Researchers conducted interviews of patients’ decision-makers to determine how well their understanding of a patient’s prognosis aligned with the physician’s prognostic estimate. The patients were receiving care in the intensive care unit and were identified by physicians as having a high risk of death.

The 229 surrogate decision-makers were primarily family members or friends of patients and served as the decision makers for 174 patients at the University of California, San Francisco Medical Center between 2005 and 2009. The surrogate decision-makers were asked to estimate the patients’ survival chances on a scale of 1 to 100. Researchers found that 53% of the time there was at least a 20% gap in the way the surrogates and physicians viewed a patient's prospects. Surrogates estimated a more optimistic prognosis while the physicians were more accurate in their predictions.

Interestingly, only 17% of the surrogate decision-makers said they had misunderstood information; most said they felt maintaining hope would be helpful to the patient. The researchers concluded that surrogate decision-makers may not want to “hear” what is said about a patient’s prognosis, and instead choose a more hopeful outlook for the patient.

 Reference White DB, Emecoff N, Buddadhumaruk P, et al. Prevalence of and factors related to discordance about prognosis between physicians and surrogate decision makers of critically ill patients. JAMA. 2016;315(19):2086-2094.

Articles

Prognosis Discordance Prevalent Among Decision-Makers at the End-of-Life

Despite advances in medication administration safety, such as use of electronic orders, electronic pharmacy systems, and bar coding, medication errors still occur. The frequency and severity of these errors have been explored in various studies, and it is estimated that medication errors cause or contribute to the deaths of 7,000 patients each year in the USA. Nurses are the final checkpoint in the medication administration process and play an important role in the final safety check.

A research team led by Linda Flynn, PhD, RN, FAAN from Rutgers University noted that RNs often intercept---and prevent--- medication errors; however, little was known about the nursesâ€™ practice environment and how it influenced their error interception practices. With funding from the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative (INQRI), the researchers conducted a study of 82 medical-surgical units recruited from 14 U.S. acute care hospitals in New Jersey to examine relationships among characteristics of the nursing practice environment, nurse staffing levels, nursesâ€™ error interception practices, and rates of non-intercepted medication errors.. Data collected for the eight-month study period included the number of medication errors per 1,000 patient days and the number of RN hours per patient day. Nurse survey data from 686 staff nurses included the Practice Environment Scale of the Nursing Work Index as a measure of environmental characteristics, and a metric of nursesâ€™ interception practices was developed for the study.

The researchers found that nursesâ€™ error interception practices included independent comparisons between the medication administration record and the patientâ€™s medical record, determining the rationale for each ordered medication, requesting that physicians rewrite orders when improper abbreviations were used, and ensuring that patients and families were knowledgeable regarding the medication regimen so that they can question unexplained variances. Researchers found that nursesâ€™ interception practices had a significant effect on the rate of medication errors. More frequent engagement by nurses in interception practices was associated with fewer documented medication errors per 1,000 patient days. For 100 units of interception practice for 1,000 patient days, medication errors decreased by an average of 19.

Flynn L, Liang Y, Dickson GL, Xie M. Nursesâ€™ Practice Environments, Error Interception Practices, and Inpatient Medication Errors.

Use of interception practices was associated with fewer medication errors.

Medication Errors

Iâ€™ve noticed an increase in the number of hospital emergency departments that have, and are promoting, specialized services for the elderly. Theyâ€™re modeled a lot like pediatric emergency departments, which provide emergency care to a very specialized patient population. Only of course, these emergency departments are providing care to patients on the other end of the age spectrum.

The geriatric emergency departments differ from traditional emergency departments in two major ways. First, most are environmentally designed or renovated to meet the needs of an older patient population, with more handrails, non-slip floors, sturdier furniture, and beds with safety features such bed alarms. Thereâ€™s also easier access to equipment often needed to assess the elderly, such as oxygen, heart monitors, etc. The other main difference from non-specialized emergency departments is staff training and expertise. There is a growing subspecialty of emergency physicians and nurses who have received additional formal and informal education and training in geriatrics. Itâ€™s thought that these new practitioners will be able to more quickly, and more accurately determine an older patientâ€™s need, particularly in emergency or urgent situations.

