Lisa Suter: Medicine, Measurement, and Equity

Harlan Krumholz: Welcome to Health & Veritas. I’m Harlan Krumholz.

Howard Forman: And I’m Howie Forman. We’re physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. Our guest today is Dr. Lisa Suter, but we always like to start off with some hot topics in health and healthcare. What do you have today?

Harlan Krumholz: Well, Howie, we’re taping this on a very special day. It’s Juneteenth, which as everyone knows is celebrated on June 19th. That’s today. And it’s a significant day in American history.

If anyone’s unaware, it’s really the anniversary of the announcement of the abolition of slavery in Texas, which was the last Confederate state with institutional slavery. And this goes back to June 19th, 1865, when General Gordon Granger arrives in Galveston and makes this announcement. And people may not realize, but the Emancipation Proclamation comes out January 1st. But I think there was some complicity by the states. I mean, people talk about how slowly news traveled, but this is really slow—six months.

But some people may think, “Well, they may have been making these announcements all over the place. Why this one?” And it really was because it was announcement in Texas when freedom finally reached all corners of the United States. And of course, we know—not real freedom. And it wasn’t over just with that announcement and not only what was going on throughout the United States at that time. And even to today, there’s work to be done.

I wanted to just also take an opportunity to say that, as you know, I’m now the Editor-in-Chief, or will be as of July 1st, for JACC, Journal of the American College of Cardiology, which is called JACC. And what we’ve done today is put out a report card on health disparities. We’ve published today—health disparities—that has been led by the way, by Yale School of Medicine student, Adith Arun and others. And the idea was to look at the number of excess deaths among Black Americans compared with white Americans.

As you know, the mortality rates in cardiovascular disease and overall are higher for Black Americans than for white Americans. We published a study in JAMA about this that was led by César Caraballo, Yale New Heaven Hospital and Yale internal medicine resident now, who led this effort to show the large number of excess deaths and years of life lost in America because of these higher mortality rates.

In this report card, this JACC report card, what we do is report on what’s it like for cardiovascular disease. And we looked between 2000 and 2022. And we say that over that period of time, there were 800,000 excess deaths, age-adjusted excess deaths among Black Americans compared to white Americans in cardiovascular disease as a result of this difference that occurred. But even more tragic—I know, it’s equally tragic but in sort of more stark terms—this equated to 24 million years of potential life lost.

And we talked about this during the pandemic, people not at the dinner table, people not in communities, people not contributing. Twenty-four million years. If Black Americans had the same rates as white Americans, that this number would be zero because there would be no excess deaths or years of life lost. Because of this difference, there are 800,000 excess deaths and 24 million years of life lost over that period from 2000 to 2022. And I think it just puts in human terms, the enormity of lost years because of these higher death rates.

And that these are persistent. We’re not showing real progress towards eliminating this. And when we looked at, for example, heart failure disparities, they’re growing. They’re actually growing over time. And so there needs to be a real call. And at some point we might on the program have some people on and talk about what needs to be done. But I mean, there’s a need for policy intervention, research and funding, community engagement, healthcare system change, monitoring reporting.

Howie, if we thought about this as an epidemic that was a blight on a certain members of our population, we would fight to eliminate it. And in this one, albeit complex, it’s social, it has a lot to do with the way our healthcare system is set up and the way behaviors and structural racism, and it’s a whole range of different influences here. But there’s an imperative for us to do something about it. On Juneteenth, I just wanted to take a moment to both honor the day, now a federal holiday, and also to talk about the report card as a means to galvanize action, not just simply to describe it but to catalyze action.

Howard Forman: Yeah, it’s great, and it is a topic that we talk about often. We’re not making the type of progress that I would’ve thought about. The first time I started to seriously think about this topic was in the late 1990s. And if you would have asked me then where we’d be 25 years later, I would have thought we had made enormous progress. And we unfortunately haven’t. We’ve improved healthcare for certain populations. A lot of your work in cardiovascular care has improved populations, but the disparities do persist. So a rising tide is lifting different boats, but it’s not narrowing the disparities that seem to be achievable.

Harlan Krumholz: Yeah, I think the bottom line here is, we can’t accept these disparities as being inevitable, and we must hold ourselves accountable for addressing the forces that produce these excess years of life lost and find a path to meaningful progress. It’s long past time that we need to actually show progress on this.

