And for doing so in the heart of Medtronic country, as the Strib reminds readers:

The state is home to Medtronic Inc., the world's largest maker of devices used in spine surgery, as well as Abbott Northwestern Hospital, which performs more spine fusion surgeries on Medicare patients than any other hospital in the country, according to the industry publication Orthopedic Network News.

We applaud the newspaper for pursuing this story, one that was recommended to them months ago by me and other members of the Minnesota Shared Decision Making Collaborative, including Dr. Craig Christianson, who is quoted in the piece. It's part of an occasional Star Tribune series, "Too much medicine? When less is more in health care."

Ratings by individual health plans or by HealthGrades or by RateMDs.com or by Angie's List? (That's where I just found a roofing contractor!)

Michelle Andrews reflects on the dilemma consumers face in choosing a doctor and in trying to make sense of physician ratings. She wrote on the Kaiser Health News site.

And on the NPR Health Blog. Excerpt:

Health insurance plans tend to evaluate doctors more on cost than on quality. Right now, most consumers still don't have much incentive to pay attention to costs, because they're not paying much out of pocket for their care.

In fact, cost remains one of the least important factors consumers consider when choosing a physician, whether primary care or specialist, according to the study. Just under 30 percent of primary care physician shoppers considered cost; for specialists, the figure was even lower: a tad more than 12 percent.

My own doctor recently had me wait in the exam room a few minutes after my original blood pressure measurement was just a few points too high to check off as satisfactory. The nurse checked it again. It had gone down in a matter of minutes. My "white coat hypertension" at play again. They let me go. I was now officially "under control" in that care setting - making the ratings look better.

That's how shallow and superficial physician ratings can be.

(Photo credit: from Waldo Jaquith on Flickr)

Medical errors, safety and quality issues are highlighted in several new health journalism efforts.

The St. Louis Post-Dispatch has a "Who Protects the Patients?" series underway. The latest story profiles a teenager who died after being suffocated at a hospital that had been warned that its restraint policies weren't safe.

A sidebar to the latest story contrasts reporting policies in Missouri with those from at least one case in Minnesota.

It's a nice job of team reporting by the Post-Dispatch.

Meantime, the Boston Globe today reports on "Mistakes that matter: 2 biopsy errors result in an unnecessary surgery and delayed treatment."

An important story, well told by the Tribune and veteran writer Judith Graham. Excerpts:

"Families have reason to be alert to risks associated with diagnostic tests such as CT scans. Kids' changing bodies and brains are especially sensitive to ionizing radiation from X-rays used in the exams. And because children have longer to live than adults, they're more likely to experience delayed effects of radiation exposure, notably a small potential increased risk of cancer.

That's not a cause to shun the tests, medical experts agree. Medical imaging is an extraordinary tool that allows doctors to make diagnoses, select optimal treatments and save lives, they say.

But it does warrant caution, and medical professionals have been adopting measures to reduce children's radiation exposure. These include adjusting CT scanner settings for smaller bodies, imaging only those areas under medical investigation and using other tests, such as ultrasounds and MRIs, whenever possible.

Yet problems remain. Some hospitals and freestanding imaging centers continue to administer adult-size doses of radiation to children, experts report. Facilities also sometimes scan children repeatedly without cause or expose children's breasts, eyes, thyroids and genitals to unnecessary radiation by scanning too broadly or failing to use protective shields.

"We still have a way to go in terms of optimizing these examinations," said Dr. Donald Frush, chief of pediatric radiology at Duke University Hospital, acknowledging the shortcomings in the medical field.

About 7 million CT scans are administered to children every year; the number is expanding nearly 10 percent annually, according to a 2008 review of radiation risks associated with CT scans for kids in Current Opinion in Pediatrics. Almost one-third of the tests are given to children in their first decade of life."

The ending of a story is often the take-home impression for readers. This one ends with the story of an 11-year old girl with Ewing's sarcoma who has had 10 CT scans in addition to X-rays and a positron emissions tomography scan, or PET scan.

"Too many, in my book," said her mother, Susanne Eyles, of Mount Prospect.

At this point, the benefits from the tests -- monitoring the progress of the girl's cancer and its response to treatment -- are far more important than any risks, said a pediatric oncologist.

"Unfortunately, we really don't have the data to say whether the number of scans we're doing are optimal," he added.

As long as Lindsey's doctors say imaging tests are medically necessary, "then we'll say yes, go ahead," her mom said. But "as a parent, I plan to keep on asking how many of these does she really need."

