#Massachusetts cares if #doctors have conflicts of interest, but do #patients care?

The Globe offers a peek at the drug company marketing/meals at smaller hospitals

Years after many big academic medical centers cracked down on industry perks, drug companies still regularly buy meals bll-leg-pix-webfor doctors affiliated with smaller hospitals, a new analysis shows, with some physicians receiving dozens of lunches and dinners in a single year.

At a number of community hospitals, well over half of the affiliated doctorswere beneficiaries of industry payments, suggesting there may be fewer restrictions on meals there than at large teaching hospitals.

Worth noting a UMass led-research mentioned in an NYTimes  column on medical conflicts of interest. The study by orthopedic surgeons reported that about 80 percent of patients “felt it was both ethical and either did not influence, or actually benefited their health care, if their surgeons were consultants for surgical device companies.”

Here’s a look at more data from the study:

Six hundred ten of 642 surveys had complete data. The sample population comprised more females and was older and more educated than the American population. About 80% of respondents felt it was ethical and either beneficial or of no influence to the quality of health care if surgeons were consultants for surgical device companies. Most felt disclosure of an industry relationship was important and paying surgeons royalties for devices, other than those they directly implant, would not affect quality of care. Respondents support multidisciplinary surgeon-industry COI regulation and trust doctors and their professional societies to head this effort.

Almost 40% of respondents felt the quality of care would be adversely affected if a surgeon received royalty payments for a medical device that would be implanted by that surgeon….  When questioned about who should be involved in regulation of COI, a majority of respondents (64.3%) felt that a combination of doctors, hospitals/universities, government, and company representatives should be involved; 34.9% of respondents felt that medical professional societies run by doctors should have the most control over COI regulation, almost two times more than the next most frequent answer; and 44.9% and 26.3% (70.2% combined) of respondents felt medical company representatives and government officials should not be involved in the regulation of COI….

Our survey found that 91% of respondents felt it was important for surgeons to disclose consulting agreements regarding devices in their
surgery (Table 3). Furthermore, 60% of respondents thought it was appropriate for surgeons to disclose consulting arrangements with all patients regardless of the planned usage of such devices in their own surgery

Also noted in the study

Leaders of the American Academy of Orthopedic Surgeons have recently made a consensus statement that the enhancement of patient care has and will continue to require orthopedic surgeons to collaborate productively with industry in the development of new technology and techniques

Also worth noting that a 2013  UConn study found the following

Overall, patients had a poor understanding of FCOI (financial conflict of interest.) Both level of education and previous discussions of FCOI predicted better understanding. This study emphasizes communication of FCOI with patients needs to be enhanced.

Finally, a Health Affairs blog post on patients and COI noted:

Physician ownership of orthopedic or spine hospitals has been correlated with higher rates of spine surgery. In these situations, doctors must keep these centers busy with procedures in order to generate profits and prevent losses; overhead costs are high, including financing, staffing, lease arrangements, and insurance. However, a busy center becomes a lucrative profit center for owning physicians.

 

 

Science writer on his two #opioid battles

Health writers know Seth Mnookin has the author of the book “the Panic Virus,” but he has a much more personal story to tell in this week’s Globe.

. throughout the course of my 43-hour stay at MGH at the end of April and into early May, I told everyone I could — from the ER doctor wFile_000ho informed me that I’d need surgery, to the anesthesiologist who prepped me for the procedure — that I was in recovery from a substance use disorder.

And while my doctors all said they were aware of the issue, it still felt as if no one was listening.

When you know an addict or alcoholic who bounces in and out of rehab for years — you wait for the final call. When he or she gets sober,  it is a fragile gift for all involved — like someone coming back from the dead. I’m a big Marc Maron fan, but I’m not sure I can watch the new episodes of his television show — his sober character relapses badly after taking  meds for back pain. At the same time, I could feel the character Don Gately’s pain as the recovering drug addict refused pain killers despite at the end of DFW’s Infinite Jest.

With all the opiate madness out there, here’s hoping we find a better way. Thank to Seth for sharing his tale.

The Times New Old Age had a post on this topic this week. 

#UMass study via KHN: Who is too sick for a #transplant?

downloadFrom Kaiser Health News

Study Suggests Federal Standard May Be Thwarting Some Transplant Patients

By Michelle Andrews

For the roughly 15,000 people who need a liver transplant, it’s a waiting game. With demand for donated livers far outstripping supply, patients may spend months or years on a transplant waitlist, their position in the line gradually improving as they get sicker. A recent study suggests that this system may be changing but not necessarily for the better.

