More on aviation and patient safety

A few weeks ago I wrote about a news article that claimed that lessons from aviation safety were now being picked up in health care circles, and I questioned how widespread such training was.

Today, while browsing Paul Levy's blog (see today's previous post), I came across an article that described his hospital's experiences using aviation's example of team training to improve patient safety in the delivery room, and expanded on the details of these techniques. The results? Pretty impressive: the adverse outcomes index went down 47% over 4 years for babies born before 37 weeks' gestation.

If readers know of other health care settings in which team training is being applied, please let me know.

Hospital executive salaries: too high?

I was struck by the candor in this post by Paul Levy, President and CEO of Beth Israel Deaconness Medical Center. Other than that, I won't comment; check it out for yourself.

Publishers pull out the big guns against open access

Our tax dollars fund scientific research to the tune of $54.7 billion per year. We know, in the case of health, that innovations can take on average 17 years to find their way into clinical practice if we leave it up to the system the way it is, but in the meantime, why shouldn't Americans have access to the results of the research we pay for? I'll confess my personal frustration at the lack of unfettered access to every imaginable journal that I enjoyed while I was in school, or working for the government. But I'm absolutely not alone in this - consumers in general need this research, and shouldn't have to pay $25 or $30 for a copy of an article.

Rick Weiss reports in the Washington Post this week on an effort led by former (liberal) Colorado congresswoman Pat Schroeder on behalf of a group of medical journal publishers against open access of publicly funded research results. The publishers argue that open access will erode their subscription base, making it difficult for them to afford to run the peer review process that's needed to ensure the quality of published scientific research. So they've hired, for close to half a million dollars, a heavy-hitting PR firm to counter the efforts of the open access movement.

Yes, we need peer review and journals. But is this really about peer review? I doubt it; I think it's more likely about profits. I imagine we can find a way to ensure that journals continue to exist in an open-access environment.

In a similar vein, the Pump Handle blog reports that the National Institute of Environmental Health Sciences has decided to discontinue the Environews section, written with the general public in mind, from its open access journal, Environmental Health Perspectives, for budgetary reasons. The news section has been an important source of information on environmental research. The Pump Handle encourages readers to ask their Representatives to make sure that this resource does not get shoved aside.

And while we're on the subject of Environmental Health Perspectives, I'm going to share with you a gratuitous link to one of my own articles, my pride and joy really, published in that journal back in 1994, in my third year of graduate school. Be warned: it's pretty geeky stuff.

Health Wonk Review is up

Check out the new issue of Health Wonk Review at the Health Affairs Blog. A number of bloggers are talking about various health reform proposals and the President's State of the Union Address, as you might expect; my recent post on the ACP proposal is in there. I'm excited to see that there's an interview with Brent James of Intermountain Health Care, one of the leaders in translating research into practice.

Thanks to ALS for reminding me to submit, and for thinking with me about what I wrote.

The high cost of prescription drugs

Think Medicare's ability to negotiate prescription drug prices is a trivial issue? Think again.

According to the Agency for Healthcare Research and Quality, the top five classes of prescription drugs in 2004 were cardiovascular drugs ($17 billion), cholesterol-lowering drugs ($10 billion), hormones ($8 billion), central nervous system drugs ($7 billion), and gastrointestinal drugs ($6 billion). Expenditures for these drugs totalled $48 billion, or three fourths of Medicare drug expenditures ($65 billion).

From the internists: an alternative health care reform program

The American College of Physicians, which represents internists and promotes primary care, issued yesterday two related papers: A Report from America's Internists on the State of the Nation's Health Care and a position paper, A System in Need of Change: Restructuring Payment Policies to Support Patient-Centered Care. Both of these are linked here. Like the variety of other proposals that have come forth in the past couple of weeks from states, presidential candidates, insurance groups, and to some extent the White House, the ACP proposal advocates making health insurance affordable to all Americans.

The ACP goes beyond other proposals in several directions, however, principally through its focus on patient-centered care, for which it advocates "advanced medical homes" - not nursing homes, but primary care centers that house primary-care providers. These providers would actually coordinate care, supported by electronic medical records, evidence-based decision-support systems, and payment policies based on defined packages of services related to care coordination. Current reimbursement for care is based solely on office visits and procedures; although capitation currently results in disincentives for office visits after a certain maximum benefit is reached, the ACP proposal does allow for fee-for-service reimbursement for office visits as part of ongoing, coordinated care. In addition, the ACP proposal advocates a performance-based component to payment, based on measures of evidence-based quality, efficiency, and patient satisfaction.

