point that staggering wait times, or even the misgiving of staggering wait times, will cause many prospective patients to avoid the ED altogether.¹

Wide-angle reports like this one demonstrate that all the ingenious, expensive, life-saving interventions are worthless if we do not first step back and survey the simple obstructions to keeping people healthy. We might do well to count something on this scale more often.

Reference:
(1) Waits To See An Emergency Department Physician: U.S. Trends And Predictors, 1997–2004. Health Affairs. 2008. [full text - restricted access] The full article contains many more interesting statistics about wait-time changes in sub-populations (race, gender, region, etc.).

“Count something.”

This keen piece of advice comes from Dr. Atul Gawande, as espoused in his most recent book, Better: A Surgeon’s Notes on Performance. Gawande is a general and endocrine surgeon at the Brigham and Women’s Hospital in Boston, MA. Although he is a surgical fledgling, completing his residency in 2003, Dr. Gawande’s insights blossom from his experience in public health issues, at one point serving as a senior health policy adviser for the Clinton administration.¹

The thesis of Better is that, while advances in medical technology, new drugs, and the like can lead to an overall healthier humanity, the most effective — and commonly overlooked — way to improve well-being is to make better use of what we already have. When he proposes that everyone in the healthcare community ‘count something,’ he means that evaluation and reevaluation of current methodology and practice are the true keys to success. We must measure ourselves, and then use those measurements to understand where shortcomings occur. He also makes it gravely clear that all doctors are not created equal in their ability to treat patients.
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Health Affairs, a journal dedicated to health policy, published an article today that reports on the forecast for healthcare spending in the US. In 2007, America spent about 16% of its Gross Domestic Product on healthcare. By 2017, that number is expected to rise to about 20% of GDP (a total of about $4.3 trillion). A 4% increase may not seem like much, but it represents a proportional growth that outpaces the adjusted growth for the 2017 GDP. By my calculations, the dollar amount of a 4% increase in healthcare-spending-as-proportion-of-GDP would cost more than current budgets for the Department of Defense, Homeland Security, Education, and Energy, combined.¹ The following chart shows the forecast for this increase:

^{Image courtesy of Health Affairs.}

This growth is equivalent to about a 6.7% increase in Read the rest of this entry »

Today I attended a forum on genetic testing for the Massachusetts General Hospital’s weekly Breast Rounds (I do research in breast oncology at the MGH). This week’s lecture, presented by Joseph D. McInerney, the Director of the National Coalition for Health Professional Education in Genetics, considered various aspects of the new wave of direct-to-consumer genetic testing. Genetic testing for specific gene markers¹ has been available for many years, and the results are primarily used by doctors and genetic counselors to determine the relative risks of disease onset and/or recurrence. This information allows the healthcare team to plan a course of treatment or preventative measures for a patient under supervised, knowledgeable care.

However, unlike “traditional” genetic testing, the professional health world does not filter this new era of direct-to-consumer genetic testing before it reaches the “consumers” (read: patients). Sites such as 23andMe.com and Navigenics.com advertise that anyone can obtain a complete genetic profile for as little as $999, which will outline propensity for certain diseases, among other recreational identifiers, like food preference. A most important note about these sorts of health-related tests: the FDA Read the rest of this entry »