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The Role Of Black Box Warnings In Safe Prescribing Practices

August 20th, 2014

In the Health Affairs article, “Era of Faster Drug Approval Has Also Seen Increased Black-Box Warnings and Market Withdrawals,” published in the August issue, Cassie Frank and coauthors compare the number of approved prescription drugs that received black-box warnings or were withdrawn from the market for safety-related reasons prior to the 1992 Prescription Drug User Fee Act (PDUFA) with black-box warnings and safety-related withdrawals in the post-PDUFA era.

PDUFA for the first time authorized FDA to collect user fees from brand-name manufacturers that submitted New Drug Applications, with the funds being earmarked for more review staff (not until 2007 were funds also permitted to be used to expand post-approval safety surveillance capacity).

As a quid pro quo, the FDA was required to act on all new drugs within a fixed deadline: drugs given priority review designations because they were particularly promising therapies offering substantial improvements in treating serious conditions were to be reviewed within 6 months and standard review drugs were to be reviewed within 12 months (later shortened to 10 months in 2002). By all accounts, PDUFA substantially expedited the review process. The review times for new molecular entities decreased from an average of 33.6 months between 1978 and 1986 to about 10 months for drugs approved between 2001-2010.

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Better Measurement Of Maternity Care Quality

August 12th, 2014

A thought-provoking paper published this month in Health Affairs shows stunning variation in rates of obstetrical complications across U.S. hospitals. This type of research is important and necessary because focusing on averages masks potentially large differences in how patient care is provided and how clinical decisions are made.

From a policy perspective, it’s crucial to identify and learn from hospitals that are “positive deviants,” that is – hospitals with better-than-expected quality of care. From a pregnant woman’s perspective, having information on hospital rates of hemorrhage, infection, or laceration during childbirth is a high priority.

Authors Laurent Glance and colleagues add to a growing literature on variation in hospital-based maternity care. Having useful quality measurement and reporting strategies to guide policy and patient decisions is an essential next step. Indeed, Glance and colleagues conclude by urging clinicians and policymakers to “develop comprehensive quality metrics for obstetrical care and focus on improving obstetrical outcomes.”

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Examining Medicare’s Hospital Readmissions Reduction Program

July 24th, 2014

New financial incentives and penalties in the Affordable Care Act (ACA) designed to optimize health care system performance are proving difficult to manage, but they are also providing new opportunities for leaders to foster collaboration between acute and post-acute health care providers.

Perhaps one of the most promising, albeit controversial, programs has been Medicare’s Hospital Readmissions Reduction Program (HRRP), which penalizes hospitals with excess 30-day readmissions for health conditions such as pneumonia, myocardial infarction, and heart failure. Although not all hospital readmissions are preventable, many could be avoided with improved post-discharge planning and care coordination.

The HHRP was designed to penalize hospitals with excess 30-day readmissions regardless of whether the patient was readmitted to the same hospital or another hospital. Although there are some exceptions (for example, readmissions due to hospital transfers or planned readmissions), most readmissions of patients with health conditions targeted by the HHRP will count against a hospital.

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Empowering Patients As Partners In Health Care

July 24th, 2014

Recently, the National Patient Safety Foundation’s Lucian Leape Institute brought together 40 patient safety experts — health professionals, patients, advocates, and others — to develop recommendations for how best to engage patients and families in improving patient safety. They represented patient advocacy organizations, health systems, professional societies, researchers, and international safety organizations.

During the course of two lengthy roundtable discussions, participants were asked to reflect on an experience in which they or someone close to them had experienced harm at the hands of the health care system and how they responded. Among the stories we heard:

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The Role Of Sales Representatives In Driving Physicians’ Off-Label Prescription Habits

June 19th, 2014

Off-label prescribing is widespread in Canada and the United States (U.S.). One in nine prescriptions for Canadian adults are for off-label uses with the highest percentages coming from anticonvulsants (66.6 percent), antipsychotics (43.8 percent), and antidepressants (33.4 percent). Overall, 79 percent of the off-label prescriptions lacked strong scientific evidence for their use.

For 160 drugs commonly prescribed to U.S. adults and children, 21 percent were for off-label indications totaling 150 million prescriptions. In this case, 73 percent had little to no scientific backing and once again psychoactive drugs such as gabapentin had the highest level of off-label use.