Grand Rounds

This week's Grand Rounds is up at the Signout Blog. As I mentioned earlier, the topic is... evidence! (Now, why didn't I think of that?) Signout Blogger has done a great job with this topic.

Perspectives on the importance of evidence in medicine

When this week's host of Grand Rounds, the Signout blog, announced a theme edition dedicated to "the interface of evidence with health and health care," I jumped up and down a bit in excitement, and today have decided to dedicate a special post to the occasion. Shameless sucking up, I know, but in any case, here are a few recent items that articulate the importance of evidence in health care.

The British Medical Journal, which is committed to promoting evidence-based medicine, has an article this month by Kay Dickersin, director of the US Cochrane Center, and colleagues on the importance of evidence-based medicine. The Cochrane Collaboration is an international effort to produce systematic reviews of evidence on clinical questions; check out their website, which offers free summaries of all of their reviews.

Anyway, here's the introduction to the BMJ article, whose content is available free, at least this month.

Evidence based medicine is healthcare practice that is based on integrating knowledge gained from the best available research evidence, clinical expertise, and patients' values and circumstances. It is curious, even shocking, that the adjective "evidence based" is needed. The public must wonder on what basis medical decisions are made otherwise. Is it intuition? Magic? The public must also wonder what happens to the research evidence in which they have invested—either directly through taxes or indirectly through buying drugs and other medical products—if it is not guiding clinical practice.

How could something so intuitively obvious to lay people not be similarly viewed by clinicians? And how could this medical milestone be so misunderstood by some? Critics of evidence based medicine worry that it dictates a single "right" way to practise, despite differences among patients; that some self appointed group of "experts" will declare only one type of study to be useful; or that healthcare decisions will be made solely on the basis of costs and cost savings. Giving a name to evidence based medicine and, now, awarding it milestone status could help everyone to realise that it is about making decisions that are based on the best available evidence, not dictating what clinicians do.

My regular readers know by now how obsessed I am with the cost of health care. Fed Chairman Ben Bernanke echoed fears about health care costs this week, pointing out how programs like Medicare, Medicaid, and Social Security will become a huge draw on our economy in years to come, as baby boomers age. It's true, of course, that costs are increasing. The value we put on health care is in part for society to decide, but my perspective is that better use of evidence-based medicine can lower costs for everyone by preventing the wasteful use of procedures, tests, and interventions that don't work (not to mention the aforemention health benefits of evidence-based medicine). Here's a press release about a new paper in Health Affairs that argues just that, more knowledgeably than I can.

The Effect Measure blog this week aimed to put Bernanke's warnings in perspective, at least in 2007 terms; check out the annual costs of entitlements compared to the war in Iraq. Nice graphic, but doesn't put to rest the question of future health care costs.

Finally, here's a plug for a blog I like, The CAM Report, which this week reported that the allopathic (mainstream) health community is now starting to argue in the mainstream medical press (in this case, JAMA) for rigorous evaluation of the evidence behind complementary and alternative medicine (CAM), expanded use of meta-analyses, and consistent reporting requirements for CAM studies.

The CAM Report gives regular updates on new research on CAM, including the good, the bad, and the ugly. If you're interested in the lively debate surrounding the evidentiary basis of CAM, you'll enjoy Respectful Insolence, by Orac; here's a typical post on this debate. I once asked Orac whether we shouldn't be equally concerned about the evidence for allopathic medicine; he agreed, but countered that allopathic medicine is at least based on sound biologically based theory, unlike much complementary and alternative medicine. Really? I've been trying, since then, to come up with examples where allopathic modalities do not have a sound theoretical/biological basis. Anyone?

This week's Grand Rounds

Kudos to Kerri for hosting this week's medical blogging Grand Rounds! And quite a creative and effective Grand Rounds it is.

Public service announcement

A confession: sometimes I get all self-important and identify myself (with some irony) as a public health professional. But then, if the topic is infectious diseases, I often have to explain to my listeners that, although my training is in epidemiology, I personally don't have much training in infectious diseases per se. So I launch into examples of other kinds of epidemiology that are more up my alley: chronic diseases, injuries, health care, etc.

Today, though, I found over at Genetics & Health (thanks, Hsien!), a really neat, pure public health video on coughing and sneezing into your sleeve to avoid spreading germs. I share it with you in the name of professional duty - enjoy! (It's actually not too gross.)

Lessons for health care from aviation

Interesting article in today's Washington Post about the 1982 Air Florida crash into the 14th Street bridge over the Potomac and its legacy, focusing on the lack of communication among crew members and subsequent reforms to aviation training.

