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News & Analysis

 

Medical News & Perspectives ......p1105

Global Health ................................p1109

News From the Food and Drug

Israeli Physician Salman Zarka, MD:

Zero Cases of Guinea Worm Disease in Mali

Administration ...............................p1110

Caring for Syrian Patients Is Our Duty

Morcellator Risk Was Known

The JAMA Forum ...........................p1107

Boosting Cognitive Development in Children Cervicovaginal Bacteria May Influence HIV Risk

New Rare Diseases Screening Test

Value-Based Purchasing: Time for Reboot or Time to Move On?

First Corticosteroid Approved for Duchenne Muscular Dystrophy

Medical News & Perspectives

Israeli Physician Salman Zarka, MD:

Caring for Syrian Patients Is Our Duty

Jennifer Abbasi

S ix years after the start of a devastat- ing civil war, more than 6 million Syrians are displacedwithin their own

country, according to a report from the United Nations and international partners. More than 4.8 million Syrian refugees have fled to Turkey, Lebanon, Jordan, Iraq, and Egypt, while more than 880 000 have sought asylum in Europe. AlthoughUS Presi- dent Donald J. Trump signed an Executive Order suspending entry to Syrian refugees this January, by the end of 2016, more than 18 000 Syrian refugees—roughly half of them children younger than 14 years—were already being hosted in cities across the United States, according to State Depart- ment data. But not all the Syrians who left their country in recent years are looking for asy- lum. Some are seeking medical treatment they can no longer obtain in their home- land. Half of Syria’s public hospitals and health care centers are either closed or are only partially functioning, the World Health Organization has said. Physicians for Human Rights reports that, facing deliber- ate attacks, more than half of the coun- try’s 30 000 physicians have fled. Faced with a decimated health care sys- tem, wounded civilians from Syria first be- gan to arrive on Israel’s northern border seeking medical assistance in early 2013. At the time, Salman Zarka, MD, MPH, MA, was a colonel in the Israeli Defense Forces (IDF) and had previously served as medical com- mander of the northernarena inIsrael.Under his watch, the IDF opened a military field

hospital to providemedical support to those Syrians who came seeking it. Since then, Zarka said, Israeli health care personnel at an IDF aid station on the border, the now-closed military field hospi- tal, and civilian hospitals have provided medical care to roughly 2500 Syrians. Most come from Syria’s southern region, close to the Israeli border. In a New Year’s speech in December, Israeli Prime Minister Benjamin Netanyahu pledged to expand medical treatment to civilians from the more distant ravaged city of Aleppo. Israel does not host Syrian refugees; the patients return to their country after receiving treatment, Zarka said. Now retired from the military, Zarka is general director of Ziv Medical Center in the city of Safed. The staff of Ziv, Israel’s northern-most civilian medical center, has treated more than 800 Syrian patients. Zarka said that although many Israelis and Syrians view each other as the enemy due to 3 wars and protracted tensions be- tween the nations, he believes it’s part of his mission to providemedical care to thosewho need it. “This is my duty,” he said. “I chose to be a physician because I believe in that.” On a recent visit to the United States, Zarka spoke with JAMA about the chal- lenges of treating Syrian civilians and why he believes medicine could be a key to peace in the region. The following is an edited ver- sion of the interview.

JAMA: How many Syrians does your hos- pital see on a daily or weekly basis?

DR ZARKA: Usually we have about 10 to 20 Syrian wounded at our hospital.

JAMA: What type of care are they coming to your hospital seeking? DR ZARKA: We have treated children, women, very young, and very old, with multiorgan system problems—mostly very serious war injuries. Others were sick. We already have 19 new babies that were delivered at Ziv.

JAMA: What types of war wounds are com- mon? DR ZARKA: Most of them have orthopedic problems because of bombardments. We had some children who have played with mines. We had some people with very trau- matic amputation of limbs. We have neuro- surgery problems. We have very compli- cated chest and abdomen injuries. Firing [injuries]. I can remember in one case [a man] was fired with a bullet in this bone. [He points to his jaw.] Another bullet in the chest. And he also was near a grenade, so he had a big problem with the abdomen, with bleeding from the liver, with bleeding from the intestine. So this man, in order to save his life, we needed to operate on him again and again. Mostly the Syrian wounded suffer from a bacteria very resis- tant to antibiotics, and this is made more complicated with sepsis disease.