It's also a nice touch to include in a story a patient/consumer anecdote that models how informed, shared decision-making can take place. Great use of the Tribune's time and energy.

This is NOT just a Minnesota issue. What's happening in Lake Wobegon country may have ramifications nationwide.

A nurse and a nurses' union governmental affairs specialist co-authored an opinion piece in the Star Tribune this week, showing how raw some nurses' nerves still are over this summer's labor dispute. The one-day strike was held and another was threatened before management and nurses settled. But if you think all is well, read the opinion piece. Excerpts:

"Inside the walls of Twin Cities acute care hospitals, all is not as healthy as the public relations flacks would have you believe. In fact, their own consultants have issued a report that substantiates the internal turmoil nurses describe. Press Ganey Associates Inc., a nationally respected employee relations firm specializing in health care, recently released "Pulse Report 2010 -- Employee and Nurse Perspectives on American Health Care." It blows the lid off this problem.

A total of 235,122 hospital employees from 383 U.S. hospitals (including Minnesota) were interviewed, and the facts are bruising:

•Nearly half of all nurses are disengaged, disempowered and unhappy on the job.

•This discontent translates into compromised patient outcomes.

•Nurses don't feel their patients are safe and don't recommend their own hospitals as centers of care.

Hospitals aren't as safe as they claim because they collect incomplete data, allowing them to be opaque about the realities nurses witness.
...
The hospitals have fashioned a good spin game that the Star Tribune has obviously bought hook, line, and sinker."

In the end, in the labor negotiations, the union gave up on its main issue of staffing ratios, announcing that it would take the matter to the state legislature instead. The piece discusses that legislative proposal:

"(The union's) proposal on staffing offers a comprehensive solution in which actual ratios are less than one page of a six-page bill. It considers how sick the patient is (patient acuity), how much nursing care time it takes to do certain patient care tasks (nursing intensity), the skill level of the registered nurses on the unit, the availability of support staff, and the type of environment.

But we butt our heads up against a culture that idolizes the theory of risk management. They maximize profits by calculating the financial risk of allowing "little" things to occur, like an excruciatingly painful stage three pressure ulcer (vs. a reportable stage four). It is a system that operates on the backs of nurses' professional ethics, valuing profit over care, seriously challenging every nurse's core value of caring for patients in a safe environment.

These are two irreconcilable forces -- and we believe in our democratic system to help mediate the path forward."

The path to the state legislature with this proposal will be an interesting and important one to follow - not only for Minnesotans, but perhaps for patients, providers and consumers across the country. Journalists should be gearing up to deal with these issues in their own communities.

Another excellent piece by John Fauber of the Milwaukee Journal-Sentinel, "Drug that could stop stroke isn't always used." This story also includes good graphics and reminders for readers on warning signs of a stroke, how to be prepared for a stroke emergency and what to do in such an emergency.

And, in that newspaper's partnership with MedPageToday.com, a version of the story appears on that site as well under the headline, "Do Certified Stroke Centers Deliver Speedy Treatment?"

Dr. Len Lichtenfeld, deputy chief medical officer for the American Cancer Society, blogs about the question, "Can You Really Measure The Quality Of Cancer Care?"

Dr. Len concludes:

"...emphasizing that just because someone says one place is better than another, or one doctor is better than another it is important to keep in mind what information stands behind those statements, and how much transparency there is in the methods and the meaning of what they say. If "quality" it is based on lower costs alone, then that frequently is a non-starter since spending more or less money is not necessarily associated with "quality outcomes."

Ultimately-in my personal opinion--it is spending money appropriately and wisely that is the key to success in cancer treatment. How we measure that accurately and consistently continues to be a significant problem. The good news-as mentioned above-is many of us are aware of that and are trying to do something about it.

We can't let perfection be the enemy of the good, but as I have maintained for years, it would be terrific if the medical profession stood up and took charge of this issue, offered transparency into what they do and how they do it, and accept that we have a responsibility to our patients to hold ourselves accountable in some reasonable way to offer the assurances the care we provide our patients meets some fundamental measure of quality care. I believe our patients are entitled to no less. We need to measure and demonstrate our commitment to our mission and our patients' expectations. Just saying we give quality medical care does not make it so.

In the meantime, we will have to settle for whatever quality measures someone offers-even if they aren't necessarily the quality measures that really define the quality of care we offer or receive. A little transparency into the process would go a long way in providing insight into the accuracy of the data and the assumptions that are made based on that data.