Moreover, doctors do not seem to know what are and are not approved FDA use for many of the drugs that they prescribe. Now an article published in the June issue of Health Affairs by Ian Larkin and colleagues points to active promotion by sales representatives as one reason for the widespread off-label use of antipsychotics and antidepressants in children.

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Health Affairs June Issue: Where Can We Find Savings In Health Care?

June 2nd, 2014

The June issue of Health Affairs, released today, features various approaches to cost-savings in the U.S. health care system. A variety of articles analyze the effects of potential policy solutions on the Medicare and Medicaid programs and their impact on the health of beneficiaries and tax payer wallets.

Federal approaches to reduce obesity and Type 2 diabetes rates by improving nutrition could work—but the how matters. Sanjay Basu of the Stanford University School of Medicine and coauthors modeled the effects of two policy approaches to reforming the Supplemental Nutrition Assistance Program (SNAP), which serves one in seven Americans. They found that ending a subsidy for sugar-sweetened beverage purchases with SNAP dollars would result in a decrease in obesity of 281,000 adults and 141,000 children, through a 15.4 percent reduction in calories by the lowering of purchases of this source. They also found that a $0.30 credit back on every dollar spent on qualifying fruits and vegetables could more than double the number of SNAP participants who meet federal guidelines for fruit and vegetable consumption.

With more than forty-six million people receiving SNAP food stamp benefits, the authors suggest that policy makers closely examine the implications of such proposals at the population level to determine which will benefit people’s health the most and prove most cost-effective.

If you’re between ages 15–39 when you are diagnosed with cancer, the implications later in life extend well beyond your health. Gery P. Guy Jr. of the Centers for Disease Control and Prevention and coauthors examined Medical Expenditure Panel Survey data and determined that survivors of adolescent and young adult cancers had annual per person medical expenditures of $7,417, compared to $4,247 for adults without a cancer history. They also found an annual per capita lost productivity of $4,564 per cancer survivor — because of employment disability, missed workdays, and an increased number of additional days spent in bed as a result of poor health — compared to $2,314 for adults without a cancer history.

The authors suggest that the disparities are associated with ongoing medical care needs and employment challenges connected to cancer survivorship, and that having health insurance alone is not enough to close the gap. They stress the importance of access to lifelong follow-up care and education to help lessen the economic burden of this important population of cancer survivors.

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Recent Health Policy Briefs: Regulating Compounding Pharmacies and Basic Health Program Update

May 1st, 2014

The latest Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation examines the Compounding Quality Act, a law signed by President Obama in November 2013, which seeks to fill the gaps in the Food and Drug Administration’s (FDA’s) inspection and enforcement oversight of compounding pharmacies.

This law was enacted in the wake of a 2012 fungal meningitis outbreak, linked to a Massachusetts drug compounding company. The outbreak caused more than 700 people to become ill and left sixty-four dead. Before the new law was passed, compounding pharmacies were primarily regulated by states, not the FDA.

The compounding pharmacy industry initially catered to patients with specialized needs. Since the 1990s, many compounding pharmacies have also begun engaging in what is now called nontraditional compounding: manufacturing certain drugs in large quantities for sale to doctors’ offices and hospitals. This health policy brief traces the evolution of compounding pharmacies and the changes brought to this industry by the new law.

Also posted today: an update to an earlier brief that provides more information on the issues surrounding the Basic Health Program and outlines options for states.

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Responding To ‘The Hidden Curriculum': Don’t Forget About The Patient

April 3rd, 2014

Narrative Matters readers might remember Joshua Liao’s moving essay about the dangers of the Hidden Curriculum. Liao, a resident physician at Brigham and Women’s Hospital, wrote about the consequences of making a serious mistake as a medical student on an obstetrics rotation. He read the essay for the Narrative Matters podcast and it’s a great listen.

Liao’s essay, penned with Eric Thomas and Sigall Bell, also generated some compelling responses. It inspired Tim Lahey to write about his experience leading the curriculum redesign at Dartmouth’s Geisel School of Medicine. And when the Washington Post ran an excerpt of Liao’s essay last week, it led Franca Posner to remind readers about “one missing piece of this puzzle”: the patient’s perspective.

Posner was once in a similar situation, but it was she on the hospital bed: “I was that woman 20 years ago, only I was almost 40 and had a 5-year-old child and five miscarriages in my reproductive history,” Posner wrote in a letter to the editor published in the Post’s Health and Science section on March 31.

