Stories about: health care costs

Wise health care spending for children with medical complexity

Spending on children with medical complexityJay Berry, MD, MPH, is a pediatrician and hospitalist in the Complex Care Service at Boston Children’s Hospital.

Growing up, my parents repeatedly reminded me that “money doesn’t grow on trees.” They pleaded with me to spend it wisely. I’ve recently been thinking a lot about my parents and how their advice might apply to health care spending for my patients.

As a general pediatrician with the Complex Care Service at Boston Children’s Hospital, I care for “medically complex” children. These children—numbering an estimated 500,000 in the U.S.— have serious chronic health problems such as severe cerebral palsy and Pompe disease. Many of them rely on medical technology, like feeding and breathing tubes, to help maintain their health.

These children are expensive to take care of. They make frequent health care visits and tend be high utilizers of medications and equipment. Some use the emergency department and the hospital so often that they’ve been dubbed frequent flyers.

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Costly overuse of anti-nausea drug in children with gastroenteritis

Despite its increased use, ondansetron has not decreased IV rehydration.
Ondansetron has not decreased IV rehydration as originally intended.
Acute gastroenteritis is one of the leading causes of emergency department (ED) visits for children, accounting for more than 1.7 million trips each year. Its standard treatment has traditionally been rehydration by giving fluids orally or intravenously. Though both methods are equally effective, oral rehydration is preferred as it results in less discomfort and helps stop diarrhea sooner. The IV route is often employed in children who are vomiting and unable or unwilling to drink a large amount of liquids.

About a decade ago, ED physicians began orally administering the anti-nausea medication ondansetron to vomiting patients with gastroenteritis who were unable to hold down oral fluids. Once the ondansetron has stemmed their nausea, children have a much easier time with oral rehydration.

However, the lack of standardized use of this drug has led to its overuse. Though intended to reduce the use of IV rehydration, ondansetron proved so effective at reducing vomiting that its use skyrocketed in the course of just a few years.

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Bronchiolitis guidelines reduce ED costs, improve care

chest x-ray
New workflows and protocols reduced chest x-rays by 23 percent, testing for respiratory syncytial virus by 11 percent, albuterol use by 7 percent and time infants spent in the ED by 41 minutes.
Bronchiolitis, a common respiratory illness among infants, is responsible for hundreds of thousands of emergency department (ED) visits each year. Best practices for managing it, established by the Academy of American Pediatrics (AAP), are fairly simple: Offer supportive therapies and let the disease runs its course, as most interventions have little or no benefit for these patients.

But despite these guidelines, bronchiolitis costs the U.S. health care system millions of dollars a year, much of that cost coming from unnecessary diagnostic tests such as chest x-rays and respiratory syncytial virus (RSV) testing.

“When a mother comes to the ED with a baby who is having difficulty breathing, it can be very frightening for her,” says Boston Children’s Hospital’s Ayobami Akenroye, MBChB, MPH,lead author of a study looking at resource utilization of bronchiolitis patients, recently published by Pediatrics. “In many cases, to help alleviate worry and ensure everything is being done to help the child, EDs will order various tests and sometimes give medication to temporarily relieve symptoms, but rarely do any of these steps impact how care is delivered or affect the clinical course of the disease. They’re usually unnecessary.”

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Consistency and cost: Why reducing variability in health care matters

Many doctors still chafe at practicing "cookbook medicine." (Tim Sackton/Flickr)
The argument that 'I do not practice cookbook medicine' still resonates with many practitioners. (Tim Sackton/Flickr)
Mark Neuman, MD, MPH, practices emergency medicine at Boston Children’s Hospital and is director of Fellow Research and Research Education. Vincent Chiang, MD, chief of Children’s Inpatient Services (CHIPS), contributed to this post, adapted from their recent commentary in Pediatrics.

It’s no secret that the U.S. health care system is in the midst of a financial crisis. As a nation, we spend nearly 18 percent of our Gross Domestic Product on health care, and health care costs remain the largest contributor to the national debt. In 2011 alone, the cost of maintaining the nation’s 5,700 hospitals exceeded $770 billion.

If ever there was a time for a societal mandate to reduce health care costs, that time is now.

It’s widely accepted that one of the first steps to reigning in runaway health care costs is reducing variability in the manner in which care is delivered. Well-defined and well-disseminated best practice guidelines can improve the reproducibility and standardization of care. In time, these guidelines may reduce costly and unnecessary tests and hospitalizations, while providing a platform on which to measure and enhance quality. More consistency may also allow providers to be more efficient with their time, space and personnel.

If it’s so costly, why is health care variability so abundant?

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Time for surgery to go global — even cost data support the argument

Cost-effectiveness ratios for many surgical procedures turn out to be comparable to those for many accepted global public health strategies.
Cost-effectiveness ratios for many surgical procedures are comparable to those for accepted global public health strategies.
While moral arguments have been made to bring surgical treatments to resource-poor countries, researchers from Boston Children’s Hospital have discovered that it also may be cost-effective.

Traditionally, global health initiatives have focused on infectious disease or HIV/AIDS outreach. However, more recent data, including a 2012 study in The Lancet, show a growing global burden of noncommunicable diseases, such as cancer, that require surgical treatment.