Just saying you measure quality cancer care does not necessarily make it so."

He's reacting to one of my blog posts from last week that was based on a commentary by former US Senator David Durenberger that was based on a story by Jeremy Olson of the St. Paul Pioneer Press.

Nice communication chain of events; let's keep the discussion going.

Former US Senator David Durenberger (R-MN), in his monthly commentary from the National Institute of Health Policy at the University of St. Thomas, writes about an example of a patient and a provider balking at evidence and outcomes data.

The commentary is built on the back of a story in the St. Paul Pioneer Press by Jeremy Olson (who is leaving soon to join the Star Tribune across the metro). Durenberger writes:

For many years MN health insurance companies like BCBSMN have been trying to convince members that they can provide more value for the premium prices they charge, because they can give members access to higher value health care services. This is what the HMO has been about for three decades and "data on docs" and the creation and sponsorship of the Institute for Clinical Systems Improvement (ICSI). For example, Health Partners Medical Group reports key clinical outcomes of more than 400,000 patients classified, since 2004, by socio-economic status, race and ethnic group because more than 90% of their patients will trust them with that kind of information.

Jeremy Olson, St Paul Pioneer Press, writes about an interesting new chapter in this effort. A 38-year-old leukemia patient is concerned that BCBSMN requires her to go to the Mayo Clinic for a bone marrow transplant rather than to the University of Minnesota where she has received all her care. "It breaks my heart," the patient says. But BCBSMN has the local and national data to show that Mayo's transplant outcomes for cases like hers are better than the UMN. The response from UMN is: "We treat the toughest cases that others won't." This is the kind of response we've become used to hearing when outcomes research is used to inform and to direct pre-paid patient decisions.

It doesn't hold water. When lives are at stake, and reputations are on the line, research data must be as precise as possible. There are those in the medical industry who love bashing insurers and managed care even more than President Obama does. Traditional insurance plans will tell you that hospitals with less than the best outcomes may be motivated by their finances in taking on cases for which success is less likely. I will always recall the two neurosurgeons involved in the development of the cyber-knife telling me about a Miami colleague who bought two and was making a mint off "hopeless" tumor cases.

When the UMN says their cancer transplant cases are "tougher" than Mayo's and therefore their success rate is lower, they need to be asked first to prove it, and then whether admission decisions can be affected by reimbursement which is unrelated to outcomes. What I would love to know, were I this patient, is which cancer centers, or which oncological surgeons, in this country have even better results for people like me than Mayo. Maybe one is right here in Minneapolis?

This gap - between what evidence shows on outcomes - and individual or institutional resistance to the evidence - is a huge barrier standing in the way of any meaningful health care reform.

Kudos to Jeremy Olson and David Durenberger for writing about it.

From today's latest addition to this excellent series:

"Americans increasingly are treated to death, spending more time in hospitals in their final days, trying last-ditch treatments that often buy only weeks of time, and racking up bills that have made medical care a leading cause of bankruptcies.

More than 80 percent of people who die in the United States have a long, progressive illness such as cancer, heart failure or Alzheimer's disease.

More than 80 percent of such patients say they want to avoid hospitalization and intensive care when they are dying, according to the Dartmouth Atlas Project, which tracks health care trends.

Yet the numbers show that's not what is happening."

Another in the excellent Associated Press "overtreatment" series. Excerpt:

"Americans get the most medical radiation in the world, even more than folks in other rich countries. The U.S. accounts for half of the most advanced procedures that use radiation, and the average American's dose has grown sixfold over the last couple of decades.

Too much radiation raises the risk of cancer. That risk is growing because people in everyday situations are getting imaging tests far too often. Like the New Hampshire teen who was about to get a CT scan to check for kidney stones until a radiologist, Dr. Steven Birnbaum, discovered he'd already had 14 of these powerful X-rays for previous episodes. Adding up the total dose, "I was horrified" at the cancer risk it posed, Birnbaum said."

This AP story raises many important questions about the quality of information consumers receive (or not) about the quality of care. Excerpt:

"Millions of seniors signed up for popular Medicare Advantage insurance plans don't get the best quality, an independent study found.
...
The analysis found that 47 percent of Medicare beneficiaries are in plans that rate three stars or two -- medium to fair quality. Just 23 percent were signed up in plans that rate four or five stars -- very good to excellent quality. Many of the rest were in plans not yet rated."

Are consumers not aware of the ratings?
Not receiving them?
Not understanding them?
Not trusting them?

These are important questions for journalists to investigate.

