The Antidote

I hate it when health care kills people...

2010-02-21T12:43:00.003-05:00

...which is why I'm happy when the media do a good job of covering this underappreciated issue. BBC Radio 4 just broadcast an excellent piece on patient safety in the UK. It focuses on alerts issued by the National Patient Safety Agency to local NHS trusts. The alerts are based in part on aggregated reports of errors - or, as some in the US call them, adverse events, to avoid the language of blame - and are meant to help trusts, which have primary responsibility for delivering safe health care, to implement specific procedures aimed at avoiding errors. Trusts are responsible for reporting back on their progress implementing the alerts; there are, evidently, hundreds of trusts that have not yet implemented at least one, and there are a couple more that have not reported back on over 30. A key problem is that there is no national mechanism or authority for enforcing compliance with the alerts, although they are issued at the national level.

The story, about 40 minutes long, did an excellent job of interweaving anecdotes with investigative reporting on NHS policies and procedures. The reporter, Julian O'Halloran, spoke with patients' family members who have now become active in improving patient safety in the UK, as well as policymakers.

One case highlighted was that of a man who was killed by a massive overdose of a painkiller. The media have focused heavily on the fact that the doctor who administered the drug was foreign and had apparently been censured by medical authorities in his home country, that he was unfamiliar with the drug in question, diamorphine, and also that the incident occurred on his first shift working in the UK. What the media have not grasped - until now - was that the drug ampule the doctor used should probably never have been in his medical kit to begin with, because such a high dose has almost no application in day-to-day use. The NPSA had issued guidance in 2006 about safe storage practices for diamorphine, to help clinicians avoid administration errors. O'Halloran spoke to the patient's son, who is himself a doctor, and who mentioned that he had never even seen such a large dose of diamorphine.

Journal Watch, Jan. 13, 2010

2010-01-18T13:23:00.002-05:00

Great stuff from the Centre for Evidence-Based Medicine at Oxford, by Dr. Richard Lehman. Now with recipes! Speaking of which, check out my new food blog - in which I figure out how to feed myself in the UK - at Emily Drinking Tea.

FDA acknowledges BPA risks

2010-01-16T10:19:00.002-05:00

Seriously, what took them so long? Their reluctance to address due caution to the chemical really presented an impression that the Agency was beholden to chemical industry interests.

Causal language and not just in the headline

2010-01-14T06:52:00.003-05:00

A Guardian article on a new epidemiologic study looking at a class of blood pressure drugs and dementia started out with a headline that was doubly misleading:

Blood pressure drugs can halve risk of dementia

First of all, this may just be my own reading problem, but when I first saw the word "halve" my brain saw "have" and interpreted it to mean that the drugs increase risk of dementia. But when I slowed down and re-read it, I was not much happier, because I've developed this intellectual/editorial tic, a tendency to notice and then question statements that imply causation. The Guardian lead reiterated the causal language:

Millions of older people who take drugs for high blood pressure or heart problems can more than halve their risk of developing Alzheimer's disease and dementia, according to research.

For the headline and lead to be supportable, there would have to be a clinical trial randomly assigning people (a lot of them) to get ARB drugs, or not. It seemed unlikely, and in fact, it wasn't the case. Here is the original article from BMJ. Sure enough, right in the article's title, it says that it's a prospective cohort study - a very good one, I'm sure, but designed to look at associations, but not causation. And here's the conclusion of the research article:

Angiotensin receptor blockers are associated with a significant reduction in the incidence and progression of Alzheimer’s disease and dementia compared with angiotensin converting enzyme inhibitors or other cardiovascular drugs in a predominantly male population.

Wordy, but - again - in terms of "association" not an active, causal verb phrase like "cuts risk by half."
Regarding expert comments, I thought the article let the head of research of the Alzheimer's Association get a little carried away with the conclusions of the study: "The prospect of using already existing drugs to help in the fight against dementia is attractive." The head of another Alzheimer's research organization did acknowledge the need for trials to confirm the link.

What color is my what?

2010-01-09T07:18:00.004-05:00

The whole Facebook bra-color thing. It started out as a silly meme, someone apparently tried to legitimize it by attaching it to breast cancer awareness, breast cancer groups tried to weigh in, and the Washington Post wrote up the whole kerfuffle.