Though some of the lessons may seem simple, such as communication and management skills, it helped break down an authoritarian cockpit culture dominated by captains. Over time, the principles learned from the disaster gradually migrated to other modes of transportation and into businesses, even hospitals.

"Even hospitals." Really? If this ethos of safety has moved into operating rooms, as described by the author, I'd like to know how widespread it really is; it also needs to go way beyond the surgical arena.

The story makes me wonder, or more accurately dread, what kind of equivalent event it will take to shake the foundations of the health care industry and bring safety to a similar level of concern. The body count in health care is a lot higher than that in aviation, but perhaps because incidents are so spread out, they just don't strike us in aggregate as catastrophic in the same way that plane crashes do.

2006 National Health Care Quality and Disparities Reports released

Please take some time to browse the 2006 National Healthcare Quality Report and Disparities Report, released yesterday by the Agency for Healthcare Research and Quality. It probably wouldn't be fair of me to comment much further on these, since I have worked on them in the past, but they're useful compilations of national-level data on a range of measures of quality and disparities, across various conditions and between priority populations. The data are collected and reported cross-sectionally, which is to say one year or several years at a time, and many are compared from year to year, to document progress. Outcome and process measures are selected with an eye to evidence that they represent quality of care.

Health Wonk Review

Health Wonk Review, hosted this week at Health Care Renewal, is up and ready for your reading enjoyment. It's a compilation of health policy writing across a wide range of perspectives.

Trend in health care costs still not in the right direction

I don't want to be the heavy here, but I'm hearing rosy interpretations of the modest flattening of the upward trend in health care costs, and someone's got to put her foot down.

This report from the American Hospital Association is a good example; sounds like spin to me:

Health care spending in the U.S. slowed for the third consecutive year in 2005, reaching almost $2 trillion or $6,697 per person, the Centers for Medicare & Medicaid Services reported today. By comparison, the spending growth rate in 2004, when $6,322 was spent per person, was 7.2%, and the growth rate in 2003 was 8.1%. Hospital care accounted for the largest share ($611.6 billion) of overall health care in 2005, with growth stable at 7.9% in both 2004 and 2005, and spending for physician and clinical services reached $421.2 billion in 2005, an increase of 7% from 2004. The health-spending share of the nation’s Gross Domestic Product increased to 16% in 2005 from 15.9% in 2004, which CMS attributed to the “lagged effects” of the 2001 recession and weaker growth in prescription drug spending. Growth also has been suppressed in recent years by an increase in tiered benefit plans and a decrease in new drugs, the agency said. Overall, growth in public spending outpaced private spending growth. The findings were published in Health Affairs .

Let's not kid ourselves. I'm no economist, but I did just take the general Graduate Record Exam (long story), for which I had to review basic algebra. The slope of the line representing health care costs over time is still positive (remember y = mx + b?). It is not negative, nor is it even flat. In other words, health care costs - already unacceptably high - are just not getting worse quite as quickly. Whether that's because of increased use of generic drugs (as CMS has pointed out), other market forces, or El Niño that's responsible, I don't know, but whatever it is, there isn't enough of it yet.

The photo says it all

Don't be shy - I'd love to know who all of you are :-) !

Antidote Interview #1: Hsien-Hsien Lei

Dr. Hsien-Hsien Lei is a genetic epidemiologist and writer, and the brains - not to mention the wit - behind Genetics & Health. We've had a number of discussions about the intersection between genetics and public health, and she was kind enough to interview me for her blog a couple of months ago.
The interview format was such a good idea, and Hsien is such an engaging person, that I had to return the favor. If you haven't already, I'm sure you'll want to check out not only her Genetics and Health blog, but her other writing projects as well. I'd like to thank Hsien not only for this opportunity, but also for highlighting my blog early on in its life.

Hsien, what made you decide to start blogging about genetics and health? What's your goal in writing this blog? Is there a particular message or messages you'd really like to get across? And what else do you do in your writing life?

It wasn't too much of a stretch to start a blog about genetics and health, two areas that I've been passionate about since grade school. Seriously. My prize winning sixth grade science project was called "Heredity, Genes, and You." One of these days I'll have to dig up the dorky picture of me holding up my blue ribbon next to my poster board with the pipe cleaner DNA helices. I even made local TV for that project. Good times. ;)

My goal in writing the blog is to make genetics seem interesting and relevant to everyday life. So much of what goes on in research is out of reach for the average non-scientist and even scientists themselves are prone to losing touch with the bigger picture. My main message is: Genetics matters to everyone everyday.