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Implementing Health Reform: Allowing Noncompliant Policies; Benefits And Payment Parameters Rule (Part 2)

March 7th, 2014

Editor’s note: Part 1 of this post discussed the Department of Health and Human Services March 5 bulletin extending until October 1, 2016 its transitional policy permitting the renewal of ACA non-compliant individual and small group health insurance policies. Part 1 also began examining the final 2015 Notice of Benefit and Payment Parameters rule, issued on the same date. Subsequent installments will discuss two final rules also issued March 5 by the Internal Revenue Service regarding reporting by insurers of minimum essential coverage and reporting by employers on coverage under employer-sponsored health plans.

Reduced notice requirement for new state exchanges. The final 2015 Benefit and Payment Parameters rule requires states that would like to begin operating their own exchanges to notify HHS of this intention by June 15 of the preceding year. Earlier rules had required a year’s notice.

Consumer assistance and privacy. States may permit web brokers to assist individuals, employers, and employees with enrolling in qualified health plans (QHPs) through their exchanges. Agents and brokers must comply with privacy and security standards protecting personally identifiable information and may not use it for marketing. The SHOP exchange, and not the web broker, is responsible for aggregating premiums and forwarding them to insurers. Web brokers must display information on all available QHPs, although insurers may refuse to provide non-appointed brokers with certain information. Web brokers must also provide enrollees with a disclaimer noting that they are not the exchange and may not have full information on all plans.

State exchanges must comply with federal personally identifiable information requirements, but may seek the approval of HHS to use this information to ensure the efficient operation of the exchange if they secure the consent of the individual whose information is to be used. Exchanges that disclose personally identifiable information to non-exchange entities (such as certified application counselors, in-person assisters, brokers, QHP insurers or others) must enter into a contract with these entities ensuring protection of this information. Non-exchange entities that must independently comply with Health Insurance Portability and Accountability Act data privacy and security requirements (such as QHPs) may be deemed to be in compliance with exchange requirements by virtue of their compliance with HIPAA as long as the HIPAA requirements are at least as protective as the exchange requirement and if the entities also comply with additional ACA data protection requirements.

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The Dangers Of Quality Improvement Overload: Insights From The Field

March 7th, 2014

Editor’s note: This post is also co-authored by Ksenia O Gorbenko, Catherine van de Ruit, and Charles Bosk of the University of Pennsylvania.

Quality improvement (QI) and patient safety initiatives are created with the laudable goal of saving lives and reducing “preventable harms” to patients. As the number of QI interventions continues to rise, and as hospitals become increasingly subject to financial pressures and penalties for hospital-acquired conditions (HACs), we believe it is important to consider the impact of the pressure to improve everything at once on hospitals and their staff.

We argue that a strategy that capitalizes on “small wins” is most effective. This approach allows for the creation of steady momentum by first convincing workers they can improve, and then picking some easily obtainable objectives to provide evidence of improvement.

National Quality Improvement Initiatives

Our qualitative team is participating in two large ongoing national quality improvement initiatives, funded by the Agency for Healthcare Research and Quality (AHRQ). Each initiative targets a single HAC and its reduction in participating hospitals. We have visited hospital sites across six states in order to understand why QI initiatives achieve their goals in some settings but not others. To date, we have conducted over 150 interviews with hospital workers ranging from frontline staff in operating rooms and intensive care units to hospital administrators and executive leadership. In interviews for this ethnographic research, one of our interviewees warned us about unrealistic expectations for change, “you cannot go from imperfect to perfect. It’s a slow process.”

While there is much to learn about how to achieve sustainable QI in the environment of patient care, one thing is certain from the growing wisdom of ethnographic studies of QI: buy-in from frontline providers is essential for creating meaningful change. Front-line providers often bristle at expectations from those they believe have little understanding of the demands of their daily work. Requiring health care providers to improve on all mandated measures at once—in an atmosphere of reduced reimbursements and frequent staff shortages—is a goal that risks burnout, discouragement, and apathy – all signs of initiative fatigue.

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Cesarean Rates: A Global Perspective

February 24th, 2014

As noted in a previous Health Affairs Blog post by Katy Kozhimannil and Ezra Golberstein, there is significant variability in cesarean delivery rates across the United States, but this is also true worldwide. Worldwide cesarean delivery rates have come under scrutiny and criticism since the World Health Organization (WHO) suggested in 1985 that the optimal rate should not exceed 10 to 15 percent.

