Stories about: pneumonia

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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A vaccine that works in newborns?

If we could immunize infants at birth, far more could be protected from infections.(DFID-UK Dept for International Development)

Right now, immunizations against most infections begin at 2 months of age. But that leaves newborns at risk for infections like rotavirus, whooping cough and pneumococcus during a highly vulnerable time.

In resource-poor countries, this is a serious problem: Many children see a health care provider only at birth, so may miss their chance to be protected. Worldwide, each year, more than 2 million infants under 6 months old die from infections, especially pneumonia. If we could immunize infants at birth, it would be a huge win for global health.

Unfortunately, though, newborns don’t respond to most vaccines. Their immune systems are too immature—which is why few vaccines for newborns exist.

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Chest X-rays: Learning forbearance

"Round" pneumonia in a 15-year-old with cough and fever. (Image: Nevit Dilmen/Wikimedia Commons)

In emergency situations involving children, it’s tempting for doctors to do everything possible to get information, especially when anxious parents are at hand. Unfortunately, that can mean a lot of unnecessary imaging and radiation exposure, and sometimes fruitless exploratory surgery.

This has spurred a search for biomarkers that can reliably make or rule out a diagnosis, as in appendicitis, and the creation of decision rules about the need for imaging, as in minor head trauma and blunt abdominal trauma, based on physical examination and limited testing, and validated by a large volume of clinical experience.

Emergency physicians Mark Neuman and Rich Bachur at Children’s Hospital Boston have been looking to reduce the use of chest X-rays in children with suspected pneumonia, where chest X-ray is usually considered the diagnostic testing modality of choice.

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New universal pneumococcal vaccine advances in early tests

Streptococcus pneumoniae in spinal fluid
Streptococcus pneumoniae in spinal fluid

Serious pneumococcal infections – pneumonia, bacteremia, meningitis – are responsible for up to 11 percent of child deaths on the planet. Vaccines exist, such as Prevnar, but they have two big shortcomings.

First, they’re designed to help people build antibodies against specific strains of pneumococcus. But new strains keep emerging, and most of those circulating in the developing world aren’t covered.

Second, they’re too expensive for most developing countries.

Six years ago, Richard Malley, of the Division of Infectious Diseases at Children’s Hospital Boston, and Marc Lipsitch of the Harvard School of Public Health, showed that there is another defense against pneumococcus that doesn’t care what strain it’s encountering. And, despite what textbooks were saying, it has nothing to do with antibodies.

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