Howard Forman: I’m glad you talked about that. Thank you.

Harlan Krumholz: All right. Hey, let’s get onto our guest, Lisa Suter.

Howard Forman: Dr. Lisa Gayle Suter is a Yale Professor of Medicine and the current Senior Director of Quality at the Center for Outcomes Research and Evaluation, also known as CORE. And it’s the organization that Harlan founded and continues to lead within Yale New Haven Health system.

Dr. Suter is a rheumatologist and an internist by training. Her research focuses on skeletal and muscular conditions such as arthritis and inflammation. But at CORE she has facilitated the development of around 50 quality care outcome measures with several dozen more in planning and continues to shape the Yale community with her expertise and dedication to high-quality care. She’s been a member of the American College of Rheumatology for the last two decades, where she also co-chairs its quality measure subcommittee.

Dr. Suter is blue through and through, having received her undergraduate and medical degrees from Yale before doing her residency and fellowship at Yale New Haven Hospital, and also the Robert Wood Johnson Clinical Scholars Program at Yale, among many other things. But I only learned this as I was reviewing today, just how much you’ve committed to Yale, and we so appreciate it. And as we’re talking to you now, I see Yale memorabilia over your shoulder, so you are really Yale.

But I want to start off, there’s a lot that we can talk about today, and you are a clinical rheumatologist and you also do research in the field. And that field has been transformed in the last three decades. I mean, just totally transformed. And I want to just allow our listeners to hear from you, who’ve worked basically as a medical student and all the way through, how much has it changed for the rheumatologist versus how much is it changing for other practitioners who are able to prescribe drugs for patients with rheumatologic conditions?

Lisa Suter: So you’re right, it has changed remarkably, and in some ways it hasn’t changed at all. So when we think about arthritis, we think about two large categories of arthritis, arthritis that comes from degeneration or wear-and-tear arthritis and arthritis that’s driven by the immune system or inflammatory arthritis. And those are very broad categories, but we treat them differently. And despite all the advances we’ve made in treating inflammatory arthritis, we haven’t made really any headway in treating degenerative arthritis. So on that side of things, not much has changed. We certainly understand a little bit more about chronic pain, but we don’t really treat it that much better than we did 30 years ago.

On the other side, we’ve made huge changes. And I think the most important thing now is when I’m training fellows and we’re talking about the impact of these chronic inflammation–driven diseases that destroy your joints and I talk about and show them pictures of the deformities that happen and how that impacts people’s daily lives—they’ve never seen those findings. And so that’s a big change.

Howard Forman: One quick follow-up question to that. You wrote, actually, you’ve written several papers on this topic over the last couple of decades, but you’ve written on the topic of optimal treatment and management of patients with knee pain, with regard to arthroplasty, I think knee replacements, and probably also imaging. And this was interesting to me when I first came to Yale because we still had a lot of clinicians wanting to image people with advanced arthritis in advance of doing an arthroscopy. And I’m just curious to hear from you, who’ve involved in quality measures, why is it so difficult to change clinical practice when we have so much evidence?

Lisa Suter: It’s a really great question, and I’m not sure I have a perfect answer, but I think part of it is that there’s a belief system, both among physicians and among patients. And the other side is, we want to help people. We want to do something to make people feel better. And that means that sometimes we’ll advise them to take medications even though those medications haven’t been shown to do anything, but they also haven’t been shown to do any harm, and maybe there’s some benefit that somebody’s going to get. And that’s one of the reasons that people get a lot of MRIs of the knee, even though there’s nothing that you can really do in response to those MRIs, but somehow maybe if they know more about what’s going on in their knee, they’ll feel better. I don’t know that that’s the case, but I do think it’s a cultural expectation that more is better.

We’ve known in medicine for a very long time that the most common conditions are preventable or the most common reasons for morbidity and mortality are preventable. And yet we still have obesity, we still have uncontrolled diabetes, and we still have arthritis from injuries even though we know certain exercises can help prevent injuries in young athletes.

Harlan Krumholz: Lisa, I wanted to ask you. Why are you so committed to the idea that measurement matters? Because of course, there are a lot of critics in the environment that say that we measure a bunch and it doesn’t matter. And this is just adding friction to the healthcare system, that it’s not really making a difference. And you and I both share the belief that measurement is critically important, but I wonder if you could explain your view of this. Why has this been worth spending your career on?