JAMA: In terms of the peoplewho are sick ... DR ZARKA: Some of them unfortunately have cancer disease. We treated a girl,

(Reprinted) JAMA March 21, 2017 Volume 317, Number 11

Copyright 2017 American Medical Association. All rights reserved.

Copyright 2017 American Medical Association. All rights reserved.

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Ziv Medical Center

News & Analysis

Ziv Medical Center News & Analysis Dr Salman Zarka is the general director of Ziv Medicaljama.com Downloaded From: http://jamanetwork.com/pdfaccess.ashx?url=/data/journals/jama/936120/ by a Rivka Sieff Hospital User on 04/28/2017 " id="pdf-obj-1-6" src="pdf-obj-1-6.jpg">

Dr Salman Zarka is the general director of Ziv Medical Center, whose staff has treated hundreds of wounded Syrian civilians.

14 years old, with a big cancer disease of the uterus who was hospitalized at Ziv for about 4 months. She was treated with che- motherapy, by surgery, and after 4 months she got back to Syria. Three weeks ago, we had a 10-year-old girl with diabetes mellitus that came to the border with a really life- threatening situation. And we treated her and provided her insulin for 6 months to get back to Syria. And I want to believe after 6 months she will come get back close to the border, and we can continue helping her if they have no facility at their country.

JAMA: What are the biggest challenges you face in treating Syrian civilians at your hospital? DR ZARKA: Money may be the first one. It’s really a big debate: Do we have to pro- vide medical support to our enemy? Syria is our sworn enemy… [because] of many wars… between the 2 countries. Ziv Medi- cal Center is a small to moderate govern- mental hospital. It’s the only one at this area, at the north of Israel, and we need to support first of all our citizens. We provide medical support to about 400 000 people living in that area. So sometimes they ask: Why him? What about us? Some of our community is the Druse community that I belong to. And the Druse community sometimes feels that we are providing medical support to the enemies of the Syrian Druse. The other issue… When you are treat- ing Syrians, mostly they have no documen-

tation about what happened, no patient files, and you need to lean just on the data that they give you. It’s really very problem- atic. It’s not the Western standard. When you’re treating Syrians, [they are] mostly alone. They have no family [with them]. These patients have only Ziv staff… to provide medical support, to pro- vide social support, to provide other needs like equipment, like clothes. We decided that we’ll treat the Syrians as if they were Israelis. We decided we have only one standard of treatment at Ziv hos-

pital. When the patient gets into the emer- gency room, whether he’s Israeli or Syrian, we’ll provide him our best.

JAMA: Who is paying for the care that they’re receiving? DR ZARKA: Most of the payment is from the Israeli government. They pay Ziv hos- pital in order to provide medical support to the Syrians. But sometimes we need more. And most of this is philanthropic from the north of Israel or from the good Jewish community or others all over the world.

JAMA: You mentioned that you are Druse. What does this mean and how does it affect your perspective on treating patients from Syria? DR ZARKA: Druse is a small community living in Israel, especially at the north of Israel, in several villages. The Druse commu- nity is more known in the Mediterranean

area, in Lebanon and in Syria. We believe in one God. We believe in reincarnation. As I said, there is a big debate—not just a Druse debate—about providing med- ical support to the Syrians. But really I’m providing medical support to all of the northern residents of Israel. Druse, Jewish, Muslims, Christians, all of them. And all of them are reflected in my staff at Ziv hospital.

JAMA: What are the biggest challenges Syrians face in obtaining health care in Israel? DR ZARKA: Especially when [the crisis] started, it’s not easy for them to come to their enemy asking for help. When it started I met a Syrian wounded [man] that used to be a Major in the Assad regime. [He] was shot at Damascus. He lost his leg and after about 3 weeks, when I met him, I asked, “Why now? Why you didn’t come before?” He said, “I want to be honest. I was educated that you are the devil. When I came here I really looked for the tails of your people. Or the big ears.” I think the other issue is they are lonely at my hospital. So I hired a social worker speaking Arabic.

