zaterdag 11 augustus 2012

Artikel Atul Gawande - standaardisatie in de zorg

In The New Yorker stond onlangs een boeiend artikel van Atul Gawande (chirurg en auteur van de boeken Better, Complications en Checklist Manifesto, zie ook eerdere post met een video van een inspirerende TED speech van hem). Het artikel heet Big Med, Analysis of Health Care, klik hier voor het artikel.

In het artikel beschrijft hij op prachtige wijze hoe een restaurant keten (Cheesecake Factory) voor elkaar heeft gekregen om op grote schaal goede en constante kwaliteit te kunnen bieden, tegen lage kosten. Het riep direct negatieve associaties op: hij neemt toch niet echt een restaurantketen als voorbeeld voor de zorg? Het lage kwaliteitsniveau van het eten en gebrek aan maatschappelijke verantwoordelijkheid van een (stereotype) restuarantketen kun je toch niet als voorbeeld nemen voor de zorg? Maar hij werkt het prachtig uit met voorbeelden van knieoperaties en IC zorg.

IC monitoring op (grote) afstand
Waarbij het IC voorbeeld een behoorlijk controversiele is. Hij beschrijft een keten van ziekenhuizen waar een Intensivist een Command Center heeft opgericht die met camera's, microfoons en IT in staat is op alle IC's de zorg te volgen. Ze kijken naar de overige patienten als al het personeel bij een calamiteit is. Ze monitoren alle patienten regelmatig en nemen eventueel contact op met de verpleegkundige of arts ter plekke. Ook zijn ze beschikbaar voor consultatie. Als het een theoretische casus was zou ik me niet kunnen voorstellen dat dit gaat komen. Maar het gebeurt al. Ik hoop dat goed onderzocht wordt wat de effecten hiervan zijn.

Onvoorspelbare kwaliteit
Mooie nuance in zijn stuk is dat hij niet stelt dat de kwaliteit slecht is in de zorg, maar te onvoorspelbaar welke kwaliteit je gaat krijgen. Dat gebruikt hij als brug naar de noodzaak van (vergaande) standaardisatie, en dat gebruikt hij als brug naar wat we kunnen leren van de restaurantketen (met overigens goede kwaliteit eten als ik hem mag geloven).

Een van zijn conclusies is dat het onontkoombaar is dat de zorg veel grootschaliger moet worden (grote ketens van ziekenhuizen) om stabiel goede kwaliteit en tegen lage kosten te kunnen bieden. Ik hoop eerlijk gezegd dat hij geen gelijk krijgt. Hij is namelijk optimistisch dat de potentiele negatieve effecten daarvan ondervangen kunnen worden, o.a. door overheidoptreden, ik ben daar minder optimistisch over. Misschien zijn er andere manieren om dezelfde effecten te krijgen. We zullen zien.

Standaardisatie bij knie-operaties
Hieronder heb ik het deel over de knieoperaties eruit gelicht (al raad ik zeker aan het hele artikel te lezen). Na het artikel volgt nog een korte reflecties op dit stuk.


Deel uit 'Big Care, Analysis of Health Care', van Atul Gawande in The New Yorker:

My mother planned to come to Boston, where I live, for the surgery so she could stay with me during her recovery. (My father died last year.) Boston has three hospitals in the top rank of orthopedic surgery. But even a doctor doesn’t have much to go on when it comes to making a choice. A place may have a great reputation, but it’s hard to know about actual quality of care. Unlike some countries, the United States doesn’t have a monitoring system that tracks joint-replacement statistics. Even within an institution, I found, surgeons take strikingly different approaches. They use different makes of artificial joints, different kinds of anesthesia, different regimens for post-surgical pain control and physical therapy.

In the absence of information, I went with my own hospital, the Brigham and Women’s Hospital. Our big-name orthopedic surgeons treat Olympians and professional athletes. Nine of them do knee replacements. Of most interest to me, however, was a surgeon who was not one of the famous names. He has no national recognition. But he has led what is now a decade-long experiment in standardizing joint-replacement surgery

John Wright is a New Zealander in his late fifties. He’s a tower crane of a man, six feet four inches tall, and so bald he barely seems to have eyebrows. He’s informal in attire—I don’t think I’ve ever seen him in a tie, and he is as apt to do rounds in his zip-up anorak as in his white coat—but he exudes competence.

“Customization should be five per cent, not ninety-five per cent, of what we do,” he told me. A few years ago, he gathered a group of people from every specialty involved—surgery, anesthesia, nursing, physical therapy—to formulate a single default way of doing knee replacements. They examined every detail, arguing their way through their past experiences and whatever evidence they could find. Essentially, they did what Luz considered the obvious thing to do: they studied what the best people were doing, figured out how to standardize it, and then tried to get everyone to follow suit.

They came up with a plan for anesthesia based on research studies—including giving certain pain medications before the patient entered the operating room and using spinal anesthesia plus an injection of local anesthetic to block the main nerve to the knee. They settled on a postoperative regimen, too. The day after a knee replacement, most orthopedic surgeons have their patients use a continuous passive-motion machine, which flexes and extends the knee as they lie in bed. Large-scale studies, though, have suggested that the machines don’t do much good. Sure enough, when the members of Wright’s group examined their own patients, they found that the ones without the machine got out of bed sooner after surgery, used less pain medication, and had more range of motion at discharge. So Wright instructed the hospital to get rid of the machines, and to use the money this saved (ninety thousand dollars a year) to pay for more physical therapy, something that is proven to help patient mobility. Therapy, starting the day after surgery, would increase from once to twice a day, including weekends.