As for my writing life, I am currently an editor at b5media.com - Science and Health as well as Family and Relationships. I also write a heart disease blog and a children's toy and book blog, PlayLibrary.com. I also keep a personal blog full of random nonsense that I want to keep in my online wunderkammer, Cottontimer.com.

What areas of genetics do you think hold the biggest potential for improving public health? Do you think genetics research is driven more by public health efforts or business concerns, and are these goals ever in conflict?

Genetics has already improved public health tremendously. For example, prenatal testing for Down's syndrome, pre-pregnancy testing for the Tay Sachs gene, and cancer screening for BRCA genes for breast and ovarian cancers. Beyond genetic testing, our understanding of genes and their function has opened up new areas of investigation into how our bodies work and provided new targets for drug treatments. If you consider crime part of the scope of public health, DNA analysis has helped us capture criminals and identify victims. Society is healthier and safer because of genomic technology.

One of the biggest potentials for the use of genetic information is in the area of personalized medicine. Each of us has a genetic make-up that determines how well we metabolize drugs. In extreme situations, some of us might develop severe side-effects to one treatment while that same treatment could save another's life. To be able to understand specific genes involved in drug safety and efficacy will not only improve our overall health, but also improve the efficiency of the healthcare we receive. Pharmaceutical companies will be able to develop more and better drugs with less waste, both money and resources. And we'll be able to tackle drug safety with more information.

As for the conflict between public health and business interests, it's the same for everything in life. Money doesn't always come along with ethical considerations or doing what's right. But without money, nothing would get done.

I'd like to ask you about one effort I heard a few years ago: individualized dietary supplement cocktails based on people's combinations of genetic polymorphisms. At the time, I raised an eyebrow, because I was skeptical that we knew enough about the effects of the polymorphisms, or of the benefits of the supplements, to come up with an effective drug. What are your thoughts on this?

I've written extensively about direct-to-consumer nutrigenetic testing (also known as nutrigenomics or nutritional genomics). I'm skeptical about their ability to give unique recommendations for each individual with regards to their diet and lifestyle. Most common sense nutrition and exercise tips will work for the majority of people. However, if a person has the money to spend on a nutrigenetic test, they may feel more motivated to adopt a healthier lifestyle. The information from these tests are vague enough that no one is going to think they can live forever by smoking 2 packs of cigarettes a day, eating only fried foods, and never getting off the sofa simply because the tests say they have one variant of this gene or another. So I don't think anyone is going to be harmed by nutrigenetic tests unless you're talking about their wallets.

FYI: Genetics and Health's previous posts on nutrigenomics.

I know your training is in epidemiology and genetics. Is genetic epidemiology a hybrid of the two disciplines, or is there more to it than that? And what's new and exciting these days in genetic epi?

I wouldn't say genetic epi is a hybrid of the two disciplines but more of an offshoot or an intermediary. There are statistical techniques that are unique to genetic epidemiology because it studies genetic factors in populations instead of individuals. (Meaning we take individual data and aggregate it to determine patterns.) I think genetic epidemiology is the most adept at teasing out genetic and environmental influences on a trait, whether it be cholesterol levels or diabetes. Genetic epi uses molecular techniques and different epidemiologic study designs to create a whole picture of a disease and its spread in the population. Very powerful and relevant.

Every time I talk about genetic epi specifically, I realize how much I enjoyed it as an active researcher.

I really admire the success and recognition you've achieved. Have you put a lot of time into publicizing your blog? On a larger but related subject, have you found blogging to be a useful mechanism for networking? Any stories you'd like to tell?

Thanks, Emily! When Genetics and Health was started in April 2005, I did go around and visit many blogs, leaving comments when I felt I had something to contribute. I still try to do that but have gotten busier with the addition of A Hearty Life so what I try to do instead of leaving comments is to read and trackback with my own posts, furthering the discussion that way. Publicity in and of itself is not something I devote myself to. Conversation is what I'm aiming for.

In terms of networking, I've met some wonderful people through my blogs, like you, who've engaged me intellectually and made me laugh when I needed it most. This is the next best thing to working in an office. Actually, it might even be better than having to slog in to work for 10 hours a day in a windowless cubicle or lab. :) I feel very fortunate to be a part of the blogging community as well as having the opportunity to share knowledge that I hope will improve people's lives.

More on journalism training

There must be something in the water today... here's a link to the rss feed for Access, the NewsU blog; it's packed with information on training opportunities for journalists. I'm going to shoot them the NIH opportunity I posted earlier this morning.

