October 22, 2014

Swimming Upstream

When is the right time to have a conversation about goals of care? Commentary coming soon.

October 19, 2014

Rating the Ratings

Earlier this month, Medicare announced that it is revising the 5-star rating system currently used to measure nursing home performance. The ratings are available on the Nursing Home Compare website, which allows consumers to learn how a facility they might be considering going to shakes up relative to others. The problem, and the reason the system is being revised, thanks to funding from IMPACT (legislation passed in September), is that it’s not so clear that the vaunted rating system measures anything meaningful.

An investigative piece in the New York Times this past summer dramatically demonstrated the gap between reality and the ratings. The reporter visited the Rosewood Post-Acute Rehab outside Sacramento, California, an attractive facility that had garnered the much sought after 5-star rating from Medicare. But it turned out that the ratings focused entirely on annual health inspections and on 2 measures reported by the nursing home itself—staffing ratios and a quality of care index. The rating left out data from state authorities, even though it is those authorities that supervise the nursing home. In Rosewood’s case, the state of California had fined the facility $100,000 in 2013 for a patient death attributed to inadequate medication monitoring. California had also received 102 patient and family complaints between 2009 and 2013, way over the state’s average. And the facility had been the subject of a dozen lawsuits alleging substandard care. The revised rating system, by drawing on external audits of nursing home quality and electronically submitted staffing data, as well as by incorporating some new measures such as the proportion of residents taking antipsychotic medications, hopes to overcome the shortcomings of the current approach. But will it?

Nursing Home Compare is not the only attempt to come up with a single, composite rating for medical facilities, and nursing homes are not the only medical institutions to be graded in this way. Hospitals are also rated, and multiple organizations offer assessments. I recently stumbled on a fascinating case: in June of 2012, the Leapfrog Institute, a non-profit think tank devoted to measuring and improving safety in medicine, came out with its first hospital ratings. It awarded an A or B to 56% of the hospitals surveyed, a C to 38%, and grades below C to 6%. The UCLA Medical Center was given an F.  At the very same time, US News and World Report came out with its annual hospital rankings. In this report, the UCLA Medical Center was ranked #5 in the country. How can the same hospital get an “F” and an “A+” for its performance? And if you think that maybe UCLA is an unusual case, it’s not. Consumer Reports, which also got into the hospital rating business, ranked MGH below average in the same year (2012) that US News ranked MGH as #1 in the country. 

The answer to why different raters have different results is that the grade depends on the methodology used to compute it. Leapfrog assesses hospitals based entirely on performance in the realm of safety and does not adjust for the severity of illness. Consumer Reports uses a complicated mixture of a safety score, a patient outcomes score, a patient experience score, a hospital procedures score, and then a rating of heart surgery, with several factors going into each of the subscores. US News and World Report looks at outcomes (by which it means mainly mortality), process (which is largely nursing staffing levels), and other factors (a big part of which is reputation).  US News also rates hospital departments (neurology, cardiology, oncology, etc). I was particularly amused a number of years ago when US News ranked the Geriatrics Department of one of the Boston teaching hospitals among the top 10 in the country. It so happened that hospital didn’t have a geriatrics department.

Americans like report cards.  We rank toasters and washing machines and cars. We rate hotels and restaurants and auto mechanics. We have institutions devoted to product evaluation (think Consumer Reports) and thanks to the Internet, we now have a slew of informal, popular evaluations (think Yelp or Trip Advisor). I admit I find these reports very useful: when I was looking for a good bed and breakfast recently, I found it helpful to learn that 50 people gave one particular inn 5 stars. I could also read the individual comments to get a sense of whether the aspects of the inn that other travelers liked were of any particular concern to me.  But can we really come up with a report card for a hospital or a nursing home? Can we really reduce performance to a single grade?

Nursing homes and hospitals will inevitably game the system, just as colleges did when US News and World Report used the number of applications/number of offers of admission as a measure of selectivity. Colleges instructed their admissions officers to travel around the country encouraging students to apply, even if those students couldn’t possibly be accepted, because the more students applied, the more “selective” the college became. Some colleges created a huge waiting list and admitted many of their freshman class from the wait list—but only counted the initial acceptance letters in the computation of “offers of admission.” Some students and families have caught on and the media has started to downplay the annual US News numbers—for the past couple of years, the college rankings haven’t been front page news in the NY Times when the new ones are released. But colleges continue to regard the rankings as important and use them in marketing. Similarly, I’ve noticed big banners in the vicinity of some of Boston’s hospitals proclaiming their latest ranking. And I learned from a terrific piece of investigative reporting produced by Kaiser Health News 
in collaboration with the Philadelphia Inquirer that the hospitals pay to advertise their rankings. US News, Leapfrog, and another rating organization, Healthgrades, charge licensing fees to hospitals for the privilege of trumpeting their “achievement.” These fees are not peanuts: Healthgrades charges $145,000, US News charges $50,000 and Leapfrog charges $12,500.

