Category: Health Policy

Today’s Most Attractive National ACO Model Is Offered By…CMS (at HealthAffairs)

I recently helped write an op-ed at HealthAffairs on the Next Generation ACO Model, one of Medicare’s pilot initiatives aimed at improving the Medicare Shared Savings Program Accountable Care Organization model:

A large national payer recently announced the opportunity for Accountable Care Organizations (ACOs) to share in 100 percent of the savings they create for the payer’s largest book of business. Providers will have complete autonomy in how they manage the health of their population, and the payer will ensure the timely flow of datasets needed to support care improvement activities. The payer will pre-define the ACO’s population and its spending benchmark, which will be adjusted for the risk of the ACO population. Consumers aligned to the ACO will be offered supplemental benefits and financial incentives to seek care from the ACO’s network.

Market-watching ACOs can be forgiven for wondering how they missed the slew of journal articles, blogs, and op-eds lauding the “best practice” design features of this new model — because they never materialized. The deal in question is, of course, the Next Generation ACO model currently being offered by the CMS Innovation Center (CMMI). But perhaps because of the hit-and-miss track record of the Centers for Medicare and Medicaid Services’ (CMS) ACO portfolio over the past five years, the reaction of the health policy intelligentsia has been curiously tepid. Savvy provider organizations, however, are increasingly gravitating toward Next Gen’s market-leading deal terms. Those ACO operators that don’t consider the Next Gen model this spring risk being locked out for the foreseeable future.

You can read it here.

NextGen ACOs and a Comment to the US Senate Committee on Finance

I wrote a post for Evolent Health’s blog and a Comment to the US Senate Committee on Finance’s Chronic Care Working Group (on behalf of Evolent).

First paragraph:

The provision of health care is changing more quickly than any time in recent memory. While this is happening in both the public and the private sector, we’re thrilled about two recent efforts coming from the Center for Medicare and Medicaid Services (CMS) and the United States Senate Committee on Finance: the first cohort of Next Generation Accountable Care Organization (ACO) members were announced, and the Bipartisan Chronic Care Working Group released a policy options document and solicited comments on it.

Check them out, and let me know what you think!

C. diff is even more common than we thought. The cure? Poop.

C. difficile was responsible for almost half a million infections and was associated with approximately 29,000 deaths in 2011″

From a recent article in the New England Journal of Medicine. Clostridium difficile, or c. diff, is a truly awful hospital- and nursing home-acquired infection that is not easily cured with antibiotics; in fact, antibiotics are often the proximate cause of a c. diff exacerbation (from a previous post I wrote on the infection):

C. diff is more difficult to treat than most other bacteria; a powerful antibiotic such as ciprofloxacin (every traveler’s favorite) will wipe out much in the gut microbiome, but not c. diff. Once the other bacteria is killed off, c. diff spreads, causing inflammation of the colon, which manifests symptomatically as diarrhea, abdominal pain, and fever in mild cases, septicemia in severe. Treatment has historically involved metronidazole or a vancomycin/rifaximin combo, which (typically) does works on c. diff.

But those antibiotic courses are long – up to a month – and only work initially 60% of the time; less often for a second or third bout of c. diff. Sometimes, a patient will have to be in a hospital bed to receive the treatment (in an isolation bed, which are always in high demand).

The solution? Poop. I’ve written enough about fecal transplants that it isn’t worth re-hashing here, but suffice it to say that the procedure is remarkably effective at tamping down a c. diff  exacerbation.

Nearly 30,000 Americans are killed annually by c. diff, which is nearly as many as are killed by motor vehicle accidents. They don’t have to be; fecal transplants are a cheap, and effective treatment, with few side effects to boot. Cue all the frustration.

The New Yorker’s Article on Fecal Transplants is Excellent

Fecal bacteria sample

On Fecal Microbiota Transplant (FMT), from a recent (excellent) New Yorker article by Emily Eakin:

“Nothing in health care works ninety per cent of the time,” Mark B. Smith, a microbiologist at M.I.T. who is a co-founder of OpenBiome, the stool bank, told me. Zain Kassam, a gastroenterologist who is OpenBiome’s chief medical officer, put it this way: “It’s the closest thing to a miracle I’ve seen in medicine.”