I think the best thing to come out of the phenomenon, which was over and done with in not much more than 24 hours, was not increased breast cancer awareness - I mean really, aren't we aware enough? - but awareness of and attention to the concept of awareness: What does it mean, where does it get you, and where do we go from here?

Breast cancer awareness needs to go way beyond a mass adolescent giggle about the color of underwear. The timing coincides nicely with the release of Barbara Ehrenreich's new book, a polemic against the feel-good-about-cancer movement. You can read an excerpt of it in the Guardian. She has this to say about awareness:

The first thing I discovered as I waded out into the relevant [breast cancer] sites is that not everyone views the disease with horror and dread. Instead, the appropriate attitude is upbeat and even eagerly acquisitive. There is, I found, a significant market for all things breast cancer-related. You can dress in pink-beribboned sweatshirts, denim shirts, pyjamas, lingerie, aprons, shoelaces and socks; accessorise with pink rhinestone brooches, scarves, caps, earrings and bracelets; and brighten up your home with breast cancer candles, coffee mugs, wind chimes and night-lights. "Awareness" beats secrecy and stigma, of course, but I couldn't help noticing that the existential space in which a friend had earnestly advised me to "confront [my] mortality" bore a striking resemblance to a shopping centre.

A lot of breast-cancer awareness focuses on unproven buddy-check programs and mammography promotion. How about more awareness of what we mostly don't know about breast cancer - what causes it and how to prevent it, not just detect it earlier?

Really?

2009-12-21T13:11:00.003-05:00

According to the Washington Post, Maine is considering adding a warning about cancer risk to cell-phones. A state legislator claims that there are "numerous studies" to support such a risk. To be fair, I'm not really current with the literature, but I do wonder: do cell phones also come with a warning about risks of crashing your car?

For that matter, how about absolute risks of cancer, contrasted with absolute risk of crashing your car? Anyone seen these numbers?

Improving dementia-care homes in the UK

2009-12-09T07:26:00.002-05:00

Today, after watching last evening this rather moving program in which someone called Gerry Robinson visits and tries to fix dementia care in the UK, I found out that Mr Robinson (actually Sir Gerry) was a businessman. That might explain why he just threw up his hands when confronted with pretty clear evidence that one of these homes was owned and run by two people who couldn't see past making a profit to the well-being of the residents (or the staff, for that matter). Robinson just wasn't ready to admit that capitalism might not always be a sustainable model for the provision of dementia care.

But that's what we have, for now. Measuring and improving quality of care for dementia is, according to the program, in its infancy, but developing measures and benchmarks based on quality of life would be a big step forward.

Tamiflu evidence questioned

2009-12-08T15:16:00.002-05:00

Cochrane reviewers have concluded in yesterday's British Medical Journal that there is little evidence that antiviral drug oseltamivir, or Tamiflu, stops flu complications in otherwise healthy people. The BMJ has a number of related articles as well.

BBC News today had a great investigative piece on the story behind the evidence; there is one crucial, oft-cited dataset belonging to Tamiflu manufacturer Roche, which Roche has not released to the Cochrane reviewers. The BBC has not yet posted a link to the story but I'll up date this when it's available. Meanwhile, the Guardian has also covered the story.
flu
Tamiflu
health news
Cochrane

Post cartoon sums up resistance to health reform

2009-11-30T06:07:00.002-05:00

Check out this Tom Toles cartoon.

Breast cancer screening - more politics

2009-11-26T08:19:00.002-05:00

Contrast the conciliatory tone of this editorial co-authored by Eric Winer, MD, Medical Director of the Susan G. Komen Breast Cancer Foundation with the gloom and doom expressed by Komen's president Nancy Brinker, as quoted in this op ed piece by Washington Post writer Dana Milbank.

Per Winer:

Fourth, we must be careful not to send a message that screening and early detection are of no value: there is no doubt that early detection of breast cancer can save lives. We are particularly concerned about the perceptions of women who are members of disadvantaged minority groups and those who lack education and health insurance. It would be lamentable if progress made in breast-cancer awareness were reversed as a result of this debate. Efforts to educate the public about breast cancer must be maintained and, in some areas, increased.

and Brinker:

The recommendations "have taken a tremendous toll, and I believe they set us back," Brinker told reporters at the National Press Club on Monday afternoon. "The women I have heard from, thousands and thousands and thousands, are justifiably outraged and worried and angry."