Although currently there is no expert agreement on a single optimal level, a general consensus has emerged that extremely low rates (less than 5 percent) suggest underuse and higher rates (greater than 10-15 percent) suggest overuse. Globally, the average rate sits slightly above that recommended level at 16 percent. However, the mean value masks the underlying variability that exists across countries and the different issues inherent in the variation. Of countries which report at least some cesarean deliveries, the range of use runs from 1 percent (Niger) to 52 percent (Brazil) of live child births.

Middle and High-Income Countries

Cesarean rates in middle and high-income countries have continued to increase over the last decade (most are significantly over 15 percent). The average rate among the Organisation for Economic Co-operation and Development (OECD)-member countries is 26.9 per 100 live births (range: 14.7 to 49.0). Comparatively, the United States has a very high rate of cesarean delivery (31.4 per 100 live births). In Switzerland, for example, cesarean section rates varied in 2010 from less than 20 percent to over 40 percent in a region. Within a region, the rates also varied by hospital. A study in France found more cesarean sections were performed in for-profit hospitals than in public hospitals, which treat more complicated pregnancies, suggesting that financial incentives may also play a role in explaining excess cesarean deliveries.

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To Pay For Medicare SGR Repeal, Build On Bipartisan Health Care Policy

February 20th, 2014

Something unexpected is happening in Washington. As most eyes track partisan battles over immigration and the Affordable Care Act, key Congressional committees have been quietly advancing truly bipartisan legislation to strengthen Medicare.

Since 2002, an outdated Medicare cost control called the Sustainable Growth Rate (SGR) has repeatedly threatened drastic Medicare provider cuts. After a decade of temporary fixes, SGR repeal appears within reach. A bipartisan, bicameral agreement by key Congressional leaders announced on February 6, 2014 goes a step further by pairing repeal with bipartisan reforms that pay physicians for the quality and value of care they deliver, not the number of tests and procedures they order.

When one of every three health care dollars is wasted on care that does not improve patients’ health, transitioning away from volume-based reimbursement would be momentous. Few policy changes are more fundamental to containing health care costs and protecting the solvency of Medicare.

The challenge in Congress has shifted from getting a bipartisan agreement on new cost controls to paying for the repeal of the old one. The Congressional Budget Office (CBO) estimates the cost of the Senate version of the bipartisan repeal bill at $149 billion over 10 years.

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If A Drug Is Good Enough For Europeans, It’s Good Enough For Us

February 14th, 2014

Note: This post is coauthored by Paul Howard and Yevgeniy Feyman of the Manhattan Institute.

Meningitis is a terrible disease that can kill its victims in a single day. About 4,100 new cases are diagnosed annually in the U.S., with a mortality rate of more than 10 percent. Even with treatment, survivors are often left with serious side effects that can include brain damage and limb loss.

A recent meningitis outbreak at Princeton University was unique, however, because the vaccines typically required by universities don’t protect against the particular strain (serogroup B or “MenB”) of the outbreak. Luckily, Swiss drug manufacturer Novartis has developed a vaccine — Bexsero — that specifically targets this strain of meningitis; the drug has already been approved for use by the European Medicines Agency (EMA), the European Union’s equivalent of the Food and Drug Administration (FDA). And within about nine months the FDA allowed Princeton University to offer the vaccine on campus to its students.

Problem solved, right? Not so fast.

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Connected Health And America’s War On Error

February 5th, 2014

Editor’s note: For more on connected health, see Health Affairs‘ newly published February thematic issue on the subject. The issue was discussed at a Washington DC briefing this morning, keynoted by the new National Coordinator for Health Information Technology, Karen DeSalvo. The Office of the National Coordinator and West Health Institute are cosponsoring a conference tomorrow on developing an interoperable health care system.

recent analysis, the annual losses are worse than any other war in our nation’s history, including the Civil War, World War II and our War on Terror. It is an undeclared “war on error” within our healthcare delivery system. It is the most deadly war we have ever waged, with errors and resultant harm in hospitals contributing to the death of nearly 1,000 people each day in the U.S., potentially more than 400,000 a year.

As with any other war, there is an enormous economic burden. The U.S. spent approximately $2.8 trillion on health care in 2012, with about 30 percent of total health care expenditures attributed to hospital services. That’s just over $800 billion annually, making America’s war on error not only the deadliest, but also the most expensive.

