Category: Policy and politics

A head lice policy that isn’t a nuisance

published date
October 20th, 2006 by

A head lice policy that isn’t a nuisance

As I’ve written before (George Bush: Louse Enabler?), schools tend to go overboard on their head lice policies, enforcing strict “no nit” rules that don’t make a lot of sense. So I was happy when I found the following announcement from a local school. It seems like a very sane way to go:

We realize that some parents are quite concerned about head lice, and wanted to provide some useful information to inform you about what we are experiencing and to reassure you about how we manage the problem as an institution. [Note: a recent newsletter article gave parents practical tips on lice management at home.]

Why are there so many cases of lice this year?

We had heard reports that summer camps were over-run with cases of lice this summer, so we anticipated that we might experience more problems than usual at the start of the school year. That is why we reminded parents about checking heads carefully before school began (in the August packet) and why we remind parents to continue to do so every week in the newsletter.

To put things in perspective, we have experienced less than ten cases of lice in the entire school so far this year.

Why don’t we do school-wide head checks like some other schools do?

Experience has taught us that conducting school-wide head checks is not only disruptive to teachers and students and very time-consuming, but also that it rarely yields any cases of lice. At home, parents can do a much more thorough exam of their own children on a regular basis. That is why we ask you to take that responsibility.

Neither the American Academy of Pediatrics nor the National Association of School Nurses is in favor of group screenings. Both research and anecdotal reports have indicated that the excessive amount of time it takes to conduct group screenings is not productive.

Why does our school have a “modified no-nit policy”?

We modified our policy several years ago to keep in line with the most recent research concerning head lice management, and we follow recommendations from the American Academy of Pediatrics and the National Association of School Nurses.

According to Richard J. Pollack, PhD, of Harvard School of Public Health, “No child should lose even an hour of school because of head lice. By the time you find head lice, that child has likely been infested for a month or more.” Therefore, we have chosen to have a different policy than the policies still in place in some other schools and school systems. Our policy reflects good, current clinical practice. We have an excellent, ongoing relationship with the local Department of Public Health, our nursing and medical liaisons there are fully supportive of how we handle head lice.

Here is what our experience has been:

  • In the several years since we modified our policy, we have actually experienced a decrease in the numbers of children who develop head lice after cases are diagnosed and appropriate management begun.
  • Most cases of head lice in our school have been discovered by parents when the child is at home. This year, only one of the cases of head lice was diagnosed by the nurses while the child was in school, and that child’s parents chose to take the child home early.
  • In every instance where the nurses have checked children’s heads in a classroom because a case of lice has been reported, no other cases have been detected from that check. That is a common reported experience from schools across the country. It bolsters the fact that head lice are less communicable than people realize. Remember, lice cannot jump or fly: they are communicated by very close contact with somebody who has the problem.

Therefore, educating students about measures to avoid the problem, such as wearing hair tied back, not sharing hats or other hair implements, and not putting heads together, is a much more effective tool than excluding children from the classroom. We also take institutional measures, such as careful vacuuming, putting away dress-up clothes, etc, when indicated. We suggest that parents reconsider having sleepovers when there are reported cases of lice in their childՉ۪s grade.

  • Once a child is diagnosed with head lice, we work closely with parents to help manage the case effectively. We check affected children when indicated and check in with parents to see if they need further advice and support. Since having head lice in the family is never a pleasant experience, we know that parents whose children have lice do everything in their power (following our instructions and those of their pediatricians) to take care of the problem.

We hope that this information helps parents to put the lice situation in perspective.

Children’s Hospital switches on the boob tube

published date
October 17th, 2006 by

Children’s Hospital switches on the boob tube

From the Boston Globe (Pediatricians criticize use of TVs in hospital)

Children’s Hospital Boston, which runs a center that is an authority on the effects of television on children, has TVs throughout the building, some of which show programs to infants.Cartoons, educational programs, and other shows are shown to children as young as 2 months old; the Globe observed two babies on their backs with screens playing cartoons a foot from their faces.

At a minimum it should help the little ones acclimate to US airports, where it can be impossible to get away from CNN.

Information is the answer

published date
October 16th, 2006 by

Information is the answer

ABC News is running Prescription for Change, a week-long series focusing on what ails the US health care system and what to do about it. As part of the event they asked me to write an opinion piece, which is published on the ABC News website under the headline More, Better Information Key in Fixing Healthcare. Matthew Holt of the Health Care Blog also contributed an article, entitled Why is Fixing American Healthcare So Difficult?

Here’s my original piece:

The US health care system is a mess by any measure. Costs are far higher than anywhere else in the world but life expectancy and infant mortality are worse than average. To add insult to injury, customer service is often abysmal.

It doesn’’t have to be this way. Other sectors of the US service economy –such as retail, financial services, and lodging– are the envy of the world. Companies like Vanguard, Target and Hampton Inns offer higher quality, better customer service and lower prices than you’ll find in other countries. The US health care system could be like that, too, but the archaic culture of medical providers, distortion of the market by the third-party payment system, and resistance to trading off costs and benefits complicate reform.

The best hope for reforming US health care lies in utilizing information. We need to generate more and better information, make better use of the information we have, and be willing to use information to make tough choices.

The good news is that it is starting to happen.

