Posts Tagged ‘Atul Gawande’

Big Medicine Is Watching You

Monday, September 24th, 2012

Big Medicine is on the way, according to celebrated author and Harvard professor, Atul Gawande, In a major article in the New Yorker, Gawande describes the new frontier of ICUs as ones where patients may be monitored not from a telemetry station within the hospital but from a remote command center filled with high-tech screens and armies of highly-trained technicians that could be miles away and serve multiple hospitals.

Gawande cites the example of Dr. Armin Ernst, who is responsible for Steward Health Care’s ICU operations at the system’s 10 hospitals, serving approximately 8,000 patients annually.  “He sees it (the ICU) as the temporary home of the sickest, most fragile people, Gawande writes.  ”Nowhere in healthcare do we expend more resources.  Although fewer than one in 4,000 Americans are in intensive care at any given time, they account for four percent of healthcare costs.  Ernst believes that his job is to make sure that everyone is collaborating to provide the most effective and least wasteful care possible.”

Ernst’s ICU command center is a one-story building that contains millions worth of technology, banks of computer screens carrying cardiac-monitor readings, imaging scans, and lab results.  Special software sends an alert when it detects patterns that raise concerns.  Doctors and nurses operate consoles where high-definition video cameras zoom into any ICU room and talk directly to the staff or to the patients themselves.  Soon, the tele-ICU team will monitor the care for every ICU patient in the Steward system.

The experience was eye-opening for Gawande.  After five minutes of observation, I realized that the remote ICU team wasn’t exactly in command; it was in negotiation, Gawande writes.  Sometimes the bedside staff resist resolving problems that the E-ICU staff identify.  You have got to be careful from patient to patient, Gerard Hayes, a tele-ICU doctor, explained.  Pushing hard has ramifications for how it goes with a lot of patients. You don’t want to sour whole teams on the tele-ICU.  Several hospitals have decommissioned their systems; clinicians have placed gowns over the camera, or torn the camera out of the wall.

Despite some opposition, there is good reason why hospitals are adopting the E-ICU model.  Remote monitoring is a high-tech solution to a sticky problem facing hospitals: how to care for the sickest patients amid a worsening shortage of intensive-care physicians.  Currently, only one third of ICU patients receive care from an intensivist.  The Department of Health and Human Services believes that demand for intensivists will outstrip supply over the next 30 years.  Initial results from the E-ICUs have been dramatic: Mortality rates are 30 to 40 percent lower when physicians provide 24/7 care to prevent complications and minimize errors. A University of Massachusetts Medical Center study of 6,400 patients in seven adult intensive-care units monitored by E-ICU showed substantial benefits in reducing both costs and mortality, according to the hospital’s director, Craig Lilly.  The hospital saved $5,000 per case, mostly because the system lets intensivists in the remote-command center “detect instability and bring new treatment to the patient before they would have received it in a typical ICU.”

Healthcare: Saving Lives or Prolonging Suffering?

Thursday, August 12th, 2010

There is a cacophony of voices in the media talking about healthcare reform, but it’s more heat than light.  That why Atul Gawande’s most recent article in The New Yorker is so important. Boston-based Brigham and Women’s Hospital general and endocrine surgeon Gawande examines how the trend to prolonging life is one of the reasons behind soaring healthcare costs.Is healthcare saving lives or prolonging suffering?  Everyone needs to read this.

According to Dr. Gawande in Letting Go, “Twenty-five percent of all Medicare spending is for the five percent of patients who are in the final year of life, and most of that money goes for care in their last couple of months which is of little apparent benefit.  Medical spending for a breast-cancer survivor, for example, averaged an estimated $54,000 in 2003, the vast majority of it for the initial diagnostic testing, surgery, and, where necessary, radiation and chemotherapy.  For a patient with a fatal version of the disease, though, the cost curve is U-shaped, rising again toward the end – to an average of $63,000 during the last six months of life with incurable breast cancer.

The big question Gawande poses is thus:  What are we getting in return?  “Patients who were put on a mechanical ventilator,” Dr. Gawande continues, “given electrical defibrillation or chest compressions, or admitted, near death, to intensive care, had a substantially worse quality of life in their last week than those who received no such interventions.  And, six months after their death, their caregivers were three times as likely to suffer major depression.”

