Meet Don Berwick

I'm really swamped this week and haven't had time to post much of substance. But I just found a link to a Boston Globe article on patient safety guru (and great human being) Don Berwick, President and CEO of the Institute for Healthcare Improvement. It's a couple of years old, but it's a good read, and since the Globe hasn't shut it down yet, I can share it with you.

Getting the word out, continued

And how could I forget to mention that the Antidote is now part of Indy Science Blogs? We are 11 bloggers who were brought together en masse as we were dissed by ScienceBlogs - who somehow neglected to use the BCC function in their "thanks but no thanks" email in response to our interest in being part of that group. So we started our own site; it's ad- and attitude-free and editorially independent. Please check out the site and the bloggers, all of whom are also linked to The Antidote.

Getting the word out

Just wanted to let readers know that I've signed a license agreement with Newstex' blog syndication service to include the content of my blog among their products. Among their clients is the information broker LexisNexis. It'll be a couple months before The Antidote's content is integrated with their feed, so we'll just be patient and see eventually how it all works out. In any case, I'm honored that Newstex found the blog and took an interest.

Wyden offers to work with Bush; Pearlstein breaks down health care costs

Senator Ron Wyden (D, OR) yesterday offered a six-point proposal to President Bush about making health care affordable for all Americans, in collaboration with a bipartisan group of nine other senators - not including Obama or Clinton. It's a general outline, vague even, but does promote preventive care and tax restructuring, and follows upon his Healthy Americans Act, rolled out on Dec. 13.

Others might argue that it's hard to get a strong, bipartisan statement in favor of universal health care (Bush's tax proposal not withstanding), but I posit that lowering the cost of health care is something every American should support. Check out Steve Pearlstein's column in today's Washington Post; doctors may wince at the implication that much of the cost of the current system allows them to line their own pockets, but they need to hear it, and everyone should have a grasp of the rest of the breakdown of costs Pearlstein presents, all of which can - and must - be addressed.

Not ready for prime time

...and yet that's just where it is.

Reuters today published a story linking vasectomy with primary progressive aphasia. Spurred by a patient with aphasia who noted that his symptoms began two years after vasectomy surgery, the researchers looked at a small sample (n=114) of men with and without aphasia, and found that 40% of aphasia patients had had a vasectomy and 16% had not. On the face of it, it looks like there may be something to it - hence the news story.

The problems:

1. Very small sample. Not tiny, but quite small. Too small, probably, to adjust appropriately for other explanatory factors. 40% of 47 men with aphasia is 19, and you don't want to break that number down much more.

2. Retrospective design. Subjects with aphasia may have been more likely to report having a vasectomy, particularly if they knew about the study hypothesis. Unlikely, perhaps - vasectomy is probably for most people a memorable event - but people have been known to forget about medical procedures.

3. Lack of context. That's because there isn't any - according to PubMed it's the first study to look at this hypothesis. As an epidemiologist, I'd say, hmm, interesting finding - let's do a bigger, better study and check it out, and let's do an animal study, say, to look more closely at the idea that antibodies against sperm could affect the brain.

What I wouldn't do is to go to the newspapers with it.

Sandra Weintraub, who led the study, acknowledged that the research involved a small number of people and said she planned to conduct a larger national study to see if the findings hold up. In the mean time, she said her findings should not stop men from getting vasectomies.

"I was hoping not to, but unfortunately it's the kind of news that ends up scaring people even though they may not need to be scared," Weintraub said in an interview.

Hoping not to what? Scare people? She's right; this is just the kind of story that does scare people. So why'd she agree to the interview? Couldn't she just have told the reporter not to bother?

Now there's a question. If any scientists out there have ever told a reporter not to bother with their work, or if journalists have ever heard that from a scientist, I'd like to know.

Health Wonk Review

Health Wonk Review #25 is up at Healthblawg. As you might have guessed, there are lots of posts on various health reform proposals, including the President's, and some other good policy stuff as well.

The Antidote Interview #2: Robert Doherty, American College of Physicians

A couple of weeks ago I alerted readers to a health care reform proposal from the American College of Physicians, which went a bit beyond the mix of health reform proposals from states, insurance groups, etc., in its focus on prevention and wholistic care in addition to advocacy of coverage for all Americans. Robert Doherty, Senior Vice President for Government Affairs and Public Policy, was kind enough to answer my questions by email, and I've included the interview below.

