Monday, April 14, 2014

Monday Morning Music

Durch Zärtlichkeit und Schmeicheln from Mozart's opera Abduction from the Seraglio:

Wednesday, April 9, 2014

Dear, Get rid of the cardstacks!

Card 1 of 1.

Tuesday, April 8, 2014

Physician division of labor impacts care

Health Affairs presents some evidence on how the type of attending physician has big effects on the type of care they provide for seemingly similar patients. From the abstract:
"Insertion rates were markedly lower when all of a patient's attending physicians were hospitalists (1.6 percent) or nonhospitalist generalists (2.2 percent), compared to all subspecialists (11.0 percent) or a mixture of physicians by type, which typically included a subspecialist (15.6 percent). The portion of patients seen by a mixture of attending physicians increased from 28.9 percent in 2001 to 38.3 percent in 2010."
This isn't an isolated finding. I'm reminded of this study from the Journal of Health Economics which similarly showed that the physician's background--in particular whether they worked in inpatient versus outpatient settings--also had big effects on the kinds of procedures they ordered.

We should, however, hesitate to call these relationships purely causal, however. One needs to also consider the physician-patient matching process works, and understand that certain types of patients may seek out certain kinds of physicians. However, we should worry about patient care coordination between physicians of different backgrounds, and we should be concerned about whether there's a lack of adequate standards for treating similar complications in similar patients.

On US News hospital rankings

Flags in front of the hospital, representing children from all over the world currently seeking treatment within.
US News has a response to some of the criticism leveled against it's annual rankings of hospitals:
"The authors used as a variable whether a hospital was among the fifty U.S. News Best Hospitals in cancer, cardiology, gynecology, or orthopedic care. They cited a 2010 study by Ashwini Sehgal to justify their use of that binary variable as a marker of reputation. It is not. Sehgal concluded that reputation contributed to the relative standings of the top fifty hospitals—in other words, which hospital is No. 1 versus No. 2. But he did not find reputation to be a significant factor in determining which hospitals were in the top fifty.

"In fact, U.S. News uses objective quality measures (primarily derived from Medicare data) such as mortality, volume, and patient safety indicators to calculate 67.5 percent of each hospital's rank-determining score in the four specialties analyzed. Reputation accounts for only 32.5 percent and will soon be reduced to 27.5 percent."
I will confess that I like the US News rankins because they happen to put my own division as the best in the country...

But I do want to point out that the US News' defense that the rankings are not significantly biased by reputations is reconcilable with the research showing that reputation apparently has a big effect. One thing you'll notice about the hospital where I work is that it's huge--depending on how you count beds possibly the largest pediatric hospital in the country--implausibly large for a city like Cincinnati. What happens is that because of it's reputation, we get children referred here from all over the US and indeed from the whole world--last time I checked, there were patients from 86 countries currently admitted to the hospital. Two things must generally be true for patients to be sent over such vast distances: 1) the hospital must have a reputation for treating whatever condition that patient has, and 2) the probability of better outcomes here must be much higher than at hospitals closer to home. Given that, you would expect the outcomes measures that US News looks at to be somewhat biased by hospitals' reputations, since reputation determines the kinds of patients a top-tier hospital will get.