Until now, this war has often been waged in hospitals, where small, poorly outfitted groups of combatants have used simple, unconventional means like prompts for hand washing, autographing surgical sites and implementing ‘no interruption zone’ for medicine preparation – with limited success. But now, new technologies like integrated sensor networks, fully integrated electronic medical records (EMRs), clinical-decision support systems and algorithm-based care, all embedded in smart and learning systems, may finally provide the tools needed to win the war.

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The Hidden Curriculum: Changing The Water In Which We Swim

January 31st, 2014

Editor’s Note: This post is a response to Joshua Liao, Eric Thomas, and Sigall Bell’s essay, “Speaking Up About The Dangers Of The Hidden Curriculum,” published under Narrative Matters in the January issue of Health Affairs.

As the lights in the auditorium go down, just before I flick on my microphone, I remember what media critic Marshall McLuhan once said about culture: We live “in an electric information environment that is quite as imperceptible to us as water is to fish.”

As a leader of my institution’s curriculum redesign effort, I often speak with departments and even the whole faculty about our plans for the new curriculum. These experiences have made me acutely aware of how well McLuhan’s quote applies to what has been called the “hidden curriculum” in medical education. Medical education, and the culture of medicine in which it occurs, influence personal identity and perception so pervasively that it can be a challenge to talk clearly about how to change the hidden curriculum.

Liao and colleagues overcome that challenge in the January issue of Health Affairs, making an eloquent call for better dialogue about how the hidden curriculum can undermine patient safety. They point out, rightly, that, “The difference between what we say we do and what we actually do as doctors and teachers can be stark.” Such verbal disconnects can undermine the culture of patient safety, a dilemma fixed first through awareness and then through the courage to speak up.

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Nursing Homes Are The Solution On Readmissions

January 17th, 2014

A recent report from the Office of the Inspector General (OIG) within the Department of Health and Human Services (HHS) argues that skilled nursing care centers, or “nursing homes,” should be better monitored by the federal government when it comes to how frequently they send patients back to the hospital. OIG recommended that the Centers for Medicare and Medicaid Services (CMS) develop a quality measure to track and publicly report nursing centers’ hospitalization rates and to have state survey agencies review the measure as part of the survey and certification process. As the largest association representing skilled nursing care centers in the country, the American Health Care Association (AHCA) agrees. In fact, we do not think OIG goes far enough. We support linking Medicare payments to skilled nursing care centers based on their hospital readmission rates.

Frequent trips to the hospital are disrupting to seniors and put them at greater risk for complications and infections. It is also costly to the system, as the OIG report demonstrates. AHCA came to the same conclusion and is already acting on the issue. AHCA wrote to Congress earlier this year in support of measuring and publicly reporting hospitalization rates among skilled nursing centers when the legislative body requested comments on how to reform Medicare post-acute care payments.

We also support the expansion of CMS’ new inspection process, the Quality Indicator Survey (QIS), which includes a process to review a center’s hospitalization rates unlike the old survey process. However, only 26 states presently use the QIS process after CMS suspended nationwide implementation due to potential budget constraints. AHCA supports CMS continuing its expansion of the QIS to all states as designed, which will have surveyors review centers’ hospitalization rates as recommended by the OIG.

We’re not just encouraging measuring and reporting; we have also developed a hospitalization measure, which we have shared with the federal government. AHCA partnered with the data analytics company, PointRight, to calculate risk-adjusted hospital readmissions during the first 30 days of a skilled nursing stay. Previously, this data was not available to individual providers and was not risk adjusted. Instead, it was reliant on Medicare claims data which did not account for individuals covered by other insurance such as Medicaid, managed care, commercial insurance, or private pay, and resulted in a two-year lag time before data were available.

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A Call To Arms: Support For Emergency Care Isn’t Making The Grade

January 16th, 2014

Emergency departments (EDs) play a critical role within the American health care system, delivering life and limb saving care daily to thousands of patients. On January 16th 2014, the American College of Emergency Physicians (ACEP) released America’s Emergency Care Environment: A State-by-State Report Card to assess support for emergency care. This Report Card, the third edition of this report, assesses the current state of the acute care system on both a national and on a state-by-state level. This most recent edition provides an alarming evaluation of the support for the emergency care system in the United States, which is particularly concerning given the current state of change and uncertainty that is pervasive throughout the US with regard to health care.

The ACEP 2014 Report Card uses objective data to track various aspects of the acute care system in order to provide a better understanding of the trajectory the overall emergency care system. It is not a report on individual hospitals or health systems, but rather a grade of the policies, regulations and governmental activities that are important supports for emergency care.