Oh, and here's a quote from a statement by Winer on Komen's website:

Susan G. Komen for the Cure wants to eliminate any impediments to regular mammography screening for women age 40 and older. While there is no question that mammograms save lives for women over 50 and women 40–49, there is enough uncertainty about the age at which mammography should begin and the frequency of screening that we would not want to see a change in policy for screening mammography at this time.

What do you think? Are the substance of what Winer and Brinker said similar enough that Winer will keep his job? (Note that Milbank himself is probably just as angry as Brinker, yet he claims he has no problem with the science, just in the way the recommendations were rolled out.) Does Winer's official Komen statement waffly enough to accommodate both his view of the uncertainty of the science and Komen's aggressive pro-screening stance? And will women reading the recommendations - or more importantly the docs who are recommending screening - really take home the message that mammography screening is useless?

I'd love to hear the behind-the-scenes discussions at Komen as they proceed.

Another new evidence blog...

2009-11-25T04:38:00.001-05:00

this one from Michael Power, one of my colleagues from a great evidence-based-medicine listserv out of Oxford University.

New evidence blog

2009-11-24T09:28:00.002-05:00

David Rind, an academic physician in Boston, has started a blog called Evidence in Medicine. Rind has a clear, persuasive, honest yet non-sanctimonious writing style. Here's hoping he doesn't get bored or overwhelmed too quickly with the task of keeping up a blog! So far he's covered vitamins, the perils of Pharma, and mammography.

And more recommendations for less screening...

2009-11-20T06:00:00.002-05:00

This time from the American College of Obstetrics and Gynecology (ACOG), for later and less frequent cervical screening among young women. A number of people interviewed by the NYTimes once again don't seem to acknowledge that there might be harms from screening; in fact, one of the ACOG guideline authors points out quite a few harms, that she claims makes the case for limiting Pap smears more compelling than that for limiting mammography.

cervical cancer
screening
guidelines

New mammography recommendations from USPSTF

2009-11-19T16:26:00.003-05:00

By now you've heard that the US Preventive Services Task Force has updated their recommendations on mammography this week. In fact, the recommendation for women 50-74 is the same as before (B recommendation). The Task Force now recommends against routine screening for women 40-49, and states that the evidence is insufficient either way for women 75 and over.

Gary Schwitzer's Health News Blog analyzes coverage by the three major network news outlets and found that it was light on evidence. And while waiting for a plane, I caught a glimpse of Florida Congresswoman Deborah Wasserman-Schulz commenting on CNN about the guidelines. The congresswoman earlier this year sponsored legislation, known as the EARLY act, to promote intensive screening and breast self exam training for young women. This legislation has been criticized by cancer experts. Wassermann-Schulz apparently doesn't see any possible downside to screening. In addition, in saying that the guidelines are "patronizing" and that women need more information not less, she apparently ignores the Task Force's statement that

The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms.

breast cancer
screening
guidelines

Clear prescription drug labels that present risks and benefits

2009-11-07T14:49:00.003-05:00

Hi folks, me again; no, I'm not dead yet!

Anyway, lest it get lost, this NYT Prescriptions blog describes an effort - now in Congress - to introduce charts (drug fact boxes) to drug labeling that present clinical benefit and side effects, side by side, in the form of understandable absolute risks. Seems so simple, but this information usually gets buried in drug-approval applications and doesn't make it into the labeling at all. And all you hear or read in direct-to=consumer drug advertising is rapid-fire or small-print, nonquantitative laundry lists of symptoms that have reported in drug studies, with no indication of whether such symptoms even differed between test and control groups, and they generally carry a legalistic, "FDA made us say this" tone. Sen. Barbara Mikulski (D-Maryland) drafted the legislation.

prescription drugs
drug labeling
FDA

Improving the End-of-Life Experience

2008-11-23T07:41:00.002-05:00

The "Engage with Grace" project was created by Paul Levy, of the Running a Hospital blog, and Matthew Holt of The Health Care Blog:

