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Sunday, August 24, 2014

Continued disruptions in health care

The New York times published a piece this morning titled " Blood Industry Shrinks as Transfusions Decline". The story contains multiple elements reflective of the changes and disruptions affecting the health care industry.

What is more fundamental in medicine than blood transfusions? There is some controversy regarding the first transfusion. It has been reported that Pope Innocent VIII received the blood of three ten year old boys in 1492 although it is not clear when the blood was infused or ingested. Jean Denis transfused lamb blood into a young woman in 1667, a procedure complicated by a hemolytic reaction which fortunately for the patient, she survived. Unfortunately for Denis, reactions in subsequent reactions were not so benign, resulting in madness and death. The practice was dropped and not undertaken at all for the next 150 years.

In the 19th century, various attempts to revive the practice lead to variable successes. However, it was not until Karl Landsteiner began to define human blood groups in 1900 that more widespread deployment of human to human transfusions could be undertaken. Blood group characterization was then refined over the next 100 years. In addition, a host of other technological breakthroughs including anti-coagulants, preservatives, refrigeration, sterile (or clean)  technique, material science (plastics), and screening for infectious diseases made the practice safer and more effective. It was during war that the much of the practical improvements were driven with life saving impacts.

As noted in the NYT piece, blood banking and the American Red Cross moved to an industrial scale after WWII, about 70 years ago. However, the heyday of transfusion medicine may be behind us. The demands for transfusions are down a almost by a stunning one third in the past five years. This appears to be due to multiple factors including the use of minimally invasive surgery, substitute products, and changing indications for use of transfusions.

Regarding the last factor, decision support tools linked to electronic health records may be having a profound effect. While changing recommendations regarding medical indications may have limited effects if deployments are dependent upon individual physicians embracing the changing recommendations, the same recommendations tend to be adopted more readily if reminders and prompts are embedded in computerized physician order entry systems (CPOE). Orders entered which are at odds with guidelines require some sort of physician action to override the defaults which are also tracked. This has changed the use of transfusions and discouraged what is now viewed as inappropriate use.

The drop in use has prompted a host of consolidations and cost savings activities. The industry is shrinking in terms of employment footprint. As noted in the Times article (emphasis mine):
The change has come as a shock to workers. Marjorie Krueger, the administrative director of the Communications Workers of America for the area including Virginia, West Virginia, Maryland, Pennsylvania and Delaware, said that when the Red Cross began laying off union-represented workers in 2010, “We honestly didn’t know how it would work, because no one ever expected to have layoffs.” The layoffs have been few, but the hours of many full-time workers have been involuntarily cut to part time, she said.
Basically, transfusion medicine is 100 years old. In some sense the history of transfusion medicine tracks the history of recent modern medicine. Changes comes both rapidly and slowly. None of us practicing now has any recollection of what practice of medicine was like without transfusions, creating the illusion of a practice which has always been with us. However, the reality is it is a very recent addition to the ancient practice of caring for the sick and injured. Because of our biases, we are surprised when technology disrupts our world changes what we view as a practice which will be with forever.

The truth may very well be that use of blood is an expensive and labor intensive approach to care where the public will be best served if it can be replaced by approaches which are safer, cheaper, and simpler. Come to think about it, this sounds like the current health care system in general. Be prepared for change. Be prepared for disruption. Don't be surprised.

1 comment:

  1. Very interesting post. While in medical school, I've found that the biggest deterrents to clinical decision support systems are my very own classmates. I am a huge advocate for the use of such tools, for the very reasons you discuss above (namely cost-savings and increased quality of care).

    The most common response I get from classmates is that it is insulting to them that a decision tree could replace their expertise. My only way to rationalize such an argument is through the lens of hubris. That I provide my patients with the highest quality of care (at the best value) is my chief concern - how I get there, doesn't really matter to me. Whether it be through following a decision tree, using up-to-date, gestalt (sparingly) or some combination therein.

    I would be interested to hear your thoughts on ways to make these decision support systems more palpable for those peers and colleagues who express similar reservations about embracing these disruptive and innovative practices.

    Do you think efforts such as PCORI will help in the creation of such systems? What are your thoughts on using decision support systems in the setting of diagnosis based on image recognition?