The Report Card’s greatest value lies in its ability to validate on a detailed level the recent claims that have been reverberating throughout the U.S. and the international community related to the important role and need for inclusion of acute care within health systems. In a recent WHO Bulletin article, an Academic Emergency Medicine consensus conference proceedings, and most recently in the entire December issue of Health Affairs, experts argue that an emergency care system is a vital aspect of a mature, functioning health system; yet, is it frequently neglected and is not receiving enough attention. While these publications have used the best data available to validate their claims, this national report provides the most current and comprehensive data that support for the system is not only fraught with deficiencies but is headed in a downward trajectory.

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Cesarean Rates: Shifting The Focus From Increases To Variability In Use

January 15th, 2014

At 1.3 million procedures each year, the Centers for Disease Control and Prevention (CDC) lists cesarean delivery as the most frequently-performed inpatient surgery in the U.S. Both public and private insurance programs pay more to hospitals for childbirth than for any other condition, and Medicaid programs fund nearly half of all U.S. births.

Cesarean delivery is a potentially life-saving intervention that can hasten delivery in order to avoid adverse outcomes for women or infants, but it carries distinct risks as compared with vaginal delivery, including infant respiratory illness and maternal complications in future pregnancies. Cesarean rates increased dramatically from 20.7 percent in 1996 to an all-time high of 32.9 percent in 2009, but have since remained stable. New data from the CDC indicate a shift in gestational age for cesarean births between 2009 and 2011, with a decrease in births at 38 weeks gestation and an increase in births at 39 weeks, consistent with the increasing policy focus on avoiding non-indicated delivery before 39 weeks gestation. The use of cesareans is changing, and clinicians, policymakers, and researchers should now shift from a sole focus on the “relentless rise” to additionally considering unwarranted variations in cesarean rates.

What We Know

Three notable patterns emerge from the available data on cesarean rates. 1) Cesarean rates are highly variable; 2) changes in cesarean rates are not correlated with changes in infant mortality; and 3) prior research shows that patient and clinical factors do not account for variation in cesarean use.

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The Moral Imperative To Disclose Medical Error: Doing The Right Thing

January 7th, 2014

Editor’s note: For more on Ascension Health’s initiative to disclose unexpected events to patients, see Ascension Health’s Demonstration Of Full Disclosure Protocol For Unexpected Events During Labor And Delivery Shows Promise, part of a cluster of articles on alternatives to medical malpractice litigation in the January issue of Health Affairs.

Over a decade has passed since the majority of health care and practitioner accreditation and certification groups mandated the full disclosure of unexpected events and medical errors to patients and their families. Yet full disclosure, an element of establishing a ‘just culture,’ is still not the norm for most providers. Disclosure is difficult and there are impediments at the systemic and practitioner levels.

We at Ascension Health used our core values of truth and justice and our identity as a healing ministry to transition to a just culture that puts the priorities of those we serve above our own. We believe that these core values and identity are not unique and that all providers have a moral compass. Thus, we put forth a call to action for all health care providers to achieve the goal of establishing a just culture with 100 percent full disclosure by 2018.

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A National Initiative To Reduce Central Line-Associated Bloodstream Infections: A Model For Reducing Preventable Harm

September 23rd, 2013

Editor’s note: A full list of coauthors and their affiliated institutions appears at the end of this post.

The work to prevent central line-associated bloodstream infections in intensive care units is one of few national efforts to use empiric data to document a decrease in patient harm across the United States. A notable contributor was the On the CUSP: Stop BSI national initiative, which built upon the work at the Johns Hopkins Hospital and in the state of Michigan. This initiative spread to 1100 hospitals in 44 states, the District of Columbia, and Puerto Rico. The rate of an infection fell to 1 infection per 1000 line-days in the majority of hospitals, a rate deemed impossible just a few years ago.

In this post, we summarize the fractal infrastructure and overall results of the initiative, explore lessons, and offer policy recommendations for other national efforts to reduce preventable patient harm.


Many efforts contributed to the national decline of central line-associated bloodstream infections (CLABSI) in intensive care units (ICU). (See here, here, here, here, here, and here.) Instrumental in these efforts were the Centers for Disease Control and Prevention’s (CDC) guidelines and infection control strategies, and hospital epidemiology and infection control. This impressive change offers an example of how the collaborative efforts of many, which were informed by evidence, research and valid measurement, can achieve widespread reduction in preventable harm.

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