In an effort to get or keep a good performance rating from the federal government, transplant centers have been labeling some patients “too sick to transplant” and dropping from the waitlist some who may been viable candidates, the researchers found. In addition, despite removing more sick patients from the waiting list, one-year survival rates for patients who received transplants didn’t improve.

The study, published online in the Journal of the American College of Surgeons in April, examined trends in “delisting” at 102 liver transplant centers, including 90,765 waitlisted adults who died, between 2002 and 2012.

Midway through the time period under study, the federal Centers for Medicare & Medicaid Services implemented a new “Conditions of Participation” policy that established performance standards for heart, heart-lung, intestine, kidney, liver, lung and pancreas transplant centers that participate in the Medicare program.

In order to meet CMS standards, liver transplant centers have to meet expected patient and liver graft one-year survival rates. Those that don’t meet the performance standards, which CMS recently eased somewhat, may be flagged for poor performance and have to implement program improvements or risk their participation in the Medicare program. (In its letter describing the new guidelines, CMS noted that one-year patient survival for liver transplants increased from 87.7 percent to 90.8 percent between 2007 and 2014.)

But something happened when the new policy took effect in 2007: The percentage of patients that liver transplant centers considered too ill or unsuitable for a transplant rose by 16 percent, and the likelihood of delisting continued to increase each quarter through the end of the study period. Compared with the time period before, the patients who were taken off the waitlist after the CMS policy change were more likely to be age 55 or older and have more severe liver illness.

The study authors speculate that the new standards made transplant centers more averse to risk and encouraged them to drop sicker patients who might affect their patient survival rates.

organ transplant_770“There’s no common definition for when someone is too sick to transplant,” said Natasha Dolgin, an M.D./Ph.D. candidate at the University of Massachusetts Medical School and the study’s lead author.

Some suggest a different way to look at the impact of the CMS policy. “Maybe centers are making the internal decision of trying to choose the best candidates,” said Dr. David Goldberg, medical director for living donor liver transplantation at the University of Pennsylvania.

The most common reason for a liver transplant is cirrhosis, or scarring of the liver, often caused by hepatitis C or alcoholic liver disease.

The severity of patients’ illness is evaluated based on their Model for End-Stage Liver Disease (MELD) score, a numerical score between 6 and 40 that predicts the risk of death within three months and is calculated based on three laboratory values.

Nationwide, 6,729 liver transplants were performed in 2014, but 1,821 patients died on the waitlist. Another 1,300 people were removed from the waitlist because they were considered too sick for a transplant. Patients’ health may deteriorate to the point that a transplant is no longer advisable, or they may contract an infection, for example, that makes delisting necessary. But those reasons don’t explain the increase in delisting following the introduction of the CMS policy, according to the study.

Still, Dolgin said she doesn’t blame transplant centers for their waitlist decisions. Once there is a “benchmark, you try to meet that.”

Kurt Schnier, an economist at the University of California, Merced who has conducted research examining the impact of the CMS policy on kidney transplant waitlisting practices, said the policy has increased the length of time patients are on the waitlist. That research is under review for publication. The CMS policy may also affect surgeon behavior at centers that don’t meet the condition of participation standards, leading them to conduct fewer transplants, for example.

“It’s a well-intended policy,” Schnier said. “The problem is that it creates perverse incentives at the physician level that may undermine the personal welfare of the general population.”

“This is part of the culture now,” said Dr. Hillel Tobias, medical director of New York University’s liver transplant service and chairman of the medical advisory committee of the American Liver Foundation. “You can’t take a chance because if your numbers go down you’re going to get canned.”

One of the goals of the CMS policy was to improve transplant outcomes because of concerns related to transplant center quality and service. Yet the study found its introduction didn’t have a statistically significant impact on mortality rates within a year of transplantation.

Liver transplants are complicated, and the fact that survival didn’t improve during the course of the study might reflect the fact that there may be complications that are not preventable, said Goldberg.

Asked to comment on the study, a CMS official said, “CMS is reviewing available evidence about the impacts of our policies on organ transplant centers. After thorough review we will determine a course of action.”

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Is response time the best way to judge ambulance services?

Tom Kimball, described as a Boston-area paramedic who will be  attending medical school this fall posed that question in a Boston Globe opinion piece this weekend. ambulances

Many cities and towns in Massachusetts still judge the performance of their ambulance services using metrics like response times, which can miss the point. An additional two minutes waiting for an ambulance will rarely make a difference for a trauma patient facing emergency surgery that may take hours.

Patient outcome is a more valuable measure of whether a medical service is doing right by people. In many areas of health care these days, it is the gold standard, a key factor in determining how much insurance companies pay service providers. Changing the terms of ambulance companies’ contracts to make good patient outcomes the goal could greatly improve the quality of medical care across the state — and save lives.

