Doctor and Patient - Paying Doctors for Patient Performance

Despite his own solid“ranking,” my colleague found himself growing more and more disenchanted with these types of reimbursement programs.“It sounds like a great idea,” he said,“but it assumes that what I do or say always has a direct effect on my patients’ health.” He described a long-term patient he had seen earlier in the week; she had poorly controlleddiabetesyet failed to come into his office regularly in spite of his numerous requests.

“She just can’t afford to take that much time off from work,” he said, adding with a sigh,“Does that make me a worse doctor?”

For a little over a decade, amid calls for improved quality and greater transparency, insurance companies across the country have been“incentivizing quality”— shifting away from traditional fee-for-service reimbursement andturning to pay-for-performance programs. Based on the experiences ofhealth maintenance organizations in the mid-1990s with assessing quality, public and private third-party payers started applying many of the same evaluation criteria to individual physicians and linking reimbursement bonuses to similar, if not identical, clinical goals. The hope was that these well-established goals, such as regularmammogramsand Pap smears andscreening for colon cancerand highcholesterol, would not only improve care and cut costs over the long run but also provide payers and the public a standardized way to compare doctors and the care they deliver.

Health care experts applauded these early initiatives and the new focus on patient outcomes. But over time, many of the same experts began tempering their earlier enthusiasm. Inopinion piecespublished in medical journals, they havevoiced concerns about pay-for-performanceranging from the onerous administrative burden of collecting such large amounts of patient data to the potential worsening of clinician morale andwidening disparities in health care access.

But there has beenno research to datethat has directly studied the one concern driving all of these criticisms— that the premise of the evaluation criteria is flawed. Patient outcomes may not be as inextricably linked to doctors as many pay-for-performance programs presume.

Nowa study published this month in The Journal of the American Medical Associationhas confirmed these experts’ suspicions. Researchers from theMassachusetts General Hospitalin Boston and Harvard Medical School have found that whom doctors care for can have as much of an influence on pay-for-performance rankings as what those doctors do.

Drawing on the experiences of more than 125,000 patients, the researchers first ranked the doctors based on criteria commonly used in pay-for-performance reimbursement plans. While they found that doctors who took care of older or sicker patients tended to rank higher, presumably because of more frequent patient follow-up, the researchers also discovered that primary care practitioners who cared for underinsured, minority and non-English-speaking patients tended to have lower quality rankings than their counterparts.

Using statistical modeling, the researchers then attempted to rerank all the doctors after adjusting for differences in patient characteristics. When they factored patient race, ethnicity, primary language and insurance status into their physician evaluations, many of the original rankings changed, with doctors who worked in community centers— and therefore with more minority and non-English-speaking patients— being more likely to improve in ranking, often by more than 10 percentile points.

“Pay-for-performance can work,” said Dr. Clemens S. Hong, lead author and a general internist at the Massachusetts General Hospital,“but we need more sophisticated measures to make sure we are actually measuring physician quality.”

Addressing the discrepancies highlighted in the study will be challenging. Some health care experts, for example, have suggested paying for improvement rather than performance. Under this model, if over the course of a year doctors are able to increase the numbers of patients who obtain screening tests according to a standardized schedule, their reimbursement would increase.

But such a payment model comes with its own set of issues.“If your patient mammogram rate is 100 percent, there’s no way to improve,” Dr. Hong said.“And do we really want to pay doctors who have only half of their patients getting their mammograms done on time?”

Nevertheless, Dr. Hong and his co-investigators believe that their study only confirms the importance of research efforts focused on developing more sophisticated pay-for-performance measures.“It’s human nature to go to where the incentives are,” Dr. Hong said. Without specific assessment criteria, attributes that are currently measured indirectly or bypassed altogether, like the ability to communicate, build rapport and work with more vulnerable and challenging patients, risk being devalued or ignored.

