Best Care at Lower Cost The Path to Continuously Learning Health Care in America (2013) / Chapter Skim
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2 Imperative: Managing Rapidly Increasing Complexity
2 Imperative: Managing Rapidly Increasing Complexity
Pages 63-90
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From page 63... ...
Prostatectomy provides the benefit of high prostate cancer–specific 20-year survival rates; even when performed by skilled surgeons, however, it carries significant risks of sexual, bladder, and bowel dysfunction, along with less common side effects such as Dr. Bennett's.
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From page 64... ...
When making these decisions, patients often lack clear and understandable information on their options, the risks and benefits of each, and the actions they can take in managing their condition. For those working in the health care enterprise, the current complexity of clinical decision making challenges human cognitive capacity to manage information.
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From page 65... ...
NOTE: ALLHAT = Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial; CASS = Coronary Artery Surgery Study; GISSI = Italian Group for the Study of Survival in Myocardial Infarction; HMG-CoA = key enzyme for cholesterol synthesis; ISIS-2 = Second International Study of Infarct Survival; MI = myocardial infarction; NCEP = National Cholesterol Education Program; NHBPEP = National High Blood Pressure Education Program; PCI = percutaneous coronary intervention; SAVE = Survival and Ventricular Englargement; TIMI 1 = Thrombolysis in Myocardial Infarction trial 1. SOURCE: Reprinted with permission from Nabel and Braunwald, 2012.
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From page 66... ...
. Further, the pace of treatment advances, as well as mutations in the virus found in the general population, requires that clinicians who work in this 2003 First fusion 30 inhibitor approved 1996 1996 FDA approves Reports on first FDA-Approved HIV Drugs test for viral clinical trials load on HAART 2007 1983-4 HIV documented First entry inhibitor and integrase strand 20 as cause of AIDS transfer inhibitor 1995 approved 1987 First protease First HIV treatment inhibitor (PI)
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From page 67... ...
1967 Combination chemotherapy 2001 60 found to be effective FDA approves first for leukemia targeted therapy (imatinib) 1974 Adjuvant chemotherapy introduced for breast cancer 50 1985 1994 First successful Genetic factors linked 1977 immunotherapy to breast cancer Hormone receptor therapy (IL-2)
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From page 68... ...
. Patients receiving a diagnosis of localized prostate cancer then must decide what course of action to take.
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From page 69... ...
Adherence to five separate sets of clinical practice guidelines for the woman's five diseases could result in adverse interactions between her medications, or a medication for one disease could exacerbate the symptoms of another (see Table 2-1 for potential treatment interactions)
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From page 70... ...
70 BEST CARE AT LOWER COST TABLE 2-1 Potential Treatment Interactions for a Hypothetical 79-YearOld Woman with Multiple Chronic Diseases Type of Interaction Medications with Medication and Medications for Disease Potential Interactions Other Disease Different Diseases Hypertension Hydrochlorothiazide, Diabetes: diuretics • Diabetes medications: lisinopril increase serum hydrochlorothiazide glucose and lipids may decrease the effectiveness of glyburide Diabetes Glyburide, None known • Osteoarthritis metformin, aspirin, medications: NSAIDs atorvastatin plus aspirin increase the risk of bleeding • Diabetes medications: glyburide plus aspirin increase the risk of hypoglycemia; aspirin may decrease the effectiveness of lisinopril Osteoarthritis Nonsteroidal anti- Hypertension: • Diabetes medications: inflammatory drugs NSAIDs raise NSAIDs in (NSAIDs) blood pressure; combination with NSAIDs plus aspirin increase the hypertension risk of bleeding increase risk of • Hypertension renal failure medications: NSAIDs decrease the efficacy of diuretics Osteoporosis Calcium, alendronate None known • Diabetes medications: calcium may decrease the efficacy of aspirin; aspirin plus alendronate can cause upset stomach • Osteoporosis medications: calcium may lower serum alendronate level Chronic Short-acting None known • None known Obstructive β-agonists Pulmonary Disease SOURCE: Reprinted with permission from Boyd et al., 2005.
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From page 71... ...