We make choices throughout our lives - where we want to live, what types of activities will fill our days, with whom we spend our time. These choices are often a balance between our desires and our means, but at the end of the day, they are decisions made with intent. But when it comes to how we want to be treated at the end our lives, often we don't express our intent or tell our loved ones about it.
This has real consequences. 73% of Americans would prefer to die at home, but up to 50% die in hospital. More than 80% of Californians say their loved ones “know exactly” or have a “good idea” of what their wishes would be if they were in a persistent coma, but only 50% say they've talked to them about their preferences.
But our end of life experiences are about a lot more than statistics. They’re about all of us. So the first thing we need to do is start talking.
Engage With Grace: The One Slide Project was designed with one simple goal: to help get the conversation about end of life experience started. The idea is simple: Create a tool to help get people talking. One Slide, with just five questions on it. Five questions designed to help get us talking with each other, with our loved ones, about our preferences. And we’re asking people to share this One Slide – wherever and whenever they can…at a presentation, at dinner, at their book club. Just One Slide, just five questions.
Lets start a global discussion that, until now, most of us haven’t had.
Here is what we are asking you: Download The One Slide and share it at any opportunity – with colleagues, family, friends. Think of the slide as currency and donate just two minutes whenever you can. Commit to being able to answer these five questions about end of life experience for yourself, and for your loved ones. Then commit to helping others do the same. Get this conversation started.
Let's start a viral movement driven by the change we as individuals can effect...and the incredibly positive impact we could have collectively. Help ensure that all of us - and the people we care for - can end our lives in the same purposeful way we live them.
Just One Slide, just one goal. Think of the enormous difference we can make together.
(To learn more please go to www.engagewithgrace.org. This post was written by Alexandra Drane and the Engage With Grace team)

Op-Ed on Health Care Reform

2008-11-23T07:25:00.002-05:00

Shannon Brownlee, author of Overtreated, and Ezekiel Emanuel, author of Healthcare: Guaranteed, two thoughtful people working toward making our health care "system" more fair, safe, and efficient, have an Op-Ed in favor of health care reform in today's Washington Post. Their goal is to dispel some myths about health care, starting with the canard that the U.S. system is the best in the world. Interestingly, further down, the authors cite survey data showing that 70 percent of Americans feel that the system needs major changes if not a complete overhaul. Still, it helps to repeat outloud and often that our system is not the best - just the most expensive. The comments about the costs of health insurance, and who pays them, are well taken and less obvious.

Read my interview with Shannon Brownlee here.

Straight shooting on evidence from the NYTimes

2008-07-28T22:55:00.002-04:00

Just noticed a new series exposing health care interventions that don't work, in the NYtimes... not in the health section, but in the business section. The first article is on an apparently dangerous prosthetic hip socket, and highlights the US' failure to implement device registries that could allow the identification of faulty implants of various kinds.

Here's the blurb:

The Evidence Gap: An Imperfect Picture

Articles in this series will explore medical treatments used despite scant proof they work and will consider steps toward medicine based on evidence.

I don't know how many of these are planned, but I imagine they could fill a couple years' worth of weekly columns.

Regarding this article, I'd quibble with the idea that registry data are evidence, per se; the problem with interpreting the data is that there are no controls. One application for registry data stems from the fact that pre-market randomized trial data that provide actual evidence for devices (and drugs for that matter) are inadequate. In this case, the faulty devices in question were found to be contaminated with oil, more of a manufacturing quality-control issue than a general validity issue. The former point still holds, but registries can still provide a useful function in pointing to problems.

Best study name ever

2008-05-02T10:29:00.003-04:00

Thanks to my friend Pam Marcus for passing this along. I thought it was an appropriate way for me to celebrate my reentry into blogging.

Lacasse A, Rey E, Ferreira E, Morin C, Bérard A: Validity of a modified Pregnancy-Unique Quantification of Emesis and Nausea (PUQE) scoring index to assess severity of nausea and vomiting of pregnancy. Am J Obstet Gynecol. 2008 Jan;198(1):71.e1-7.

Thank you, CBO

2007-11-14T13:59:00.000-05:00

California HealthLine today reports on a new Congressional Budget Office Report that finds that inefficient delivery of health care, and delivery of interventions of dubious value, will swamp the effect of the aging of the population in increasing health care costs over the foreseeable future.

"The nature of the long-term fiscal problem has been misdiagnosed," Orszag said, adding that the aging population "is not by any means the main factor" behind the projected rise in cost growth. He noted that many new medical treatments and tests are "of dubious value." He said that in their efforts to stem the growth of health care costs, Congress and federal policymakers need to promote cost effectiveness and "evidence-based" medicine (Reuters, 11/13).