Even more startling, Wright had persuaded the surgeons to accept changes in the operation itself; there was now, for instance, a limit as to which prostheses they could use. Each of our nine knee-replacement surgeons had his preferred type and brand. Knee surgeons are as particular about their implants as professional tennis players are about their racquets. But the hardware is easily the biggest cost of the operation—the average retail price is around eight thousand dollars, and some cost twice that, with no solid evidence of real differences in results.

Knee implants were largely perfected a quarter century ago. By the nineteen-nineties, studies showed that, for some ninety-five per cent of patients, the implants worked magnificently a decade after surgery. Evidence from the Australian registry has shown that not a single new knee or hip prosthesis had a lower failure rate than that of the established prostheses. Indeed, thirty per cent of the new models were likelier to fail. Like others on staff, Wright has advised companies on implant design. He believes that innovation will lead to better implants. In the meantime, however, he has sought to limit the staff to the three lowest-cost knee implants.

These have been hard changes for many people to accept. Wright has tried to figure out how to persuade clinicians to follow the standardized plan. To prevent revolt, he learned, he had to let them deviate at times from the default option. Surgeons could still order a passive-motion machine or a preferred prosthesis. “But I didn’t make it easy,” Wright said. The surgeons had to enter the treatment orders in the computer themselves. To change or add an implant, a surgeon had to show that the performance was superior or the price at least as low.

I asked one of his orthopedic colleagues, a surgeon named John Ready, what he thought about Wright’s efforts. Ready was philosophical. He recognized that the changes were improvements, and liked most of them. But he wasn’t happy when Wright told him that his knee-implant manufacturer wasn’t matching the others’ prices and would have to be dropped.

“It’s not ideal to lose my prosthesis,” Ready said. “I could make the switch. The differences between manufacturers are minor. But there’d be a learning curve.” Each implant has its quirks—how you seat it, what tools you use. “It’s probably a ten-case learning curve for me.” Wright suggested that he explain the situation to the manufacturer’s sales rep. “I’m my rep’s livelihood,” Ready said. “He probably makes five hundred dollars a case from me.” Ready spoke to his rep. The price was dropped.

Wright told me that about half of the surgeons appreciate what he’s doing. The other half tolerate it at best. One or two have been outright hostile. But he has persevered, because he’s gratified by the results. The surgeons now use a single manufacturer for seventy-five per cent of their implants, giving the hospital bargaining power that has helped slash its knee-implant costs by half. And the start-to-finish standardization has led to vastly better outcomes. The distance patients can walk two days after surgery has increased from fifty-three to eighty-five feet. Nine out of ten could stand, walk, and climb at least a few stairs independently by the time of discharge. The amount of narcotic pain medications they required fell by a third. They could also leave the hospital nearly a full day earlier on average (which saved some two thousand dollars per patient).

My mother was one of the beneficiaries. She had insisted to Dr. Wright that she would need a week in the hospital after the operation and three weeks in a rehabilitation center. That was what she’d required for her previous knee operation, and this one was more extensive.
“We’ll see,” he told her.

The morning after her operation, he came in and told her that he wanted her getting out of bed, standing up, and doing a specific set of exercises he showed her. “He’s pushy, if you want to say it that way,” she told me. The physical therapists and nurses were, too. They were a team, and that was no small matter. I counted sixty-three different people involved in her care. Nineteen were doctors, including the surgeon and chief resident who assisted him, the anesthesiologists, the radiologists who reviewed her imaging scans, and the junior residents who examined her twice a day and adjusted her fluids and medications. Twenty-three were nurses, including her operating-room nurses, her recovery-room nurse, and the many ward nurses on their eight-to-twelve-hour shifts. There were also at least five physical therapists; sixteen patient-care assistants, helping check her vital signs, bathe her, and get her to the bathroom; plus X-ray and EKG technologists, transport workers, nurse practitioners, and physician assistants. I didn’t even count the bioengineers who serviced the equipment used, the pharmacists who dispensed her medications, or the kitchen staff preparing her food while taking into account her dietary limitations. They all had to coördinate their contributions, and they did.

Three days after her operation, she was getting in and out of bed on her own. She was on virtually no narcotic medication. She was starting to climb stairs. Her knee pain was actually less than before her operation. She left the hospital for the rehabilitation center that afternoon.


Boeiende casus. Wat vooral opvalt is de combinatie van een andere manier van denken (5% vs 95%) en vervolgens stug doorzetten, ook al maak je je daar niet populair mee. Omdat je gelooft in de kwaliteitsverbetering. Maar ook mooi en belangrijk dat hij niet doordramt. Hij geeft wel voldoende ruimte dat het werkbaar blijft, zoals de keuze uit drie protheses. Die balans vinden tussen standaardisatie en ruimte is spannende. Inspirerend verhaal.

P.S. Zie ook blog van Mark Graban naar aanleiding van het artikel van Gawande

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