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Malpractice Changes In Massachusetts Offer Injured Patients New Options

Tue, 01/20/2015 - 12:17pm
Malpractice Changes In Massachusetts Offer Injured Patients New Options January 20, 201512:17 PM ET

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Michelle Andrews

When a woman had gallbladder surgery at a Massachusetts hospital in 2013, doctors noticed something suspicious on a CT scan that they thought could be ovarian cancer. But the recommendation that she get a pelvic ultrasound fell through the cracks. Months later, she was diagnosed with stage 3 ovarian cancer.

Normally, this type of medical mistake could mark the start of a protracted malpractice lawsuit. But a recently enacted state law establishes a process and time frame for discussing mistakes designed to benefit patients, doctors and hospitals. The woman in this case used the process, according to her attorney who recounted the basic facts in an interview but declined to provide identifying details.

The law mandates that people give health care providers six months' notice if they intend to sue. The woman's lawyer notified the hospital of the mistake. Hospital officials, who had 150 days to respond, determined that their actions hadn't met the standard of care. The hospital arranged a meeting between the woman and one of their physicians to talk about why the error occurred and the measures being taken to make sure it won't happen again. The physician apologized, and soon after the woman accepted a financial settlement from the hospital.

The whole process took about a year, far less time than a drawn-out legal battle would have involved, says Jeffrey Catalano, the Boston attorney who represented the woman.

"The hospital did the right thing," he says. "My client felt really good about it. She felt like she was heard."

Traditionally, medical liability reform has often focused on laws that set caps on the dollar amount that plaintiffs can receive in damages. But interest in non-traditional types of medical liability reform has been growing.

In 2010, the Obama administration awarded $23 million in planning and demonstration grants around the country as part of a patient safety and medical liability reform initiative.

Boston's Beth Israel Deaconess Medical Center and the Massachusetts Medical Society received a planning grant for $274,000 to develop a road map for a statewide communication, apology and resolution system.

Communication and resolution programs are gaining in popularity. Advocates emphasize moving quickly when a medical error is made to discuss it with the patient and the patient's family, apologize and, if the standard of care hasn't been met, offer compensation.

In Massachusetts, six hospitals joined a pilot project to implement the model. Medical, legal and consumer groups that had participated in developing the road map formed a health care alliance to exchange information and develop best practices, and provide support for the hospital pilot projects.

In turn, that law bolsters the alliance's efforts to change how medical injuries are addressed. In addition to the six-month cooling off period before a suit can be filed, the law requires that patients be told when medical mistakes are made that result in unexpected complications and allows providers to apologize for unanticipated outcomes without fear their words will be used against them in court.

The broad-based Massachusetts' effort is modeled after the University of Michigan's communication and resolution program. Since the program began in 2001, medical malpractice costs have declined as have the rates of claims and lawsuits, according to a 2010 study published in the Annals of Internal Medicine.

Saving money shouldn't be the primary motivation for adopting a program, says Richard Boothman, the chief risk officer for University of Michigan Health System and the man who pioneered their program. Patient safety is the goal.

"The very best risk management is to not hurt anybody in avoidable ways, and the second best [strategy] if we do hurt someone is not to do it again," he says.

Copyright 2015 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
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When Bariatric Surgery's Benefits Wane, This Procedure Can Help

Mon, 01/19/2015 - 3:33am
When Bariatric Surgery's Benefits Wane, This Procedure Can Help January 19, 2015 3:33 AM ET Listen to the Story 3 min 24 sec  

For most of her life Fran Friedman struggled with compulsive eating. At 59 years old she was 5 foot 2 and weighed 360 pounds. That's when she opted for bariatric surgery.

The surgery worked. Friedman, who is now 70 and lives in Los Angeles, lost 175 pounds. "It was a miracle," Friedman says, not to feel hungry. "It was the first time in my life that I've ever lost a lot of weight and was able to maintain it."

Friedman kept the weight off for almost 10 years. But then to her dismay she started to gain it back. "I thought I was cured," she says. "I thought I could eat like regular people."

She's not alone, says Dr. Rabindra Watson, Assistant Clinical Professor at the University of California, Los Angeles, Division of Digestive Diseases.

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About one in three patients regain significant amounts of weight a few years after surgery to reduce the size of the stomach pouch. Bariatric surgery shrinks the stomach to about the size of an egg, so people feel full from eating very little food. The problem is that over the years the stomach stretches, and when that happens, Watson says, "Patients are able to eat more at one sitting and they feel hungrier more often."