Boston surgeons can help patients get a new penis, or lose the old one

CaptureNot at the same place. Both the Globe and WBUR report today on Boston Medical Center’s new male-to-female gender reassignment surgery program. News comes just after MGH’s announcement of the first penis transplant.

From the Globe

Boston Medical Center plans to become the first hospital in Massachusetts — and one of a few in the country —to offer gender reassignment surgery, responding to a growing and unmet demand for treatment in the transgender community.

The hospital said more than 100 patients have already signed on to a waiting list to be evaluated for surgery — even before it has widely publicized the program. Boston Medical Center has long provided primary care, mental health services, and hormone therapy for transgender men and women, and most of the patients considering surgery are from the Boston area. Capture2Across the country, many hospitals have been reluctant to offer male-to-female and female-to-male genital surgeries, but health care providers said that is slowly changing as insurance coverage expands and public acceptance of transgender people grows.

 

Do we need to learn to live with sponsored health care content?

I was going to scan in the front page of today’s Globe, which features a story on Partners staff complaining about how hard it is to learn the new $1.3 billion HIT system. There was a teaser nestled up to it for a story on the first penis transplant. That juxtaposition made me wonder how a slip of the finger on keyboard might impact the noted surgery. But, I decided to be a grown up.

Instead, I’ll let someone else rag on the Globe, or in this case the sort of Globe. That would be the part of the Globe Media Co. that is hiring new staff, not the newspaper itself, which is offering staff buy-outs.

Over at Health News Review, Trudy Lieberman complains about a “serious and rapidly emerging dilemma for consumers of health news. What’s real journalism and what’s “content” masquerading as journalism as we know it?  Examining stories on The Guardian’s Healthcare Network site and on STAT, the fledgling digital news service that’s making a name for itself with loads of daily content, I discovered a blending of traditional stories with advertising and promotion that simply fools the reader.

She goes on: When I first caught on to what STAT was doing, I felt deceived like I was when I read The Guardian’s breakthrough piece. The pooh-bahs at STAT are making it easy for me to read something I don’t want to read and confusing me with look-alike content prepared by some of the biggest names in the healthcare business— Cigna, CVS Health, Johnson & Johnson, Baxalta, a new biopharmaceutical company, and PhRMA whose contributions to Morning Rounds have included “America’s biopharmaceutical researchers and scientists are tireless in the fight against disease” and “Imagine “smart bombs” that fight cancer and reduce side effects.”

First, my conflicts. I was involved in a major sponsored content project once. And I have a family member who works at the Globe.  And while I’m not a big fan of native advertising, I am a big fan of good journalism and we need to pay for it somehow. Or, the folks at STAT will be getting those buy-out offers.

Plus, it looks pretty well-Capturemarked to me with all that orange.  Also, I’m not sure the idea is so much to hide PR in news-sheep’s clothing. My understanding it that the idea is to get this stuff out on social media where the orange banners and disclosures don’t show up — social marketing. That concerns me, along with all these university and hospital publication that look and sound like news but are PR and marketing. Many will argue — we report these stories just like journalist. The difference is — who do they answer to? Who is the customer? That would be the marketing staff at institution or the hospitals, not the reader. But, that stuff gets tweeted out and no one knows the difference. My journalism students don’t know the difference.

Honestly, I hate this stuff as much as Lieberman does. I want to keep that wall between advertising and editorial up. Are native advertising and social marketing, by nature, deceiving the reader?  You could make that argument.  But, I see the dilemma. Here’s hoping we find a better way to support good journalism.

 

 

Docs reject Harvard jobs because of conflict of interest policy?

Well, that’harvard meds  what Dr. Peter Slavin, president of Massachusetts General Hospital, told STAT news in a story about Harvard’s revised conflict of interest policy:

Slavin said the change may help with a recruitment problem: “Some faculty don’t come because they perceive that Harvard Medical School has rules that are much too restrictive.”

Or they leave, according to Gretchen Brodnicki, dean for faculty and research integrity.

 Brodnicki said she has heard anecdotes of faculty leaving, or being unable to conduct specific studies, because of the rule, though she said the impact is hard to measure.

Here’s the new rule:

First, the school is raising the thresholds: Faculty will have to receive at least $25,000 in income (up from $10,000), or hold $50,000 in equity of a publicly traded company (up from $30,000) to trigger the prohibition on clinical research. Faculty still cannot hold any equity in a privately held company if they want to do clinical trials on that company’s product.

Second, the school will now allow faculty to petition for an exemption if they’re over those thresholds and still want to do the research.

 

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