JAMA: What particular cultural issues should US physicians be aware of if they’re treating Syrian refugees here? DR ZARKA: I think treating refugees is very complicated and very challeng- ing. These days we are talking… about tradition-related medicine. You know, health is part of tradition. It’s part of reli-

gions. It’s part of [a] way of life. And it dif- fers for people all over the world. When Western people have a cancer disease, they will go every place searching for treatment. Sometimes a more traditional community behaves different. They think that this cancer disease is part of their des- tiny, something that God sent. And they need not struggle against it.

JAMA: Why is it important for you to be in-

volved in the care of Syrians? DR ZARKA: For me, as a physician, it’s really very clear. I swore to provide med- ical support. Maybe when this started, I thought, “This is my enemy.” But during the last 3 years I really feel that I, my military staff, and my Ziv staff, we are very lucky for the opportunity to provide medical support to these people in their time of need. I think

  • 1106 JAMA March 21, 2017 Volume 317, Number 11 (Reprinted)

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Aubrey LaMedica/Harvard T.H. Chan School of Public Health

medicine really could be a bridge between people, can connect people, and maybe in my vision at Ziv hospital, maybe there is better future for all the children of the area. Maybe we suffer enough with war. Maybe we can dream about a better future. We have started talking about establishing a bigger clinic near our border [with Syria].

News & Analysis

And then we can connect with videoconfer- ence between Ziv and this clinic. Dreaming to change the area you need to think out of the box.

JAMA: Do you have any othermessages for physicians who might be thinking about treating refugees?

DR ZARKA: I think all of us swore… to save life and really to make life better for all kinds of people. I think we can do it. And I think usually physicians are not just physicians.

They are leaders in order to change this world. I want to hope so.

Note: The print version excludes source references. Please go online to jama.com.

The JAMA Forum

Value-Based Purchasing: Time for Reboot or Time to Move On?

Ashish K. Jha, MD, MPH

T hese are difficult days for those of us who have advocated for pay- for-performance (P4P) as a policy

tool to improve health care quality. The idea behind P4P has always been simple:

physicians and hospitals should be finan- cially rewarded for providing high-quality care and financially penalized for provid- ing low-quality care. Although this idea has been around for some time, it gained national traction over the past decade, as policy makers pushed toward paying for “value” and not just volume. What began as experiments with P4P in the early 2000s became a major policy focus with the passage of the Affordable Care Act (ACA). Six years after the ACA’s passage, the evidence on P4P in general is largely mixed, and the evidence on Hospital Value-Based Purchasing (VBP), the national hospital P4P program, is discouraging. The early studies on P4P found that these programs had little effect on quality but provided bonuses primarily to thosewho were already doing well. A key study found that the largest hospital-based P4P pro- gram known as the Premier Hospital Qual- ity Incentive Demonstration, had no effect on patient outcomes. This program pro- vided bonuses and penalties of up to 2% of total Medicare payments to hospitals based on their performance on a series of quality metrics. However, there has been the mounting evidence—even in multiple meta-analyses that P4P programs were having little effect across a range of clinical services, from quality of ambulatory care to rates of breast cancer screening. Despite this, Congress created multiple P4P pro-

grams within the ACA to incentivize better care. Although some, like the Hospital Readmission Reduction Program, appear to have had modest effects, the national VBP effort is not.

The Evidence Around VBP

When VBP was created, it was structured largely on existing P4P models that al- ready had been found to be largely inef- fective. To reward or penalize hospitals, the program made 2% of overall Medicare payments contingent upon performance on a complex set of measures, includ- ing process measures, mortality rates for targeted conditions, patient experience, and even “efficiency.” Two recent studies have illuminated the VBP’s effects on patient outcomes. The first comprehensive study, pub- lished in early 2016, found that 3 years after the initiation of the program, it had no impact on patient outcomes. Before the program began, mortality rates for the targeted conditions (acute myocardial infarction, congestive heart failure, and pneumonia) were collectively declining at approximately 0.13% per quarter (or about half a percentage point per year). After the VBP incentives kicked in, mortality reductions actually slowed, to 0.03% per quarter. Comparisons of hospitals par- ticipating in the program with control hos- pitals or targeted conditions with nonin- centivized conditions provided a similar picture. Instead of accelerating improve- ments in patient outcomes, VBP incen- tives appeared to have no effect or possi- bly even a detrimental one.