At the same time, hormonal changes that reduce the appetite and take effect immediately after the surgery begin to decline. Watson says we don't know for sure, but it's possible the body begins to adapt to those changes, which is why the weight loss is reversed over time.

For Fran Friedman, it meant a 20-pound weight gain and a bout of depression. "The reality hits," she says. "Do I want to go back to where I was or do I want to maintain this level of quality of life?"

So Friedman opted for a less invasive procedure to make her stomach smaller again. It's called Transoral Outlet Reduction – or TORe for short. It's one of several procedures designed to help people maintain the benefits of bariatric surgery. This procedure involves inserting an endoscope through the mouth into the stomach while the patient is under anesthesia. It costs $8,000 to $13,000 and insurance coverage varies.

If the stomach pouch has stretched, new sutures are put in place to once again reduce the size of the stomach. After the surgery, Watson says, patients report feeling fuller and less hungry and they ultimately gain greater control over what they are eating. And research conducted over the past decade suggests it works. There are no significant side effects to the surgery, and patients can return to work the day after they have the procedure.

For Friedman, it did the trick. She has lost 30 pounds since her second surgery. And now, she says, with the help of a support group she is recommitted to watching what she eats and how much she exercises. She wants to lose another 20 pounds. And more importantly, she wants to keep the weight off.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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Sure You Can Track Your Health Data, But Can Your Doctor Use It?

Mon, 01/19/2015 - 3:32am
Sure You Can Track Your Health Data, But Can Your Doctor Use It? January 19, 2015 3:32 AM ET

fromKQED

Amy Standen Listen to the Story 3 min 48 sec   Katherine Streeter for NPR

Dr. Paul Abramson is no technophobe. He works at a hydraulic standing desk made in Denmark and his stethoscope boasts a data screen. "I'm an engineer and I'm in health care," he says. "I like gadgets." Still, the proliferation of gadgets that collect health data are giving him pause.

Abramson is a primary care doctor in San Francisco and lots of his patients work in the tech industry. So it's not surprising that more and more of them are coming in with information collected from consumer medical devices — you know, those wristbands and phone apps that measure how much exercise you're getting or how many calories you're eating.

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The "wearables" market is growing fast. Credit Suisse estimates it's already worth between $3 billion and $5 billion. Add to that nearly 50,000 health apps, and you have a booming new digital health industry aiming to transform health care in the same way Amazon took on publishing.

Abramson says all the information these devices collect can be overwhelming. One of his patients arrived with pages and pages of Excel spread sheets full of data — everything from heart rate to symptoms to medications. Abramson says he didn't know what to do with it all.

"Going through it and trying to analyze and extract meaning from it was not really feasible," he says.

To Abramson, the spreadsheets just didn't say all that much. "I get information from watching people's body language, tics and tone of voice," he says. "Subtleties you just can't get from a Fitbit or some kind of health app."

Despite this reluctance on the part of doctors, technology startups are actively trying to insert their products into the doctor's office.

“ "We can't make the leap that just because this data is coming in digitally that it's accurate."

Doctors get pitches from entrepreneurs almost daily, says Dr. Michael Blum, a cardiologist at the University of California, San Francisco. "Their perspective is, 'You old doctors have kept things the same as they are for 50 years. We've got new technology and it's going to disrupt health care,'" he says.

Don't get him wrong. Blum thinks health care needs an update, for sure.

The problem is, just because a device looks shiny and new doesn't mean it's useful. FitBits and Apple Watches aren't regulated by the Food and Drug Administration. In fact the FDA doesn't intend to regulate what it calls "low-risk devices" that are only intended to promote general wellness, like weight loss, physical fitness or stress management. Only medical devices that are intended for use in the diagnosis or treatment of disease need FDA approval.

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Blum says, "We can't make the leap that just because the data from these low-risk devices is coming in digitally doesn't mean that it's accurate." He says validation studies are needed.

Often that task falls to doctors and hospitals. At UCSF, Blum now heads an entire new department created to sort out which technologies are game changing and which are dead ends.

Other health care groups are following suit, running pilot studies that give devices to people with certain illnesses to see whether they help.

Bret Parker is taking part in one such study for Parkinson's disease. He's 46 years old, lives in New York City and has blogged about his illness. "When I heard there was a trial that involved a wearable that would help me better manage my symptoms and my condition, I said to myself, 'Well, that's a pretty cool thing. I've got to try that.' "

Bret Parker went skydiving in 2013 to raise money for the Michael J. Fox Foundation. Parker participated in a study earlier this year about whether a wearable tracker could effectively measure the severity of tremors caused by Parkinson's.