Itâ€™s well recognized that the number of people in the U.S. aged 65 and older will continue to grow for the next couple of decades, and that about 25% of the population will be age 65 or older 25 years from now. Medicare and other data document that the elderly typically have a number of comorbid conditions that impact vital organ systems and can make assessment and treatment of these conditions especially challenging. Making geriatric emergency care available appears to be a great way to meet these emerging needs.

Geriatric Emergency Departments

	The Commonwealth Fund Health Insurance Tracking Survey of U.S. Adults found that 25% of adults (defined as ages 19 to 64) experienced a gap in their health insurance in 2011, and 69% of these adults remained uninsured for one year or more. The Commonwealth Fund supports independent research on healthcare issues with the goal of improving healthcare policy and delivery.

	Of those who were uninsured at the time of the survey or were insured but had experienced a gap, 41% previously had employer-based coverage, 18% had Medicaid, 6% had an individual plan, 7% had been insured through another source, and 27% never had health insurance. Among those who had employer-sponsored insurance prior to their gap in coverage, 67% reported a loss or change of a job as the primary reason. The researchers also found that people who had gaps in coverage were less likely to have a regular physician and less likely to undergo preventive care.

	Beginning in 2014, the Affordable Care Act will provide near-universal health insurance through a substantial expansion in Medicaid, subsidized private health insurance offered through new state insurance exchanges, and new insurance market rules that will prevent health insurers from denying coverage or charging higher premiums to people with preexisting health conditions. The findings of the survey support the need for federal and state policymakers to implement the new law.

	Collins SR, Robertson R, Garber T, Doty MM. Gaps in Health Insurance: Why So Many Americans Experience Breaks in Coverage and How the Affordable Care Act Will Help. 

http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2012/Apr/1594_collins_gaps_in_hlt_ins_tracking_brief_v2.pdf

2011 survey finds 25% of adults experienced a gap in health insurance last year.

Health Insurance Gaps

I have to admit that I get sucked right in when sensational medical headlines appear on my computer’s homepage. A case in point was the June 9, 2012, CNN headline news of “10 shocking medical mistakes” reported by John Bonifield and Elizabeth Cohen (

). As I’m sure the reporters were hoping, I was curious when I read the headline and wanted to see what kinds of things made this top ten list. I also wanted to assess the accuracy of the reporting.

The ten shocking medical mistakes and “ways not to become a victim” included patient misidentification (make sure staff checks your identity) and retained surgical “equipment” “(if you have unexpected pain, ask if you might have a surgical instrument inside you”). I laughed out loud when I read this; although not an impossible occurrence, it’s much more likely that a sponge would be left behind. This list continued with “lost patients” (patients who wonder because of dementia); however, I wonder how this constitutes a medical mistake. I laughed again with “fake doctors” and the advice to confirm that your physician is licensed. Probably better advice is for consumers to go to a hospital’s physician finder site, Health Grades, or a similar informational site to learn about a physician’s education, training, certification, etc. The next item on the list was the “ER waiting game,” with the suggestion of calling your physician on the way to the emergency room so that you won’t “get sicker while waiting for care.” This is a troubling suggestion as the whole point of emergency care is that it is emergency care. If you’re in good enough shape to call your physician on the way to the ER, you probably should be going to an urgent care center or the physician’s office instead. Air embolism was the next mistake, followed by operating on the wrong site surgery. I’d like to look up the statistics on this, as I believe that the incidence of wrong site surgery has dramatically decreased as a result of the safety measures mandated by The Joint Commission. Infection spread by hospital workers not washing their hands was next on the list, and the advice was to make sure that workers’ hands are washed. “Look alike tubes” was mistake #9 and the example was that a chest tube and feeding tube can look alike. The corresponding example, however, was that of a toddler who was given tube feedings via a central venous catheter (not a chest tube). The last mistake was “waking up during surgery.” The writers ended their piece by asking readers to submit their personal stories of medical mistakes.

And submit them they did---over 1200 comments posted in a couple of days. Many of the mistakes reported were common complications of treatment that can occur as result of other causes, not because of mistakes. One person pointed out that infection, for instance, can also occur from visitors not washing their hands prior to touching a patient. Another person, an RN, wrote that the piece was fear mongering at its best. I have to agree.

Is the list of "10 shocking medical mistakes" informational or just sensational?