This piqued my interest; as Darius Tahir put it on Twitter,

Pretty much. I’ve written about fecal transplants and the microbiome a number of times in the past few years – see here, here, and here, for starters – and am glad to see some of the same research discussed in this article.

Life-Saving Poop, Now in Pill Form

Ingesting fecal material is an excellent way to pick up some pretty nasty diseases, like cholera, typhoid fever (as I can personally attest), and a variety of other diarrhea-causing agents that, together, kill 800,000 children five years or younger each year. That’s 2,200 child deaths each day. It’s horrifying.

But paradoxically, ingesting cleaned, filtered, and safe fecal material can save lives, too.

Fecal bacteria sample


Researchers at Massachusetts General Hospital have created a pill containing filtered fecal material that successfully treated 19 of 20 patients with Clostridium difficile, according to a study in the Journal of the American Medical Association. 

It’s worth repeating: this is a poop pill. And it holds the potential to save tens of thousands of lives every year. 

Though the study was quite small, it shows that fecal transplants – an extremely effective but tedious and labor-intensive procedure – can be accomplished using two or three days’ worth of simple-to-ingest pills. If larger clinical trials are successful, this will be a game-changing therapy.

Clostridium difficile, or c. diff, is a disease that is resistant to many antibiotics and kills 14,000 Americans each year. I wrote a lot about it for a Project Millennialpost last year, but the short version is that c. diff is a hospital-acquired infection that becomes problematic once a patient’s microbiome is altered – often by antibiotics that kill many types of bacteria but spare c diff.  Unconstrained by the “good” bacteria (yes, I’m simplifying here), c. diff takes over the microbiome, causing diarrhea, fever, abdominal pain, and sometimes septicemia.

Treating a c. diff exacerbation with the traditional antibiotic regime can take weeks (often in an inpatient setting) and isn’t all that effective. Fecal transplants, by contrast, lead to quick recovery and are very effective; they don’t actually wipe out c. diff, but in restoring microbiome homeostasis they “tamp it down.” And the procedure works.

More trials need to be completed to ensure that a fecal transplant in pill form is as safe and effective as early results indicate.  If the trials are successful, this therapy will be an absolute medical game-changer.

In addition to being easier to carry out, a fecal transplant in pill form will mitigate the yuck factor (even if it doesn’t entirely get rid of it). The pill fecal transplant works in a matter of days and would likely be done on an outpatient basis, which would save thousands of dollars per patient and free up hospital beds for other patients.  And finally, it bears repeating that the therapy works.

Intriguingly, this modest success opens up the possibility of pill fecal transplants for other ends, like treating depressing and losing weight. Of course, much more research needs to be done in these areas, but the prospect of probiotic therapy for various illnesses would be significant.

Isn’t science cool? Scientists and doctors have managed to turn one of Death’s surest weapons against it, if only a little.

One-Fifth of Americans Worried About Getting Ebola Yesterday

Via Teju Cole's excellent satire at the New Yorker

Via Teju Cole’s excellent satire up at The New Yorker

Over one-fifth of Americans worried – in the past 24 hours – about getting ebola, according to a just-released Gallup poll. Six Americans are believed to have contracted ebola (a number which may or may not include the man who had ebola in Texas, Thomas Eric Duncan, who passed away this morning), and the risk is effectively non-existent, but almost one-in-seven Americans thinks that is is “very likely” or “somewhat likely” that they, or someone in their family, will get ebola.

The Gallup poll wisely compares perceptions of ebola now to the H1N1 outbreak in 2009 (also known as the swine flu):

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In other words, Americans are as concerned about ebola – a disease that poses no risk to them – as they were about the swine flu, a disease that may have infected over 10% of the American population and that killed 3,900 Americans. (This number, of course, is also only a fraction of the number of Americans that die each year from the “common” flu)

Any disease with a high case fatality rate is going to cause people to worry, and doubly so for a “new” or “foreign” one. But a cool, calm, and collected media apparatus would be able to tamp down fears of ebola if it was interested in doing so. That’s not good for gaining eyeball share, though, so organizations like CNN are sensationalizing the “outbreak” of ebola in America by comparing it to – and yes, this is true (see above) – ISIS, a terrorist group. This is disgusting and immoral in and of itself, but it also takes away mindshare from more pressing concerns, like getting a flu shot.

