In football, each play is itself a battle that is either won by the offense (by gaining yards or scoring) or the defense (by causing a loss of yards, a turnover or scoring). While the score ultimately determines who wins or loses, both coaches and players know that execution of individual plays and adjustments made during the game set the course for the final outcome.
It’s a similar situation in health care and, in particular, cancer care. Once the foe is identified, a plan of attack is formulated and carried out in a series of steps. Throughout the course of treatment, progress is evaluated and the next steps are modified based on the effectiveness of the previous steps.
For both cancer treatment and football, there may come a point when time is running out, the plan isn’t working and attack options are depleted. This is where the two scenarios part ways. In football, aggressiveness is a given, no matter how far behind you are. Not so much with cancer.
Unfortunately for many U.S. cancer patients nearing the end of life, aggressive treatment is not taken out of the playbook in favor of palliative or hospice care. New analysis of 2010 data from the Dartmouth Atlas Project shows 29 percent of cancer patients being admitted to an intensive care unit (ICU) during their last month of life. Worse, that number represents an increase (up from 24 percent) during the period from 2003-2007. Iowa’s numbers, while notably better than much of the nation, are also headed the wrong direction: 15 percent for 2003-2007, 20 percent in 2010.
The percent of patients who saw 10 or more different physicians during the last six months of their lives rose from 46 percent to 58 percent, suggesting that more patients may have experienced fragmented care. Again, Iowa’s numbers are better, but the trend is also headed upward, from 34 percent to 44 percent.
There are more hopeful numbers that indicate less aggressive, more patient-centered care. Nationally, the percent of cancer patients dying in the hospital decreased more than four percentage points, from an average of 29 percent of patients from 2003-2007 to 25 percent in 2010. Iowa also improved, from 22 percent to 19 percent.
Studies have consistently shown that cancer patients do not want aggressive care at the end of life, yet Dartmouth’s data show that these preferences are not resulting in appropriate care. The study’s authors see the disconnect coming from lack of effective communication and the medical cultures that permeate organizations and among individual providers.
Fundamental to patient-centered cancer care are health care providers educating patients about their prognoses, eliciting their preferred treatment approaches and formulating care plans that respect their choices regarding the goals of care. This is what patients want, but a collusion of silence and health care fragmentation results in too many patients left uninformed of their prognoses and the option of hospice. Many are informed far too late, the Dartmouth study shows, resulting in hospice referral only in the last few days of life.
Hospitals must continue to be leaders that embrace patient- and family-centered care for all patients, especially those with cancers with poor prognoses. Hospitals should continually examine their rates of ICU utilization, hospice referral and other utilization measures and then ask, do these results reflect a practice of educating patients about their prognoses, prompting their choices and forming care plans that respect patients’ care goals?
Health care reform presents an important opportunity to restructure health care and transition from serving the needs of institutions to providing care that focuses on patients as well as the family members and friends who care for them. To keep all the important players on the team, health care and healing must be more than a win-lose proposition. When it comes to patient-centeredness, how you play the game really does matter.
On Thanksgiving Day, thousands of Iowa hospital employees will be at work, ready to provide the care Iowans have come to expect, no matter the day or the hour. Their commitment means patients receive the right care, in the right place, at the right time.
It also means patients are grateful for the difference their hospitals have made in their lives. Some of those patients share their stories of compassion, healing and gratitude below:
- A Sumner woman is winning a long, difficult battle against lymphedema.
- A Spencer woman is back to giving after successful eye surgery.
- A Knoxville woman is recovering from life-saving surgery.
- A Parkersburg man is managing Type 2 diabetes with determination.
- A young Illinois family’s tiny newborn is beating the odds.
- A Newton man turns his life around after triple bypass.
- A home health aid is this Cedar Rapids patient’s “guardian angel.”
- An Illinois soldier fights back from a serious spinal injury.
- An Osage man gives thanks for the two hospitals that worked together to fix his heart.
- A Decorah EMT is back to saving lives after surviving a heart attack.
- A Fairfield woman is grateful for the care her mother received.
- A Pella great-grandmother is getting great care at home.
- A Fort Dodge patient with chronic health issues benefits from innovative, coordinated care.
- A host of patients served by Wheaton Franciscan Healthcare-Iowa (Waterloo/Cedar Falls/Oelwein) Iowa Specialty Hospital (Belmond and Clarion) and Horn Memorial Hospital (Ida Grove) also share their uplifting experiences and gratitude.
The city of Spencer has become Iowa’s first certified Blue Zones community. Certification recognizes Spencer’s successful implementation of the Blue Zones Project, a first-of-its-kind population health program that focuses on making long-lasting upgrades to the living environment. The project brings the world’s best practices in food policy, built environment, purpose and social networking to demonstration cities.