“When you shine a light on certain measures, you take away from others that are also important,” Dr. Hong said.“Fee-for-service has already driven physicians away from primary care. If we don’t address patient differences, we may do the same thing with pay-for-performance.”

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A Needle (the Origin of a Deadly Malaria Strain) in a Dung Stack

And now it has yielded an unexpected gem: The most dangerous form ofmalariaoriginated in gorillas, not chimps, as had long been believed.

In and of itself, knowing that does nothing to help defeat malaria. But malaria experts were pleased to learn it— and it shows what wonders can be performed when you have 2,700 fecal samples in your freezers and a little imagination.

“There’s a lot you can do with ape scat,” Dr. Hahn said.“It’s worth its weight in gold.”

Dr. Hahn, a virologist at the University of Alabama at Birmingham, is an expert not in malaria but in S.I.V., or simian immunodeficiency virus, the precursor to the virus that causesAIDSin humans. But she has made deals with primate researchers all across Africa who collect fecal samples for their own projects, to have them take extras for her.

They go into vials with a special solution, called RNAlater, that preserves the nucleic acids of all the cells in the sample— which includes not only what apes eat, but cells sloughed off their gut linings, which contain all the things infecting them. She has systematically sequenced the genes of many of those infective agents: S.I.V., simian foamy virus,hepatitisand now malaria parasites.

Herstudywas published Thursday in Nature.

Knowing that gorillas are the source is not going to lead to a new drug, but it is reassuring in one important way, said Frank Collins, a malaria expert at theUniversity of Notre Dame. The human disease probably came from a mutant parasite that crossed over from a single gorilla thousands of years ago. That implies that if malaria is ever wiped out in humans, it is unlikely that it will ever be reintroduced from apes.

Reintroduction is not an idle threat. In 1932, the Rockefeller Foundation gave up on its 17-year campaign to eradicateyellow fever. Its scientists had realized that monkeys carried the same virus, so it would never be wiped out without wiping out monkeys, too.

Opening the freezer door and rescreening 1,827 dung samples from chimpanzees, 805 from gorillas and 107 from bonobos yielded several surprises, Dr. Hahn said.

Chimpanzees across Africa had various malaria parasites; bonobos, their closest relatives, did not. West African gorillas were infected, but East African ones were not. (The populations are kept separate by wide rivers like the Congo and by humans who chop down their jungle habitats and hunt them.)

Until recently, it had been believed that the falciparum strain of malaria— the most deadly kind, which can kill in 48 hours— came from chimpanzees, because the closest relative to it that had been found, the reichenowi strain, was common in chimps.

But previous surveys of ape malaria— which go back as far as 1907— have had obvious flaws, several malariologists said. Most sampled only a few apes, who were usually in captivity or in ape sanctuaries close to humans. One bonobo in one previous study, Dr. Hahn said, had parasites that not only were identical to human strains, but showed resistance to malaria drugs— which meant the bonobo must have caught them from a nearby human, not the other way around.

With the exception of 28 samples from a gorilla troupe habituated to humans,“all my samples are from the forest floor,” she said.

One researcher who sends her samples is David B. Morgan, a primatologist at Lincoln Park Zoo in Chicago and for theWildlife Conservation Societybased at theBronx Zoo, who studies gorillas and chimpanzees in the Goualougo Triangle of the Congo Republic. Dr. Morgan uses fecal samples to track hormone levels, parasites and even family relationships.

He does not try to get blood samples with“biopsydarts” or capture or tranquilize apes for study.

“We want to have as little impact on them as possible,” he said. (Primatologists now frown on the friendly banana-sharing that so endearedJane Goodallto readers of National Geographic decades ago.) He and his local trackers stay at least 35 feet from troupes they watch. They are vaccinated against diseases that apes can catch, take deworming pills and even defecate in bags that they carry back to camp so as not to risk infecting apes with human parasites, which has happened at other sites, he said.

Chasing samples is hard work, said Sabrina Locatelli, aState University of New Yorkprimatologist who works in Africa and collaborates with Dr. Hahn.