A notable thing about the current political climate in the U.S. is that the time really does seem to be ripe to reopen the debate on how to reform health care, and it's important that all voices be heard. I'm happy to host some of that debate right here, so here's one perspective, and please bring on your comments!

The timing of this proposal is interesting, given that, in the past couple of weeks, we've seen health care reform proposals from states, presidential candidates, the insurance industry, and even the White House. How does the ACP proposal fit in?

I think we are seeing an congruence of interest in expanding HI coverage that is being driven by several factors: the upcoming Presidential election, where health care reform is expected to be a major issue; the Democratic take-over of Congress, which will result in a greater emphasis on health coverage (although most of the recent joint statements from different stakeholders were the result of discussions that had started long before the mid-term elections), and very significantly, the positive press that Romney and other governors have received on their respective states' proposals to expand coverage. At the same time, the number of the uninsured keeps rising, there has been a slow erosion of employer-based coverage, and more cost-shifting to individuals. All of this suggests an opening for groups to get attention to proposals that until recently may not have been considered to be politically realistic. Notwithstanding all of this, I don't think we will see major reforms at the federal level until after the 2008 elections.

ACP was part of a coalition of physician organizations that recently came out with joint principles on expanding access but was not directly involved in the other coalition activities. We've been struck though that many of the ideas being proposed--expanding Medicaid to all people up to the poverty level, providing advance refundable tax credits to low income persons to buy into the Federal Employees Health Benefit Program, and providing federal funding support for states that wish to develop their own plans--are very consistent with a proposal that ACP released in 2002, and that was introduced as bipartisan bill, The HealthCARE Act, in both the 108th and 109th Congresses.

The proposal that ACP released on Monday, though, is different in one key respect: we go beyond proposing how to extend health insurance coverage to redesigning how medical care is organized, reimbursed and financed in the United States. We think the U.S needs to do both: make sure all residents have affordable coverage, but also create a higher quality and more efficient model of delivery called patient-centered care. Otherwise, more people will have coverage, but they'll get their care under a system that is fragmented, expensive, and provides inconsistent and inadequate quality. Other countries with more successful systems provide universal coverage AND have redesigned their health system around patient centered primary care.


How can the proposed plan address health care costs? You're proposing extending health care to all Americans; would that not increase costs still further? Will the plan address overuse of health services?

Our plan is based on strong evidence that a health system organized around patient-centered primary care will achieve better quality at lower cost. The materials we provided to the press on Monday cite numerous studies that show that the availability of well-supported primary care, both within the US and in other countries, is positively associated with fewer hospital admissions, lower utilization, reduced mortality, longer life spans, fewer ICU admissions, few ICU deaths, a better overall composite quality score--and lower per capita health care expenses. Our plan directly addresses over-use of services by rewarding reward physicians for managing care and providing preventive services rather than ordering more tests or procedures.

We also provide evidence that helping primary care physicians acquire the tools and systems to help them manage care effectively--things like tracking patients based on disease condition (patient registries), secure email consultations, evidence-based guidelines at the point of care--will result in better care and lower overall costs.

In our view, it makes sense to combine expansion of health insurance coverage with patient-centered care to help reduce the costs of insuring more people.

Also, Health Affairs published an article about a year ago that found that the US already spends approximately $100 billion annually on the uninsured (cost shifting, lost productivity, uncompensated care, and federal, state, and local spending) but we spend it very ineffectively and inefficiently. Redirecting these expenditures to provide everyone with affordable coverage would be a far wiser use of these resources.

We also support creating a process for identifying services that are overpriced by Medicare and other payers. There is evidence that services that are overpriced also tend to be overutilized.


How does the primary care-centered plan differ from the HMO gatekeeper model, which some research has shown does not improve cost or health outcomes?

Our proposal is not a gatekeeper. Patients would not have to get permission from a primary care doctor to see a specialist. They would have an ongoing and trusted relationship with a primary care physician who will advise them if and when specialty care is needed, and who would be best qualified to provide that specialty care, but it would be the patient's decision. Physicians in the patient centered medical home would help arrange for specialty care when needed. And they would make sure that when a patient is seeing multiple clinicians, there is one clinician--the personal physician in the patient-centered medical home--that is integrating all of the information from the other clinicians to make sure it results in a consistent and integrated plan of treatment. This is unlike the current fragmented system when there is no one accountable for the patient's whole health and information often is not shared among clinicians or shared incompletely.