So no, America, despite what you hear on the radio or the television, ebola is not a threat to you. Do literally anything else but worry. Get a flu shot. Donate to MSF/Doctors Without Borders. Help – in whatever way you can – to reduce the ebola threat to Liberians and others in West Africa.

Treating the Physical and Emotional Wounds of Obstetric Fistula in Tanzania (ThinkAfricaPress)

Obstetric fistula repair patients at Comprehensive Community-Based Rehabilitation in Tanzania (CCBRT), a large disability hospital in Tanzania. Photo credit: Benjamin English

Obstetric fistula repair patients at Comprehensive Community-Based Rehabilitation in Tanzania (CCBRT), a large disability hospital in Tanzania. Photo credit: Benjamin Eagle

Via ThinkAfricaPress

DAR ES SALAAM – Last fall, Agnes, a 26-year old hairdresser living in Mwanza, Tanzania, was pregnant with her second child.  She went into labor on the way to visit family in the south of the country and rushed to the nearest public hospital.

It was like too many public hospitals in Tanzania: overcrowded, under-resourced and understaffed. Alone and unexamined, she had a relatively common birth complication – obstructed labor – but wasn’t noticed, or cared for, by the too-few nurses on shift. After an agonizingly long time in labor pain, she was finally examined, and scheduled for an emergency caesarian section. The procedure was a success, and her new baby girl, Aditha, was born.

But because her obstructed labor wasn’t dealt with timely, an obstetric fistula – a hole between the birth canal and the bladder (known as VVF) or rectum (RVF)– formed. The caesarian section probably saved Aditha’s life (most babies born during obstructed labor do not), but it was too late to prevent Agnes from the physical and social consequences of an obstetric fistula.

Her doctor recommended she go to Comprehensive Community-Based Rehabilitation in Tanzania (CCBRT), a large, disability hospital in Dar es Salaam known for its fistula repair operations. After her caesarian section wound healed sufficiently, she did.

CCBRT, a 230-bed hospital set up as a public private partnership with the Tanzanian Ministry of Health, is nothing like its public peers. Its walls are painted with pictures of animals and disabled children; the wards are quiet, calm, bright, and well ventilated; the place just feels clean. There’s even a playground for kids to play on.

I spoke with Agnes in one of the two obstetric fistula wards – a bright, inviting space filled with a number of nurses chatting with patients. Sitting on her bed in a blue hospital gown with Aditha playing at her side, Agnes told me what life was like with an obstetric fistula. Constantly “wet” from the urine and feces that uncontrollably leaked out of her, she couldn’t resume her normal life. “I could not go for weddings, I could not work. I felt bad. It was isolating,” she said. Her normal life was effectively over.

Physically, “a woman with a fistula will leak urine or feces or both,” Dr. D’Mello, an obstetrics and gynecology specialist at CCBRT, told me. As unpleasant as always being “wet” would be, the social and cultural symptoms of the disease may be worse. Like Agnes, they are shunned and isolated by their friends and family members.

Patients at CCBRT. Photo credit: Benjamin English

Patients at CCBRT. Photo credit: Benjamin Eagle

They’re also stigmatized. “[Women] are told the myth that surrounds fistula – that you have been unfaithful and this is a punishment for being unfaithful,” Dr. D’Mello said. “So admitting that you have a fistula is kind of opening up this whole stigma… so even declaring that you have a fistula is really not acceptable.” (Agnes asked that her full name not be used and that I not take her photograph out of concern that her neighbors and relatives may learn about her condition)

This is changing in Tanzania, though. The President of Tanzania, Jakaya Kikwete, has been vocal about the need to treat fistula patients humanely: “Society should understand that it is curable. We should stop shunning women suffering from the condition but instead encourage them to come out for treatment.” According to Dr. D’Mello, this and other efforts have been successful at partially reducing the stigma Tanzanian women with fistula face.

