Coca-Cola Joins BIO

I was reading today's POLITICO Influence that I receive by email when I was surprised to read: "COCA-COLA JOINS BIO: Coca-Cola Company has joined the Biotechnology Industry Organization. The trade group is expanding its multinational members. The group also added Scott Vitters, general manager of the PlantBottle Packaging Platform for Coca-Cola Company, to its Industrial and Environmental Section Governing Board."

Expanding its members?  When I looked at the webpage for BIO it indicated that it was the world's largest biotechnology organization http://www.bio.org/articles/about-bio.  Now that is what I call expansion.

Freedom is Not About the Size of a Sugar Sweetened Drink

Today, the Alliance was the lead signatory on an amicus (friend of the court) brief filed in the NY Appellate Division of the Supreme Court supporting the NYC Board of Health’s (BOH) public health rationale and authority to limit serving sizes of sugar sweetened beverages to 16 ounces in New York City food service establishments. The brief filing comes two weeks after a lower court ruled that the NYC BOH policy could not be implemented following a court challenge organized in part by the beverage industry.

While we were able to have many signatories to our Amicus Brief what was most interesting and challenging were all of those organizations that should have immediately signed on and who were silent.  If you are concerned about wellness and health promotion then you should be focused on those actions that support people be healthy.  

Instead what we found was that trigger words were thrown around to invoke a knee-jerk response but were often devoid of content.  The refrain that people's "freedoms" were being attacked seem not only misguided but made light of the very concept of freedom.  More than anything it is very sad to see the effect of financial pressure placed on organizations to make decisions that are contrary to their espoused mission.

It is a reminder that decisions based on integrity are priceless.

Forget about pay for performance (P4P)

The principles of behavior modification demonstrate the importance of incentives. What is also well documented is that extrinsic rewards, i.e., financial incentives, have limited impact on complex behaviors.  Moreover, extrinsic rewards are most effective with young children. 

Consequently, based on the science of human behavior P4P would result in the desired performance in very limited settings and situations. We should not be surprised by the outcomes that we have experienced by applying P4P to health care...more money is not the answer.  

http://content.healthaffairs.org/content/31/9/1932.abstract?sid=6eb2c26a-18b9-4a35-a1cc-5b44b41c8ca2

When Setting Targets Misses the Mark

The solution to the problems we face in health care are frequently reduced to one sentence pronouncements.  National health care is put forth as the best answer and in the same breath the National Health Service, a la British model is lauded as the way to go. And while that model may have elements we may want to adopt (home visits for parents of newly born infants) we also need to be well aware of its failures.

Today's New York Times on Page 9 describes the recent report which looked at conditions at Stafford Hospital in England from 2005 to 2009 where care became so negligent that, "...patients left unbathed and lying in their own excrement and urine..patients left so thirsty that they drank water from vases..."  It seems that they were trying to meet health service targets and balance the books. While many of the senior managers were let go, the top regional person is now at the helm of the National Health Service in England and it seems that no one lost their license because of the way patients were treated.

There are many lessons to be learned from Stafford hospital.
http://www.nytimes.com/2013/02/07/world/europe/hospital-report-cites-appalling-suffering-in-staffordshire.html

Epilogue: Case Study Ellen—Good Policy is Not Enough

These last few months have been so intense.  I have seen health care providers who struggle as they try to care for patients while others acted as if caring for a patient was a burden.  It was at the point of patient care that I saw the greatest variability in how someone was treated.  

I remember the nurse in the step-down unit who had said that the IV should be changed every 72 to 96 hours and became annoyed that after 96 hours I asked how come the IV had not been changed.  Her response was that she was dealing with more pressing patients and she would get around to it.  It was clear that the needs of the individual had become either dominated or subservient to some benchmark or target. This is not the health care any of us want or deserve.

As all this occurred I contacted the leadership at Georgetown University Hospital and they were responsive to my many concerns.  They  made it clear that the policies they had developed had not been followed.  All were apologetic and all apologies were accepted but the bottom line is that the patient suffered and died.

Part IV: Case Study Ellen— Another Trip to the ER

I returned to DC on Monday and my intention was to visit Ellen at the Rehab Center and see how she was doing.  The plan was that she would be there for a while to regain her mobility and then go home.  As I was driving I decided to call Ellen's daughter to see how things were going.  

She let me know that the Rehab Center wanted to call 911 and have an ambulance take  Ellen to Suburban Hospital.  Ellen's white blood cell count was high and they felt she needed to be taken there even though her primary doctor was affiliated with Georgetown University Hospital (GUH).  We were told that the Montgomery County ambulance would not take her to GUH which is located in Washington, D.C.  The only way Ellen could get to GUH was by hiring a private ambulance. And so we did.

So once again Ellen, her daughter, and I were on our way back to the ER.  This time I  let the Georgetown staff know we were coming ahead of time.  We were glad that Ellen was put in the same area designated as Fast Track B. We chuckled about what "Fast Track" means.  

This time Ellen had a wonderful nurse (Jason) who did all he could to make her comfortable.  The 4th year resident (Bobby) had a good disposition and was very patient with her. Ellen had blood drawn, ultrasound of a swollen leg, chest x-ray, and answered many questions. The physician on duty told us that her white blood cell count should not have been alarming as that may have occurred because of some of the medicines she was taking.

In the end they released her to go back to the Rehab Center.  There was nothing wrong with her or perhaps more accurately there was nothing found that could be fixed. Consequently, at 2:20am on Tuesday Ellen was transported back to the Rehab Center by the regular ambulance service.  On Thursday at 1:45pm Ellen died.

Part III: Case Study Ellen— Shades of Patient Dumping

Ellen's daughter, Ann, had been told that Ellen would be moved on Monday to a Rehab facility and so Ann had gone to visit other family members in Delaware to discuss the situation with them. Ann felt that her mother was in a safe place--- Georgetown University Hospital.

Saturday at about 6pm I was called by a representative of Georgetown University Hospital (they meant to call Ann) and was informed that Ellen would be moved that evening to the Rehab facility.  I told the woman that I was the friend and not the daughter and thought it was a terrible idea to move her.   It seemed that now that the insurance had been approved that they were going to move Ellen to the Rehab facility. I let the person who called me know that the person she needed to talk to was Ann (Ellen's daughter) and gave her the correct number to call.  

How had this situation come about?  It seems that Saturday during the afternoon a physician called Ann to confirm the DNR that Ellen wanted and Ann said yes she understood that is what her mother wanted. There was no mention that she was going to be moved that evening.

The move on Saturday was totally unexpected and far from good or responsible care.  Ellen was weak, fragile, and readying to go to sleep when she was disrupted with the news that she would be moved.  A person too weak to go home and yet moved on a Saturday night. One can only imagine the enormous amount of stress this put on Ellen.

Is this patient dumping.  How could anyone have allowed that?  This is not the way that patients or their families should be treated.