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Thu, September 18, 2014

A new study put out by senior author Beth Tarini, MD, MS, shows that primary care doctors report challenges to incorporating genetics assessments in routine primary care. Dr. Tarini commented, "Genetics is not just about rare diseases and specialists. PCPs [Primary Care physicians] rely on genetics frequently during preventive care visits – especially when taking family histories and assessing a patient’s risk of more common, but chronic, diseases. So the fact that PCPs report many barriers to embracing and performing these tasks is concerning," The study also found that many Primary Care physicians feel as though their expertise on genetic medicine is insufficient.

Susan Dorr Goold, M.D., M.H.S.A., M.A., professor of Internal Medicine, and Health Management and Policy, was awarded a two-year, $391,000 grant from the Agency for Healthcare Research and Quality (AHRQ) to engage Michigan communities in deliberations about Medicaid priorities. Led by Goold and community partner Zachary Rowe, the project will engage communities in a priority setting exercise using the Choosing Health Plans All Together (CHAT) exercise. The award-winning CHAT tool provides structure, feedback and adaptability. It has a been used by multiple policy makers and community organizations, and a solid record of published research.

 

Valerie Kahn, MPH

Center Manager

Valerie joined CBSSM as the Center Manager in the fall of 2012 after working as a Project Manager at CBSSM since 2009. Valerie continues her work on research projects involving medical decision making and doctor-patient communication. Valerie received her MPH in Health Behavior Health Education from the University of Michigan.

 

 
Last Name: 
Kahn

Chris Krenz, BA

Research Associate

Chris Krenz joined CBSSM in the fall of 2014. He received his BA in Sociology from the University of Michigan, minoring in Philosophy. Before coming to CBSSM, Chris was located at the Institute for Social Research, working on projects concerning the health of Pacific Islanders and other minority populations.

Chris primarily works with Dr. Raymond De Vries on a study exploring factors that influence whether biobank donors provide consent for their biological material to be used in research.

Research Interests: 
Last Name: 
Krenz
Tue, January 16, 2018

CBSSM Director, Reshma Jagsi was recently interviewed for the LA Times article, "Will medicine be the next field to face a sexual harassment reckoning?" This article discusses her 2014 survey on sexual harassment and gender bias in academic medicine, as well as her recent article on the #MeToo movement as it relates to medicine in the New England Journal of Medicine.

Sorry, Doc, that doesn't fit my schedule (Feb-04)

Patients sometimes skip treatments because they just feel too busy. What should physicians do when their patients ignore their recommendations?

Imagine you are a businessperson who works long hours and you are on your way up to having a successful and lucrative career. You have a major business deal that will consume nearly all of your time over the upcoming month and your boss is relying on you to make sure the deal goes through. This is your chance to really make your mark and show your corporation that you are the kind of person that can handle deals as big as this one. Also suppose you have been smoking on and off for 25 years. You know it's a bad habit that could destroy your lungs, but you just can't quite kick it. Lately, you have been feeling tired, you have been experiencing chest pains when you are really busy at work and when you exercise, and you have had trouble breathing when climbing a flight of stairs. The chest pains are usually relieved by a little rest, but you decide it's time to get this examined by a doctor.

One day after work, you go to see Dr. Coral, who gives you a stress test and determines that you'll need an appointment for an angiogram to better evaluate your coronary arteries. Fortunately, you find one free day right before things get hectic at work, so you schedule the angiogram. Now imagine you have just had the angiogram and you are recovering in a paper gown waiting for Dr. Coral to come back with the results. Dr. Coral enters the room to speak with you and he has a serious look on his face. He says,

"I have both good and bad news for you. The angiogram shows that your 3 main coronary arteries are all severely blocked. The good news is that we caught this before you had a major heart attack."

"The bad news is that I am recommending you have triple bypass surgery as soon as possible. Your heart is working overtime, and it is just a matter of time until it gives out."

The news is shocking, but in addition to your health concerns, you also have the business deal to worry about. This deal is an opportunity to make a name for yourself, and your boss has been very vocal that he was counting on you, trusting that you'd be the one for the job. You find yourself having to weigh your work ambitions against the recommendation from Dr. Coral because if you get surgery, there is no way you'd be able to take on your current work responsibility.
 
Which of the following decisions would you be most likely to make?
 
  • I would put aside Dr. Coral's recommendation and instead take responsibility at work for the current deal. I'll wait to have surgery in about a month.
  • I would follow Dr. Coral's recommendation by having surgery immediately, even though this forfeits the current opportunity at work.

A little feedback on what you chose.

