Hospital Compare adds patient outcomes

The Centers for Medicare and Medicaid Services (CMS) has just added 30-day mortality measures for heart attack and heart failure patients (separately). These are the first actual patient outcome measures to be included in this national, voluntary, hospital-specific public reporting database. In addition to the rates themselves, the site compares the rates to the national average (better, about the same, or worse).

The rates are also risk-adjusted to even out differences in the underlying morbidity of patients. The 30 days include patients who die outside the hospital, because there are also differences in how quickly hospitals discharge patients. This is, however, a potential source of error, because it's fairly difficult to capture deaths that occur outside the hospital. Last time I checked, there was a substantial time lag before such information was available via national data sources. If readers know how hospitals typically get such information, I'd be interested.

Top 100 health care blogs

(Warning: potentially confusing cross-referencing ahead...)

Thanks to Tony Chen of Hospital Impact, and one of my fellow World Health Care Bloggers, for pointing out the Healthcare 100 blogs, indexed by rankings in Google, Bloglines, Technorati, and eDrugsearch. The World Health Care Blog is number 47, and The Antidote is number 58! Lots of other blogging colleagues/buddies of mine are there as well; check it out.

Chemotherapy: profits vs. questionable benefits to patients

A story in the NYTimes today reports that oncologists are still trying to find ways to profit from treating their patients with expensive drugs, even though Medicare has cracked down on such profits two years ago (by limiting the markups docs can charge to 6% above the cost of the drug).

Doctors can get around the limitations in reimbursement by simply offering drugs to more patients, whether or not they'll benefit from them.

“There’s pretty good evidence at this point,” said Dr. Richard Deyo, professor of medicine at the University of Washington and an expert on health care spending, “that there are plenty of patients for whom there’s little hope, who are terminally ill, whom chemotherapy is not going to help, who get chemotherapy.”

Some doctors claim that the Medicare limitations are going to result in a lack of access to needed drugs for patients in rural areas, for example, although an unspecified federal commission cited by the article found this not to be the case.

In such a climate, how common are honest conversations between doctors and patients about the risks and benefits (not to mention the costs) of chemotherapy in terminally ill patients? I'd like to see studies on utilization of chemotherapy in settings where oncologists can't profit from use of the drugs (and I'm not sure where those are, given multiple payers, including Medicare, available in most care settings in the US), compared to those where they can. The extra-credit part would be comparing real health outcomes - not 5-year survival! - in different settings.

The fog of medicine

Baffling news from the recent American Society for Clinical Oncology meeting, about which the public should probably not yet make too much of a fuss; however, the NY Times chose to report on it, so there you are. Here's my take on what I've read in today's article.

Researchers presented an analysis of pathology samples from a study that had previously shown that breast cancer patients classified as positive for the HER-2 gene allowed them to benefit from treatment with trastuzumab (Herceptin). Another look at the HER-2 positive samples showed that 20% of them were actually HER-2 negative - and yet half of those women benefited from treatment with trastuzumab, a drug that specifically targets HER-2.

This could mean any (or more than one) of three things, none of which we have enough information at this point to be confident:

- the tests (immunohistochemistry - for the protein - and fluorescence in situ hybridization - for the gene) are worse than we thought
- the threshold for classifying a patient as HER-2 positive is wrong
- trastuzumab is not as specific to HER-2 as we thought (suggesting that women with HER-2 negative tumors could also benefit)

The studies described are small, and even those at the meeting (including the Times writer) did not have the benefit of all the methodological and data details we would in a peer-reviewed, published paper. In other words, these findings are meant to be chatter amongst investigators, and to suggest directions for more definitive research: for example, why did the women in the early studies test positive for HER-2, and negative now? were there other genes involved that could affect the results of the tests and/or the activity of trastuzumab? I'm not a molecular biologist, or an oncologist, so I'll stop there.

Regarding the NYTimes story itself, if it had fallen clearly into the excitement-of-science category, perhaps - perhaps - I'd have been OK with it, but there's a little too much hype offered up front by a National Cancer Institute scientist, suggesting that the results are potentially "practice-changing."

Democratic candidates: debate excerpts

The Kaiser Family Foundation has posted a compilation of health care-related excerpts from the recent Democratic candidate debate in New Hampshire.

Early detection of cancer

My fellow blogger Orac, an oncologist, has a great post (from back in April; somehow I missed it) on why screening for cancer is a complicated issue that should be approached with cautious weighing of risks and benefits. And here's his Part 2, with specific reference to breast cancer.

Be sure to read the comments - surprisingly, all were supportive - and check out the 9-minute video offered in the first post by Tracy of Dr. Barry Kramer (full disclosure: he's my former boss).