The World Health Organization estimates that worldwide, two million women currently live with obstetric fistula, with 50,000 to 100,000 women developing it each year. It’s a disease borne of poverty and lack of access to appropriate maternal care; the global burden falls entirely on women like Agnes, who live in poor countries with inadequate health care systems.

Tanzania, an east African country roughly the size of Nigeria, has 45 million people – only 360 of which are physicians. It has the fewest physicians per capita in the world, according to the New England Journal of Medicine: just 80 per 10 million people. Its neighbors – also severely lacking – have far more (see chart); South Africa and the United States have 95 and 300 times as many physicians as Tanzania, respectively.

Screen Shot 2014-05-22 at 12.40.15 PM

The supply of healthcare infrastructure – operating theaters, equipment, and trained staff – hasn’t nearly kept pace with demand in Dar es Salaam. Dr. Brenda D’Mello told me that when she worked at a large public hospital in Dar es Salaam, it was common to see “three, four, five, six women on a bed, every space in between filled with the women.”

“Women were delivering on the floor,” she said.

In urban settings, an obstetric fistula is a direct consequence of the available infrastructure’s inadequacy. A dearth of operating theaters, clinicians, and medical equipment forces physicians to constantly triage cases: “You would get people, women who needed a caesarian section, and they are more than one at a time, and there is one theater. So you end up numbering them by priority,” Dr. D’Mello told me. “The problem with labor: the woman is not going to die… so you can actually wait longer and longer and longer.” After the baby has died, the woman is unlikely to be the patient at highest risk, so she waits, and waits, and develops a fistula.

Improving hospital infrastructure and increasing healthcare staff capacity at the public and private level – to be sure, no simple task – will likely help prevent future fistula cases.  And it will make patients happier, too. Agnes told me that “there is a big difference” between public hospitals and CCBRT. “Doctors and nurses really care about the patients. The food is nice. Nurses are loving to patients.”

(It’s worth noting that nurses in public hospitals are loving to patients too – but at an under-resourced hospital where the nurse-to-patient ratio may be 1 to 10 on a good day, it’s a lot harder to show.)

Photo Credit: Benjamin English

Photo Credit: Benjamin Eagle

Incontinence resulting from the fistula causes another unique problem for patients: near-constant dirty hospital sheets. At CCBRT, though, Agnes told me, “I get fresh linens every day; when I soil [them] I get new ones. It’s a very clean environment.”

CCBRT provides care for patients with many types of disabilities: cleft lip and palette; burns; club foot; and more. Patients under five and women with obstetric fistula are guaranteed free treatment; middle-class and wealthy Tanzanians pay for the care they receive, which subsidizes care for the poor. Next year, a major expansion will allow it to deliver 15,000 babies per year.

But a few years ago, it found its surgeons ready but its beds empty: women weren’t coming to have the surgery, even though it was free to them (it costs the hospital about $415 for each fistula repair). One of the largest hurdles to providing fistula care is simply that women don’t know it is available; another is that Tanzania is a vast country, and getting from, say, Kigoma in the west to Dar es Salaam in the east is inordinately expensive for many women.

To mitigate these issues, CCBRT created a unique model that draws on a human-powered referral network; M-PESA mobile payment technology; and relationships with far-flung hospitals.

CCBRT’s Ambassadors are an integral part of the obstetric fistula repair program – a human-powered referral network for the hospital. About 550 former patients have been trained to sensitize their communities about obstetric fistula – and to seek out fistula cases (and other disabilities). When an Ambassador finds a fistula patient, she informs a CCBRT staff member, who uses Vodacom’s M-PESA mobile money platform to send enough Tanzanian shillings to cover the cost of a bus ticket.

Until 2012, patients were sent exclusively to the flagship hospital in Dar es Salaam, but thanks to funding from the Vodacom Foundation, CCBRT has assisted in the training and implementation of fistula repair programs in Kigoma, Arusha, and Moshi. Now, patients go wherever is closest, and are picked up at the bus station by a CCBRT staff member. The Ambassador is then sent a small “finder’s fee” of about 10,000 Tanzanian Shillings ($6) to cover the costs of transport and to serve as a small incentive.