With colobus monkeys, who rain feces down from 70 feet up in the forest canopy, finding samples“means keeping your head up and your neck bent to spot them, so it can be painful,” Dr. Locatelli said.

With chimps and gorillas, she said, you follow them until they start building nests for the night, take a GPS point, go back to camp, get a few hours of sleep, and then come back early in the morning to look for samples, which are usually in or near the nest. With luck, the nest also has a few stray hairs, useful for DNA analysis.

Explaining her job to local officials is not easy either, she added.

Seven years ago, she said, when she was negotiating for permission to track bonobos in the Congo, she tried to explain what she wanted by showing park officials a vial of gel used for drying samples.

“It had these tiny blue beads in it,” she said.“People thought I was smuggling diamonds. They just would not believe me. They were saying‘Why would this tiny woman come so far to collect bonobo poop?’ ”

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Robert W. McCollum, Who Studied Viral Diseases, Dies at 85 - Obituary (Obit)

The cause washeart failure, said his daughter, Cynthia McCollum.

Most of Dr. McCollum’s research was done during his nearly three decades as a professor and later chairman of the epidemiology department atYale.

Working on a team at Yale led byDr. Dorothy M. Horstmannin the early 1950s, Dr. McCollum and his colleagues collected blood samples from people with polio and their families. They used some of the samples to isolate the polio virus and discovered that before it reached the spinal cord and paralyzed patients, it circulated in the blood.

That finding was a breakthrough in the understanding of how the virus causes the disease and formed a basis for the development of polio vaccines, which elicitantibodiesto block the virus before it enters the spinal cord.

In the late 1950s, while still at Yale, Dr. McCollum collaborated withDr. Saul KrugmanatNew York Universityto study hepatitis, which can causeliver diseaseand significantly contribute toliver cancer. Their team investigated the disease’s spread through blood transfusions by tracing its patterns in patients at theWillowbrook State Schoolon Staten Island.

The study drew controversy in the late 1960s after accusations that the team had used retarded children as human guinea pigs. But its chief critic in the New York Senate, Seymour B. Thaler of Queens, later conceded that the work had been conducted properly.

The research distinguished serum hepatitis, which is caused by the transfusions, from the more common form, infectious hepatitis, which is spread directly from person to person. That led to research by Dr. McCollum and Dr. Krugman that found that gamma globulin— antibodies collected from blood donors— can prevent hepatitis resulting from a blood transfusion.

Dr. McCollum was also a member of a research team that discovered that using blood from paid donors was risky because it tended to transmit hepatitis. The recommendation that blood banks stop using blood from paid donors has been widely adopted. Dr. McCollum was also on a team at Yale that discovered the viral cause of infectious mononucleosis.

“Bob made substantive contributions to our understanding and the prevention of viral diseases that affect millions of people globally,” Dr. John F. Modlin, a professor ofpediatricsat Dartmouth, said on Friday.

Robert Wayne McCollum Jr. was born on Jan. 29, 1925, in Waco, Tex., the youngest of four children of Robert and Minnie Sue McCollum.

He received his bachelor’s degree from Baylor in 1945, his medical degree from Johns Hopkins in 1948 and, 10 years later, a doctorate in public health from theLondon School of Hygiene and Tropical Medicine. He was hired as research assistant inpreventive medicineat Yale in 1951, but a year later was serving in Korea as a captain in the Army Medical Corps, assigned to a special MASH unit researching hemorrhagicfever.

Dr. McCollum left Yale in 1982 to become dean of the Dartmouth Medical School. In his nearly nine years as dean, he oversaw substantial increases in research financing and established eight new endowed chairs for the school’s faculty. He also played a central role in the creation of the Dartmouth-Hitchcock Medical Center in Lebanon, N.H. Dr. McCollum retired as dean in 1990 and retired from teaching in 1995.