Essential training for health journalists

If you're a health journalist or editor, apply now for NIH's Medicine in the Media course, which will equip you, in a hands-on learning experience, with the tools you need to critically evaluate medical research. The course will be held April 12-14, 2007, in Potomac, MD; the application deadline is February 2.

Weekly this and that - Jan. 4, 2007

There was a nice range of health stories in the news in the past week; here are a few that piqued my interest.

Dieting articles and disordered eating

The Associated Press reported this week that girls who read magazine stories on dieting demonstrate unhealthy weight-loss measures, such as fasting and cigarette smoking, five years later. I am concerned about this, and I'm not saying it isn't true, but much as I would like to say "See? I told you the media had an impact," I don't think this observational study rises to the level of cause and effect. Although the study took into account whether girls were concerned about their weight to begin with or not, there are just too many other factors that could contribute to disordered weight loss strategies to make this study believable. Other factors I would've considered: What else did girls read? what did they take away from the articles? what about physical activity?

I'd be interested to hear more thoughts.

In the "too much medicine" department...

Gil Welch, Lisa Schwartz, and Steve Woloshin had an essay in this Tuesday's New York Times health section on the epidemic of diagnoses.

They conclude:

As more of us are being told we are sick, fewer of us are being told we are well. People need to think hard about the benefits and risks of increased diagnosis: the fundamental question they face is whether or not to become a patient. And doctors need to remember the value of reassuring people that they are not sick. Perhaps someone should start monitoring a new health metric: the proportion of the population not requiring medical care. And the National Institutes of Health could propose a new goal for medical researchers: reduce the need for medical services, not increase it.

Or as my former boss used to say, "The definition of a well person is someone who hasn't been worked up sufficiently."

Also in this department is a new study from the University of Michigan showing that a third of implanted cardioverter defibrillators - devices that restore heart rhythms - are unnecessary. As you can imagine, these things are quite expensive, with a $90,000 lifetime price tag. The good news, according to the study authors, is that a simple heart rhythm test can distinguish patients who will benefit from the device from those who won't.

the "too much drug advertising" department...

Drug advertising costs are up 9% from last year. Thanks to the Health Wisdom Blog for pointing out this item in BrandWeek. According to the article, pharmaceutical companies spent $4.1 billion on advertising last year. All of us are paying those bills.

and the "in case you were worried it was all bad news" department...

After last January's depressing stories in the New York Times on diabetes in New York City, this one cheered me up considerably: it's an effort by the city of Asheville, NC, to offer preventive diabetes care and free diabetes medicine to municipal employees via specially trained pharmacists. The 10-year-old program has resulted in a doubling of the number of employees with their blood sugar under control and lower health care costs for the city; they estimate annual savings of $2000 per patient.

A call to action: improving the culture of aging

Abigail Trafford offers an inspiring, multilevel agenda for improving the lives of older people - which will be most of us someday, let's not forget - in her column in this past Tuesday's Washington Post. I particularly noted this item:

Expose ageism. Prejudice against older people is insidious. In a recent study by the International Longevity Center in New York, researchers found bias and negative stereotyping in many arenas, from health care to the media. Discrimination in the workplace is so prevalent that AARP advises people of a certain age not to list age or graduation dates on their résumé.

Accepted quality measures don't measure quality

Today's issue of JAMA has a research article (press release here) that sounds a little dry, but is actually pretty important. It examines the ability of five accepted quality-of-care measures for heart failure to predict rehospitalization and mortality. The five are process measures that are used by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to accredit hospitals.

The study, by UCLA researchers, found that the five measures (provision of discharge instructions, evaluation of left ventricular systolic function, administration of ACE/ARB for left ventricular systolic dysfunction, smoking cessation advice/counseling, and anticoagulant at discharge for patients with atrial fibrillation) were by and large not strongly or statistically signficantly predictive of either 60- to 90-day mortality or of rehospitalization rate. Another measure not in standard use, though - administration of beta-blocker - was strongly associated with improved outcomes.

Kudos to JAMA for publishing this article. The hospitals, etc., who are investing a lot of money measuring quality are going to be upset, throw up their hands, and say, "What are we doing?" However, there is the saving grace of the one non-measure - beta-blockers - that was strongly related to the outcomes. That means that there is, in fact, the potential to measure actual quality via process measures; we just need to pick the right ones. Everyone, now, should be primed to demand better validation of quality measures, and, at the very least, transparency in the validation process which has to this point been quite obscure.