Lisa Suter: I will say that measurement has a critical place in illuminating what we can’t see. And as human beings, we’re fallible, and we need information to overcome the lens through which we see things because oftentimes, those lenses are cloudy or tilted or what have you. And going to the data and looking at the data and using data to guide our behaviors is a critical part of the establishment of the whole field of medicine. And I think where we need to keep going, we can’t ignore data, and for me, the measurement means I can have an impact at the national level, and it means also that I can do it in a way that engages everyone in the process, from patients to physicians.

Harlan Krumholz: Just to give people a quick sort of concrete feeling for this, I mean, could you just describe maybe one measure that you thought was important and meaningful and has helped advance progress for patients?

Lisa Suter: Absolutely. Oftentimes we have challenges in terms of getting the data to measure all of the patients or many of the patients in the United States. So Medicare is one of the largest insurers, and therefore patients who are enrolled in Medicare have administrative claims or billing data around their hospitalizations and healthcare. And we use some of that data to anticipate and measure outcomes like returning to the hospital after an admission for a heart attack. And those readmission measures also account for the differences in clinical comorbidities and health severity, disease severity across patients and across hospitals, and allow us to compare hospitals against a national benchmark or a national standard.

More recently, we’ve begun to look at patient-reported outcome data. So when we actually survey a patient and ask them what pain are they feeling and how functional are they. And right now hospitals are in the process of collecting the first data for a patient-reported outcome-based measure in Medicare’s payment programs that isn’t focused on experience, it’s actually focused on patient’s symptoms. And that’s for patients who’ve undergone either total knee replacement or total hip replacement. And we are looking at that data now, and it is eventually going to be a mandatory measure. Right now it’s being voluntarily reported by hospitals.

Harlan Krumholz: What is the measure?

Lisa Suter: The measure takes ... it asks patients how much pain and how much difficulty in function are they having before they have their surgery, and then allows them to recover from their surgery for a period of time. And after 9 to 12 months, they’re asked those same questions again. And the measure determines whether or not they have changed at least a certain amount between before their surgery and after their surgery, looking at the impact of the surgery on their pain and their function.

Howard Forman: I’m curious to hear when it comes to measures, and this is so outside of my wheelhouse, and so I’m speaking as sort of hopefully a listener in asking this question, do these measures have a life cycle? Is there a time where they come on board their use and then they become less useful because either everybody’s improved to a certain standard or unfortunately people learn to game them somehow? What is the life cycle for measures?

Lisa Suter: So there is a life cycle. There are actually multiple life cycles. From Medicare’s standpoint the life cycle is you develop it, you implement it, and each year you update it in response to changes in the healthcare system. And every year, Medicare reevaluates measures in terms of performance in the United States, and occasionally a measure will be what’s called “topped out,” meaning that everybody’s performing very well on it. And at that time, CMS recommends, have a process for recommending, that measures be retired.

Interestingly, our outcome measures where we’re measuring outcomes as opposed to the process of care, so for a heart attack patient, the mortality of that patient group as opposed to whether or not the hospital administered beta blockers or other appropriate medications in terms of following guideline concordant processes of care, those outcome measures are we’re never going to get to zero. We might get to parity across all hospitals and all patients, but there’s always going to be a certain number of patients that die or are readmitted after a heart attack, whereas the process measures can get to 100% perfect performance and they’re much more likely to be retired from use than the outcome measures.

Harlan Krumholz: Over the years, we’ve gotten some criticism from time to time to some of the measures. One of the measures that was most controversial was the readmission measure. Actually, it’s one of the ones I’m very proud of, because again, we were sort of like you said, throwing light on an issue that people tended to ignore. They could push people out of the hospital because of the incentives. You were paid the same amount if you got three days or four days, hospitals were shrinking lengths of stay, but if people ended up coming back more often, there was no line of sight into that.

These have been in place now for about a decade or more actually, a little bit more. And with just a little bit of gain, I’m just wondering, as you look back on the readmission measure, you’re still very much involved in kind of its evaluation and continued refinement. Do you have thoughts about whether or not there are things that we should be doing that would make that better or more impactful, or should we even continue it?