Courtesy of Bret Parker

Parker enrolled in a pilot study to see whether an activity tracker made by Intel would be useful to track the severity of his tremors. It creates a digital diary showing how tremors respond to minor changes in diet, sleep patterns or what time of day Parker takes his medication.

Parker says in the early stages of his disease, he didn't pay close attention to those kinds of details. But as the Parkinson's progresses, he believes he'll have to change his approach.

"This is going to be a battle between me and Parkinson's in the years to come," he says. "As it advances, it means I've got to be better and smarter at my role in it."

He hopes the wearable will help him do that.

Copyright 2015 KQED Public Media. To see more, visit http://www.kqed.org/news.
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Calif. Strike Highlights Larger Issues With Mental Health System

Sun, 01/18/2015 - 4:57pm
Calif. Strike Highlights Larger Issues With Mental Health System January 18, 2015 4:57 PM ET NPR Staff Listen to the Story 4 min 51 sec  

A Kaiser mental health worker with the National Union of Healthcare Workers looks through a pile of signs Monday during day one of a week-long demonstration outside of a Kaiser Permanente hospital in San Francisco.

Justin Sullivan/Getty Images

This past week, more than 2,000 mental health workers for the HMO health care giant Kaiser Permanente in California went on strike.

The strike was organized by the National Union of Healthcare Workers. The union says Kaiser Permanente patients have been the victims of "chronic failure to provide its members with timely, quality mental health care."

On Thursday, about 150 Kaiser Permanente employees picketed the Woodland Hills Medical Center in the San Fernando Valley. One of them was therapist Deborah Silverman. In her eyes, the biggest problem at Kaiser right now is understaffing.

Silverman says there are so many patients waiting to see therapists, that Kaiser sends new patients to see her, even if she's already overbooked. She says for three days over a two-week period she had four people she didn't know.

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"I have to put them some place, and I didn't have any appointments for at least three weeks. So that's a huge emotional cost to me," Silverman says. "I either have to try to find someone else who has an open slot, which means the person has to switch, or people have to wait, and they've come to see you. It makes you feel — it really bumps up against our ethical standards."

Silverman says switching therapists often makes it difficult to establish a bond and make progress.

John Nelson, Kaiser Permanent's vice president of government relations, says the company delivers some of the highest-quality mental health care in California and in the country. But, he says, they absolutely want to get better.

"Really the only way we can do that is by working together," Nelson says. "So we need our therapists and psychologists and others to be working with us, and constructively on how to get better, and not walking away from patients and being gone for seven days."

But it's not just the union saying there's a problem at Kaiser.

In 2013, the state of California fined Kaiser $4 million, finding that some of these problems — like the long wait times, and the company discouraging people from seeking costly individual therapy — violated federal and state laws about mental health care.

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April Dembosky has been following the story for NPR member station KQED. She says even though Kaiser paid the fine last September, the union is still unhappy.

"They're arguing that Kaiser has simply shifted resources," Dembosky tells NPR's Arun Rath. "So that fine was directed mainly at initial visits ... [those] arguing they had to wait an unreasonably long time" to be seen for their first visit.

Dembosky says the union is alleging that now patients might get that initial appointment faster, but "good luck with a follow-up appointment."

"They're saying people are still being made to wait two, four, six weeks," she says.

Dembosky says she thinks what might be happening now, as far as patient wait times, is a result of campaigns that have sought to reduce stigma around mental health services. Some of that seems to have worked and more people with mental health problems are coming forward, she says.

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"In my reporting I'm seeing this come up in several other venues, not just at Kaiser," she says, including the state's university system. "This is something that ... is an issue that's coming up in other health care systems."

Dembosky says there is also a shortage of mental health care professionals to meet the demand of new patients — not enough people are completing the lengthy licensing process necessary to provide care.

Meanwhile, there's no sign that an agreement between Kaiser Permanente and the union is imminent — but Kaiser's mental health workers will be back on the job Monday.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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One Scientist's Race To Help Microbes Help You

Sun, 01/18/2015 - 5:46am
One Scientist's Race To Help Microbes Help You January 18, 2015 5:46 AM ET Katherine Harmon Courage

Biologist Rob Knight, co-founder of the American Gut Project, recently moved the project to the University of California, San Diego's School of Medicine.

Casey A. Cass/University of Colorado

The rate of recent discoveries about the human microbiome has been dizzying. And Rob Knight wants to crank up the pace.

One of the top scientists in a field that's discovering possible bacterial influences on everything from diabetes to depression, Knight was also co-founder of a massive citizen science experiment called the American Gut Project. He recently moved from the University of Colorado, Boulder and took the gut project with him — to the medical school at the University of California, San Diego.