Sensational Medical Reporting

The US spends more on healthcare than 12 other industrialized countries; however, that care is not superior in terms of patient outcomes. According to a study conducted by 

, the US spent nearly $8,000 per person in 2009 on healthcare services, while other countries in the study spent between one-third (Japan and New Zealand) and two-thirds (Norway and Switzerland) as much and obtained similar, and sometimes superior, patient outcomes.

Higher prices and greater use of technology appear to be the main factors driving the high rates of US spending, rather than greater use of physician and hospital services. US hospital stays cost more than hospital stays in other countries. A typical US hospital stay cost about $18,000 while in Canada, the cost was $13,000 and in Germany, it was just under $10,000.

Prices for the 30 most commonly used prescription drugs were a third higher in the US (no surprise there) compared to Canada and Germany, and more than double the amount paid for the same drugs in Australia, France, the Netherlands, New Zealand, and the United Kingdom.

The researchers noted that Japan offers an interesting model for controlling costs. Japan is the lowest-spending nation of the group ($2,878 per capita in 2008). Japan operates a fee-for-service system, while offering unrestricted access to specialists and hospitals. Rather than containing costs by restricting access, Japan instead sets healthcare prices to keep total health spending within a budget allotted by the government.

I traveled to Japan last year to teach the nurses there, and the first thing I noticed was that nobody there was fat. In fact, some employers require annual girth measurements of its employees. There’s also a big emphasis on healthy eating and exercise in Japan. Junk food is relatively hard to find, and although there are fast food restaurants in Japan, the portion sizes are small. While I was there, a doctor said that he thought that Americans are eating themselves to death—that just might be correct.

	D. Squires, Explaining High Health Care Spending in the United States: An International Comparison of Supply, Utilization, Prices, and Quality. 

Japan spends the least on healthcare and the US spends the most--without providing superior care for the money.

Healthcare Spending

The news story getting a great deal of attention this week was first reported by Reuters and then picked up by other media outlets. Obesity is on the rise, and our society is challenged not only by the costs of obesity, but also by meeting the societal needs of obese individuals. Reuters cited many design changes that are occurring; for example, some U.S. hospitals are replacing wall-mounted toilets with sturdier floor toilets to better support heavy patients. Seats on trains and in sports stadiums are now larger. Wheelchairs and ambulance stretchers (and some ambulances too) are now larger than they were just a few years ago. The Reuters news story can be found at 

http://www.reuters.com/article/2012/04/30/us-obesity-idUSBRE83T0C820120430

The U.S. health care reform law of 2010 allows employers to charge obese workers 30-50% more for health insurance if they decide to not participate in wellness programs. The law also encourages obese individuals who have Medicare and Medicaid to see primary care physicians about losing weight, and funds community weight loss demonstration programs.

The percentage of Americans who are obese (with a BMI of 30 or higher) has tripled since 1960, to 34%, while the incidence of morbid obesity (BMI above 40) has risen sixfold, to 6%. The obese are absent from work more often than people of healthy weight. Obesity-related absenteeism costs employers as much as $6.4 billion a year.

The high medical costs of obesity are well known. However, recent estimates put the price tag at about $190 billion—yes, billion&mdash;per year. This is double recent estimates, and is reflecting more precise methodology in determining accurate medical costs. The high costs, as well as the impact of obesity on our society, are frightening. So pass the carrots, please. 

Costs associated with obesity are even higher than originally thought.

Pass the Carrots Please

Most everyone has heard references to the Nurses’ Health Study, which was begun in 1976 to determine the long-term effects of diet, hormones, environment, and the workplace on health and longevity. When the study was begun 4 decades ago, the researchers were brilliant to choose nurses as the study population since nurses understand the importance of research and generally speaking, are “type A” people who would likely hang in with the study for the long-term. And they have. Over 90% of the 238,000 nurses initially enrolled are still actively participating in the study.

The Nurses’ Health Study researchers are now seeking 100,000 new participants to form a diverse cohort of female RNs or LPN/LVNs (or students) who are between the ages of 20 and 46 from across the U.S. and Canada. Nurses and students can be working, not working, or retired. The study objectives remain the same—to learn more about the long-term effects of diet, hormones, the environment, and the workplace on nurses’ health.  More information about what we’ve learned from the Nurses’ Health Study is available on the study’s website, 

Surveys are done online every 6 months and data are protected. Email notifications are sent as reminders to take a new survey, and the system is set up so that if an interruption occurs while completing a survey, data that have been entered are saved. Survey 1, which is completed when an individual joins the study, collects demographic data, a medical history, and information about lifestyle and occupational exposures. Survey 2 includes a detailed reproductive history and questions about current diet and physical activity. Survey 3 updates the medical history and asks about lifetime physical activity. Participants may be asked if they are interested in participating in sub-studies on specific topics, such as fertility. Each of the Nurses’ Health Studies continues throughout the lifespan of the participants. Nurses and students who are interested in participating in this study and meet eligibility requirements can join the study by visiting 

Landmark study seeks 100,000 new participants.

