Dr. Gawande Speaks on Quality and Disparities

Dr. Atul Gawande was the featured speaker at Monday morning’s MGH Disparities Forum, organized by The Disparities Solutions Center at MGH. He spoke about the “bell curve” of care, with the best performers at the top, the worst at the bottom, and the majority in the middle. As Dr. Gawande pointed out later in his talk, those at the top are often providing the best care at the lowest cost, and, often, vice-versa for those at the bottom. Dr. Gawande said that we do not look closely enough at what is happening at the top that leads to the best quality care but we also pay even less attention to those at the bottom and how they can get better. He said those at the bottom are often where the greatest disparities are happening, and, as he related later in the talk when speaking about where he has seen the greatest adoption of surgical checklists to prevent surgical complications and deaths, often because of a lack of time and resources at hospitals that see many uninsured patients but also because there may not be an organization and leadership that is prioritizing improvements in care at those institutions. He did also point out that those in the middle and at the top also have much work to do on reducing disparities, even though it is often hard for those at the top to admit that they have disparities.

Dr. Gawande compared today’s national reform landscape with what happened after Medicare became law in 1965. Knowing that the road toward implementation of health reform will no doubt be rocky, he said that we also need to recognize that Medicare implementation was not smooth, though it is now a hugely popular program. He talked about resistance from the AMA at the time, which thought Medicare would lead to socialized medicine, and also resistance from hospitals in the South which had segregated patients by race and, if they wanted to receive Medicare funds, were required to stop such practices. Thus, as he said, Medicare had a major impact on dismantling disparities that existed at the time.

Dr. Gawande also spoke about his work with the Word Health Organization on developing a surgical checklist for care to reduce surgical deaths and complications. 
The pilot test phase of developing the checklist included the use of the checklist at 8 hospitals around the world with varying levels of resources and technology as well as poverty and need among patient populations. Surgical complications decreased by 36% and deaths decreased by 47% on average. The decreases were greatest in the poorest hospitals but there were significant decreases in the well-resourced hospitals as well. In the U.S., about 15% of hospitals are currently using the checklist, and most of them are the better-resourced hospitals.  Again, as mentioned above, those hospitals resisting its use are often, but certainly not always, those with larger populations of uninsured, minority patients. HCFA and the Consumer Health Quality Council are advocating for legislation on the use of checklists in MA hospitals. Learn more on the HCFA website.

Dr. Gawande closed his remarks by saying that work on improving the quality of health care IS the work to reduce the cost of health care.

Deb Wachenhein
Quality Manager

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