Stories about: health care utilization

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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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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It’s the system, not the parts, says Gawande

Gawande-InnovationSummit0889-K CohenWrapping up the National Pediatric Innovation Summit + Awards on Sept. 27, emcee Bruce Zetter, PhD, who runs a lab in Boston Children’s Vascular Biology program, remarked, “I thought I was going to learn about technology. What I learned about was communication.”

Surgeon, writer and public health researcher Atul Gawande, MD, MPH, laid bare this often overlooked element of medicine in his closing keynote. He eloquently made the point that communication—and more specifically systems—is where innovation is most needed and where it can have the most impact.

“We have emerged from the century of the molecule to the century of the system,” Gawande said.

Right now, these systems are broken, seemingly everywhere. Gawande recounted the sad tale of Duane Smith, a patient who survived a severe car crash that ruptured his spleen, only to lose his fingers, toes, nose and job from an ordinary strep infection.

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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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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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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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