Surgical disease was previously thought to comprise at least 11 percent of the total global burden of disease, but the Lancet paper showed approximately 25 percent of people requiring surgical assessment, based on a widespread survey in Sierra Leone. Additional research has revealed that up to 85 percent of pediatric patients in Africa have a surgical condition by the age of 15 years.

“However, the prevailing perception is that surgical care is too expensive and not cost-effective enough to bring to developing countries,” states Tiffany E. Chao, MD, a Paul Farmer Global Surgery Fellow in the Plastic and Oral Surgery Department at Boston Children’s.

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Reforming health care: 11 uncomfortable challenges

Facing the Giants (ForeverMan724)
Facing the Giants (ForeverMan724)

Does clinical medicine have the courage to lead health care reform? A former pediatric resident at Boston Children’s Hospital recently asked this question before a standing-room-only audience during the hospital’s annual Blackfan Lecture. I’m talking about Donald Berwick, MD, MPP, FRCP—co-founder and president emeritus of the Institute for Healthcare Improvement (IHI) and Administrator of the U.S. Centers for Medicare & Medicaid Services (CMS) from July 2010 to December 2011.

Berwick, who may run for Massachusetts Governor in 2014, didn’t just ask physicians and hospitals to embrace health care reform, as they’ve come to embrace quality improvement programs and checklists. He urged them to lead. To rescue health care.

In 1998, the Choluteca Bridge was one of the few in Honduras to withstand Hurricane Mitch. Unfortunately, the river beneath it had moved, leaving a bridge spanning dry land. “This,” Berwick declared, “is American health care.”

So why can’t we move the bridge to the river? Following Gloria Steinem’s advice to name a problem before trying to tackle it, Berwick outlined 11 uncomfortable challenges—11 “monsters under the bed” that need to be faced.

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Pediatric complex care: A day in the life

Afraa Bakhit, from the Middle East, is among the hospital’s most complicated patients. Her disorder is unknown.

This is the first post of a two-part series on children with complex medical needs. Details on some patients have been changed for privacy reasons.

This morning, as every morning, the Complex Care Service (CCS) team huddles in a tiny office deep inside Boston Children’s Hospital. They have 14 patients to discuss, each with a mix of problems that involve multiple clinical departments. Many of them are repeat visitors.

The team begins tackling each case in decreasing order of difficulty. “It seems to be the best way to prioritize the patients with the most immediate needs,” says Mindy Morin, MD, MBA, who’s the attending physician this week. Also on the team are two nurse practitioners, a clinical nurse educator and two resident physicians.

Two-year-old Afraa Bakhit from Dubai tops the list for the sheer number of departments consulting on her case: Genetics, Cardiology, Immunology, Infectious Disease, Rheumatology, Pulmonology, Anesthesia and now a specialist from the Vascular Anomalies Center.

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A rising tide of neurologic impairment: Where’s the medical home for these children?

Many doctors feel unprepared to care for children with neurologic impairment. (Photo: Lindsey Hoshaw)

Jay Berry, MD, MPH, shown here with patient Kyler Quelch, is a pediatrician and hospitalist in the Complex Care Service at Children’s Hospital Boston. He leads the multi-institutional Complex Care Quality Improvement Research Collaborative.

As a general pediatrician, albeit one with experience in complex care, I find it extremely challenging to take care of children with neurologic impairment. A child’s nervous system can be “broken” for many reasons: a congenital brain or spinal cord malformation, severe head or neck trauma, a genetic condition or, like an increasing number of children, being born prematurely.

Most of the time, we can’t “fix” a broken nervous system. We can only try to support the body functions that are impaired as a result. Functions we take for granted: breathing, eating and digesting, moving, talking. We don’t have a lot of scientific evidence to guide us when doing this,

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Innovation opportunities from healthcare reform

President Obama signs the Patient Protection and Affordable Care Act, March 23, 2010 (Pete Souza/Wikimedia Commons)

National healthcare reform, including President Obama’s Affordable Care Act of 2010, is being driven by widespread dissatisfaction with the high cost and limited accessibility of care. Although we’ve yet to feel the full impact of these national reforms, the reform experience in Massachusetts indicates that mandated universal coverage, by itself, has failed to drive down costs.

So, in Massachusetts, we’re now in the next phase of healthcare reform, focusing on how to control and cut costs while still providing nearly universal access to high quality services and care. The need to bring down costs is stimulating healthcare innovation in three major areas – perhaps offering some lessons for the nation as it moves toward universal care.

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Reducing unnecessary care: The SCAMPs manifesto

Can we reduce health care costs without rationing? (Image: Fibonacci Blue via Flickr)

We all know the problem: The cost of health care needs to come down. About five years ago, pediatric cardiologists at Children’s Hospital Boston realized it was critical to practice more cost-effectively. “Most of the money that is going to be removed from the federal budget to reduce budgetary deficits is going to come from health care in one fashion or another,” cardiologist-in-chief James Lock told an audience of senior Children’s physicians last month. “There’s no question we were under a tremendous amount of pressure.”

Seeking to eliminate unnecessary care and testing, Lock’s team first turned to clinical practice guidelines, or CPGs, a tool meant to standardize “best practices.” But it soon became clear that CPGs were ineffective, giving no insight into how to improve care or how to deal with unexpected findings. Even worse, over time, many mandated CPGs have been shown to be wrong by subsequent data.

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