One of the most maddening aspects of looking at the current US health care system is the fact that, although the US spends more per capita on medical care than any other developed country, it gets, at least on average, worse outcomes on common measures of public health such as infant mortality and life expectancy. One of the problems is the perverse incentives that are built into the current system of fee-for-service treatment covered (or not) by insurance. I have also thought for some time that part of the problem is related to the institutional culture within which medicine is practiced in the US; to me, some aspects of that culture resemble a medieval artisans’ guild more than a 21st century profession.
In the last few days, I have read a couple of articles that have reinforced this feeling. The first article appeared in the New York Times, and describes how some hospitals, such as Seattle Children’s’ Hospital, are reaping benefits from improving some of the “housekeeping” aspects of their operation, like inventory management. Under the previous (non)system, individual areas and nurses kept their own “stashes” of critical supplies that they needed for patient care. Now,
There are two bins of each item; when one bin is empty, the second is pulled forward. Empty bins go to the central supply office and the bar codes are scanned to generate a new order. The hospital storeroom is now half its original size, and fewer supplies are discarded for exceeding their expiration dates.
Anyone who has ever studied inventory management even a bit will recognize the description of a two-bin inventory system. The idea is simple. Suppose it takes a week to order and receive a quantity Q of a given item, and that on average we use N of the items each day. Then we want the number of items ordered to be at least a week’s supply:
Q ≥ 7 N + S
where S is a safety factor to cover delays or mistakes in delivery. It is not hard to see how this simple idea can be adjusted to account for minimum order sizes and other “wrinkles”. This is about the simplest inventory management system possible; that it is a real innovation is somewhat disturbing. It is of course true that health care is different in some very important ways from, say, manufacturing automobiles, but it is not different in every way.
The second article, from the Washington Post, discusses the problem of hospital-acquired infections, specifically catheter-related bloodstream infections [CRBIs], which can develop through the improper insertion or care of intravenous tubes, and which affect approximately 80,000 patients per year in the US, resulting in about 30,000 deaths. According to a study carried out by the Association for Professionals in Infection Control and Epidemiology, most of these infections could be prevented if medical personnel consistently followed a five-step checklist:
- Wash hands with soap
- Clean the patient’s skin with an effective antiseptic
- Cover the patient with a sterile drape
- Wear a sterile mask, hat, gown, and gloves
- Put a sterile dressing over the catheter site
These are not exactly cutting-edge, high-tech procedures. I doubt that Joseph Lister, the father of antiseptic surgery, would find any of them puzzling. The problem appears to be a lack of understanding and focus, on the part of hospital managements, on the prevention of infections, rather than treating them after they occur, even though preventing infections is substantially cheaper than treating them.
One of the ideas that has been talked about recently, in the context of the health care reform debate, is “evidence-based” medicine. What this should mean is some systematic way of keeping track of what treatment is done, how it is done, and what the outcome was. The evidence from these reports is that we have a very long way to go. The good news is that there are significant improvements available; and, to use the hackneyed phrase, they’re not rocket science.