Besides his daughter, he is survived by his wife of 56 years, the former Audrey Talmage; a son, Douglas; and two grandchildren.

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Cases Without Borders - Weighing the Lives of Premature Babies in Haiti

It was the first week of May, almost four months after the earthquake, and the situation remained dire. Rubble was everywhere, many buildings were unusable, and all of the pediatric care was being given in tents. Supplies were sparse and unreliable.

The obstetricians at the General were on strike, and women in labor were being told to go elsewhere. But word had gotten out that there were American doctors at the hospital, and many patients simply refused to leave.

So it was on that rainy Sunday evening that there were six women in active labor in the emergency room. And soon one of them, in her late teens, gave birth to a tiny boy, just 2 pounds 3 ounces. A neonatologist on our team estimated that he was two months premature. (The mother claimed she hadn’t even known she was pregnant.)

Premature babies can get into a lot of trouble, and the smaller they are, the higher their risk of complications. They usually have difficulty maintaining a normal body temperature, losing heat to their surroundings faster than they can generate it. This is why they are kept in incubators until they are able to stay warm on their own. They are at high risk for infections, along with feeding and breathing problems.

Once the baby was born, we dried and swaddled him and started looking for a place where he could be cared for until he was stable enough to be sent home. There were no working incubators at the hospital, nor any free beds in the pediatric tents, and we had no luck finding incubators at otherhospitals.

Then an American physician at another medical camp told us that he had faced a similar situation some days before, and had built his own incubator—“MacGyver” style, as he put it. He suggested we do the same.

So that’s what we did. We took a cardboard box from the medical supply room, padded it with some surgical drapes and a blanket and found a desk lamp with a working bulb to serve as a source of heat. Voilà! Our youngest patient now had an incubator.

The next morning we tried to persuade the attending Haitian pediatrician to accept the baby to the pediatric tents.“Don’t be absurd!” she scoffed, as I recall.“A baby that small will not make it. He has no chance of survival, and we have no spare beds to waste.”

None of us felt comfortable arguing with her. Still, we knew that to send the baby to his mother’s tent city while he was still so vulnerable would be a death sentence. So we decided to keep him and his mother in the emergency room until a proper place could be found— understanding that we needed to find a solution before returning to Boston, as the group that would follow us did not include pediatricians qualified to treat complications of prematurity.

A baby bottle was found, along with clothes and diapers. The nurses taught his mother how to express milk into the bottle and to feed him. We’d been calling him“baby in the box”; now he became Jack, as in Jack in the box. He did very well, and his mother, after overcoming her surprise at his unexpected appearance, bonded with and cared for him devotedly.

Each day we pressed his case to the Haitian medical team, and each day we were turned down.“There is no room for him,” we were told, though there seemed to be beds for other children in the pediatric tents.

Finally, on Friday, we found an incubator for him at another hospital. We transferred him and his mother there, satisfied that we had gotten him through those first few days, but soberly aware of the odds he faced going forward. The next day we left for Boston.

Six weeks after our return, at an informal reunion, the neonatologist told us he had learned that Jack had been discharged home with his mother in good health, weighing five and a half pounds.

We were thrilled. Our stubbornness had paid off.

But our euphoria was tempered by a somber reality. Looking at the big picture, we had to concede that the Haitian doctors were probably right.

We were in Port-au-Prince, after all, not Boston. Surely the Haitians, acutely aware of what they could and could not do with the resources they had, would know better than a group of well-intentioned foreigners accustomed to the best equipment money can buy. Didn’t it make more sense to invest time, effort and scarce resources in a baby with a better chance of surviving?

Yet ultimately this was not an abstract discussion about the proper allocation of medical resources in an impoverished country, but a decision about the fate of a baby who was very much alive. He was our patient, and we were determined to give him the best possible care.

In the little-picture view, a life had been saved.

Dr. Dennis Rosen is a pediatric pulmonologist at Children’s Hospital Boston and an instructor at Harvard Medical School.