Nurses Needed for the Nurses' Health Study

On April 18, 2012, the Massachusetts Medical Society and an alliance of healthcare organizations announced a major initiative to improve the medical liability system in that state. The 

) describes a new approach to improve patient safety, increase transparency, reduce litigation, and cut costs to the healthcare system. The 

 proposes a process of disclosure, apology, and offer (referred to as “DA&O”).

With a DA&O model, healthcare professionals, institutions, and their insurers disclose adverse outcomes to patients and their families. They also investigate and determine what happened, establish systems to improve patient safety and prevent the recurrence of these incidents, and when appropriate, apologize and offer financial compensation. These proactive actions are intended to avoid patients resorting to legal action when adverse events occur. Patients may still pursue legal action, but legal action would become a “last resort.” Adverse events in which the provider or institution is deemed to have met the standard of care would be vigorously defended.

Seven hospitals in Massachusetts have agreed to participate in a pilot program that will implement these reforms in 2012. They include the Beth Israel Deaconess Medical Center in Boston, Beth Israel Deaconess Hospital-Needham, and Beth Israel Deaconess Hospital-Milton, Baystate  Medical Center in Springfield, Baystate Franklin Medical Center in Greenfield, Baystate Mary Lane Hospital in Ware, and Massachusetts General Hospital. Implementation of the roadmap in Massachusetts is being supported in part by grants from the state’s three largest health insurers: Blue Cross Blue Shield of Massachusetts, Harvard Pilgrim Health Care, and Tufts Associated Health Plan, along with the Reliant Medical Group.

New approach to improve the medical liability system expected to reduce healthcare costs.

Disclosure, Apology, and an Offer

At the American Association of Cancer Research annual meeting, held in Chicago, IL, on March 31-April 4, 2012, Ning and colleagues from Virginia Commonwealth University presented interesting data on cancer survivorship. Their presentation was titled “Cause of Death in Cancer Survivors” (abstract LB-339; available at 

). My first thought when I saw the title was that cancer survivors don’t die of cancer. So what do they die from?

The researchers noted that cancer treatment has improved over the past few decades and cancer survivors are now living much longer. They identified 1,807 cancer survivors from the 

National Health and Nutrition Examination Survey (NHANES) 

1999- 2004. Cancer survivors were identified if they self-reported having ever been told that they had cancer or a malignancy of any kind; however, those with skin cancer and individuals under 18 years of age were excluded from the study. Causes of death were based on the National Death Index (NDI). All participants were followed from the start date of the survey to December 31, 2006, by linking National Death Index (NDI) death certificate records. The follow-up time ranged from 0 to 17.3 years and 776 participants died during this period. The causes of death were classified into 3 categories: related with cancer, indeterminate, and not related with cancer. The causes of death were then stratified by the duration since the diagnosis of cancer, which was calculated as follow-up time plus years between age at NHANES survey and age when being diagnosed with cancer. Commonly reported types of cancer were prostate (n=165), breast (n=141) and colorectal cancer (n=117).

During the course of the 17+ year study, 776 cancer survivors died — 51% from cancer and 49% from other causes. Cardiovascular disease was the primary cause of non-cancer deaths, and respiratory disease was another common cause. The researchers found that the longer patients survived after their initial cancer diagnosis, the more likely they were to die from another disease; 32.8% died from another condition within 5 years of diagnosis compared with 62.7% after 20 years.

With nearly half of cancer survivors dying from other causes, the implications of the study are clear. Oncology clinicians need to not only monitor cancer survivors for long term effects of treatment, we must also monitor our patients for diseases that commonly occur as people age, such as heart disease. We also need to monitor for other commonly occurring diseases, such as diabetes. With close monitoring, cancer survivors may one day also be heart disease survivors and live long, healthy lives. 

About half of cancer survivors die from cancer, but the other half die from other causes

Lisa Schulmeister