There are now so many rating agencies, using very different rating scales and arriving at widely discrepant results, that there is even an organization, the Informed Patient Institute, that grades the raters. But the truth is that it is impossible to distill the performance of a complex institution such as a hospital or a nursing home to a single measure. Such efforts will inevitably hide the very real variability in performance depending on just exactly what is looked at. What you need to know depends on why you need to know it. Are you an insurance company, deciding whether or how much to reimburse a facility for a particular service? Are you a patient choosing a hospital (actually, you probably won’t have much say in the matter; in case of emergency, you will be taken to the nearest facility; and in other somewhat less urgent situations, where you go is typically determined by who your doctor is). Are you a patient or family member choosing a nursing home for long term care (you may have a fair amount of choice)? For short term rehab (you will have less choice in the matter)?

So will the revised ratings of nursing homes (coming in January, 2015) make grades meaningful? Probably not. Requiring nursing homes to report data on staffing electronically will likely improve the accuracy of their reporting—but is the degree of improvement worth the millions of dollars that will be spent on this? Including the rate of antipsychotic medication prescribing as a quality indicator might tell us something about whether nursing homes are unnecessarily and inappropriately sedating their residents—assuming the measure has corrected for the rates of serious psychiatric illness in the facility. The bottom line is that a single grade cannot capture all the features of a medical facility’s performance that are relevant to all the different individuals and groups for whom the ratings are intended. It’s time to abandon composite ratings.

October 15, 2014

The Report Card Mania

We give grades to nursing homes, to hospitals, to state health care systems: does this help improve quality? Post coming soon!

October 12, 2014

Farewell to All That

In his 1905 farewell speech to the faculty of Johns Hopkins University Medical School, Dr. William Osler commented that the school was wise to hire someone young and energetic in his stead (he was very distinguished—and 55 years old). In passing, he mentioned Anthony Trollope’s satirical novel from 1882, “The Fixed Period,” in which all 67-years olds are to be sent to a special sanctuary, a kind of cross between a high-end resort and a liberal arts college, and given one year to put their affairs in order. At the end of the year, the plan is to chloroform them. The idea was to make sure that everyone quit while he was ahead, without waiting for the decline thought to inevitably accompany aging. Osler’s speech sparked a huge outcry in the media, which inveighed against his alleged endorsement of universal, mandatory euthanasia. Osler, who was well known as a joker and prankster, had endorsed no such thing. His remarks about the “comparative uselessness of men over 40 years of age” and his recommendation for compulsory retirement at age 60 were said tongue-in-cheek.

A similar media frenzy ensued nearly 80 years later when then governor of Colorado, Richard Lamm, was quoted as saying that elderly, terminally ill patients "have a duty to die.” Lamm hastened to assure the public that he didn’t actually mean that seriously ill patients should commit suicide, assisted or otherwise. What he meant, or so he insisted, was that it made no sense from a societal perspective to expend enormous resources on medical care for the dying. His choice of words was unfortunate, as was his failure to acknowledge that another reason for limiting care near the end of life was precisely that it aggressive treatment did little, if any good, not merely that it cost a lot.

Now enter Ezekiel Emanuel, an ethicist, physician, and health policy guru, with his loud proclamation that once he reaches the age of 75, he wants treatments devoted only to his comfort, not to prolonging his life. Emanuel, unlike Trollope and Lamm, is dead serious, as his article in the Atlantic, "Why I Want to Die at 75," attests.

At its core, his argument shares the legitimate concern of his intellectual predecessor, philosopher Daniel Callahan, that failure to accept our inevitable mortality is leading us to make foolish decisions about medical care. As patients we choose, as a society we pay for, and as researchers we pursue treatments that offer a vanishingly small possibility of prolonging life, treatments that come with tremendous physical and emotional suffering and enormous cost. To the extent that Emanuel is arguing that this approach is wrong, I agree with him entirely. To the extent that Emanuel is arguing that we as individuals need to revise our goals of medical care as we age, I agree with him entirely. But to the extent that he is arguing that life is worthless after age 75 and that it would be better to forgo all medical care except that focused on comfort after one's 75th birthday, I think he is fundamentally misguided. 