This model has been an unabashed success. Before it began, in 2009, CCBRT did 163 fistula repair surgeries; this year, it did 713 (513 at the flagship hospital alone).

Whether or not she becomes an official ambassador, Agnes is likely to spread the word. “I expect to tell all women who have this problem to come to CCBRT,” she told me, unprompted.

I asked how she was feeling now, two weeks after her surgery. She flashed an enormous smile and said simply, “I feel good!” She’ll stay at the hospital for a few more weeks to ensure that the surgery was successful. She’ll spend some time with the women who have shared in her suffering, and then she’ll go home.



If Physicians Outperform Nurses at Primary Care, the Evidence Doesn’t Show It (At The Incidental Economist)

Via The Incidental Economist:

The following is a guest post by Mike Miesen, a Business Strategy Analyst at a New York City-based global health social enterprise. Find him on Twitter: @MikeMiesen.

Cardiologist Dr. Sandeep Jauhar recently took to the op-ed page of the New York Times to argue that legislation to broaden the scope of practice for New York nurse practitioners is a mistake:

Though well intentioned, such proposals underestimate the clinical importance of physicians’ expertise and overestimate the cost-effectiveness of nurse practitioners.

The first contention is rebutted by a vast body of research on this question. The second is based on a cherry-picked, underpowered study that doesn’t directly support the argument.

To argue that nurse practitioners (NPs) are unable to provide the same quality of care as physicians, Dr. Jauhar marshals this evidence:

When I was doing my internship, 15 years ago, a fellow intern told me about a patient she had seen in the clinic whose voice was hoarse. She had no idea what was wrong with him, but her primary-care instructor, on a routine pass by, immediately diagnosed goiter, an enlargement of the thyroid gland.

It’s telling that he uses an anecdote to make his case; he would be wholly unable to do so with data.

Simply put: the preponderance of empirical evidence indicates that, compared to physicians, NPs provide as good – if not better – quality of care. As I’ve written previously, patients are often more satisfied with NP care – and sometimes even prefer it.

The Institute of Medicine is unambiguously clear about this:

No studies suggest that APRNs [Advanced Practice Registered Nurse]  are less able than physicians to deliver care that is safe, effective, and efficient or that care is better in states with more restrictive scope of practice regulations for APRNs.

Even the National Governor’s Association – in 2012, hardly a bastion of left-wing sentiment – concluded:

None of the studies in NGA’s  [National Governor’s Association] literature review raise concerns about the quality of care offered by NPs. Most studies showed that NP-provided care is comparable to physician-provided care on several process and outcomes measures. Moreover, the studies suggest that NPs may provide improved access to care.

When NPs provide frontline primary care, patient safety is not at risk. Full stop.

Dr. Jauhar’s second contention is that NPs aren’t as cheap as people think. To back it up, he cites a 1999 study published in Effective Clinical Practice:

…primary-care patients assigned to nurse practitioners underwent more ultrasounds, CT scans and M.R.I. scans than did patients assigned to physicians. The nurse practitioners’ patients also had 25 percent more specialty visits and 41 percent more hospital admissions.

Some context helps: the study looks at a set of utilization measures and health outcomes for patients at Baltimore Veterans Affairs Medical Center who were assigned to either an attending physician, resident physician, or NP.  But there is a severe, methodological flaw: in some cases, an NP chose which group each patient was assigned to! So, this was hardly a pristine, randomized experiment. Also, it’s just one study, and one within a system– the VA – that’s quite a bit different than the rest of the US health care system. One should never draw conclusions from just one study, and certainly not one with clear flaws and threats to generality.

But you can set those limitations aside, because the figures Dr. Jauhar cites on specialty visits and hospital admissions aren’t even statistically significant (only ophthalmology visits were). Dr. Jauhur argues that NPs’ greater use of diagnostic scans is “to compensate for a lack of training,” which could be true, or, as the study’s authors hypothesize, it could also be due to physicians asking for the extra tests to be done or specialists ordering the extra tests. In any case, the study doesn’t shine any light on the cause.