It's not that physician's don't care about your other values, but they are primarily concerned about your health, and you might not even have lived long enough to finish the business deal if you didn't have this surgery immediately. This does, however, bring up an important fact: patient's do sometimes reject their physician's medical judgment, and it can be at a great cost to their health.
 
Why should a patient be part of the decision-making process?
 
Why shouldn't Dr. Coral just tell you that you need surgery and leave no alternative? Efforts to share decision-making with patients are important because they acknowledge patients' rights to hold views, to make choices, and to take actions based on personal values and beliefs. In addition to being ethically-sound, this shared decision-making process also leads to improved patient health outcomes.
 
What can a physician do to help the patient choose surgery?
 
To answer this question, first it needs to be emphasized that in order for a patient to be able to participate in the decision-making process, the patient must be able to soundly make decisions. This sounds abstract and subjective, but it can be broken down into something a little more concrete. Decision-making capacity (DMC) is based on four guidelines:
 
The patient is able to:
 
  • understand the information about the condition and the choices available;
  • make a judgment about the information in keeping with his or her personal values and beliefs;
  • understand the potential outcomes or consequences of different choices; and
  • freely communicate his or her wishes
Based on these four elements, it is possible to see what a physician can do to help facilitate a "good" health decision. In order to make sure a patient fully understands the situation, a physician can ask him or her to state their understanding of the problem and of the treatment options. Also, a physician should use clear and unambiguous language with the patient at all times. Although a report might be quite clear from a physician's perspective, a patient might not be as clear about all the details. In the situation you were asked to imagine, Dr. Coral should tell you that you will die without this surgery and that waiting is not a safe option.
Also, there might be other factors keeping a patient from following a physician's recommendation. Again, in your hypothetical situation, your boss was putting a lot of pressure on you not to let him down. Also, this decision would potentially have an effect on your advancement at work. You might not have felt free to elect surgery even if you knew it was the only good decision for your health. By directly acknowledging and addressing a patients' concerns, physicians may facilitate a decision for the surgery.
 
In conclusion, if a physician feels that a patient is not able to fulfill one or more of the elements of DMC then his or her ability to make that decision should be brought into question and surrogate decision makers should be sought. For more serious decisions, the standards for DMC should be higher than for less important decisions or those with less significant outcome differences among the choices.
 
For more information see:

 

Submit Your Paper for Consideration in the ASBH Student Paper Competition

If you are a student who would like to be considered for the Student Paper Award, please send your paper to the ASBH office in an electronic format (Word or PDF) to candersen@asbh.org, with “ASBH Student Paper Competition” in the subject line.  All papers need to be received at the ASBH office by July 15, 2013 to be considered.    The Awards Committee will review and rank all submissions.  The top three papers will be placed in a special session at the Annual Meeting, and one winner will be chosen at the meeting by the Awards Committee. The award will be presented during the Members’ meeting.

All papers will be assessed anonymously.  Do not include identifying information in your paper submissions, such as title pages with your name. Previous winners are not eligible for consideration. Eligible papers should be no more than 3500 words in length. A student is defined as one who is actively pursuing an advanced degree and has not received a doctoral-level degree (e.g., MD, PhD, JD or equivalent degree). Authors who are not students according to the definition above are not eligible for the Student Paper Award. Coauthored papers are eligible only if all authors are students.

If you have any questions, please do not hesitate to contact the ASBH office at: info@asbh.org

Thank you,
 
American Society for Bioethics + Humanities (ASBH)
Phone: 847-375-4745

www.asbh.org

 

What is the price of life? (Aug-03)

Do you think that your life is worth more than the amount that the government usually uses as the maximum to spend to provide one year of life?

Imagine that you are a member of a government panel that is trying to decide how cost-effective a medical treatment must be in order for the government to cover the costs of the treatment. Suppose that a certain treatment could provide one additional year of life to an otherwise healthy person. What is the highest amount the government should be willing to pay per person for this treatment?

How do your answers compare?

For the past twenty years, the figure most often used as the maximum amount to spend to provide one year of life has been $50,000. This figure was originally proposed since it was the cost of a year of kidney dialysis, a lifesaving treatment that the U.S. government funds in Medicare.

Should the number be higher or lower than the current standard?

Conventional wisdom would suggest that the number be higher to take into account the inflation that has occurred in the years since the standard was developed. Current practices such as annual Pap smear screening for women with low risk for cervical cancer, which has a cost of $700,000 per year of life gained, also suggest that society is willing to pay more than the current standard for a year of life. The authors of the cited article recommend, based on current treatment practices and surveys of the general public, that the cost-effectiveness threshold should be revised to be around $200,000.

