The Bell Curve

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The Bell Curve

• Is it okay to be average?
• Who is the average person in this school, class,
  ect?
• Is trying hard enough? See Falling Down.

2
Meaningful way to measure the immeasurable

• Once you have some data what you do with it
  ingenuity that makes a dif. In lives grades, ,
  politics, and so on.
• Well see how this applies to treating a rare
  fatal ailment of the respiratory system

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Case study Annie, Signs/symptoms

• Salty taste to the skin
• Wheezy breathing
• Small end of the growth chart
• Not quite malnourished, but not healthy
• Failure to thrive
• Can be lots of causes GH, lead poisoning, HIV,
  parasites
• Do a sweat test measure conc of Cl in sweat

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Diagnosis

• High Cl Cystic Fibrosis
• Recessive gene carried by 10 mil Americans
• Sits on arm of chromosome 7
• 1K kids a year diagnosed

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Pathology

• Mutant protein messes with cells metabolism of
  Cl
• Cl build up thickens secretions around body
• Flow of digestive enzymes from pancreas blocked
  less able to absorb food
• Thickened mucus covers airways, shrinking lung
  capacity, till you have none

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Prognosis Lucky for Annie

• She lives in Cincinnati.
• C. Childrens Hospital reputation as one of the
  best in the country
• Where the bible of the specialty was written
• Staff skilled, energetic, dedicated
• Staff learns about patients before meeting them
• They give you a summary of your visit at the end.
• After a meeting median survival for CF 30 years
  in Annies life that could go to 40

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Treatment

• Enzyme pills, other supplements, calorie rich
  diet, percussive therapy to loosen mucus in
  lungs, inhalant
• New life for Annie's family

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However and but you see

• CCHospital not the best, just an average program.
  
• So what?

9

• At an avg. center patients live 30
• At the top 46
• And for some predictors like Lung capacity
  CCHospital was in the bottom 25
• And CCH knows these stats.

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Assumptions vs. Reality

• Dif among hospitals doctors insig.
• Everyones pretty good
• Evidence shows its more like a bell curve

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Whats the Bell curve mean?

• For a hernia operation
• Bottom 1 in 10 chance of recurrence
• Middle group 1 in 20 chance
• Elite 1 in 500
• A hernia is a protrusion of a tissue, structure,
  or part of an organ through the muscular tissue
  or the membrane by which it is normally contained
  

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• For N.I.C.U. death rates 16, 10, 6
• In vitro fertilization attempts 15, 40, 65
  success rates
• SOME PLACES ARE BETTER THAN OTHERS

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• Are all Dr.s doing the best job they can?
• Giving patients the best chance?
• Should Drs have published win/loss records?
  Should teachers?

14

• Healthgrades.com will tell you basic stuff
• Fired before? Criminal record?
• But you want to know more than that
• But detailed comparisons get hard
• 86-92 the gov. released a death list ranking
  hospitals by death rate of elderly and disabled
  patients on medicare.
• Why is this a useless list?

15

• Most elderly/disabled are already sick to begin
  with.
• Public ignored rankings
• Why is death rate for average patients a poor
  indicator?

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• It rarely happens and when it does its
  inevitable cancer, car crashes
• What do you really want to know about your Dr?

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• How doctors do in the typical stuff
• Measure of the process
• What steps do they take along the way
• This huge load of paperwork is now being studied.
• USNewsWorldReport ranks hosptials by
• Ability to excel at treating a variety of
  demanding illnesses within a specialty,
  affiliations with medical schools, surveys of
  physicians, reputation, d.rate, advanced
  facilities

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Back to CF

• CFF Always been ahead in recording care
• In the 1960s a guy named LeRoy Matthews drove
  everyone crazy.
• Im way better than everyone else
• My mortality is 2, everyone elses is 20
• No one knew so they did a study and he was
  exaggerating, but he was better than everyone
  else
• Just like me.

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Be a positive deviant

• Matthews tried every new approach, hounded his
  patients to treat themselves
• He was aggressive from the start.
• So everyone started doing what he did and CF
  mortality declined

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• Matthews has stayed ahead of the bell curve even
  as everyone else improved.
• Avg 30 years vs. 46
• Its tough explaining why variability remains.
• CF Is incredibly standardized. We know how to do
  it right.
• What happens when patients find out about
  variability?