Obviously Congress needs to take the lead in addressing this struggle. Senate Finance Committee chair Max Baucus pledged to address the problem aggressively; I hope he does, and I hope Budget Chief Orszag doesn't lose his job saying what needed to be said.

NY Times skewers "natural" claims of beauty products

2007-11-01T08:30:00.000-04:00

Natural does not equal healthier, nor does it even equal, well, natural. An article in today's Times skewers the marketing ploys of a variety of beauty products available at stores like Whole Foods, and reiterates that there's no evidence that individual ingredients benefit health or beauty, or that claims of their natural or organic provenance are even necessarily true. Manufacturers profit handsomely on consumers' emotional beliefs that natural is somehow better.

"We’re seeing an increased consciousness that what you put on your body is as important as what goes in your body,” said Jeremiah McElwee, the senior coordinator in charge of personal care at Whole Foods, which is the company’s fastest-growing department. “The biggest impetus for buying natural or organic body care is the perceived health benefit.”

Emphasis on "perceived."

New website on reporting guidelines

2007-10-25T23:23:00.000-04:00

The Equator website serves as a resource for consistent, accurate reporting in the literature of new research in a variety of health disciplines (e.g., systematic reviews, clinical trials, observational studies). Several of these disciplines have their own guidelines (e.g., the CONSORT guidelines for clinical trials), which are enforced by some of the leading journals. The site provides resources for authors, editors, and guideline developers.

reporting guidelines

Another online evidence-based medicine course

2007-10-23T19:32:00.000-04:00

This one is from the University of North Carolina Health Sciences Library (my favorite library in the whole world, as it happens...) and the Duke University Medical Center Library.

(The photo is of UNC's Old Well, which is more photogenic than the library...)

New quality/safety blog

2007-10-23T11:00:00.000-04:00

Robert Wachter, professor at UC San Francisco, author of Internal Bleeding, and patient-safety leader and innovator, has a new blog. This post nicely illustrates the health care quality learning curve as experienced by interns.

Be skeptical; be very skeptical

2007-10-22T12:17:00.000-04:00

The Kaiser Daily Health Policy Report has a piece today about an effort to survey Wellpoint's many (35 million) about their physicians in order to provide consumer-based rankings, also to include comments. All together now: "The plural of anecdote is not data." Indeed, as one consumer group interviewed by Kaiser said, these rankings are likely to be skewed to the negative by patients who have had bad experiences. There are better ways to collect consumer-centered data - for example, AHRQ's CAHPS measures - than mass rants of the type Wellpoint proposes.

I don't have much use for Zagat's restaurant reviews, either, for the same reason.

Gross, but thought-provoking

2007-10-10T19:40:00.002-04:00

Kent Sepkowitz, writing for Slate, asks whether we might not be better off in terms of immunity by living under less sterile conditions. His recommendation to scientists: figure out if there's a level of excrement we can eat that would boost our immune systems without killing us. I imagine susceptibility varies by age, and I do know that we live longer as a population than we used to before sanitation. Other than that, I'm not a microbiologist, and I can't decide whether this idea is completely wacky or not.

Any discussion?

Good news on hospital death rates

2007-10-10T17:15:00.001-04:00

The Agency for Healthcare Research and Quality has released new data showing that mortality rates for six conditions and six procedures have declined steeply over a 10-year period from 1994 to 2004. In brief,

AHRQ compared the death rates for 1994 and 2004 for patients who were hospitalized for heart attack, congestive heart failure, stroke, pneumonia, gastrointestinal hemorrhage, or hip fracture.

For every 1,000 patients admitted for their condition:

o Heart attack deaths fell by 43; deaths from congestive heart failure, pneumonia, and stroke each dropped roughly 30; deaths from gastrointestinal hemorrhage declined by 21; and 16 fewer died from hip fracture.

For every 1,000 patients who underwent six surgical procedures examined:

o Abdominal aortic aneurysm repair deaths plunged from 103 to 74;
o Deaths from craniotomy – an operation for brain lesions and other conditions – declined from 83 to 68;
o Deaths from heart bypass surgery fell from 48 to 28, angioplasty deaths diminished from 16 to 12, those from carotid endarterectomy – an operation to avert stroke – fell from 12 to 7, and
o Deaths from hip replacement surgery declined by half – from 4 to 2 per every 1,000 operations.