Lisa Suter: So we’re still getting questions about, is the hospital the only entity that should be responsible for readmissions to the hospital and does the hospital really have the ability to influence readmissions? And I will say that one of the hot topics in our nation right now but also in healthcare is equity of care and healthcare disparities across different patient groups or historically marginalized groups. And we know that across outcomes, there are disparities. Sometimes they’re not in the direction that we expect, but oftentimes there is asymmetrically distributed care or access to care. And we are just beginning to understand how to effectively illuminate those disparities in ways that are not only thoughtful but also conform to the legislative constraints that Medicare is required to adhere to. And that makes it a challenge, but a really critical challenge. So I will say in measurement, equity is essential, and we’re just scratching the surface of that in measurement.

Howard Forman: We’re taping this on Juneteenth today, which commemorates the end of slavery but also acknowledges the original sin of the founding of our country. You have said recently, and I think you’re quoting others, but you said there’s no quality without equity and no equity without quality. And I just want our listeners to understand what you mean by that or how they should understand that. I know you touched on it, but just more directly on that point.

Lisa Suter: So you can’t have equitable care if people are ... I mean, I guess technically you could have equitable care and have it all be terrible, but that isn’t really our goal in healthcare. So the goal really is to elevate everyone, and resources are not uniformly distributed in healthcare in our country. And yet despite that, some healthcare providers or institutions, health systems are able to provide to communities that have fewer resources and provide really outstanding care. I think, Harlan, you or your early work in heart attacks and door-to-balloon time illustrated just how critical institutional culture and leadership are in changing practice and in really achieving phenomenal heights of clinical care. And I think the same.

Howard Forman: And let me just say because we don’t say it enough: truly changed medicine and saved lives, made people’s lives better. I mean, we just don’t say it enough. Harlan often is described as a scholar or researcher, I mean, if that was the only thing he did 20-plus years ago now, he changed medicine. Sorry. Go on.

Lisa Suter: And we’re still trying to measure that, now using electronic clinical medical record data that’s captured electronically. So there’s still work to be done, all the more reason to say measurement is important because it has moved the needle, but it doesn’t mean that the needle doesn’t need to move more. And that’s particularly true with equity.

Harlan Krumholz: Just so we could talk about this for a long time, but as we sort of get to closing up, what do you think are the future frontiers for this? I mean, what’s going to happen with measurement as we move into this era of big data and artificial intelligence and all this sort of stuff coming down the pike? Is it going to change the way we measure and be accountable for our care?

Lisa Suter: Yes. I think one of the challenges is sometimes measurement is ahead of clinical care. I mean, in hip and knee replacement, even surgeons who acknowledge that pain and function were the reason they’re doing surgery weren’t collecting systematic pain and function data on their patients. And so sometimes you’re measuring to push clinical practice towards what research tells us is the best direction.

So where are we going? I think we’re going to, I would hope, a place where data is truly more fluid in the healthcare system, both for providers and for patients so that patients can carry their data with them and they can carry measures with them and they can track their own information in real time. So I think there’s a lot to be gained from the technological advances.

Howard Forman: We are so fortunate to have you with us at Yale, and thank you for joining us on the podcast. This is awesome.

Lisa Suter: Well, thank you so much. It’s been a real pleasure.

Harlan Krumholz: Thank you.

Howard Forman: Thank you very much.

Harlan Krumholz: Howie, that was a terrific interview. I’m so glad to have Lisa on. But now let’s get to one of my favorite features of the podcast. Howie Forman, what’s on your mind this week?

Howard Forman: Yeah. So this week our nation’s Surgeon General, Vivek Murthy, our friend, our former student wrote an op-ed in The New York Times making the impassioned plea for Congress to pass laws to protect the nation’s children from the effects of social media. And he logically reaffirms the case that we have a serious mental health crisis among our youth and that there is strong evidence to suggest that some of it is due to social media.

A few of his points, I’m just going to quote from the op-ed itself. “Adolescents who spend more than three hours a day on social media face double the risk of anxiety and depression symptoms. And the average daily use in this age group as of the summer of 2023 was 4.8 hours. And additionally, nearly half of adolescents say social media makes them feel worse about their bodies.”

He then makes the case that a Surgeon General’s warning needs to be displayed on social media to encourage parents and their children to limit usage. But just as importantly, it would force a reckoning about what we do and don’t know about social media’s role in the developing brain.

He further asks Congress not only to pass a Surgeon General’s labeling requirement, which it turns out is required under law, but also privacy protections and restrictions on the use of features that encourage excessive use by those same social media platforms.

