Riddles in
Accountable
Healthcare
A Primer to develop analytic intuition for
medical homes and population health
Eran Bell...
Copyright © 2015 Eran Bellin
All rights reserved.
ISBN: 1503053873
ISBN 13: 9781503053878
Library of Congress Control Numb...
Contents
Preface · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · xi
Introduction...
vi | Er a n Bel l in C on t en t s | vii
Chapter 6 Does My Regional Health Information Organization
Prevent Hospital Admis...
viii | Er a n Bel l in C on t en t s | ix
Population Health
The Socioeconomic Status Trilogy
Chapter 23 Does Low Socioecon...
— xi —
Preface
In the United States, accountable healthcare, with measurable
improved health outcomes, is the purpose of a...
— xiii —
Introduction
In 2007 the US government instituted the Physician Quality
Reporting Initiative as a voluntary progr...
xiv | Er a n Bel l in In t r odu c t ion | xv
wrong. Critics of the measure accused it of distorting medical judgment,
enc...
of 8

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  • 1. Riddles in Accountable Healthcare A Primer to develop analytic intuition for medical homes and population health Eran Bellin
  • 2. Copyright © 2015 Eran Bellin All rights reserved. ISBN: 1503053873 ISBN 13: 9781503053878 Library of Congress Control Number: 2014919449 CreateSpace Independent Publishing Platform North Charleston, South Carolina Dedication To the associates of Montefiore Medical Center, who are daily transform- ing our organization into an ever-better steward of population health. To my father, Lowell Bellin, who introduced me to public health and communal responsibility. To my mother, Talah Bellin, who encouraged careful thought and clear exposition.
  • 3. Contents Preface · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · xi Introduction · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · xiii Solving Riddles in Healthcare Chapter 1 How I Solve Accountable Healthcare Riddles Clinical Looking Glass—Temporally Aware Cohort Builder· · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · 3 Chapter 2 How Great is Our Reputation? The Wrong Question Answered Carefully Can Clarify Our Values· · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · 7 Chapter 3 How Do You Know if Your Healthcare System is Right-Sized? · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · 11 Preventing Readmissions Chapter 4 Does Visiting Your Doctor after Hospital Discharge Prevent Hospital Readmission? Or Is Seeing Your Doctor Dangerous? · · · · · · · · · · · · · · · 23 Chapter 5 Heads or Tails—Which End is Up? Choosing Between Two Sides of a Durational Event· · · · ·Choosing Between Two Sides of a Durational Event· · · · ·Choosing Between Two Sides of a Durational Event 29
  • 4. vi | Er a n Bel l in C on t en t s | vii Chapter 6 Does My Regional Health Information Organization Prevent Hospital Admissions? · · · · · · · · · · · · · · · · · · · · 33 Chapter 7 How Could Your Privacy Decisions Impact My RHIO Experience? Don’t Silence My Silence · · · · · · · · · · · · · · · · · · · · · · · · 37 Accountability Chapter 8 Am I My Brother’s Keeper? The New Longitudinal Healthcare Paradigm· · · · · · · · · 41 Chapter 9 To Corrupt Man An Impossible Goal, Inadequate Surveillance, Harsh Punishment, and a Failure of Integrity and Leadership Promote the Dishonorable · · · · · · · · · · · · · · · · · · · · · ·45 Chapter 10 I Am Not Responsible Until I Say I Am The Folly of Reliance on Unexamined Billing Processes· 51 Chapter 11 Who Is Responsible for the Events of the Hospitalization? · · · · · · · · · · · · · · · · · · · · · · · · · · · · · ·55 Data Analytics and Predictive Models Chapter 12 Epidemic of Diastolic Dysfunction in the Bronx Knowing the Source Is Half the Battle· · · · · · · · · · · · · · 59 Chapter 13 Predictive Analytic Surprise How Good Care Confounds Biologic Intuition in Building Predictive Models · · · · · · · · · · · · · · · · · · · ·63 Chapter 14 Can We Learn from One Another? Do We Have to Validate Each Study in Our Own Environment? · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · 67 Chapter 15 Adjustment or Excuse? What Happens When You Adjust for Race? · · · · · · · · · · 71 Chapter 16 Why Am I Doing Better than You in Each of My Subgroups, but Overall You Are Looking Better than Me? Simpson’s Paradox · · · · · · · · · · · · · · · · · · · · · · · · · · · · 73 Developing Longitudinal Intuition Chapter 17 Does Zero Mean Never? How the Question, Its Context, and Statistics Drive Judgment · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · 79 Chapter 18 Will I Be Able to Play the Piano? Worse Disease Gets Better Outcome Cull the Herd and Leave Only the Strong · · · · · · · · · · · 87 Chapter 19 Paradoxical Worsening of Metrics as Care Innovation and Implementation Improves Quality A Cautionary Tale in Deep Venous Thrombosis · · · · · · · 91 Chapter 20 But It Makes Biologic Sense… The Illusion of the Known: “It isn’t what we don’t know that gives us trouble. It’s what we know that ain’t so.” —Will Rogers · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · 93 Chapter 21 An Epidemic of Hypercalcemia “Once you eliminate the impossible, whatever remains, no matter how improbable, must be the truth.” —Sherlock Holmes · · · · · · · · · · · · · · · · · · · · · · · · · · · · 97 Chapter 22 Big Is Better? But Is It Enough?· · · · · · · · · · · · · · · · · · · · 101
  • 5. viii | Er a n Bel l in C on t en t s | ix Population Health The Socioeconomic Status Trilogy Chapter 23 Does Low Socioeconomic Status Predispose to Higher Readmission Rate? How Intervention Thwarts Attribution with No Good Deed Going Unpunished· · · · · · · · · · · · · · · · · · 109 Appendix 1: Group Definition in Cohort-Builder Clinical Looking Glass · · · · · · · · · · · · · · · · · · · · · 118 Appendix 2: Single-Created Variable to Represent Socioeconomic Status· · · · · · · · · · · · · · · · · · · · · · 119 Chapter 24 I Am Too Poor to Benefit from SES Improvement Threshold in the Service of Understanding · · · · · · · · · 121 Chapter 25 Inadequate Power Obscures Findings · · · · · · · · · · · · · · 125 The Obesity Epidemic Trilogy Chapter 26 Where All the Children Are Above Average Lake Wobegon Meets Public Health · · · · · · · · · · · · · · 133 Chapter 27 Belching Fat Fat Pollution—the Modern Scourge of High BMI· · · · · 137 Chapter 28 How Can We Be Getting Fatter When a Higher Percentage is Losing Weight?· · · · · · · · · · · · · · · · · · · · · · 141 Silencing Death – The Unsolved Riddle Chapter 29 When the Dead Are Silenced, Who Speaks for the Living? Blind to One Million US Dead—How Public Policy for Healthcare Is Thwarted· · · · · · · · · · · · · · · · · · · · · · · · 145 About About Advanced Analytics · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · ·153 About Me · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · ·155 Epilogue: About Montefiore Medical Center, Bronx, New York· · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · ·Bronx, New York· · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · ·Bronx, New York 159 Bibliography · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · 161
