Recent news from WHO

170 Bull World Health Organ 2009;87:169–170 | doi:10.2471/BLT.09.030309 News US$ 20 million, out of total Medicare budget for hospitals of US$ 120 bil- lion – at the same time. But is it working? According to Wachter, since October 2008, his staff has been extra vigilant in examining pa- tients on admission. The hospital also now employs a nurse-specialist who walks the wards monitoring the state of patients’ skin, trying to stop bedsores from developing. “People will say, well that’s a good thing, but it is also possi- ble that it is taking us away from more important tasks,” Wachter says. Mean- while, there is the issue of the perceived injustice. “Let’s say I’m a hospital, and I’m doing everything right, including turning the patient religiously, and yet the patient develops a bad bedsore. If all of a sudden I’m not getting paid the US$ 5000 [that] I would have been getting before, that feels unjust,” he says. And it’s not just a question of hurt feelings. Says Pronovost: “Nonpayment for complications that are truly not pre- ventable may reduce access for patients at risk for these complications. Obese patients [who are] at increased risk for decubitus ulcers, deep vein thrombosis and infections may be at risk of being turned away, for example.” Meanwhile, things are also likely to change on the wards. How to deal with patients falling is a case in point. For Wachter, while it is obvious that preventing patients from falling is a valid objective, it is a mistake to attach a financial penalty to such things hap- pening. “The only way we can prevent 100% of falls is by tying people to their beds,” he jokes. On a more serious note, Doctors intubate a patient in the United States of America. W HO /P AH O/ Ar m an do W aa k he says that while nobody is going to tie “Mrs Jones” to her bed, they might be inclined to discourage her from getting up. “As a result of that, Mrs Jones might end up spending even more time in the hospital, recovering slower and costing Medicare more,” Wachter says. “She might also be at higher risk for a DVT (deep vein thrombosis).” CMS spokesperson Ellen Griffith emphasizes that the CMS rule regarding falls was based on broad consultation, but also points out that it will come up for review this spring. “CMS will as always be open to input from interested parties, particularly where comment is backed by hard data,” she says, adding that CMS is committed to this policy and that this includes “refining it as appropriate to avoid unintended con- sequences for patients and to minimize undue burden on hospitals”. That CMS is ready to change its rules is borne out by the shift of emphasis it has effected with regard to pressure ulcers. The original rule included all such ulcers. After re-examination of the issue, CMS restricted the rule to stage III and IV ulcers, severe lesions involving subcu- taneous tissue. Pronovost, who is working with WHO’s Patient Safety Programme to see if ‘never-events’ represent a possible area for common work across countries in the next two years, believes that, whatever the arguments for and against, the policy should only be introduced after careful testing. “This will never be perfect,” Pronovost says, “but how ac- curately we can measure and how much we can prevent should be transparent.” WHO’s Kelley concurs, saying: “The approach should be one of piloting and testing new measures beyond the cur- rent core list.” Meanwhile, problems loom that go way beyond disgruntled doctors. Pronovost fears that hospitals may be tempted to cheat to avoid penalties – failing to diagnose conditions that de- velop during a hospital stay, for exam- ple, or failing to report them when the patient is discharged. Wachter warns of even darker clouds on the horizon. “I think if you are a private insurance company in the business of returning profits to your shareholders and you see this government-blessed initiative that says we’re not going to pay for these bad things, you’re going to take note,” Wachter says, adding: “You don’t have to be too Machiavellian to say that insurers are going to look at this to see how they can improve their bottom line and call it patient safety. I actually think that is inevitable.” ■ Recent news from WHO • WHO said, on 30 January, that Zimbabwe’s cholera outbreak, one of the world’s largest ever recorded, was far from being under control. It said that an enhanced response was needed to reverse the epidemic that has infected more than 60 000 people and killed more than 3100 since August 2008. It called for urgent action to increase awareness, particularly at the grassroots level, with regard to prevention and treatment measures and to make more medicines available, particularly oral rehydration salts (ORS) and chlorine tablets, at community level so that health-care workers and ordinary people themselves have the means to quickly treat cases of cholera that emerge. • WHO said, on 21 January, that it had received US$ 9.7 million in grants from the Bill & Melinda Gates Foundation to work with UNICEF and partners to conduct crucial research in children’s medicines. The aim of this research would be to increase the number of medicines designed and formulated specifically for children. Currently, many medicines are only designed for adults. For more about these and other WHO news items please see: http://www.who.int/mediacentre