By NIRAN AL-AGBA, MD (7)
I will never forget her face. She was only thirteen. She had a significant cognitive disability, a result of an anoxic injury at birth. She found her way to my clinic one late Friday afternoon in July almost two decades ago. Her mother was a nurse and noticed her daughter had not had a period in the last two months. Her pregnancy test came back positive. I wanted to cry.
The questions I had to ask this young girl were agonizing. When asked if she had sex, she looked at me and shook her head back and forth, to say no, she had not had sex before. She was telling the truth. Having sex implies consent. When I asked if someone had touched her private area, she nodded her head up and down and said there were two boys. She thought they might have been about her age. She did not know who they were. She had never seen them before or since. I asked if she could remember their faces. She could not.
The two boys pushed her down on a grassy area next to the high school football field when she was walking home one day. She remembered it was raining because she had been looking up at the sky until they stopped hurting her. She told me about the pain she experienced, down there, and she pointed to her vaginal area. She told me there was some bleeding afterward at home. She did not tell anyone about what had happened, even her mother. I am not sure if she really understood what had been done to her. I tried to put myself in her place to understand how hard it must be to be telling me her story now.
Taking her small hand in mine, I told her she was pregnant. Her shoulders slumped forward and she looked at the floor. “Do you know what that means?” She nodded her head up and down, then said “there is a baby in here” gesturing toward her abdomen. It was more question than answer. She was not capable of understanding how horrifying it was that she never made a choice to become a mother.
She was still a child herself.
By STEPHEN SOUMERAI and KIP SULLIVAN (29)
Federal programs designed to cut costs and improve health by penalizing doctors and hospitals are failing at an alarming rate. Some of them actually harm patients, and many don’t cut costs. One in particular, the Hospital Readmissions Reduction Program (HRRP), may have caused thousands of deaths instead of preventing them, and probably hasn’t saved money during its seven years in operation.
The Centers for Medicare and Medicaid Services began reviewing the safety of this program on Jan. 19. It shouldn’t take CMS nearly four months to err on the side of caution and pull the plug on it.
The HRRP was imposed upon Medicare by the Affordable Care Act. Its goal makes sense: reduce the number of patients readmitted to hospitals soon after being discharged. But its approach — penalizing hospitals millions of dollars if their rate of readmissions within 30 days exceeds an arbitrary threshold — makes no sense at all.
The HRRP and other federal “pay for performance programs” were under fire before they began. Evidence suggested that some hospitals would try to avoid penalties by not readmitting patients within the 30-day window, or if they showed up in the emergency department during that time would treat them there and send them home or place them in so-called observation units rather than admitting them to the hospital. There were also indications that these kinds of programs would disproportionately harm socially disadvantaged individuals.
Influential health policy experts either ignored this evidence or downplayed it.
By PETER ELIAS, MD
I precipitated a recent online discussion about healthcare’s obsession with measurement (quality metrics is the current buzz phrase) when I quoted two aphorisms that highlight some problems with metrics and targets:
Goodhart’s Law: “When a measure becomes a target, it ceases to be a good measure,”
Campbell’s Law: “The more a metric is used, the more likely it is to “corrupt the process it is intended to monitor.”
One comment rubbed me the wrong way because it implied that measurement reduces harm:
“In my experience, what unites liberal and conservative doctors alike is their conviction that they are being measured unfairly….My view is that those who are upset about the burden on physicians of unnecessary measurement need to show that they understand the death and injury toll of lack of measurement caused before we trust them with the pruning knife.”
Measurement does not reduce harm or improve quality.
I love data (the result of measurement). As a clinician I used measurement all day, every day. I couldn’t have practiced medicine without it. But measuring a patient’s blood pressure does absolutely nothing to change that patient’s blood pressure. What improves the blood pressure are interventions. If the right thing is measured correctly, and if the measurement contributes to well-tailored interventions, then improvement occurs. Measurements must be part of a process by which one can improve the quality of one’s interventions.