Overview from Commonwealth Fund President Karen Davis:

• Patient safety: The U.S. ranks last on patients experiencing a lab test error, including wrong tests or delays in being notified about abnormal results.
• Effectiveness: The U.S. ranks first on provision of preventive services such as pap tests, mammograms, and counseling on diet and exercise. However, it ranks last on patients not filling a prescription, skipping a recommended test, treatment, or follow-up, or not visiting a doctor when needed due to cost.
• Patient-centeredness: The U.S. ranks last on patients leaving a doctor's appointment without getting important questions answered.
• Timeliness: The U.S. ranks last on difficulty of getting needed care on nights or weekends; Australia also ranks low on this measure. The U.S. and Germany had the shortest waiting times for elective/non-emergency surgery.
• Efficiency: The U.S. ranks last on visiting the emergency room for a condition that could have been treated by a regular doctor.
• Equity: The U.S. ranks last on disparities between below- and above-average income groups regarding not filling a prescription or skipping medication doses due to cost.

"Our fragmented health care system and lack of a strong primary care foundation show up in performance gaps throughout the studies," says Fund President Karen Davis, the report's lead author.

  (press "play" button to start video)

U.S. Ranks Poorly on Many Measures in Cross-National Patient Surveys

Executive Summary

U.S. health care leaders often say that American health care is the best in the world. However, recent studies of medical outcomes and mortality and morbidity statistics suggest that, despite spending more per capita on health care and devoting to it a greater percentage of its national income than any other country, the United States is not getting commensurate value for its money. The Commonwealth Fund's cross-national surveys of patients' views and experiences of their health care systems offer opportunities to assess U.S. performance relative to other countries through the patients' perspective—a dimension often missing from international comparisons.

In 2004, we reported on U.S. performance using Commonwealth Fund international survey data from 2001 and 2002. This report updates these findings using data from two recent surveys. The first survey was conducted in 2004 among a nationally representative sample of adults in five nations: Australia, Canada, New Zealand, the United Kingdom, and the United States. The second survey was conducted in 2005 among a sample of adults with health problems in the same five nations and Germany. This report ranks the countries in terms of patients' reports on care experiences and ratings on various dimensions of care. While focusing on a limited slice of the health care quality picture—patient perceptions of care received—as well as a limited number of countries, the surveys nonetheless offer valuable insights.

We organized patients' responses according to the Institute of Medicine's (IOM) framework for quality, outlined in the six bulleted points below. We then ranked each country's score on individual items from highest to lowest. For each IOM quality domain, we calculated a summary ranking by averaging the individual ranked scores within each country and ranking these averages from highest to lowest score.

Overall, the findings indicate that the U.S. health care system often performs relatively poorly from the patient perspective. The U.S. system ranked first on effectiveness but ranked last on other dimensions of quality (Figure ES-1). It performed particularly poorly in terms of providing care equitably, safely, efficiently, or in a patient-centered manner. On measures of timeliness, the U.S. system did not score as well as some of the other countries and rarely received top scores. For all countries, responses indicate room for improvement. Yet, the other five countries spend considerably less on health care per person and as a percent of gross domestic product than the United States. These findings indicate that, from the perspective of the patients it serves, the U.S. health care system could do much better in achieving high-quality performance for the nation's substantial investment in health.

(Our website) U.S. Ranks Poorly on Many Measures in Cross-National Patient Surveys