Of course if Dr. Emanuel wishes to decline medical treatment in the future, that is his prerogative. Contemporary biomedical ethics teaches respect for individual autonomy, which means every individual is free to refuse any (or all) proffered medical treatments. So why should anyone apart from his friends and family, and perhaps his physician, care about the personal decisions that Emanuel makes about his medical care? The reason that people care—and that there has been a strong and negative reaction to Emanuel’s announced plans—is that they rest on various assumptions which, if true, would suggest that everyone else ought to consider the same approach. So it is essential to examine critically Emanuel’s views of what matters in life and his implicit belief that the only possible goals of medical care are either maximization of comfort or prolongation of life.

As a quick way to get a sense of what Ezekiel Emanuel considers important, take a look at PubMed, which lists all published scientific publications. Emanuel published 19 articles in 2013, almost all of them in leading journals including the New England Journal of Medicine, JAMA, and the Lancet. And that doesn’t include all his New York Times op-ed pieces (he is a “contributing opinion writer” for the Times), which arguably are far more influential. Now move on to Emanuel’s bio. He is Chair of the Department of Medical Ethics and Health Policy and Vice Provost for Global Initiatives at the University of Pennsylvania. As to what he does in his spare time, apparently he climbs mountains—the Atlantic article features a photo of him and his two nephews, with whom he recently climbed Mt. Kilimanjaro. Dr. Emanuel (he is also an oncologist) continues, at age 57, to function at a level that many would place somewhere off in the stratosphere.

So Emanuel is something of a superman and he’s concluded that when he stops being able to keep up his current pace, he can’t imagine that life will be worth living. Not that he plans to commit suicide or to ask anyone else to end his life. He will simply forgo all potentially life-prolonging therapy and die at the earliest opportunity. Now here is the first place where Emanuel is sadly misguided. He fails to understand or at least acknowledge the importance of any dimension of life other than what he has thus far experienced—success measured by the publication count and the prestigious positions, the mountains scaled, literally and metaphorically. It’s not just that proclaiming that life must be lived at a fevered pitch or not at all seems to categorize most of the rest of us as not-living-a-worthwhile-life; after all, Emanuel doesn’t claim to be imposing his standards on everyone else. It’s that Emanuel’s relentless desire for a narrowly defined kind of accomplishment gives short shrift to precisely those activities that many cultures deem of greatest value. The Jewish tradition, for example, calls upon every individual to participate in acts of loving kindness (gemilut chasadim) and in efforts to repair the world tikkun olam), however small those efforts.  Every stage of life comes with its challenges and its possibilities and it’s up to us to try to do our best in whatever condition we find ourselves.

But while I feel sad that such a talented and (otherwise) insightful person as Dr. Emanuel fails to see any merit to a life other than the one he is currently leading, that is not my main criticism of his stance. Nor is my main criticism that he is na├»ve if he believes that forgoing life-prolonging therapies such as pacemakers and antibiotics will necessarily shorten his life, when many people live for years without such treatments. Moreover, excluding a treatment from consideration merely because it might lengthen life may well have several presumably unintended consequences: refusing a flu shot (in the hope that you might contract the flu, develop complications, and die, a relatively unlikely outcome) has public health consequences as you may transmit the flu to others who do not share your death wish; and declining a pacemaker (in the hope that a slow heart rate might be lethal) may result in falls, broken bones, and dizzy spells all of which impair your quality of life without killing you. The primary difficulty I have with Emanuel’s perspective is that he completely misses the possibility that someone might have any other goal aside from maximizing comfort, on the one hand, or prolonging life, on the other. My view is that this is in-between position that Emanuel ignores is precisely what most people find themselves endorsing as they age.

We are both mortal and at high risk of experiencing increasing disability in the last couple of years of life (though not, as Emanuel seems to think, starting at age 75). The implication of these realities is that when death appears on the horizon (if, for instance, you develop a fatal illness) or when frailty rears its head (if, for example, you develop one or more impairments in your basic daily activities), it is a signal to reconsider the goals of medical care. Most people, I have suggested elsewhere in this blog as well as in my book, The Denial of Aging: Perpetual Youth, Eternal Life, and Other Dangerous Fantasies, choose comfort as their primary goal if death is imminent and choose maintaining their daily functioning, that is maximizing their quality of life, if they are becoming frail. Most people make this switch even though they continue to wish for a longer life; they are simply saying that if the price they have to pay for longer life is pain and suffering (in the first case), or poor quality of life (in the second), they are not interested. Dr. Emanuel, in his black-and-white, all-or-nothing view of the world, fails both to recognize that there is a middle ground where people choose treatments that promote quality of life, and that decisions to forgo treatment are predicated on the need to make trade-offs, not on the wish to die.