Community leaders, volunteers and organizations throughout Spencer have been working to reach this milestone since May 2012, when the community was named one of the state’s first Blue Zones Project demonstration sites. Positive health and wellness outcomes from the city’s effort include:
- Spencer municipal government reported reducing city workers’ health care claims by more than 20 percent and nearly half of city employees eliminated at least one risk factors for cardiovascular disease and diabetes, such as high blood pressure, high triglycerides and high glucose.
- More community walkability was created by appropriating $200,000 to new sidewalk construction, leading to 200 citizen applications for new sidewalks and implementing a policy requiring sidewalks for future construction.
- Spencer elementary schools claim a 10 percent increase in the number of students walking or biking to school from the 2011-2012 school year compared to the 2012-2013 school year.
- The number of community gardens increased from one location with seven plots to three locations with 36 plots.
- Some 250 walking groups around the city have logged more than 136,000 walking minutes since the project’s inception.
Spencer achieved Blue Zones certification after making well-being improvements across the community, including these key milestones:
- 50 percent of the top employers became designated Blue Zones worksites.
- 25 percent of schools, restaurants and grocery stores met the necessary criteria to become Blue Zones Schools certified.
- 20 percent of citizens committed to the Blue Zones Project and completed at least one well-being improvement action.
- The community successfully completed the Blue Zones Community Policy bundle.
Among the other impressive economic and health gains from the project:
- Spencer Hospital reported that insurance paid claims increased by only 1.4 percent between 2011 and 2012 compared to the national trend of 7 percent and the hospital’s average of 15 percent over the previous five years.
- The hospital also reported that its most recent wellness screening revealed that more than half of those screened eliminated one or more risk factors for cardiovascular disease and diabetes compared to the previous year. Only 6 percent experienced an increase.
- Fulltime and volunteer firemen working with the Spencer Fire Department lost a combined total of 130 pounds, an average of 7.22 pounds each.
- Spencer Municipal Utilities reported that employees screened between 2012 and 2013 also experienced significant reductions in risk factors for cardiovascular disease and diabetes.
The Blue Zones Project is the centerpiece of the Iowa Healthiest State Initiative, which aims to make Iowa the national leader in wellbeing by 2016. Fifteen Iowa communities are currently part of the Blue Zones Project. For more information, visit www.bluezonesproject.com.
Even as some members of Congress continued to rail against the Affordable Care Act all the way to the brink of an international monetary crisis, the good folks at the Dartmouth Atlas once again are highlighting practical data regarding how to control overall health care spending.
As the Dartmouth Atlas has concluded previously, it’s not so much providing people with health care coverage that drives costs within the system, it’s evaluating how that care is delivered. This time researchers turned their attention to Medicare Part D’s prescription drug benefit. The results show, once again, that care provided in the Upper Midwest is more effective and less costly than care delivered in urban centers on the coastlines.
In 2012, 37 million Americans were enrolled in Medicare Part D. Prescription drugs currently account for 11 percent of annual Medicare spending, or approximately $60 billion a year. Medicare prescription drug costs are expected to comprise almost 20 percent of total Medicare spending by 2020.
The Dartmouth Atlas evaluated prescription drugs by three values of efficiency: (1) treatments that are clinically effective; (2) treatments that involve a wide degree of prescriber or patient discretion (and therefore may have uncertain efficacy) and (3) treatments with evidence of potential harm in specific populations (the risks outweigh the rewards).
What they found across the board is that where there’s a high concentration of practitioners, there’s a higher concentration of drugs being prescribed. When comparing the lowest prescription drug costs per Medicare beneficiary in St. Cloud, Minnesota ($1,770 per beneficiary) with the highest in Miami ($4,738 per beneficiary), the difference is staggering.
Iowa ranks well below the national average spending of $2,670 per beneficiary, with three Iowa hospital referral regions – Cedar Rapids, Iowa City and Mason City – falling among the 10 least expensive regions in the nation.
Again, the value of Iowa’s conservative practice of high quality care is undeniable. In Iowa, the patient comes first and practitioners aren’t needlessly churning the fee-for-service system.
So what does this mean? It means that the Iowa Hospital Association’s longstanding advocacy in support of value-based purchasing – rewarding states that control health care spending – is right on target. It means that pundits who talk about the “over-capacity” of the health care system may have a point, but that their attention ought to be focused on the country’s urban centers, not on states like Iowa.
It means that politicians should concentrate less on the rhetoric demonizing social service programs and more on the data that indicates how to model those programs to serve the greater good and improve efficiency.
As irreplaceable pillars in the community, Iowa’s community hospitals fulfill many roles: safe havens for those seeking healing; hubs for community wellness; engines that generate billions of dollars in economic activity. Similarly, our 70,000 employees are many things to the people they serve: kind and patient listeners; skilled and caring healers; gentle and loving therapists for mind, spirit and body. Watch this video and see the difference your hospitals make every day.