CT Center for Patient Safety
CT Center for Patient Safety Newsletter

June 2016
In This Issue
Value of Care

There is a trend in health care delivery reimbursement.  The model is slowly changing from one that has traditionally paid a fee for health care services that are delivered to one that is reimbursing providers for quality of care that is delivered.  This change in the model of health care reimbursement is driving change in the delivery of health care to the consumer.  You are probably wondering what this means to you. 

I means several things.  First, we have to consider that many people are now paying more out of pocket than ever before.  Employers are offering higher deductible plans to keep the premiums down and the same is available to individuals through Access Health CT, the CT health insurance exchange.  But with higher deductibles, if you do need medical care, it will likely cost more out of your pocket.  This makes it more important than ever that consumers look for high quality health care at the best possible prices.  What no one wants to see is patients skipping visits, medications or other care because they can't afford it.

This then brings us to a challenge: how do we, as patients, know if we are getting good value of care?  How do we know if we are paying more or less for our services at the closest hospital versus the one a few more miles away?  Do we know which hospital realizes the best results for treating the condition that we need attended to? When we go to the pharmacy to pick up our prescription, what do we actually know about the medication?  Do we know if the expensive, newer pill is more effective than the older but similar medication that is available as a generic?

These are the questions that we, consumers of health care, need to begin asking ourselves.  We need resources and transparent data (which is sometimes still too hard to come by) to support our decisions.  Patients need to know where to find tools and decision aids that will allow them to make informed decisions, smart decisions, about the best care, the right care for the right price - the best value they can achieve for their money.
Measuring Hospital Value of Care
There are several comparison tools that are available for aiding patients in choosing hospitals.  The Centers for Medicare and Medicaid Services (CMS) is working on ways to support consumers in making these challenging choices on where to go when you have a choice.  The Medicare Hospital Compare website (https://www.medicare.gov/hospitalcompare/About/What-Is-HOS.html) allows you to choose up to 3 hospitals and compare them against each other on several variables including patient safety measures and their value of care in three categories:  heart attack, heart failure and pneumonia patients.  You can view a chart that provides a relational perspective after selecting your 3 hospitals on the home page, choosing to compare them, and then selecting the "payment and value of care" tab. 
Another site that compares patient safety measures is the  Leapfrog  Hospital Safety Score (http://www.hospitalsafetyscore.org/about-us/newsroom/display/442022).  While there is no feature that takes cost into consideration on this site, patients can measure quality of care through the ratings.  According to a study done by Johns Hopkins Medicine's Armstrong Institute for Patient Safety and Quality of the Leapfrog safety scores, they found "a 9% higher risk of avoidable death in B hospitals, 35% higher in C hospitals, and 50% higher in D and F hospitals, than in A hospitals."   Based on these findings and the scores of hospitals, a value of care assessment can be made by patients

Measuring Medication Value of Care
When it comes to medications, the availability of information is even more scarce than in other areas of health care.  There are no available scorecards or websites that allow consumers to view enough transparent information to make an informed decision in the same way as we can with hospitals.  In an April 2016 article in the New York Times, What Drug Ads Don't Say
there is a thoughtful discussion on what information would be helpful to consumers and would support their ability, and their physicians ability to make more informed choices.  Typically, prescribers consider various factors when they choose what they believe that the best medication is for their patients.  Most often, their information comes from the drug manufacturers themselves.  Patients access to information is even more challenging.  According to the NY Times, "In 2014, drug makers poured $4.5 billion into so-called direct-to-consumer advertising, a 30 percent increase over two years."  Often in the past, of the studies that are done on medications before they are brought to market, we hear about the ones with positive trial results rather than those that had negative findings.  More recently, companies are required to "register their clinical trials in a federal database, [but] they often don't publish the results in a timely fashion."
Something such as the scorecard that the Leapfrog hospital rating system created for hospitals does not exist for medications, and patients need to take the time to research medications on the various individual sites that exist.  It would be helpful for patients to have a place to go where the effectiveness and the price of medications could be compared against each other.  Where apples could be compared to apples and statins to statins. This article discusses some ways that this could be accomplished and for those wishing to get a deeper understanding, provides a good read on the topic.  Patient activists, including the CT Center for Patient Safety, are working on advancing transparency and making comparable information on medications available to the public.
June Health Hint
The Zika virus is on many people's mind.  The CT Department of Public Health is focusing their concern on Americans who are traveling to Puerto Rico this summer. For those who are making this trip, the DPH recommends that travelers:
  • use insect repellent,
  • wear long sleeves and pants, and
  • stay in places with air conditioning or that use window and door screens.
  • Women who are pregnant should not travel to areas with Zika and if they must, they should talk to their doctor for guidance first. 
As of June 1st there have been 14 patients with Positive Results for Zika Virus.
This is also the start of summer and we want to impress upon everyone the need for diligence and caution when swimming, boating and with regard to sun exposure.