And tellingly, the study does not actually investigate the costs incurred by NPs or physicians.

Dr. Jauhar is right: there isn’t much solid research investigating the cost of NP-led care compared to physician-led care in America. But the research that exists lends credence to the assertion that NP-led care is often less costly than physician-led care (these aren’t unbiased sources, of course, but decent reviews of the literature nonetheless).

Where does that leave us? Compared to physicians, NPs provide a similar, or better, quality of care; are a more agile and flexible workforce to deploy, taking a fraction of the time to trainearn less; and the preponderance of evidence indicates they are able to provide care more cheaply.

Given all this, it’s very hard to view arguments to the contrary as anything but willful ignorance of evidence. And it’s very hard to discount self-interested motivations to make those arguments.

UPDATED: Fact-Checking an Article on Saving Mothers Giving Life in the Christian Science Monitor

1/22 Update: I received a response from the author, Howard LaFranchi, late last week, but haven’t had a working computer until now. He made a number of updates to the article, as he notes in his email to me (which I’m posting in full, with his blessing):

Dear Michael: Please find below a link to the corrected version of my maternal mortality story with Uganda now featured in the lede instead of Zambia.

You are indeed correct that Zambia did not implement a transport voucher program under the Saving Mothers program. My error was to conflate information I was provided on the challenges and programs in the two countries. That has now been corrected.
Your other criticisms, however, pertain to information and statistics provided by USAID, CDC, and the ministries of the two countries involved. I don’t agree with your observations, but you might want to take them up with the institutions you question.
I appreciate that a reader with your knowledge took the time to call my attention to the errors in the piece. On the other hand, I have to say that I find it a bit disheartening that someone involved in addressing the issue of maternal mortality would advocate “removal” from a general-interest site of an article that deliverers some good news on the issue.
In any case, thanks for your interest.
Best wishes, Howard

 I have a few thoughts on this, but will likely write a separate post (or update this post) later this week outlining them rather than doing so now. I very much appreciate Mr. LaFranchi allowing me to post his response.

It’s rare that I find an article (published in a prominent outlet) that is so inaccurate I feel compelled to spend some time researching and writing a rebuttal. But it happens.

This article is from the Christian Science Monitor, a great publication. Unfortunately, almost everything – the title, the statistics, and lede – is inaccurate or misleading. It needs to be modified or removed.

A bit of background: a USAID-backed partnership, Saving Mothers Giving Life (SMGL), is working to reduce maternal mortality in western Uganda and parts of Zambia, with possible scale-up districts/countries to follow. It’s a big project – $280 million over ten years (at least), with USAID, the Norwegion Ministry of Foreign Affairs, and Merck for Mothers working in tandem with the Ugandan and Zambian Ministries of Health. The partnership is implementing a number of health-systems-strengthening-related interventions that it hopes will ultimately lead to fewer maternal deaths in the area.

Let’s go through the article, paragraph by paragraph. Starting with the title (likely from the editor, not the author):

How a simple travel voucher is saving the lives of pregnant African women

This is a misleading title, for a few reasons. Even a travel voucher scheme is really complex to implement in low-resource settings like Uganda; getting the amounts right, sensitizing the community, monitoring to ensure it’s working properly – all difficult. Furthermore, the title gives the impression that SMGL is a travel voucher scheme only, when vouchers are one small piece.

While we’re on the subject, the author later notes that the project:

…has a lot more to it than rides on the motorized cycles used in those rural areas. But the availability of transportation is one key reason the program has shown impressive results in a short time, experts say

That’s quite the claim for an anonymous “experts say,” and neither the SMGL 2013 Annual Report nor the Columbia University external evaluation of SMGL analyzed specific interventions for efficacy.

Continuing, the lede:

In rural Zambia in southern Africa, a pregnant woman faces on average a five-hour walk to reach prenatal care – or a facility equipped to handle complications in birth

This could very well be true, but, like the rest of the article, there’s no linked source. I did a quick search and didn’t find any time study or survey on pregnant women in Zambia, though that obviously doesn’t mean this statement wrong – just not simple to source.