Aubrey LaMedica/Harvard T.H. Chan School of Public Health medicine really could be a bridge between people,Hospital Value-Based Purchasing (VBP), the national hospital P4P program, is discouraging. The early studies on P4P found that these programs had little effect on quality but provided bonuses primarily to thosewho were already doing well. A key study found that the largest hospital-based P4P pro- gram known as the Premier Hospital Qual- ity Incentive Demonstration, had no effect on patient outcomes. This program pro- vided bonuses and penalties of up to 2% of total Medicare payments to hospitals based on their performance on a series of quality metrics. However, there has been the mounting evidence—even in multiple meta-analyses that P4P programs were having little effect across a range of clinical services, from quality of ambulatory care to rates of breast cancer screening. Despite this, Congress created multiple P4P pro- grams within the ACA to incentivize better care. Although some, like the Hospital Readmission Reduction Program, appear to have had modest effects, the national VBP effort is not. The Evidence Around VBP When VBP was created, it was structured largely on existing P4P models that al- ready had been found to be largely inef- fective. To reward or penalize hospitals, the program made 2% of overall Medicare payments contingent upon performance on a complex set of measures, includ- ing process measures, mortality rates for targeted conditions, patient experience, and even “efficiency.” Two recent studies have illuminated the VBP’s effects on patient outcomes. The first comprehensive study, pub- lished in early 2016, found that 3 years after the initiation of the program, it had no impact on patient outcomes. Before the program began, mortality rates for the targeted conditions (acute myocardial infarction, congestive heart failure, and pneumonia) were collectively declining at approximately 0.13% per quarter (or about half a percentage point per year). After the VBP incentives kicked in, mortality reductions actually slowed, to 0.03% per quarter. Comparisons of hospitals par- ticipating in the program with control hos- pitals or targeted conditions with nonin- centivized conditions provided a similar picture. Instead of accelerating improve- ments in patient outcomes, VBP incen- tives appeared to have no effect or possi- bly even a detrimental one. Ashish K. Jha, MD, MPH Value-based purchasing efforts fo- cused on more than just mortality. Another key metric incentivized by the program is patient experience. So has it improved patient experience in US hospitals? The answer is no, according to a recently published study. Before it was established, the proportion of patients rating their hos- pital highly was increasing by approxi- mately 1.5% per year. After VBP was estab- lished, that increase slowed to 0.6% per year. Again, comparing the effects with those at non-VBP hospitals did not im- prove the picture. Why Is Hospital VBP Failing? Those of us who have been advocates of P4P have argued that VBP as designed was destined to fail because key principles of what makes good P4P programs have not been met. As I noted in a JAMA Viewpoint jama.com (Reprinted) JAMA March 21, 2017 Volume 317, Number 11 Copyright 2017 American Medical Association. All rights reserved. Copyright 2017 American Medical Association. All rights reserved. 1107 Downloaded From: http://jamanetwork.com/pdfaccess.ashx?url=/data/journals/jama/936120/ by a Rivka Sieff Hospital User on 04/28/2017 " id="pdf-obj-2-62" src="pdf-obj-2-62.jpg">

Ashish K. Jha, MD, MPH

Value-based purchasing efforts fo- cused on more than just mortality. Another key metric incentivized by the program is patient experience. So has it improved patient experience in US hospitals? The answer is no, according to a recently published study. Before it was established, the proportion of patients rating their hos- pital highly was increasing by approxi- mately 1.5% per year. After VBP was estab- lished, that increase slowed to 0.6% per year. Again, comparing the effects with those at non-VBP hospitals did not im- prove the picture.

Why Is Hospital VBP Failing?

Those of us who have been advocates of P4P have argued that VBP as designed was destined to fail because key principles of what makes good P4P programs have not been met. As I noted in a JAMA Viewpoint

(Reprinted) JAMA March 21, 2017 Volume 317, Number 11

Copyright 2017 American Medical Association. All rights reserved.

Copyright 2017 American Medical Association. All rights reserved.

1107

Downloaded From: http://jamanetwork.com/pdfaccess.ashx?url=/data/journals/jama/936120/ by a Rivka Sieff Hospital User on 04/28/2017