Biology Reference
In-Depth Information
Based on monitoring of data, if one spots a problem, instituting process improvement
measures is carried out and then one has to check if the tested measure improves metrics. One
can never relent and believe one has solved a problem because it can re-occur. For example,
we were running a deep wound infection rate of 4.2% several years ago but by a concerted
effort we reduced it down to 1% and saved costs (about $57,000 per episode). We then had to
change our patient cleaning solution used prior to surgery which resulted in a significant
increase in infections and we had to work on bringing it down again. Nevertheless, in the last
two years, we have had a 0.1% deep wound infection rate for regular STS defined heart
operations and for all cardiac operations, which totals over 8,000 operations over two years,
at 0.2%. This persistent effort at maintaining high quality outcomes is what has made the
Cleveland Clinic the top Cardiovascular Program for 18 years and a three star coronary artery
bypass and a three star aortic valve STS program (less than 2% of programs). Our mortality
rate for both coronary artery bypass surgery and aortic valve replacements runs between 0.3%
and 0.6%.
The cost of medical care can be staggering. At Shongwe, everything that was potentially
safe to keep for other patients was kept. For example, left over unused sutures were kept in a
sterilizing solution so that they could be used for other patients. Everybody was cost
conscience because of budget constraints and the desire to treat as many patients as possible.
In the United States, for us in cardiac surgery, the process is more formalized in that we keep
track of all our costs and negotiate aggressively for the lowest costs for devices, like, for
example, heart valves, as long as they meet our quality metrics, safety, and surgeon's choices
of what they believe is best for patients. For independent private practitioners this incentive to
keep cost down is not as great since essentially the hospital carries the cost of devices the
practitioner chooses to use, irrespective of cost. Furthermore, for most US physicians there is
little incentive to limit testing for the sake of hospital expenses, indeed the opposite may exists.
More testing may or may not bring more money into a private groups practice and hospitals
may even have joint ownership with doctors for testing procedures like MRI machines, thus
resulting in overuse. One benefit of group practices such as ours is that there is no incentive to
duplicate tests. Indeed, we often discuss jointly at disease team meetings which tests are
needed before ordering them. There is however one factor that importantly influences testing in
the USA and that is physician self-protection against lawsuits, called defensive medicine.
Basically the issue is that physicians order tests that may not be entirely needed to protect
themselves against lawsuits. The extent of this is difficult to quantify but it has been estimated
that in total defensive medicine and prevention dealing with medico legal litigation costs about
$200 billion yearly based on three separate studies. To look at another way, this expense could
provide free health insurance for some 40 million Americans on a yearly basis. It is extremely
unlikely that any Washington reform would result in more of this money being ploughed back
into healthcare to reduce expenses. Furthermore, if a few court cases go against a hospital that
is self-insured it is enough to push a hospital into the red and restrict capital expenditure
needed for new projects or buildings or patient care.
Payment: The differences in regard to health insurance are simple. At Shongwe, patients had
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