Key Findings

• Patient safety: Among sicker adults, Americans had the highest rate of receiving wrong medications or doses in the prior two years. Among sicker adults who had a lab test in the past two years, adults in the U.S. were more likely than their counterparts in the other countries to have been given incorrect results or experienced delays in notification about abnormal results, with rates double those reported in Germany or the U.K. Rates of lab errors were also relatively high in Canada.
• Effectiveness: The indicators of effectiveness in the 2004 and 2005 surveys were grouped into four categories: prevention, chronic care, primary care, and hospital care and coordination. Compared with the other five countries, U.S. patients fared particularly well on receipt of preventive care and care for the chronically ill, although all countries had considerable room for improvement. Canada scored well on primary care, and Germany ranked first on hospital care and coordination. Across the indicators of effectiveness, the U.S. ranked first and New Zealand ranked last.
• Patient-centeredness: In 2004 and 2005, survey questions asked patients to rate the quality of their physician care in four areas: communication, choice and continuity, patient engagement, and responsiveness to patient preference. On measures of communication and patient engagement, New Zealand ranked highest. Germany was first on measures of choice and continuity, and Australia performed well on responsiveness to patient preference. Across the measures of patient-centeredness, Germany generally was highest, followed by New Zealand. The U.S. ranked last on nearly all aspects of patient-centeredness.
• Timeliness: Germany and the U.S. stand out among the six countries in terms of patients with health problems reporting the least difficulty waiting to see a specialist or have elective or non-emergency surgery. Yet Americans, along with Canadians, were more likely to say they waited six days or more for an appointment with a doctor or had trouble getting care on nights and weekends. Across all five measures of timeliness, Germany and New Zealand ranked first and second, respectively. The U.K. ranked fifth, and Canada ranked last.
• Efficiency: The 2005 survey included four questions on coordination of care that serve as indicators of health care system efficiency. Compared with their counterparts in other countries, sicker adults in the U.S. more often reported that they visited the emergency room for a condition that could have been treated by a regular doctor had one been available and that their medical records or test results failed to reach their doctor's office in time for appointments. About one of four U.S. sicker adults reported these concerns. U.S. sicker adults, along with their German counterparts, also were more likely to be sent for duplicate tests by different clinicians. On measures of efficiency, the U.S. ranked last among the six countries, with Germany and New Zealand ranking first and second, respectively.
• Equity: Nine measures from the two surveys gauged the extent to which patients' income affected their ability to access care. The U.S. scored last on seven of the nine measures of low-income patients not receiving needed care and had the greatest disparities in terms of access to care between those with below-average and above-average incomes. With low rankings on all measures, the U.S. ranked last among the six countries in terms of equity in the health care system. The U.K. ranked first, with no or negligible differences in terms of patients' access to care by income. The U.S. is the only country surveyed with large numbers of uninsured, and this contributed to its low rating for equity in the health care system. But even among above-average income respondents, the U.S. lagged considerably behind their counterparts in other countries.

Summary and Implications
These rankings summarize evidence on measures of quality as perceived or experienced by patients. They do not capture important dimensions of effectiveness or efficiency that might be obtained from medical records or administrative data. Patients' assessments might be affected by their experiences and expectations, which could differ by country and culture. Yet, reports from the World Health Organization (WHO) that compare health care system performance using measures such as life expectancy, infant mortality, or preventable years of life lost as well as health expenditures also suggest that the U.S. achieves the least for its population among these six countries. A working group—supported by The Commonwealth Fund and with experts from each of the five countries surveyed in 2004, the Organization for Economic Cooperation and Development (OECD), and WHO—developed a set of indicators that provide measures of clinical effectiveness. It found that none of the five countries included in the study—Australia, Canada, New Zealand, the U.K., and the U.S.—were systematically best or worst on measures of clinical effectiveness, confirming the mixed story reported by patients.

On four of the six domains of quality of care included in the Institute of Medicine framework, the U.S. performs relatively poorly from the patients' perspective. On timeliness, the U.S. performs about average. Effectiveness was the only measure on which the U.S. system performed slightly better than the five other countries, due largely to greater use of preventive care services and better care for the chronically ill. Notably, both of these dimensions of quality have been the focus of quality and reporting measurement in the U.S. for more than a decade.

Findings from the 2004 and 2005 surveys confirm many of the findings from surveys in 2001 and 2002. In the earlier surveys, the U.S. ranked last on measures of patient safety, patient-centeredness, efficiency, and equity. However, compared with the earlier surveys, the U.S. has improved on measures of effectiveness, from being tied for last place with Australia to ranking first among the six countries. The earlier surveys included only limited effectiveness measures while the more recent surveys contained a broader array of measures.

The findings suggest that, if the health care system is to perform according to patients' expectations, the U.S. will need to remove financial barriers to care and improve the delivery of care. Disparities in terms of access to services signal the need to expand insurance to cover the uninsured and to ensure that the system works well for all Americans. Based on these patient reports, the U.S. should improve the delivery, coordination, and equity of the health care system.

Citation

Note the enormous inequity between the costs of care in the U.S. and the rest of the "advanced" countries. Since, compared with all the other countries cited, only the United States has introduced "managed care." 

And if it costs up to twice as much to deliver lower quality, it would seem probable that the chief change in the American healthcare system in the past 20 years--the "managed-care experiment"--has been a healthcare failure and a market failure as well. -- Jack C. Schoenholtz, M.D., F.A.C.Psych.

                                             *              *             *

Psychiatric Terms

(from Weill Medical College Department of Psychiatry)

Agoraphobia--fear of having a panic attack (intense and overwhelming anxiety) in a place where there is no one who can help you and you cannot easily escape.  This fear often keeps people from leaving home or traveling.

Anorexia nervosa--an illness in which a person cannot maintain normal weight, is very afraid of gaining weight, sees oneself as heavy or fat even though the person is significantly underweight, and refuses to eat enough to maintain a normal body weight.

Anxiety disorder--one in a group of illnesses in which the most important symptom is anxiety.  This group includes Obsessive-Compulsive Disorder, Panic Disorder, Posttraumatic Stress Disorder, Social Phobia and Specific Phobia.