It is is a useful statistic to have; it’s visceral and emotional, and can help readers empathize with women going through pregnancy in difficult settings. But it’s useful only if it’s accurate.

Compounding the above criticism, here’s the next paragraph:

Enter a very simple idea – transport vouchers for pregnant women. Over the past year and a half of a new US-initiated program for addressing maternal mortality, Zambia began providing thousands of vouchers for women to be able to access pre-natal care and properly equipped birth facilities

This is flat-out wrong; SMGL doesn’t provide transportation vouchers as part of its program in Zambia. From the external evaluation of SMGL (p. 25):

“…over half the women (58%) who had heard of SMGL in Uganda reported familiarity with transportation vouchers compared to only 3% of women in Zambia. The contrast is unsurprising, as the SMGL program in Zambia did not provide transportation vouchers” (emphasis mine)

Sloppy journalism, plain and simple.

Here’s the next paragraph (I’ve also included a bit about Uganda from a later paragraph for clarity):

Zambia records about 2,600 maternal deaths every year, giving it a maternal mortality ratio of 440 per 100,000 live births. (In the US, the number is closer to 12 per 100,000)… [later, regarding Uganda – MM] … the maternal mortality ratio in the four districts fell from 452 to 316 per 100,000 births. Uganda’s national average is 438.”

The Zambian figure, 440 per 100,000 live births, is for 2010, and comes from the World Health Organization (WHO). For the same period and from the same source, the Maternal Mortality Ratio is 21 per 100,000 in the United States, not 12. (This is probably just a typo that was not corrected by the editor.)

Uganda’s national average is not 438, as best I can tell; according to the same source linked above from the WHO, it’s 310 per 100,000 live births in 2010. The author may have a separate source for his figure, but unless he has some reason to believe the WHO analysis is wrong for Uganda, he should be comparing apples to apples.

The author continues:

But in the maternal care facilities in the four Zambia districts participating in the Saving Mothers Giving Life (SMGL) program, the maternal mortality ratio fell by 35 percent.

This isn’t technically wrong, according to the SMGL 2013 Annual Report. But this number tells us a lot less than we would think – something that the average reader may not immediately intuit. It’s the job of a journalist to help walk the reader through statistics like this.

At the most basic level, this figure fails to tell us what would have happened in that facility were it not for SMGL; it doesn’t give a counterfactual. Maybe a similar, non-SMGL district also saw a 35% reduction in the Maternal Mortality Ratio; perhaps a similar district saw its Maternal Mortality Ratio double. We just don’t have the context, and insinuating this reduction is both good and a result of SMGL isn’t exactly appropriate.

Even if the SMGL Annual Report listed results from comparison districts, we still need to take the figure with some skepticism. SMGL wasn’t set up as a randomized controlled trial – the leadership hand-picked which districts it planned to work in – so we can’t say for sure that SMGL’s results in these districts could be expected elsewhere, nor can we say that SMGL caused the MMR to drop by 35%.

There were comparison districts in both countries for the external evaluation, but they were not random and not selected at the start of the intervention, so, in the authors’ words, “we can compare performance of SMGL versus comparison districts as of May 2013, but we cannot assess whether there was change in the SMGL districts during the year of program implementation.”

The bottom line is this: readers need more information before they can understand what “fell by 35%” actually means, and it’s a journalists job to find that information and walk them through it.

Finally, after a quote from Dr. Rajiv Shah, the administrator for USAID, the article continues:

The Saving Mothers initial program cost $20 million – or about $7 per birth under the program in Zambia, and about $13 per birth in Uganda.

This is going to get wonky, so I won’t bury the lede: the above figures make no sense to me, and I have no idea where they came from. To start, $20 million is the cost of the pilot program for both Uganda ($10,505,255), and Zambia ($8,144,510), some of which was long-term capital investment (e.g., equipment, construction) and some of which was short-term/admin expense (e.g., salaries, transportation vouchers) over a 17- and 20-month period, respectively.