I hope that in all the furor over Dr. Emanuel’s article in the Atlantic—and he has certainly triggered a storm of protest—we will be able to get beyond the arrogant implication that only a life of intense and continuous activity is worth living, and accept the more modest reminder that is at the heart of his article: that we are all mortal. And as we approach the end of our lives, we may wish to modify our hopes and expectations in accordance with the reality of our situation and seek medical treatments that correspond to our new goals of care.

October 08, 2014

October 05, 2014

To Cover or Not to Cover

The day of decision is coming. The Centers for Medicare and Medicaid Services (CMS) will decide soon whether to go along with the recommendation of the independent review panel, MEDCAC, against coverage of lung cancer screening using low dose CT-scans, or to bow to political pressure  to cover the test (see my post on June 23, Politicians: Keep Out). A spate of recent commentaries in medical journals weigh in on the debate. Most seem to support coverage, although they add a few caveats. Two of these caveats are intriguing: using a registry to actually generate data about what happens to older patients who are screened with lung CT scans and mandating the use of a formal shared decision making process.

Writing in a recent issue of JAMA, Harold Sox, a distinguished physician with a long career promoting evidence-based medicine, recognizes the weaknesses of the available data, principally the National Lung Cancer Screening Trial (NLST). The NLST simply was not representative of the Medicare population because it included only a small number of patients over age 65 and only a very small number over 70. Moreover, the patients followed—who had a lower risk of death if they underwent the screening with CT scans compared to screening with regular xrays—in all likelihood did not have multiple other chronic conditions, the norm for Medicare patients. But Sox is clearly worried about depriving those older patients who might benefit from screening if Medicare categorically refuses to cover the test. He therefore veers towards recommending coverage, but with the proviso that a registry be maintained that tracks all patients who are screened to see what happens to them. In principle, this information could be used to modify the rules about coverage later on. Taking away coverage for something that was previously offered is certainly possible—coverage of bone marrow transplants for breast cancer was rescinded after it was found to be both tremendously toxic and no more beneficial than conventional, less risky treatment—but it happens rarely because of pressure from patient advocacy groups, regardless of the data.

A second opinion piece in the same issue of JAMA argues that CMS should provide coverage but should address MEDCAC’s concerns by mandating “shared decision-making.” Shared decision-making rests on patients’ understanding the risks and benefits of the various options and deciding, in concert with their physician, which approach is most consistent with their own values and preferences. Now I am a fan of shared decision-making. And I support the use of decision aids, as proposed by the authors of this article, which are formal tools that systematically describe the risks and benefits of the alternatives in clear, readily understandable language illustrated by simple graphics. But for shared decision making to make sense, we have to know the risks and benefits of the alternatives. The reason that patients should have a choice to make is that some patients may be willing to accept one risk (say losing their independence) in exchange for a particular benefit (say a small chance of extending their life) while other patients might not. In the case of CT-scanning for lung cancer, the problem is that we simply don’t know what the risks and benefits are in older patients in general and in older patients with multiple co-morbidities in particular. So it’s just not possible to design clear and accurate decision aids to help patients think about screening for lung cancer.

The real issue is whether and under what circumstances it is appropriate to extrapolate from situations where we do have data to situations where we don’t. Sometimes there are plenty of good reasons for making such a leap. It seems reasonable to provide a treatment to a mature 17-year-old, for example, even though he is technically a child, and even though studies of the treatment were done in patients over age 18. After all, physiologically and socially, the 17-year-old is almost identical to the 18-year-old. Sometimes what initially seems reasonable proves not to be: it turns out that the data on first generation left ventricular assist devices (a high tech device that is essentially a partial artificial heart) could not be extrapolated from men to women because the devices were often too big to fit into a woman’s chest. Sometimes, however, there is good reason to believe that data obtained from one group cannot be extrapolated to another. There is good a priori reason to believe that neither safety nor efficacy data will be the same in old, sick patients as in young, healthy patients. It is eminently plausible to believe that the 75 year old with heart disease and diabetes might run into problems when undergoing open chest surgery to remove a lung cancer. The only way to know is to do a study involving older patients: there aren't any good shortcuts. 