Should the number increase, decrease, or stay the same over time?

Again, it seems that the threshold amount should increase over time due to inflation. However, other factors come in to play that affect the value.

Since new technologies are emerging all the time, some of which will be deemed cost-effective, there will be more and more treatments to be offered in the future. Also, the rate of use of treatments is an important consideration, because even if a new treatment is more cost-effective than an old one, if it is used more often it will end up costing more to society overall. With more treatments becoming available and more people being given treatments, the threshold cost will probably have to decrease so that insurance companies and the government can keep up with the increasing availability and demand.

Why is this important?

Insurance companies and government health care entities face a continuing struggle when trying to determine which medical treatments to cover. Health care costs are increasing rapidly, so these groups will be facing even tougher decisions in the future. Establishing cost-effectiveness guidelines would be extremely helpful as an aid to making the decisions about treatment coverage. Evidence shows that the current threshold is probably not an accurate reflection of the desires of society or actual prescribing practices. It needs to be adjusted to become useful once again, and must be reevaluated periodically to make sure the value keeps up with trends in the health care market, rather than being left alone without question for two decades as is the current situation.

For more information see:

Ubel PA, Hirth RA, Chernew ME, Fendrick AM. What is the price of life and why doesn't it increase at the rate of inflation? Archives of Internal Medicine. 163:1637-1641, 2003.

Funded by Health and Human Services, Department of-Agency for Health Care Research and Quality

Funding Years: 2014 - 2016

'Value-based purchasing' is a quality improvement strategy that links payment with healthcare outcomes, by paying less or not at all for poor outcomes. The Centers for Medicare and Medicaid Services (CMS) seeks to decrease the rate of hospital-acquired complications (HAC) and readmissions by holding hospitals financially accountable using risk-adjusted rates. CMS risk-adjustment models for outcomes of mortality and readmission include patient characteristics from routine administrative discharge data (e.g., diagnosis codes) with age and gender as the only socio-demographic variables. Research suggests other important patient characteristics such as functional status, mobility and level of social support also impact patients? risk for readmission and certain complications (e.g., pressure ulcers). To date, variables such as functional status, mobility and social support have not been included in risk-adjustment models because they are not available in routine discharge data; also, socio-demographic variables (e.g., income or education, which may relate to a patient?s ability to maintain functional status and secure social support) have not been included in risk-adjustment for outcomes due to concerns that adjusting for such factors would be akin to condoning poor care delivered to vulnerable patients. In order to determine how much socio-demographic factors relate as risks for poor hospital outcomes and readmissions (as intrinsic patient factors compared to factors extrinsic to patient and a function of the hospital), a more robust patient-specific data source is required than routine discharge data. To address this question, we will utilize a unique data source to extend our prior work examining the impact of value-based purchasing programs (including non-payment of HACs) on vulnerable patients and hospitals; we will use the nationally representative Health and Retirement Study (HRS) (with detailed data such as a patient?s functional status, mobility, social support, income and educational level) linked to patient-specific Medicare claims data. Our specific aims are:

  1. To assess change in performance of our recently constructed risk-adjusted model for complications of pressure ulcers and urinary track infections as HACs after enhancement with HRS patient-specific measures (e.g., functional status, mobility, social support).
  2. To assess change in performance of CMS?s risk-adjustment models for readmission (for pneumonia, heart failure, myocardial infarction) after enhancement with HRS patient-specific measures.
  3. To evaluate the performance of the HRS-variable enhanced risk-adjustment models for HACs and readmission after replacing some HRS variables with census derived, zip-code level variables (such as median level of education, and income).
  4. Using statewide Medicare claims data; to evaluate the performance of risk-adjustment models for HACs and readmission enhanced by census-data derived zip-code level socio-demographic variables.

PI(s): Laurence McMahon Jr

Co-I(s): Timothy Hofer, Theodore Iwashyna, Kenneth Langa, Jennifer Meddings, Mary AM Rogers

Lesly Dossett, MD, MPH

Faculty

Dr. Lesly Dossett MD, MPH is Assistant Professor of Surgery in the Division of Surgical Oncology at the University of Michigan. Dr. Dossett is an Honors Program and Summa Cum Laude graduate of Western Kentucky University. She earned her medical degree at Vanderbilt University School of Medicine in 2003, attending on a United States Navy Health Professions Scholarship. She completed general surgery residency at Vanderbilt University Medical Center in 2010, where she served as Administrative Chief Resident.

Last Name: 
Dossett

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