21

• CChospital decides to tell patients where they
  are on the bell curve.
• Why? They got a boatload of from a guy named
  Don Berwick

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Berwick

• Former pediatrician founded Institute for
  Healthcare improvement
• Gives out big for trying new ideas
• Harvard Prof.
• 2002 Modern Healthcare called him the 3rd most
  powerful person in American healthcare after the
  secretary of health and human services 1st, head
  of medicare medicaid 2nd, where is surgeon
  general?
• Good paper idea Who is currently the top 3 most
  powerful people in healthcare in the U.S.?

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Why is Berwick powerful

• Because of how he thinks
• What happens to flawed organizations in a
  disaster?
• Firefighters in a forest fire
• Students in a school shooting.
• Cthulhu, Godzilla, or zombie outbreak,
• Indiv. Lose the ability to think as indiv, and
  act together.
• This is happening to medicine

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Berwicks solution

• Measure processes
• Be more open about what we are doing
• Patients should have total access
• No secrets
• This is a moral good, he claims
• Is it?
• Should students have total access to what
  teachers do, if thats the case should teachers
  have total access to what students do?

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Berwick got his from Robert Wood Johnson
Foundation

• nations largest NP Org. devoted exclusively to
  health.
• 10 billion in assets, generating grants
  approaching 500 million a year
• From 91 -03 spent 446 mil fighting tobaccoo cos
• Now using lessons from that to target obesity.
• Opposed by tobaccoo and alcohol groups
• The guy who made Johnson Johnson
• WWII Brigadier Gen.

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CChospital tells its patients where it stands

• They didnt make excuses, and to the patients
  they appeared desperate to do better.
• Patients stayed because they known these
  drs/nurses for years, and believed in them.
• Why is belief in that sentence? This is science.
  

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Other NPO sources of big

• Howard Hughes Memorial Institute
• Worth 16.3 bil,
• For years Hughes was the sole trustee and put all
  of his companies stocks into it, making a huge
  defense contractor a tax exempt entity
• The man
• Wellcome Trust in UK
• Worth 26.8 Billion

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So CCH tells the patients

• Some patients would leave if things didnt
  improve.
• The hospital put patients families on review
  committees to assess what the hospital could do.
• They got the names of the best CF centers and
  went there

Truth, Justice, The American Way
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The best

• Minnesota CF cntr. At Fairview-University CH in
  Minneapolis
• Headed by Warwick, the guy who originally studied
  LeRoy Matthews claims in the past
• Does whatever he can
• They do everything everyone else does, but they
  do it dif.

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Compare CCH and MCFC

• Teen might be at 67 lung capacity, down from
  normal 80
• do some Q A
• School? Meds? Calories?
• send a nurse home to check
• And schedule an earlier return visit than normal

• Teen might be at 90 down from normal 110 (They
  do better than normal)
• Do some Q A
• Same as the other, but they get more intense,
  arent satisfied with answers
• Will gently remind patients of mortality until
  they cry.
• FOCUS, AGRRESIVE, INVENTIVE
• Dont like it, go die somewhere else
• Not everyone can work with this, but he gets
  results

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The Minneapolis looks at it

• CF patients are good scientists, they experiment
  with their treatments.
• Sometimes they stop treatment and they dont get
  sick and think were nuts
• BUT chance of getting sick with CF on any one
  day is 0.5
• THEN chance of getting sick with CF on any one
  day with treatment is 0.05

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SO WHAT

• 99.5 chance of health vs 99.95 chance is pretty
  small on one day.
• Over a year that turns into 83 vs. 16
• ALL THE SMALL THINGS MAKE A DIF.
• Butterfly/Hurricane
• Warwick has the bedside manner of Montel
  Williams, Oprah, Dr. Phil.
• And he can improvise, invent, think fast on the
  spot

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• If that 67 teen was with Warwick shed already
  have feeding tube in her
• Warwick doesnt wait for national results, he
  goes with what works.
• Hes innovated
• Mechanized chest thumping vest
• New, powerful ways to cough
• So CCH is changing to follow his ways

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• Current thought is that Drs rely on science and
  skill.
• True that is the basics of what is expected
• Aggressiveness, diligence, and ingenuity can pull
  you out of average. Then everyone has to catch
  up to you
• You have to have the capacity to learn and change
  and do it faster than everyone else

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How should the bell curve be used

• Fine the bottom half?
• Inform patients of your score?
• Correlate pay with ranking?
• Probably
• Insurance cos hold back 10 of payments until
  specific goals are met
• Medicare wont pay for intestinal transplants
  until surgeons have good track record

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Raises questions

• WHO GETS TO GRADE?
• Are they grading the right things
• Is there shame in being average?
• Not for some things
• But If youre a professional there is.