Walt Bogdanich and a team of reporters produced a powerful package entitled, "Radiation Offers New Cures, and Ways to Do Harm."

He profiled two people who died - one who received seven times his prescribed dose and one who absorbed "27 days of radiation overdoses, each three times the prescribed amount." But the story also was built on months of research and examination of thousands of pages of public and private records and dozens of interviews.

What makes this so important is that, as the story explains, Americans receive far more medical radiation than ever before. And some of it comes from technologies about which there is tremendous professional enthusiasm - such as IMRT or intensity-modulated radiation therapy. "Without a doubt," the story states, "radiation saves countless lives and serious accidents are rare. But patients often know little about the harm that can result when safety rules are violated and ever more powerful and technologically complex machines go awry."

I'm not going to post more excerpts here because you should read the entire piece and note the other elements of this rich multimedia package - video, interactive graphics, photos, and information graphics.

Powerful, tragic, important. Terrific journalism.

The Chicago Tribune, in the middle of a good story with a catchy headline - "The United States of Anxiety: Worried Sick Over Our Health Care" - includes some vital messages:

"Polls show voters worry a lot about health care and how much they spend on it. Presidential candidates John McCain and Barack Obama have responded by peddling plans they claim will help more Americans attain and afford care.

But neither candidate has focused publicly on treating the real problem: why American medical care costs too much and isn't as good as it should be.

We waste money on tests and visits to specialists that don't make us better. We spend big to add a few weeks or months to the inevitable end of a dying patient's life. We use expensive technology at any cost, even when it exceeds our needs, and we fail to encourage simple, proactive steps that would keep us healthier and save us money. We often don't know which treatments work the best, so we err on the side of too much care, for too much cost, with sometimes damaging consequences.

As a result, Americans pay significantly more for medical care than anyone else in the industrialized world. Every year, we spend a bigger chunk of our family budget on doctor bills, hospital stays and prescription drugs. Yet we trail several other nations in health-care quality, access and efficiency.

Most Americans have long assumed that more is better when it comes to their health: more doctors, more tests, more hospital time. But a decade of comprehensive studies suggests that all those visits and tests and hospital stays are often a waste of money—and sometimes a drag on our well-being."

As we flip the calendar over from a very busy May into a sunny June, I want to reflect on the common themes in the blog entries of the past four days:

1. My PLoS Medicine article, “How Do US Journalists Cover Treatments, Tests, Products and Procedures? An Evaluation of 500 Stories.�

2. The Commonwealth Fund analysis on variations in child health care across the US.

3. Another "more care isn't always better care" study - this time in JAMA.

4. Consumer Reports releasing an online tool using Dartmouth Atlas data to allow you to look at aggressive vs. conservative care - comparing hospitals on this scale.

Connect the dots. Jack Wennberg's work rings through these themes.

Inexplicably widespread variations exist in the way health care is practiced in this country and more data comes in every day. More evidence also comes in every day that "more and newer isn't always better" in health care. And journalists are spending too much time on the "more" and the "newer" rather than on questions of evidence, costs, quality and access to care.

As a result, many consumers aren't getting much smarter at a time when some policymakers, employers and insurance company marketing folks push "consumer-driven health care" plans. Americans don't know what they're buying with the health care dollar and giving them more "skin in the game" doesn't make them smarter - only makes them hurt more - if they're not educated in the dots.

Don Berwick and the Institute for Healthcare Improvement have done important work in addressing health care quality issues. But they may have overstepped the boundaries of evidence with a recent study that drew a lot of news coverage, claiming that hospitals they worked with saved over 122,000 lives by cutting down on errors and improving care.

"The Numbers Guy" column by Carl Bialik in the Wall Street Journal says the studies warrant a second opinion. Bialik quotes Dr. Bob Wachter of UCSF, author and lecturer on medical errors: ""I don't think it saved 122,300." He added that, like in a political campaign, the health-care campaign used "statistics selectively to try to mobilize your base to do good. It's understandable. It's not good science."

Dr. Gil Welch of Dartmouth and the VA said, "I think there's been a tendency in the errors business to first overstate the size of the problem, and now, I'm afraid, to overstate the effect of interventions on the other side."

Read Bialik's full article. It does a good job of questioning claims and pointing out how well-intentioned advocates may be driven by passion more than by evidence, and how journalists can easily get sucked into the vortex. (Bialik points out how the Wall Street Journal reported the Berwick claims, along with the Associated Press, U.S. News & World Report and many other media.)