Let’s look at figures for Uganda:

  • According to the SMGL 2013 Annual Report, $10,505,255 was allocated to Uganda, of which 29% was for capital expenditures which were expected to last for five years. So, taking .71*$spent+ (.20*capex) should give us a very conservative figure (i.e., erring low) to start with: $8,068,036 ($7,458,731 + .2*(.29*10,505,255))). At $13 per birth, there would be 620,619 births, according to the statistics the CSM author reports
  • Quick gut check: is 620,619 births reasonable? The same report lists Uganda as having 1.5 million births per year, or about 2.125 million every 17 months (the time period listed for the disbursement in Uganda). Does it make sense to have 29% of the country’s births come from four western districts (Uganda has 111 districts total)? Probably not
  • Furthermore, the external evaluation lists  78,400 “deliveries, annual” in the four Uganda districts in 2011. Correcting for number of months and assuming this only is facility deliveries (to err on the side of caution), the estimated total number of births in the four districts during the period would be about 198,333 – less than one third the figure I got by reverse-engineering the author’s data.

I could do the same with the Zambian figures, but it’s beside the point. The author should back up his assertion with data and sources; right now, it’s as if these figures were just pulled from the ether.

But. Let’s assume, for the sake of argument, that the author’s figures hold up. What do they tell us? With the right additional information, it’s possible we could use them to best prioritize the next marginal dollar of investment; it would be better, one could argue, to invest that dollar in an area with a high birth rate than an one with a low birth rate, all else equal.

Or maybe not. Why not ask if its possible to invest in family planning services that will drive down the number of births in an area? That wouldn’t be captured in this metric (it would actually make the cost per birth higher), but it could be a valuable way to reduce the number of maternal and child deaths.

All of which is to say: this metric doesn’t tell us anything meaningful.

The author then spends the remainder of the article discussing maternal mortality more generally.

The point of this isn’t to castigate one specific writer, or even one specific publication – it’s to highlight the need for quality journalism on global health/development topics. If it’s worth writing about (and it is!) it’s worth writing about well.

I’ve emailed the author and will post a response if I receive one.


California’s Scope of Practice Bill Was Shot Down Last Night. Here’s Why That Matters

(Via Project Millennial)

An effort to increase the scope of practice for Nurse Practitioners in California was voted down 6-3 yesterday by the California Assembly.

Senate Bill 491 originally would have explicitly allowed NPs to practice certain procedures without oversight from a physician:

“This bill would revise these provisions by deleting the requirement that those acts be performed pursuant to a standardized procedure or in consultation with a physician and surgeon. The bill would also authorize a nurse practitioner to perform specified additional acts, including, among others, establishing physical diagnoses and prescribing drugs and devices” (emphasis mine)

It was watered down during its short life, and the explicit authority was diluted to vague “additional acts”:

Existing law authorizes the implementation of standardized procedures that authorize a nurse practitioner to perform certain acts, including, among others, ordering durable medical equipment, and, in consultation with a physician and surgeon, approving, signing, modifying, or adding to a plan of treatment or plan for an individual receiving home health services or personal care services… This bill would authorize a nurse practitioner to perform those acts and certain additional acts without physician supervision if the nurse practitioner meets specified experience and certification requirements (emphasis mine)

But, the effort was still to no avail.

The bill’s early death was ferried through by the California Medical Association, an interest group representing physicians. Its president, Paul Phinney, argued that the bill would fracture coordination of care: “What the bill would do is break down the cooperation, the tight cooperation between physicians and nurse practitioners.”

Put a different way, though, that’s the point.

What Dr. Phinney refers to as “tight cooperation” is a requirement that NPs have a physician looking over their shoulders to OK the plan of care for their patients.

As we’ve discussed before, it’s not clear that this oversight is beneficial to – or even preferred by – patients. Research has shown that, in some circumstances, quality and patient satisfaction are higher when a NP cares for a patient compared to a physician, and when time is a factor, patients sometimes even prefer being seen by a NP.

California is behind the curve on efforts to allow NPs and Physician’s Assistants to “practice at the top of their training.” The majority of states have far fewer restrictions on what the advanced clinicians are able to do:



The bill’s author said he’s hoping it will be reconsidered in the future.