Attention-deficit hyperactivity disorder (ADHD)--an illness in which children, teens or adults cannot pay attention, sit quietly, remember instructions, wait for a turn or keep from speaking out when it's not time to speak.

Avoidant personality disorder--a persistent and rigid pattern of avoiding social situations, low self-esteem, fear of criticism, fear of being foolish, and fear of embarrassment.

Bipolar disorder--another term for manic-depression, an illness in which there are cycles of depression and mania.

Borderline personality disorder-- a persistent and rigid pattern of losing control of feelings and impulses, and extreme instability in relationships and self-image.  Behaviors often include rage, self-mutilation, suicide attempts or threats, and intense, stormy relationships.

Bulimia nervosa--an illness in which there is frequent binge-eating (that is, eating large amounts of high-calorie food in a short period of time).  The binges are followed by attempts to make up for eating so much by vomiting, using diuretics or laxatives, strict dieting, fasting or vigorous exercise.

Dementia--a brain disorder where there is loss of memory and other important functions of the brain (for example, the ability to speak, the ability to recognize ordinary things, the ability to plan or organize).

Dependent personality disorder--a personality problem in which a person is unable to cope because of extreme lack of self-confidence, a wish to have others assume responsibility for one's life, and consistently putting the needs of another person before one's own needs.

Depression--an illness in which there is a long-lasting mood of sadness, despair or discouragement in which a person has trouble functioning at home, at work or at school.  Symptoms may include slowed thinking, lack of pleasure, guilt, hopelessness, and problems with eating and sleeping.

Dissociative disorders--illnesses that involve dissociation (splitting off of groups of mental processes from consciousness), for example, amnesia, or multiple personality disorder.

Eating disorder--severe trouble with eating behaviors.  Examples are anorexia and bulimia.

Factitious disorders (Munchausen)--an illness in which there are physical or psychological symptoms that are intentionally produced in order to assume the sick role.

Generalized anxiety disorder (GAD)--an illness in which a person has unrealistic or excessive anxiety about one or more problems.

Insomnia--trouble falling asleep or staying asleep.

Mood disorders--psychiatric illnesses in which the most important symptoms are problems with mood.

Narcissistic personality disorder--a psychiatric problem in which a person behaves consistently with an exaggerated sense of self-importance and specialness, uses other people, and lacks genuine feelings for other people.  People with this disorder often lack self-esteem and need excessive admiration from others.

Obsessive-compulsive (OCD)--one of the anxiety disorders in which a person has obsessions (insistent thoughts, impulses or images that cannot be dismissed) and/or compulsions (persistent urges to perform a ritual, such as hand-washing or checking things)

Obsessive-compulsive personality disorder--a persistent preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency.

Oppositional defiant disorder--a childhood disorder in which there is uncontrollably negative and hostile behavior.

Panic disorder--an illness in which a person has panic attacks (sudden episodes of intense and overwhelming anxiety)

Paranoia--suspiciousness caused by misinterpretation of actual events

Pervasive development disorder (PDD)--one of several disorders that begin in infancy, childhood or adolescence, causing severe and pervasive problems in several areas:  social interaction, communication, or the presence of stereotyped behavior, interest and activities.  Includes autism and Asperger's Disorder.

Posstraumatic stress disorder (PTSD)--an anxiety disorder in which living through an overwhelming mental or physical stress is followed by persistent symptoms of reexperiencing the event in the person's mind, avoiding things that remind the person of the event, numbness, and severe anxiety or irritability.

Psychotic disorders--psychiatric disorders that causes loss of touch with reality

Schizoaffective disorder--a disorder in which there are problems both with psychotic symptoms and with mood symptoms (mania or depression).

In schizoaffective disorder there must be a period of time in which psychotic symptoms are experienced with an abnormal mood.

Schizophrenia--a disorder that includes psychotic symptoms such as delusions and hallucinations which interfere with one's ability to function.

Seasonal affective disorder--a disorder in which mood is strongly affected by the season of the year.

Sleep apnea--a sleep disorder in which a person gets very poor quality sleep because he or she stops breathing repeatedly during the night, causing the person to repeatedly wake up gasping for air.

Sleep disorders--disorders in which people have problems with sleep

Social phobia--a disorder in which a person experiences severe and overwhelming fear of all social situations or of specific social situations, e.g. eating in public or using a public bathroom.

Specific phobia -- an illness in which there is extreme fear caused by a specific object or situation, e.g. spiders, dogs, high places, closed-in places.  This happens even though the person knows the fear is excessive or unreasonable.

Substance abuse -- using a substance (usually a street drug) excessively, even when it hurts relationships with other people, prevents doing well at work or school, ruins a person's health or creates trouble with the law.