Suggestions for water safety:
  • Use the buddy system when participating in water activities.
  • Always supervise young children.
  • Learn to swim and take basic water safety lessons.
  • Stay sober when doing all water activities.
  • Use life jackets when boating.
  • Electricity and Water don't mix. Make sure pools and hot tubs are properly inspected.
  • Learn CPR.
  • Germs in pools and hot tubs can cause illness.
  • Protect your skin with sunscreen.
  • Pay attention to your body - don't become dehydrated.
Source: The Fitzpatrick Agency
Join Our Mailing List
Dear Members, 
I would like to bring you up to date on the legislative session that just ended in Hartford.  While the session was heavily focused on budget related issues, some legislation addressing the opioid crisis in Connecticut made it to the Governor's desk.  Legislation requiring that first responders in all municipalities now be equipped with and trained in the use of opioid reversal drugs such as Naloxone was signed into law (HB-5053).  Another bill that was signed limits opioids to a 7-day supply per prescription and per refill and also establishes the study of impediments for insureds to receive substance use disorder treatment (HB-5620).  

Advanced Practice Register Nurses (APRNs) were given additional authority and responsibilities  (SB-67) and the definition of "telehealth provider" was expanded to include speech and language pathologists and respiratory care practitioners (SB-70).  

Of particular interest to seniors who will be most impacted by it, the CARE ACT which provides support for any individual who a patient designates as a caregiver and who will provide post-discharge assistance to the patient in the patient's home in the community following discharge from a hospital was extended to patients being discharged from a nursing home facility as well (SB-166).  

We will continue to follow any further legislation that gets signed and refer you to the Connecticut General Assembly home page for updates.

Lisa Freeman
The Most Important Conversation You'll Ever Have - Part Two
Choosing A Healthcare Proxy

Guest Contributor: Jim Kinsey, Director Planetree Member Experience

Last month we introduced the concept of advanced care planning and making you wishes related to healthcare known before a crisis presents itself.  This month we will discuss choosing a healthcare proxy.

A healthcare proxy is a trusted and reliable person that you can authorize to make decisions for you when you are unable to make those decisions for yourself.  Many people feel that identifying a healthcare proxy is as simple as asking someone to do it and then sign a form or two and you're finished.  Still others feel the healthcare proxy responsibilities are the role of the eldest child or spouse.  While these individuals may be the right person to be your healthcare proxy, we cannot assume without a conversation that they understand what choices are important to you and have a grounded understanding of and an ability to advocate for your choices.  Additionally, the person you choose should be able to advocate for your wishes with medical professionals and family members-think of it this way, they are your voice when you have no voice!

This important conversation should focus on your choices for your healthcare when you can no longer make those choices for yourself.  This should include, life prolonging treatment, CPR use, ventilator use, antibiotic use and feeding tubes.  These choices should not be made lightly and should include education for yourself and for your healthcare proxy.  There are many websites that can assist with identifying educational resources for you and your family.  The Conversation Project and My Five Wishes are two of the most popular websites that support individuals in developing their advanced care plan and educating the healthcare proxy. 

Be sure to include in this conversation defining the situations when a healthcare proxy is activated.  In most states the proxy is only activated when you are unable to make decisions for yourself and are unable to communicate those choices for yourself. 

Following the conversation and your healthcare proxy agrees to supporting you; you should identify the required documentation in your state and be sure to tell your healthcare proxy where this document will be kept and consider providing a copy to the proxy as well.

While it would feel that this completes the process, it truly is not a static process.  You and your healthcare proxy should stay connected and discuss, at least annually, that your choices are remaining as documented and that the proxy desires to continue in their role.  As we age and as our health may experience changes, the choices and the proxy should be reviewed more frequently based on the current healthcare needs. 

Next month we will explore how to integrate these choices into your current care encounters, how do we engage our healthcare providers in a discussion about our choices, our preferences and our values. 
When prediction models don't work

Cardiovascular disease is the leading cause of death followed by cancer.  So it is no wonder that medical researchers are looking for the best predictors of these ailments so that patients can reduce the likelihood of dying from these causes.  A review recently took place and the findings stated that there were 363 cardiovascular risk predictors found.  Among them were the heightened risk of being a smoker, having diabetes, high blood pressure, high cholesterol and triglycerides and being obese.   Clearly, there were many others.  But the different prediction models proved to be less helpful than one might expect.  The review found that clinical and methodological information often varied from model to model.  Definitions were found to be inconsistent, important information was missing in many cases and validation was not provided making the models less reliable.
The big question becomes how useful are tools such as this when there are so many and when the tools themselves have questionable integrity.  Physicians and policymakers are not certain which predictors they should use.  They can potentially end up misleading and causing more of a problem than they avoid.  The review suggests that given the vast amounts of data that is readily available, future studies should compare the current models to each other and custom tailor them to specific settings that are more closely aligned with real life situations.  Predictors are helpful when they are validated and the integrity of the research is sound. There are many useful and reliable predictors, but it is important to make sure that this is the case.

Medical Error: Third Leading Cause of Death

By Lisa Freeman

Many major news outlets have recently carried a story highlighting findings that "medical error is now the third leading cause of death in the U.S."
According to an analysis of existing research, Martin Makary, M.D., of Johns Hopkins University, has determined that over 250,000 Americans die each year from medical errors in hospitals, ranking it behind only heart disease and cancer.  The estimate is probably understated because it does not include deaths due to medical errors that occur outside of hospitals. It also does not include those due to certain recognized causes of sentinel events (unexpected events involving death or serious injury) such as communication breakdowns, diagnostic errors or other human factors. 

In fact, in 2013 John James, a retired NASA scientist whose son died as a result of medical error, had his research published in the Journal of Patient Safety.  He estimated that "440,000 Americans experience a preventable adverse event while hospitalized that contributes to their death."   Continue Reading