How will procedure-focused care settings, such as diagnostic and screening radiology facilities, be addressed? more broadly, what happens to the rest of the non-primary care health system, from ambulatory care to hospitals?

Our proposal is based on the idea that patients need to have a single site, and a single physician (their personal doctor in a patient centered medical home) who is responsible for their whole health. But that physician is responsible for assuring that they have access to a team of health professionals to provide them with the full spectrum of services needed, including imaging, hospitals, etc as needed. We do believe though that effective management by a personal physician will reduce duplicate and unnecessary testing (for instance, it is not uncommon today for tests to be repeated just because one clinician does not know what tests another clinician had previously ordered) and hospital admissions by helping patients avoid complications that can lead to hospitalization.

We also believe that there will need to be a re-allocation of dollars to support patient-centered primary care.

How does prevention fit in with this proposal? Will it reduce the perverse incentives we have seen, for example, with diabetes care?

Prevention is an integral element. Patient-centered primary care is designed to assure that patients have access, through the patient-centered medical home or by referral, to all preventive and screening services that are supported by evidence-based guidelines. Physicians will develop self-management plans in partnership with patients to help them maintain healthy lifestyles and prevent complications

What is ACP's strategy for working with Congress to promote this program?

We developed a legislative roadmap that identifies different options for Congrses to move the program forward: Medicare legislation that addresses physician payment cuts and pay for performance, reauthorization of the S-CHIP program to encourage states to make the medical home available to all S-CHIP recipients, legislation to promote health information technology, and legislation to provide federal funding for states that develop their own programs to expand access and improve quality. We will also ask Congress to work with us to assure that CMS moves forward in a timely manner on a demonstration of this model that was mandated by the 109th Congress. In all of our contacts with Congress, we will emphasize that this model has the potential to substantially improve quality and lower costs and should be advanced through a variety of legislative approaches.

Who is likely to disagree with this approach?

I can anticipate that there will be concern among some providers that this model will redistribute dollars and resources toward primary care, and give more control to the primary care physician, at their expense. We will need to persuade Congress and the Congressional Budget Office that it will save money. Providers who benefit from procedures that are overpriced will likely object to a process that could result in reductions in those fees.

Physical activity for aging: where's the context?

Reuters published an article this past Friday about a new study showing that older adults can maintain their balance if they exercise regularly, even if they start at retirement. Good news, maybe, but it really misses a lot of the context of the field by focusing on a single (observational) study.

There is a large body of literature suggesting that physical activity (by a number of definitions) for older people maintains function, prevents falling, does all kinds of good things. The problem is that most of these studies are observational, and don't account sufficiently for the fact that the folks who are exercising are probably already healthier to begin with, in ways that may be difficult to measure and correct for, and thus at lower risk of the outcomes measured by the studies. The current study is just another stitch in the fabric of that evidence, and suffers from the same weakness. There is, though, a recent study from the National Institute on Aging; it's a randomized trial that specifically addresses this potential weakness. Investigators administered a structured exercise intervention to elders at risk of losing their walking ability. The study confirmed the observational literature by showing that subjects who received the intervention were statistically significantly more likely to maintain their walking ability and their walking speed over the course of a year.

By the way, something tells me I may have written about this randomized trial here before, but I couldn't find the post, so if any of you sharp readers can find it, please let me know.

Elder care: overlooking the root of the problem

An article in Sunday's NYTimes begins with a somewhat breathless description of a remote-sensing system for looking after older adults living in the community. The system involves video cameras and a little box, connected to the Internet, in which folks can answer questions about how they're doing with the push of a button. An expert on aging services then admits that the systems are not a substitute for human caretakers, and the article finishes up with some discussion of choosing care managers (such as social workers and nurses).

The article does not present any context regarding the prevalence and health impact of isolation of elderly people from their communities. While we're thinking about designing communities to increase physical activity, is it too late for us, as a society, to structure communities to support the needs of older adults, too, so that they are safe, well looked after, and have meaningful human contact on a regular basis? In many societies, and formerly in our own, older people lived with their families. Real communities could, to some extent, obviate the need for the fixes described in the Times article.

The risks of isolation are vividly described, and a case for connected communities made, in Eric Klinenberg's Heat Wave, a terrific, compelling book that makes you forget you're reading a work of sociology.