Generating more and better information

The kind of information we take for granted in other sectors is unavailable in health care:

  • How good is your doctor, really?
  • Which specialist is best for your condition?
  • Is that academic medical center with the great reputation better than the community hospital down the street?
  • How likely are you to die from a medical error?
  • How much does an operation cost at one hospital compared to another?
  • Does that drug you were prescribed work? What were the other options for treatment?
  • How much does the drug really cost (not just the co-pay)?
  • Is the drug any better than a generic?
  • How does your genetic makeup affect the treatment you should get?

These questions are beginning to be answerable. Consortia like Massachusetts Health Quality Partners and Integrated Healthcare Association along with private companies such as HealthGrades provide objective information on quality and patient experience. (They still can’t quite say ““customer satisfaction.”) Medicare’’s Hospital Compare website has information about key quality indicators. Various ““transparency”” initiatives are underway to provide information on costs. Consumer Reports rates drugs and Wal-Mart is showing just how inexpensive generics can be. Genetic profiling is farther off, but groups like the Brain Resource Company are starting to make personalized medicine a reality.

Making better use of information

It’s not enough to make information available. We have to become better users of information and better communicators. We should also analyze and act on data that are currently ignored. Empowered consumers are taking the lead: doing research on the internet, establishing personal health records, demanding a greater role in their care, even negotiating prices. Now we need medical professionals to step up.

Many physicians are lousy communicators. Doctors are hardworking and dedicated, but generally donՉ۪t use email, donՉ۪t keep records electronically, rely on treatments theyՉ۪re comfortable with rather than using evidence-based medicine, and are insufficiently skeptical of information from biased sources (like drug reps). Physicians rarely explain alternative treatments; many do a poor job communicating diagnoses, laboratory findings and information about drugs. Primary care physicians and specialists often drop the ball in communicating with each other about patients they are treating, leaving the patient or caregiver to try to close the loop on their own. And most physicians have no idea what anything costs.

Pharmacists are rarely better. They spend six years in school learning more about drugs than most doctors will ever know, then disappear to the back of the pharmacy to count pills. Pharmacies are convenient and accessible; their pharmacists are a vast untapped information source.

The introduction of electronic health records and electronic prescribing are helping, but are only part of the solution. We need health information exchanges, like the ones piloted by the Massachusetts eHealth Collaborative, to share patient data. We need secure, efficient platforms such as RelayHealth for doctor/patient messaging. We need decision support tools like SimulConsult to organize clinical findings to help diagnose rare diseases, sparing patients the misery of going from doctor to doctor in search of a name and treatment for their condition. We need more patient communities such as Patients Like Me and treatment planning tools such as NexCura.

We should make better use of information from existing diagnostic tools. Advanced analysis software from companies such as AMID mines digital data from inexpensive ultrasounds, reducing the need for expensive MRIs and PET scans. iCardiac Technologies analyzes ECGs already collected for clinical trials, identifying cardiac safety problems early in drug development, before the next Vioxx comes to market.

Using information to make tough choices

Better availability of information will improve quality and customer service, but while information technology cheerleaders promise that big cost savings will inevitably follow adoption, thatՉ۪s by no means certain. Some efficiencies will be gained by eliminating transcription costs and reducing duplication of tests, but better information may actually lead to higher spending. After all, with more information about their conditions, patients may seek additional treatment.

Information can be used to hold down health care costs, but that requires political will. In the UK, the ironically named NICE (National Institute for Health and Clinical Excellence) evaluates treatments based on data and decides if benefits outweigh costs. When the answer is no, as it often is, the National Health Service won’t cover the treatment. In Germany, whole classes of drugs are evaluated to determine whether on-patent products are more effective than generics. If not, branded products are reimbursed at the same (low) level as generics.

If we choose as a society to use information for hard decisions, costs will be contained. But the model will be different from the UK and Germany. WeՉ۪ll use incentives and cost sharing, not outright bans and price controls. Examples are emerging in the public and private sectors.

Within a decade there will be plenty of good information available and we’’ll have learned to use it well. Then we’ll finally be headed toward a health care system worthy of respect.

Underworked docs in the UK

published date
October 11th, 2006 by

Underworked docs in the UK

An article in the Daily Telegraph, Britain will need to hire thousands more “junior” doctors due to European Union work restrictions. The docs can currently work 58 hours per week, but an EU directive will compel a drop to 56 hours in 2007 and 48 hours in 2009. What’s more, time on call must be counted in the total.

There’s such a thing as a doctor working too many hours, but this is ridiculous.

This conscientious objector case is a little shocking

published date
October 9th, 2006 by

This conscientious objector case is a little shocking

From the Boston Globe (Army-financed doctor granted objector status)

An anesthesiologist whose medical training was financed by the Army must be discharged from the Army Reserve as a conscientious objector, a federal judge ruled yesterday.

Dr. Mary Hanna, for whom the Army paid approximately $184,000 to attend the Tufts University School of Medicine, had been scheduled to report to active duty Tuesday at Fort Bliss, Texas. Last December, as she neared the end of her residency at Beth Israel Deaconess Medical Center in Boston, Hanna notified the Army that her renewed religious beliefs [she is a Coptic Christian] were now incompatible with military service.

I don’t know the woman or the details of her case, but it all sounds a little too convenient.

There’s a long history in the US of conscientious objectors serving as medics or performing alternative civilian service (along with some “absolutists” who refused to serve in any way.) Is it really too much to expect for Dr. Hanna to work in an Army field hospital in Iraq or Afghanistan? How about a military hospital in Germany? Or a VA hospital in Boston? Or a public clinic?