Apples, oranges, and brightly colored machine tools

Clearly someone is looking out for me today. Here I am, getting my bad self bogged down in a high-flown assessment of the meaning of high health care costs in the U.S. – not my field, but who’s counting? – when a glance at the clock tells me it ain’t gonna happen. If I’m going to keep my promise to get something posted before a reasonable bedtime, I thought, best to shelve health care costs for now and find myself a nice, straightforward epidemiology target. And maybe mix a few metaphors while I’m at it.

And there it was in my news feeder, the first one on the list from the Center for the Advancement of Health: Fish Fatty Acids May Prevent More Sudden Deaths Than Defibrillators. And yes, it’s just as surreal as it sounds. (As in, “How many surrealists does it take to change a lightbulb? Answer: Two. One to hold the giraffe, and the other to fill a bathtub with brightly colored machine tools.”) To be fair to the CFAH writer, the news article is based on a soon-to-be-published article (October) in the American Journal of Preventive Medicine, by TE Kottke and colleagues, which I have not yet seen, so I am relying only on the news article.

OK. Without getting into the numbers, let’s just say they are estimates, not measurements on actual people. The population examined is a simulated population, because it is “difficult to compare their effectiveness across a [real] population.” But the respective effectiveness of omega 3’s and defibrillators at lowering cardiac death is known from research – albeit with some kind of range of uncertainty attached to each. That’s one thing I’d like to see acknowledged – is there some kind of lower and upper bound on the relative effectiveness of these two preventive agents? And where does that uncertainty come from? Yes, there are very good quality studies, such as intervention trials, showing that omega-3 fatty acids, those found in fish, lower heart disease risk, but the endpoint of cardiac death comes from somewhat lower-quality prospective cohort studies (with attendant uncertainty in dietary consumption estimates).

But really, my first thought when I read this article was, Show me the policy relevance of this article. Why are we comparing fatty acids in fish with defibrillators? Is there actually someone making a choice on behalf of a population between one and the other, some Wizard of Oz who gets to say, “Well, we do need to prevent cardiac deaths, but those defibrillators are too expensive and people aren’t trained to use them right; you shall eat salmon instead. I like salmon.”? In what universe? Or someone says, “I think I’m having a heart attack; someone give me an omega-3 supplement, quick!” Sorry, too late; we blew our defibrillator budget on canned fish, and a supplement is not going to help you at this point if you foolishly snuck all your tuna salad to the cat. I'm exaggerating a little here for effect; the authors did discuss an intervention of daily omega-3 supplements, not fish, but I think my point still holds. (Wait - do you think it makes a difference whether people eat fish or take supplements? Hmmm...)

Tomorrow I shall call the editorial office of the American Journal of Preventive Medicine and get a copy of the paper. If it clears up my confusion, I’ll let you know.

American Journal of Preventive Medicine

cardiac defibrillators

omega-3 fatty acids
diet

sudden cardiac death
fish

Music hath charms and all that... but do you need a study?

An article in August 24th's New York Times describes a musician playing gentle, soothing Celtic airs and lullabies on a small harp in a hospital unit where heart patients are recovering from surgery. Patients and hospital staff interviewed for the article attested to the relaxation they experienced when the harpist played. Turns out it's part of a privately funded research study - staff are monitoring patients' vital signs at regular intervals before, during, and after the harpist's daily visit to the recovery unit.

The benefit of music seems so obvious, and any downside so elusive, that one might question the point of studying it - it's what I used to refer to as "duh" research, used to confirm what you already know. And in the scope of things perhaps competing priorities with potentially higher public health impact might in fact win out.

But quantifying the benefit and the possible risk are important. Try this exercise. Close your eyes, imagine a soothing harp melody, imagine you're a new cardiac care director, and now imagine that the Celestial Guild of Therapeutic Harpists has deep pockets and powerful lobbying connections, and somehow convinces the hospital accrediting organization to bypass its usual scientific review and declare that employment of white-robed, harp-strumming musicians is a high priority in ensuring quality of cardiac care. It's obvious, isn't it? Look how happy those people in the NY Times article are! What's not to like? (And you'd better like it, because your accreditation is in jeopardy if you don't.)

"Hang on a second!" the hospital association barks, shattering your reverie. "That harpists' union has us over a barrel. Forget about the cost of spiral CT for lung cancer screening, we can bill for that; those blithering angels want $500 per patient per day, and Medicare won't cover it."

"Not to mention," the nurses' union chimes in, "we've had three nurses fall asleep on the job under the influence of harp music. An orderly in San Jose got himself so soothed, he wheeled a sleeping patient all the way to the morgue before the patient woke up."

Oh. Um... maybe a little study would be a good idea after all. Let's make sure we have a few hard patient and cost outcomes - and outcomes for effects on staff while you're at it - and standardized measures of musical exposure.

Far-fetched, perhaps, or is it? Such is the paradox of complementary and alternative medicine (CAM). Herbs, supplements - they seem so benign, so... so natural (note: poison ivy is a natural herb; it sure ain't benign...). So... expensive, often. Very likely: Americans spend $34 billion a year on CAM (Herman et al., 2005), which means that we're using a heck of a lot of it (36% of American adults use some form; NCCAM, 2004), or it costs a lot; my guess is that both are true. And about most CAM therapies, we just don't have much evidence for safety or effectiveness (let alone cost effectiveness).

Bottom line: since patients are using this stuff, we do have to ask, in a very directed way, "What's not to like?" and at the same time "What IS to like?" Consumers have a right to know that the treatments they're spending money on are safe and effective - especially in a regulatory climate of, well, complete absence of regulation, at least for dietary supplements. The only way to get to that knowledge is through high-quality research.

What do I mean by high-quality research, anyway? Stand by...
Complementary and alternative medicine
Cost effectiveness
music

Premature baby...mice?

This is the kind of press release that makes me want to hurl flowerpots at closed windows. The title, "Constant lighting may disrupt development of preemies' biological clocks" would lead most reasonable folks to the conclusion that premature babies were somehow involved in the article.

But no. It's about baby mice, which are supposed to be comparable to human preemies because they're born at an earlier stage of development. I can't comment on that - obviously the funders of the study thought it was a fair assumption. But c'mon, if the study did not in fact look at premature human babies, then don't put it in the title, because some people won't read any further than that, and we frankly don't know yet whether the results can be extrapolated.


biological clocks
premature babies
constant lighting
press release

What we're doing

This blog represents an unsystematic effort to cast a critical - not cynical, we hope - eye on new health and health care research, policy directions, and news reports. There's a lot of health news out there, and we know that people, even doctors, get a lot of their health information from the media. We posit that there's often a lot beneath the surface that the public doesn't get to see, and that many health writers don't have the opportunity to address.

From the relative luxury of our position as bloggers, free of deadlines, corporate influence (as far as we know), gag orders, or even a regular day job, but with a certain broad training and experience in health research and health care policy, we'd like to ask readers' indulgence as we delve into topics that interest us and share our humble opinions and analysis. Comments and questions are, of course, always welcome.

About the title: "Universal Antidote" was a label I once saw on a small brown bottle while I was working in a toxicology lab, and it made me laugh. (It's just activated charcoal.)

Allons-y!