Substance dependence -- addiction; needing to use a substance (usually a street drug) so much that if the substance is stopped abruptly, there are dangerous physical symptoms, like fever, shaking, sweating, or seizures.  Needing to use the substance/drug so much that it keeps a person from working, going to school, having good relationships and obeying the law.

Substance related disorders -- a group of illnesses including problems with substance (usually street drugs) abuse and dependence.

Department of Psychiatry, Weill Medical College

From the American Psychiatric Association

March 2005

Medication Dosing and Blood Levels

Rye Hospital Center is acutely aware of the changes in our knowledge and the importance of keeping up to date with the latest changes in science-based 21st Century medicine. What matters is not so much how much is ingested but rather, how much of the medication enters the blood stream.

There are three primary factors that influence the amount of drug that finds its way into the blood stream. First is the rate of liver metabolism. Bipolar medications are absorbed through the walls of the stomach and intestines and go directly to the liver, although some are able to be changed directly in the intestines or kidney. In the liver, the drug molecules are acted upon by liver enzymes that begin a process generally referred to as biotransformation. Liver enzymes chemically alter the medication in ways that allow the drug to be more readily excreted from the body. The liver's function is to detoxify the body. Thus, in this so-called first pass effect through the liver, a good deal of the drug is transformed and then rapidly excreted. However, some of the medication initially escapes this process, makes its way through the liver and into circulation and thus is allowed to begin accumulating in the blood stream. How rapidly the liver metabolizes drugs depends on a number of factors. This resulting blood level is what matters when it comes to reducing symptoms. (Note: two mood stabilizers are not metabolized in the liver and directly excreted by the kidneys: lithium and Neurontin. However, Neurontin is not FDA approved for bipolar disorder).

Genes play a significant role in this process. A small percentage of people are known as rapid metabolizers. They take certain drugs and then eliminate them very quickly. The result is that even though they may be taking what seems like an adequate dose of the medication, little actually gets into the blood stream. Once it is discovered that someone is a rapid metabolizer, then usually they are prescribed very high doses of medications and eventually enough gets into the blood stream to be effective. Again, this has nothing to do with how severely ill they are …it's just a matter of the liver's metabolic rate. Conversely are hypo-metabolizers. This also small percentage of people, have fewer than average liver enzymes. The effect is that they can take a very small dose of a medication, and on its trip through the liver, only small amounts are transformed and excreted. The result is often very high blood levels of the medication and severe side effects or toxicity. The ultimate solution for hypo-metabolizers thus is to use very small doses. Sometimes when a person is first treated they will experience serious side effects and this may be due to hypo-metabolizing. It is often hard to know ahead of time if this will happen with any one given individual. Thus if your patient has had an experience of encountering very intense side effects with other medications in the past, one may anticipate that they are a hypo-metabolizer, and thus initial dosing is done gradually.

A second factor determining blood levels of medications is the functioning of the kidney. Sometimes genetic factors play a role here too, but more often problems can occur due to kidney disease. Thus, for some bipolar medications, pretreatment labs will include an assessment of kidney functioning (this is especially important for patients being treated with lithium).

Finally and increasingly, a number of drugs can adversely affect liver metabolism and thus alter blood levels. Here is where drug-drug interactions can cause significant problems (see article below this one). This applies to many prescription drugs, over-the-counter drugs, herbal and dietary supplement products and recreational drugs. The use of prescription drugs must be carefully monitored by the treating physician. In addition, even modest amounts of alcohol can have significant affects on the liver. St. John's Wort, a popular herbal product for the treatment of depression, is well known for causing some very significant changes in liver metabolism.

August 2004

Cardiac Effects of New Psychiatric Medications

With increasing concern over potential toxic effects of new drugs on the heart, Rye Hospital has begun to measure special aspects of electrocardiograms that could signify the possibility of a dangerous event occurring.

The case in point is the measurement of what is called the "QTc" interval--that electrical part of the heartbeat which may be prolonged either by certain drugs or by combinations of drugs that could produce fatal arrhythmias.

All patients are routinely given a "baseline" cardiogram. Those who require the use of the newer drugs or combinations of drugs that can be additive in their cardiac conduction effects, and prolong the QT interval, have repeated studies to determine whether they should need a change.

Indeed, because even some antibiotics and foods like grapefruit and/or its juice can cause such critical, additive problems, we constantly endeavor to make our doctors aware of the latest findings by researchers.

April 2004

Latest CMS Survey:

The federal Center for Medicare and Medicaid Services performed its annual "unannounced" recertification survey this month. We passed with flying colors!

(No "deficiencies" and no "formal concerns" to report.)

_______________________________________

March 2004

Rye Hospital Center starts

a new Doctors Page (click)click)