Agreeing to pay for the test would no doubt be politically expedient. It would not be a wise decision.

September 30, 2014

To Cover or Not to Cover

A chest CT scan showing what is almost certainly lung cancer: the Centers for Medicare and Medicaid Services will decide soon whether to cover screening for lung cancer with CT scans. The debate heats up as the decision nears. My thoughts coming next weekend.

September 28, 2014

The Coming Cataclysm

Some time in the next 6 years the world will experience an unprecedented cataclysm. Not a tsunami or an epidemic or a large scale war, although those are possible, too. This seismic shift will go undetected by the majority of the world’s population and yet it will change our lives. Between 2015 and 2020, for the first time in world history, the population of people over 65 will be greater than the population of children under 4.

It’s all nicely laid out in a report issued a few months ago that didn’t get very much attention. I didn’t notice it at all. It was the US Census Bureau’s Report “65+ in the United States” and it consists of nothing but statistics. Most of the observations and the predictions are nothing new: the population of older people has grown (it reached 40.3 million in 2010); the median age is increasing (up from 22.9 in 1900 to 37.2 in 2010); life expectancy has shot up (going from 47.3 at birth in 1900 to 78.7 at birth in 2010 and going from 11.9 years at age 65 in 1900 to 19.2 years in 2010); more women than men make it to old age (in the over 90 set, there are only 38 men for every 100 women); the population is becoming more diverse: 84.8% of the population self-identify as white in 2010 compared to 86.9% in 2000).

But buried amid the welter of interesting but not novel data about the US are some striking statistics about the entire world. First and foremost is the unprecedented demographic shift that will take place between 2015 and 2020: the total number of people over age 65 will exceed the number who are 4 or younger. This is because both fertility and mortality rates have been falling. As a result, people over 60 went from 8% to 11% of the population between 1950 and 2011, but by 2050 they will make up 22% of the world's population--2 billion people. Looked at a little differently, the global population is projected to increase by a factor of 3.7 between 1950 and 2050, but during that same century, people who are 60+ will go up by a factor of 10 and people who are 80+ by a factor of 26. 

Today, the countries with the highest proportion of people over 60 are Japan (31%), Italy (27%), and Germany (26%) with 7 other European countries not far behind. But the countries that are aging most rapidly include 4 in the Middle East (UAE, Iran, and Oman) and 4 in Asia (Singapore, Korea, Viet Nam, and China).

Accompanying the shifting age distribution will be an ever more dramatic dependency ratio: the number of people over 65 for every 100 people aged 20-64. This means that fewer and fewer young people will have to sustain more and more old people. And it will be in the low and middle income countries that all this transformation will be occurring most rapidly.

The reason all this matters is that it will put an enormous strain—economic, medical, and social—on everyone, but especially on the poorest countries in the world. It will affect demand—for goods (more walkers than tricycles) and for labor (more personal care attendants than elementary school teachers). The net effect may be as destabilizing as nuclear weapons. As a position paper published by the State Department and the National Institute on Aging put it, global aging represents a “triumph of medical, social, and economic advances over disease”—but it also represents an enormous and most governments have not even begun to plan for the long term.

So we have one more thing to worry about, along with climate change and religious fundamentalism and infectious diseases. What can we do about it? We do not need to accept the doomsday scenario of massive workforce shortages, asset market meltdowns, economic growth slowdowns, financial collapse of pension and healthcare systems, and mass loneliness and insecurity. But we do need to take steps now.

There are lots of interventions that can make a difference. 
One is to raise the normal legal retirement age. Another is to use international migration. A third is to reform health care systems, incorporating new models of long term care. A fourth is to encourage businesses to employ older workers, enabling them to work part time and facilitating their continuing productivity through environmental modifications that address mobility, vision, hearing, and other deficits. Economists, sociologists, demographers, historians and physicians at places including the World Bank and the Stanford University Center on Longevity have come up with a menu of strategies.

It’s up to all of us to pressure both the private and public sectors to act. Contact your senators and representatives. Write letters to the editor to major newspapers. The time to act is now.

September 21, 2014

From Dust to Dust (or Dustbin?)

