|WHAT WE’RE READING
Stuff we read this week that made us think
A jarring report on a children’s heart program
Since 2016, pediatric cardiologists at North Carolina Children’s Hospital have questioned the hospital’s cardiac surgery outcomes, asking in department meetings, “Would I have my children have surgery here?”, while still referring patients to the program, according to a must-read New York Times investigative report. The thoroughly-researched investigation uncovered a pattern of poor outcomes, lack of transparency, and inaction by hospital leaders—much of it substantiated by secret recordings made at department meetings. The hospital’s cardiac surgery program, part of Raleigh, NC-based UNC Health Care, continued to operate for years despite concerns about safety, junior surgeon turnover, low volumes and lack of resources. (The hospital does not have a cardiac ICU or a cardiac intensivist.) The program’s mortality rate appears to be more than double that of the average pediatric cardiac surgery program. But the hospital is one of a small fraction of programs that does not submit data to the gold-standard Society of Thoracic Surgeons (STS) outcomes registry, so actual performance over time is not publicly known—nor was it made available to inquiring referring cardiologists.
The situation at UNC highlights structural issues endemic to healthcare quality and safety, perpetuated by a defensive culture and a flawed payment system. UNC administrators failed to follow through on promised safety investigations, and implicitly threatened staff cardiologists who considered referring elsewhere with staff cuts, should surgery volumes fall—creating a culture in which speaking up in the face of serious quality concerns is frowned upon. Compare this to the culture of the Toyota Production System, where any concerned worker can stop a production line if serious problems occur. Or commercial aviation, where recently all Boeing 737 MAX planes worldwide were grounded until their safety could be ensured. Further, despite research showing a strong correlation between program volume and outcomes, hospitals are reluctant to walk away from low-quality, high-margin lines of business—even if lack of scale jeopardizes outcomes. According to the Times, two-thirds of all pediatric cardiac surgery programs operate within 25 miles of another similar program. It takes a population of 500,000 people to provide enough volume for one pediatric cardiologist—and several of those are required to support one surgeon. Regional centers of excellence that put safety and quality ahead of institutional prestige and financial performance should be the norm, especially for programs that require very specialized expertise.
Price discrimination on aisle two
Most parents of small children would tell you that there is one Tylenol (acetaminophen) product for infants and a different one for older children. But a story on NPR reveals that these two varieties of Tylenol are exactly the same medicine, at the same concentration, put into two different bottles—but sold at dramatically different prices. Infant Tylenol was three times more potent than the children’s version until 2011, when the formula was changed at the urging of the Food and Drug Administration to prevent overdoses. Today both versions contain 160 mg/5 ml of liquid Tylenol. But the price differential remains: Infant Tylenol is now sold at $4.99 for a one-ounce bottle; the children’s bottle also costs $4.99, but for four ounces of liquid. A company representative justified the 300 percent price difference as due to a harder plastic bottle and dosing syringe for the infant version (unlikely, as a quick Amazon search shows that a similar oral syringe costs a mere 11 cents). There is no special dosing information on Infant Tylenol either. Both versions say to “ask a doctor” for children under 2. Johnson & Johnson, the maker of Tylenol, has gotten away with blatant overcharging for nearly a decade, showing just how difficult healthcare prices are for consumers to evaluate—even for the simplest things. When it comes to our health, or that of our children, most of us are just in the habit of following labels and instructions, and not asking questions.
Sorry, but there’s no magic to 10,000 steps a day
Though we have long relegated our Fitbits to a dusty drawer, there was a time when we walked around aimlessly in the evening in pursuit of that magical 10,000 steps per day. It turns out that goal wasn’t based on science at all, but instead had its origins in a marketing campaign for a Japanese pedometer. A new paper in JAMA attempts to actually measure what level of step activity is needed to increase longevity, evaluating four years of pedometer data from over 17,000 older women (average age of 72). Researchers found good news for those of us who have trouble hitting the lofty 10,000 step goal: participants who walked an average of just 4,400 steps per day had 41 percent lower mortality compared to those who walked an average of 2,700 steps. There was a further steady decline in mortality up to approximately 7,500 steps, after which gains tapered off. While it’s hard to argue against physical activity, the 10,000 steps goal is an example of pseudoscience that has been perpetuated by media, fitness gurus, and healthcare organizations, with insurers like UnitedHealthcare even incorporating it into their benefits plans. The goal can be frustrating for individuals who can’t regularly hit it, often leading to less activity rather than more. While the new study is far from conclusive, activity programs oriented around lower levels of moderate activity likely present a better option for improving the health of a population.