Each clinician managed a median of approximately 250 unique primary diagnoses, 280 unique medications, and 130 unique laboratory tests. These figures were even higher for those clinicians in primary care fields, such as internal medicine, who managed a median of 370 unique
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From page 72... ...
Acute Chronic Preventive Care Care Care 3.7 hrs 3.0 hrs 1.3 = 8.0 hours/day on direct patient care hrs Following guidelines would require that physician to spend... Acute Chronic Preventive Care Care Care 3.7 hrs 10.6 hrs 7.4 hrs = 21.7 hours/day FIGURE 2-4 Time requirements for a primary care physician to treat a standard patient panel.
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From page 73... ...
While strategies to overcome cognitive errors in clinical decision making are beginning to be identified (Croskerry, 2002, 2003; Redelmeier, 2005) , time and resource constraints, increasing stress among providers, and growing complexity are all barriers to overcoming the risks of these errors.
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From page 74... ...
. The pace at which new knowledge is produced outstrips the ability of any individual clinician to read, remember, and manage information that could inform clinical practice.
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From page 75... ...
. Similarly, the results of major clinical trials often are not implemented in regular clinical practice, as was the case for the Occluded Artery Trial (OAT)
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From page 76... ...
Since then, knowledge of the molecular drivers of non-small-cell lung cancer has increased dramatically; by 2009, nine different driver mutations had been identified (IOM, 2011)
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From page 77... ...
MANAGING RAPIDLY INCREASING COMPLEXITY 77 FIGURE 2-6 Evolution in knowledge of the genetic driver mutations associated with non-small-cell lung cancer. SOURCE: Reprinted from Pao and Girard, 2011.
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From page 78... ...
Indeed, as noted earlier, this growth in knowledge may be expanding beyond the limits of what human cognitive capacity can handle. Conclusion 2-1: Diagnostic and treatment options are expanding and changing at an accelerating rate, placing new stresses on clini cians and patients, as well as potentially impacting the effectiveness and efficiency of care delivery.
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From page 79... ...
Further, while patients with the highest health care costs represent only 5 percent of the total population, their care consumes 50 percent of total health care resources. ADMINISTRATIVE COMPLEXITY Administrative complexity, including complicated workflows and fragmented financing, exacerbate the challenges posed by the clinical complexity described above.
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From page 80... ...
Inefficient workflows also restrict the amount of time nurses can spend directly caring for patients; indeed, it has been found that hospital nurses spend only about 30 percent of their time in direct patient care (Hendrich et al., 2008; Hendrickson et al., 1990; Tucker and Spear, 2006)
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From page 81... ...
PT 3 Fax Comp R Ph Reg External Fax Fax PT 4 STAT Fax R Ph Accudose Comp R Ph ASAP Fax Accudose Accudose Inventory R PH goes to batch and Refill Refill batch room fills STAT order Pharm STAT Tech Tube system PRN RN packs up med dose Pharm Tech FIGURE 2-8 Diagram of processes for filling a medication order at one academic medical center. SOURCE: Adapted and reprinted with permission from Thompson et al., 2003.
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From page 82... ...
This frequent turnover in insurance relationships has implications for health care costs and outcomes. While many payers support preventive care and chronic care management, frequent changes in insurance enrollment lessen the incentives for investing in early interventions that can reduce long-term health care costs (Cebul et al., 2008)
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From page 83... ...
2004. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction)
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From page 84... ...
2002. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction -- summary article: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients with Unstable Angina)
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From page 85... ...
2005. A human factors engineering conceptual framework of nursing workload and patient safety in intensive care units.
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From page 86... ...
into the changing landscape of patients hospitalized with initial acute myocardial infarction: Worcester Heart Attack Study. Circulation.
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From page 87... ...
2012. A tale of coronary artery disease and myocardial infarction.
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From page 88... ...
2008. Trends in presenting characteristics and hospital mortality among patients with ST elevation and non-ST elevation myocardial infarction in the National Registry of Myocardial Infarction from 1990 to 2006.
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From page 89... ...
2008a. Comparative effectiveness of therapies for clinically localized prostate cancer.
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