So I encourage our readers to read the op-ed and to reflect back on the advisory, which came out 13 months ago. We’ll link that in the notes, and we’re also going to try to have the Surgeon General come on in the next few months. But I wanted just to highlight a few of my own thoughts on this.

So number one, I agree that we know too little and that what we do know is already troubling. I also agree that we cannot wait for perfect information to act and that the Surgeon General’s warning is seemingly the least we could be doing until we know more.

This is all easier said than done during partisan times, however. There’s already a bipartisan piece of legislation called the Kids Online Safety Act or KOSA, but this has become very controversial because of the relative moderation that it requires of social media companies and the concerns that this could extend to, for instance, suicide hotlines. Some of these things are easy to fix and modify. Some have actually been fixed in more recent versions of this act. Others are harder.

We’ve seen all too often important legislation pass with great delay or doesn’t pass at all because everybody thinks that they have to pass the perfect. And here I think Dr. Murthy has laid out a very reasonable starting point.

But can Congress take yes for an answer? Even his very minimal request might be challenging. Warning labels have not been uncontroversial. Over a decade of litigation ensued after the FDA demanded that graphic warnings be applied to cigarette packages.

And we should be cautious about the precise way in which we regulate social media because there is evidence of benefit as well as harm from social media. So even if I believe that the net effect favors harm right now, I might still want to mitigate the loss of benefit and whatever regulations are developed.

This is all to say that, just as you talked about in the introduction, that we should be doing more, this is an example where we should be having a much more vigorous discussion about this topic. We should be actively funding research that answers the many questions that remain. And we should also not lose sight of the risks to young developing brains because they are absolutely our future.

Harlan Krumholz: Yeah, great topic, Howie. I’m really glad you brought it up. It’s so great to see Vivek take this on to get a lot of attention. I’m at actually Aspen Health run by our friend Ruth Katz, who was recently on the program, and Vivek has ... the closing ceremony is really Vivek coming out and talking about this issue. I saw he was on the TV. You may have seen that the Los Angeles school system is banning cell phones.

Howard Forman: Yes. We’re all trying to.

Harlan Krumholz: And no, as of January 1st, I think they passed the resolution that they will begin—

Howard Forman: I’m just saying these things end up going through the courts and I don’t count on anything until I see it, but yeah.

Harlan Krumholz: Well, we’ll see. But in any case, there’s lots of actions, and we definitely are in a period where we know that there have been profound effects. Of course, we lived through the pandemic. There’s lots of other factors, but I don’t think that there’s any doubt that social media is playing a role in what’s going on as it is with our politics. And despite the opportunity to have great potential positive possibilities for our society, it has a dark side as well. And thank you, Howie, for raising this. Lots of good issues and—

Howard Forman: He raised it. I’m just amplifying. But I agree. We just need to talk about it more. And like I said, I’m going to try to get him on. We’ll hopefully get him to talk about this himself.

Harlan Krumholz: But let’s just say that we talk about infectious agents. We need to be thinking about social factors that influence health. And so sometimes that’s just about the very important factor of poverty and deprivation, which is an important factor that we should be attacking. But then this is another social factor that was introduced into our society, and we have to be able to be tracking it and understand what it is to be mature enough to be able to use tools like this without having them have the untoward effects.

Howard Forman: I agree.

Harlan Krumholz: You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

Howard Forman: So how did we do? To give us your feedback or to keep the conversation going, email us at health.veritas@yale.edu or follow us on any of the social media.

Harlan Krumholz: And as you know, we want to hear your feedback. We’d like to hear your questions, experiences with these topics. We read it all. Also, when you do it online and rate us, it helps other people find us. We invite you to do so.

Howard Forman: Yeah, we appreciate it. And if you have questions about the MBA for Executives program at the Yale School of Management, reach out via email for more information or check out our website at som.yale.edu/emba.

Harlan Krumholz: Health & Veritas is produced with the Yale School of Management and the Yale School of Public Health. Thanks to our researchers, Ines Gilles and Sophia Stumpf, and to our producer, Miranda Shafer. We’re so grateful for them.

Howard Forman: We certainly are.

Harlan Krumholz: Talk to you soon, Howie.

Howard Forman: Thanks very much, Harlan. Talk to you soon.