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F.D.A. to Severely Restrict Diabetes Drug Avandia

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Pill Drop-Offs Aid Effort to Clear Medicine Cabinets

From 10 a.m. to 2 p.m., people young and old delivered bag after bag of pills, including the types of powerful painkillers and anti-anxietydrugs that theDrug Enforcement Administration, which coordinated the program nationally, was hoping for. More than anything, the goal was to empty homes of legal but dangerous drugs that the authorities say are driving addiction and crime around the country.

“We’re getting a cocktail of just about everything,” said Milton Tyrrell, a special agent for the D.E.A. in Worcester who was supervising the collection in Russell Park.

Some of those who showed up did not want to identify themselves or discuss what brought them out, silently dumping their pills into boxes provided by the D.E.A. and hurrying off. Others said they were dropped off drugs that had belonged to relatives who were now dead, or elderly people who had let medicines pile up in their homes for too long.

“My 99-year-old aunt read about it in the paper and cleaned out all her medicine cabinets,” said Judy Hayden of Worcester, who brought mostly blood-pressure medications.“Thank God they’re doing this, because it seems like the whole city is on pills.”

Nationally, there were more than 4,000 drop-off locations– mostly police departments, but also sports complexes, big-box stores, strip malls and even a race track. In Worcester, Mr. Tyrrell listed Vicodin, Percocet and Lorazepam, which is taken for anxiety, among the drugs collected, as well as less potent medications that had been sitting in people’s bathrooms for decades.

Mary Whitehead Santos of Charlton, who dropped off two shopping bags full of pills, said her son, a physician, had talked her into doing so. Some of the drugs she deposited into the collection boxes had been prescribed in the mid-80s, she said.

“I kept hanging onto them thinking,‘They’ve got to be good for something,”’ she said, laughing.“My son kind of forced me out here, I guess. I’m not bringing the hard-core stuff that they’re looking for, but it’s good to finally be rid of it.”

In East Boston, a neighborhood of Boston that has struggled with addiction problems, the police station serving as a drop-off spot did not see much activity– possibly, officials there said, because the city only got the word out over the last week or two. Still, Joe Favale, a retired police officer, brought two bags that his girlfriend and a friend of hers had assembled. The bags contained three bottles of oxycodone, a highly addictive painkiller, as well as drugs formigraine headaches,asthma,acid refluxand other ailments.

“She wouldn’t throw it out because she was concerned for the environment,” Mr. Favale said of his girlfriend.“I myself was totally unaware that you shouldn’t throw the stuff away. When I have a couple of pills left over, I’m used to putting them down the garbage disposal.”

While the main goal of the take-back day was to reduce the volume of pills in households, law enforcement officials said the environmental benefits were important, too. The collected drugs will be incinerated instead of flushed down toilets, which can release them into the water supply.

Mr. Favale, who said he retired from the Boston Police Department in 2007, said he was taken aback by how big a problem prescription drug trafficking had become.

“The whole time I worked here in the 80s and 90s,” he said,“the concern was street drugs– reefer, cocaine, stuff like that.”

Matthew Murphy, assistant special agent in charge of the D.E.A.’s New England field division in Boston, said he had heard anecdotally that many sites in the region had an“overwhelming” response.

Mr. Murphy said that in Massachusetts, the National Guard would transport all of the drugs collected to five incineration sites and most would be destroyed by day’s end.

“We didn’t know what to expect,” he said.“But the public has been great; we had to go to trash bags in some cases because we ran out of boxes. We’ve had people show up and bring pharmaceutical products they’ve had around for 30 years.”

Mr. Murphy said he had heard about oxycontin and oxycodone, some of the most addictive opiate painkillers, being dropped off at several locations around New England. Even if only a small amount of that type of drug was collected, he said, the whole effort would be worthwhile.

“Any amount of that is great to get off the streets,” he said.“For us, that’s huge.”

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Vital Signs - A Good Massage Brings Biological Changes, Too

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