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The project lets anybody, for a $99 fee, have the microbes of the gut, mouth, skin or other orifices inventoried. And it's not just for people, but pets, too. Last year I roped my husband, mom and dog into having their gut microbes analyzed along with mine in hopes of discovering what microscopic stories we share. (You can read more about the results here.)

I caught up with Knight by phone on Friday to talk about what's next. Below is an edited version of our chat.

What is the current state of microbiome research?

Right now a lot of microbiome research is about pattern discovery. We're finding connections between microbes and all kinds of conditions we never knew they were involved with — ranging from obesity to colon cancer to rheumatoid arthritis and (in mouse models) even things like autism, depression and multiple sclerosis.

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In the future it's going to move beyond the correlations to actually finding out which of those conditions microbes cause — and which of those conditions we can either predict or modify with improved knowledge about the microbial world.

What are some of the current challenges in microbiome research?

In microbiome studies, some of the effects are so obvious that you can see them with just a handful of people. But other effects you might need to get a population of fives of thousands or tens of thousands to be able to understand what's going on.

That becomes especially true if you start to look at combinations of variables. So, maybe exercise has a particular effect on your microbiome if you're on a special diet, or if you're taking a particular drug. Once you start to look at those combinations of factors (talking about, say, racial or ethnic background, or medication or lifestyle effects, such as diet and exercise) in combination and trying to make predictions, you could see how you would need relatively large numbers of people to even begin to get anywhere.

Another challenge is in computation. The ability to generate the data has greatly outstripped a lot of people's ability to analyze the data.

Then there's the user interface. Especially if we want to get this into the hands of clinicians, which we do, and to people who want to interpret their own microbiome results, you really don't want a huge table of numbers. So we are trying to make this easy for users to understand — the same way that GPS went from being just inscrutable numbers to being a map where you can see, turn by turn, where you're supposed to go. That's what we mean to do for the microbiome — to make it easy to use.

With your move from CU Boulder to UCSD, where do you hope to take microbiome research next?

There are several things that are exciting about this move. One is that San Diego is one of the world's premier biotechnology hubs. So being able to collaborate with companies on technology and being able to help companies discover, for example, if a particular probiotic, prebiotic or diet will affect your microbiome. Being able to work with these companies directly to figure out whether their product has an effect — and whether that effect is beneficial or harmful — is really exciting.

Another factor is getting the resources at the [UCSD] medical school — and at the Rady Children's Hospital. The bio bank here is collecting 300,000 biological specimens a month, so we will be able to add a microbiome dimension to the study of diseases — including diseases where there is no hint yet that the microbiome is involved. When you consider the number of diseases where, just over the last five years, it went from being crazy to think the microbes were involved to now being crazy to think the microbes aren't involved, it's amazing how rapidly the evidence has been accumulating. There's a lot of potential there.

What's happening with the American Gut Project?

We have our equipment up and running in San Diego, so we're able to do DNA extractions, PCRs, sequencing and so forth. And samples that have been sent to Boulder are being redirected to San Diego, so no one needs to worry about their sample being lost!

What's next?

We're hoping to scale it up and decrease costs.

We want to reach out to people who share the same factors — whether it's people who live in the same area, do the same sport, have the same diet, are taking the same medication or have the same medical condition. Finding out what matters and what doesn't matter in your microbiome — and which of these factors in which you resemble another person also cause your microbiome to be similar — is going to be really fascinating.

I can't say anything too explicit yet, but we're also looking to partner with companies where we might be able to do things like integrated human genome and microbiome sampling.

We already launched the British Gut Project and the Australian Gut Project, and expanding those kinds of spinoffs to more countries is going to be exciting.

It's going to take a while, but the potential is just tremendous, especially given the disparities between countries — even those that share a border — in a lot of conditions that we now know are linked to the microbiome. So understanding what factors affect those health issues across different geographic regions is going to be very exciting.

We are also hoping to create an open platform where any scientist, physician, educator, student or anyone at a company can very rapidly look at the dataset to get an idea about what the effect on the microbiome a treatment or product might have — and then use that as a basis for designing more carefully controlled studies.

And we think there's a tremendous amount of potential for medical education about probiotics, prebiotics, antibiotics and the microbiome.

I think the possibility of not just discovering patterns but turning those patterns into things that actually affect and benefit people's lives is tremendous.

Katherine Harmon Courage is a freelance health and science journalist based in Colorado. She is the author of Octopus! The Most Mysterious Creature In the Sea, now available in paperback.

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