  • 6. — xi — Preface In the United States, accountable healthcare, with measurable improved health outcomes, is the purpose of all healthcare expendi- tures. If we are to follow a group of patients to an agreed-upon outcome, we must work to develop our analytic skills and intuition. Such wisdom is earned through years of making mistakes, together with a willingness to learn from them. Riddles in Accountable Healthcare is a quick-start guide for those wish-Riddles in Accountable Healthcare is a quick-start guide for those wish-Riddles in Accountable Healthcare ing to develop longitudinal healthcare analytic intuition. Using real- world examples with data occasionally modified to make the instructive point, this book explores questions raised by analysts who have worked in a medical center committed to longitudinal population health. I am inspired by the writers Berton Roueché,1 Stephen Dubner,2 and Malcolm Gladwell,3,4 who have shown that important truths can be transmitted through engaging and insightful vignettes. I hope that this book will find a receptive audience not only in schools and with practitioners of public health, health administration, medicine, and nursing, but also with members of the general public who are interested in understanding issues that drive policy decisions in healthcare—an industry that consumes 18 percent of the US gross national product. Eran Bellin, MD January 20, 2015
  • 7. — xiii — Introduction In 2007 the US government instituted the Physician Quality Reporting Initiative as a voluntary program to encourage physicians to provide better care by following specific medical guidelines. By first pro- viding a “carrot” of increased dollars, the initiative was designed to en- courage doctors to change their practices before the eventual “stick” in later years of financial penalties for not following the guidelines. Thus, through a combination of legislation and financial incentives, the fed- eral government had essentially decided it would practice medicine. Notable among the guidelines was a protocol for the management of pneumonia in emergency rooms. This measure required every pneu- monia patient be treated with antibiotics immediately in the ER before even reaching the hospital floor. To the average onlooker, this seemed like a good idea. If you were sick enough to be hospitalized, the conven- tional wisdom said, you should get your medicine as soon as possible. You should not have to wait for hours in the ER and then for hours in a hospital bed before receiving lifesaving antibiotics. The National Committee for Quality Assurance (NCQA), the American College of Emergency Physicians, and the American Medical Association’s consortium for Performance Improvement all endorsed the pneumonia treatment guideline, also known as Physician Quality Reporting System Measure (PQRS) #59. By 2009, 11 percent of eligible providers were reporting on their compliance. Yet in January 2013, PQRS #59 was retired. Why? Its retirement was not an indication of its success. Retirement, in this case, was an indication that the guideline had gone wrong—terribly
  • 8. xiv | Er a n Bel l in In t r odu c t ion | xv wrong. Critics of the measure accused it of distorting medical judgment, encouraging irresponsible prescribing practices, and potentially con- tributing to the emergence of superbugs—infections highly resistant to antibiotics. Whaterrorledthemedicalcommunitytothisunfortunateguideline? A published study had shown that early antibiotic therapy saved lives.5 However, the guideline writers approached the article without a full awareness of time—without what I think of as temporal intelligence. The study identified pneumonia patients from discharge diagnoses and reported that those patients who had been treated with antibiotics in the ER had a lower death rate. The guideline writers surmised that by requiring antibiotic administration for pneumonia patients in the ER, doctors could achieve better results in a larger population. Regrettably, they failed to recognize that emergency physicians ex- perience “time’s arrow” in the forward direction. ER physicians con- front diagnostic uncertainty in the narrow window of time available to them to evaluate a patient.6 Only 50 percent of those affirmatively di- agnosed with pneumonia are known to have it in the emergency room. Discharge diagnoses are determined at the date of discharge and en- tered into the medical record by billing clerks four to seven days after discharge. Therefore, the only way ER physicians could possibly achieve the 100 percent compliance required by the guideline was to treat every- one in the ER with an antibiotic—a requirement impossible to achieve without wasteful and potentially dangerous exposure of large numbers of patients to unneeded antibiotics. The organization of medical care is changing in the United States with more accountability for the long-term outcome. For those who build policy as well as for those who implement programs, an understanding of how to think about new questions is critical to planning, implementa- tion, evaluation, and learning from errors. This book is designed to expose the reader to “riddles”—questions whose answers become crucial as we try to determine what we should measure and what we should learn from what we measure. Riddles isRiddles isRiddles written in a discursive, engaging style to encourage you to develop deep intuition, whether you make healthcare policy, are subject to it, or pay for it. It should therefore be of value to everyone.

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