Dr. Gawande notes that in one study, “Researchers followed 4,493 Medicare patients with either terminal cancer or congestive heart failure.  Surprisingly, they found no difference in survival time between hospice and non-hospice patients with breast cancer, prostate cancer, and colon cancer.  Curiously, hospice care seemed to extend survival for some patients; those with pancreatic cancer gained an average of three weeks, those with lung cancer gained six weeks, and those with congestive heart failure gained three months.  The lesson seems almost Zen:  you live longer only when you stop trying to live longer.”

In one case Dr. Gawande describes, “Aetna decided to let a group of policy-holders with a life expectancy of less than one year receive hospice services without forgoing other treatments.  A patient like Sara Monopoli (who was diagnosed with terminal lung cancer at the age of 34) could continue to try chemotherapy and radiation, and go to the hospital when she wished – but also have a hospice team at home focusing on what she needed for the best possible life now and for that morning when she might wake up unable to breathe.  A two-year study of this ‘concurrent care’ program found that enrolled patients were more likely to use hospice:  the figure leaped from 26 percent to 70 percent.  That was no surprise, since they weren’t forced to give up anything.  The surprising result was that they did give up things.  They visited the emergency room almost half as often as the control patients did.  Their use of hospitals and I.C.U.s dropped by more than two-thirds.  Overall costs fell by almost a quarter.”

Attacks on Healthcare Reform Similar to Medicare Battle in 1965

Tuesday, April 20th, 2010

Dr. Atul Gawande:  “The battle for healthcare reform has only begunWhen President Lyndon Johnson signed Medicare into law on July 30, 1965, he faced a year of nearly crippling attacks from groups like the American Medical Association (AMA) and conservatives who feared an onslaught of “socialized medicine” and threatened to boycott the new program.  Although memories of the Medicare battle have faded over 45 years, similar battles could be fought over the passage of the Patient Protection and Affordable Care Act. This is the opinion of Dr. Atul Gawande, general and endocrine surgeon at Boston’s Brigham and Women’s Hospital and Associate Professor of Surgery at Harvard Medical School.

Writing in The New Yorker, Gawande notes that because most of the healthcare reform act’s provisions phase in at a slower pace than did Medicare, it is even more open to attack.  “The context, of course, is different.  The AMA endorsed the legislations; hospital associations were supportive.  Once the public option was dropped, most insurers favored the bill.  The medical world will wage no civil resistance.  This time, the threat comes from party politics.  Conservatives are casting the November midterm elections as a vote on repealing the health-reform law.  If they regain power, they are unlikely to repeal the whole thing.  Instead, they will try to strip out the critical but less straightforwardly appealing elements of reform – the requirement that larger employers provide health benefits and that uncovered individuals buy at least a basic policy; the subsidies to make sure that they can afford those policies; the significant new taxes on household incomes over $250,000 – and thereby gut coverage for the uninsured.”

Gawande notes that reform is hardly a government takeover of healthcare, as many opponents contend.  Rather, its success relies on communities and clinicians.  “We are the ones to determine whether costs are controlled and healthcare improves – which is to say, whether reform survives and resistance is defeated,” according to Gawande.  “The voting is over, and the country has many other issues that clamor for attention.  But, as L.B.J. would have recognized, the battle for healthcare reform has only begun.”

The Checklist Manifesto

Wednesday, February 24th, 2010

Surgeon Atul Gawande believes that a simple checklist can cut deaths from operating room errors. Atul Gawande, general and endocrine surgeon at Boston’s Brigham and Women’s Hospital, Associate Professor of Surgery at Harvard Medical School, and columnist for The New Yorker, has written “The Checklist Manifesto:  How to Get Things Right”,  a book that describes how miscommunication in the operating room can lead to tragic results.  Currently, Gawande’s book ranks # 10 on the New York Times’ list of best-selling non-fiction books.

The book grew out of work Gawande did for the World Health Organization, which asked him to help them find a way to reduce surgical deaths.  According to Gawande, “We knew we had technology and incredible levels of training, people working unbelievably hard.  But we have more than 100,000 deaths just in the United States following surgery.  Half are avoidable, from our studies.  What could we do?  We have found this idea, this extra tool that others were using in aviation, in skyscraper construction, and thought, well, let’s give it a try.”

Surgeons, according to Gawande, are human.  “We miss stuff.  We are inconsistent and unreliable because of the complexity of care.”  To achieve better results, Gawande brings a simple checklist into the operating room to make certain that everything is in place to assure a successful procedure.  For example, when the operating team is introduced to each other by name, the average number of complications and deaths fell by 35 percent.

Commenting on the success of checklist use in the operating room, Gawande says “I have not gotten through a week of surgery where the checklist has not caught a problem.”