The new IOM report, “Dying in America,” is a masterpiece. Written in the matter-of-fact language typical of non-partisan reports by committees of experts, it makes recommendations with which no rational person could possibly disagree. Of course a few extremists have already gone on record as disagreeing: a spokesman for the National Right-to-Life movement was quoted in the NY Times as claiming that the report’s alleged focus on “cost slashing” would reinforce “well-founded fears” that advance care planning is intended to “push patients to accept premature deaths.” The truth is that the report says relatively little about cost and what it does say is simply that a side effect of following its recommendations, suggestions made in the spirit of improving the quality of care and assuring that patients’ wishes are followed, will likely be a fall rather than a rise in the cost of health care.

The report includes “clinician-patient communication and advance care planning” as the topic of one of its 5 recommendations, and it is presumably this section that is the core of the right wing critique. But the explicit goal of advance care planning is to enable patients to participate in decisions about their health care and to make those decisions in accordance with their values, goals, and (informed) preferences. The report rightly recognizes that this isn’t going to happen unless clinicians take the initiative and that all the planning in the world will be inconsequential unless it is implemented when you become ill. The idea that discussing what kind of medical care you want near the end of life is tantamount to suicide is patently absurd. It would be more accurate to say that failing to discuss your wishes is tantamount to assuring you will spend your final days in the hospital, tethered to machines, and in pain.

While the recommendations of “Dying in America” are straight-forward and unobjectionable, they are also cleverly designed to be “actionable,” to lead to concrete steps to promote change. Its recommendation regarding the delivery of care states that “government health insurers and care delivery programs, as well as private health insurers, should cover the provision of comprehensive care for individuals with advanced serious illness who are nearing the end of life.” This is in marked contrast to the language of the IOM’s 1998 report, “Approaching Death: Improving Care at the End of Life,” which addressed the same theme by urging that “people with advanced, potentially fatal illnesses and those close to them should be able to expect and receive reliable, skillful, and supportive care.” The only way that patients can “expect” to receive this kind of care is if the delivery system provides it.

In a similar spirit, “Dying in America” tackles professional education and development by urging that certification, licensure, and accreditation of clinicians require evidence of competency in palliative care. By contrast,  the earlier report exhorted educators and other health professionals to “initiate changes in undergraduate, graduate, and continuing education to ensure that practitioners have relevant attitudes, knowledge, and skills to care well for dying patients.” Without specifying what those changes are or requiring that they be reflected in licensing exams or accreditation processes, not very much will—or did—happen.

Finally, the new report singles out payment systems as critical to promoting change, suggesting that health care delivery systems—the networks of hospitals, doctors, and clinics that actually provide medical care—must provide the services that comprise comprehensive palliative care and health insurers must pay for them. The preceding report acknowledged the role of financing, but embedded its recommendation amongst a series of quality improvement measures and spoke in very general terms of the need to “revise mechanisms for financing care so that they encourage rather than impede good end-of-life care.”

The weakest recommendations of both old and new reports on dying are for ongoing public education and engagement. Other than the specific suggestion that professional societies should publish brochures and that government agencies should support relevant research, there is little beyond a vague exhortation that faith-based organizations, consumer groups and others talk about the end of life. Previous public engagement campaigns, of which the Robert Wood Johnson’s multi-million dollar “Last Acts” program was the most spectacular and the “Conversation Project” the most recent, proved disappointing. Perhaps the forthcoming campaign, to be supported by the same anonymous donor who subsidized (but had no control over the contents of) the current report, will elaborate further.

My main concern is that this spectacular report will be filed away, as happens with so many comprehensive, thoughtful reports on all sorts of topics Certainly the IOM has had some notable successes. “To Err is Human: Building a Safer Health System,” issued in 1999, did shine a bright light on medical errors and catalyzed efforts to make American hospitals safer. But the IOM has produced 898 reports, according to its website. How many of those have had an impact and how much impact have they had?

I could just as well ask: What makes a book a best seller? Why do certain fashions catch on and not others? Publicists have their own ideas about how to sell books (which, speaking from experience, tend to be pretty unimaginative and outdated); Madison Avenue has its model for advertising campaigns and marketing strategies. Malcolm Gladwell, in his book “The Tipping Point,”itself a bestseller, argued that to create a “social epidemic,” you need 3 crucial kinds of people (connectors, mavens, and salesmen), you need to make sure the content is “sticky enough” to be retained by those who are affected, and you need to be sure the context is right. 

“Dying in America” lays out the facts and the arguments. It offers "actionable" recommendations, but the question is whether anyone will act on them.  The implementation campaign must begin now, otherwise this magnificent report on “dust to dust” will go into the dustbin.