The death rates for the six conditions and six surgical procedures are risk-adjusted, meaning that AHRQ’s researchers took into account differences in how ill patients were over time when calculating the results.

Isn't getting old hard enough as it is?

2007-10-09T08:00:00.000-04:00

The New York Times today reports on various forms of mistreatment and bias against elderly gay people, especially in assisted-living and long-term care facilities. There are not a lot of data here, just a few anecdotes and examples of efforts to address the problem, but that's ok - the fact that it ever occurs is unacceptable. And you can sort of see what's going on - elderly people slowly lose their ability to control the environment they live in, and the world at large is still quite homophobic. So if you've grown up in the closet and eventually gotten past all the barriers to coming out, you now find yourself in a position of going back in, or struggling mightily to surround yourself with people who will accept you.

The problem simply had never occurred to me, and I have few words to express how sad it makes me.

Why universal coverage is not socialized medicine

2007-10-08T08:34:00.000-04:00

Ezekiel J. Emanuel, bioethicist at the National Institutes of Health, lays it out in this Washington Post op-ed piece.

The Antidote in translation

2007-10-07T08:57:00.001-04:00

Scanning links to this blog in Technorati, I found that one of my recent posts (mostly consisting of data from AHRQ) has been fully translated into German! Thanks to Healthy Index for taking the time to include the content. Based on my very limited German, it does appear that this was done by a human, not by a machine like Babelfish, which is helpful in a pinch but not particularly reliable, and sometimes downright hilarious, at least for language geeks like me.

Edit: thanks to my friend Z, with whom I probably should have checked before posting, for pointing out that it is an automatic translation after all. (Just goes to show how nonexistent my German really is these days...) So my new German readership are probably scratching their heads a bit.

One of my readers pointed out the following amusing choice of a bullet, however:

O arme Amerikaner really just means "Poor Americans," (meaning Americans without resources) not "Oh, you poor Americans." At least I think it does... Europeans don't feel that sorry for us, do they?

AHRQ e-updates available

2007-10-03T17:02:00.000-04:00

The Agency for Healthcare Research and Quality has a new email notification service, where users can sign up for new Agency information (research, guidelines, etc.) in categories of their choosing. Sign up here.

health care quality

More on health coverage: a case study

2007-10-03T10:15:00.000-04:00

From the macro-level previous post, to the micro...

Ryan Healy, at The Brazen Careerist blog, a 20-something writer, muses on the implications of taking a job without health insurance and buying individual coverage. (He also touches on issues of screening and prevention.) Whether or not Ryan intended to make a political statement with this piece, it's a good illustration of just why universal health care is a good idea.

Update on health-insurance coverage in the US

2007-10-03T08:54:00.000-04:00

The Agency for Health Care Research and Quality (AHRQ) has just released data on the extent of lack of health coverage, and in particular the lack of continuity of coverage. This is of course a central issue for presidential candidates and others who are debating what to do about the problem. From AHRQ's News and Numbers:

More than 17 million Americans under age 65 – almost a third of whom are middle income, could be considered continuously uninsured. This means that they have not had health insurance to help cover their medical bills for at least four years, according to the latest News and Numbers from the Agency for Healthcare Research and Quality. Middle income Americans are defined as living in families earning between 200 percent and 400 percent of the federal poverty thresholds, which vary according to family size and composition. In 2004, the base year for these data, poverty level income for a family of four averaged $19,307. From AHRQ's News and Numbers: The AHRQ data examined Americans who were continuously uninsured for at least four years between 2002 and 2005 as well as those who were uninsured for shorter periods over those years. The AHRQ data also show that:
o Poor Americans, those in families with incomes at or below the Federal poverty line, comprised about a quarter of the continuously uninsured. In contrast, less than 10 percent of the continuously uninsured were people who lived in families with incomes over 400 percent of the Federal poverty line.
o Fully 17 percent of Hispanics were continuously uninsured, compared with 7 percent of blacks, and 4 percent of whites.
o Some 12 percent of people age 25 to 29 years of age were continuously uninsured, followed by Americans age 18 to 24 (11 percent), 30 to 34 (10 percent), 35 to 54 (8 percent), and 55 to 64 (5 percent). However, only 2 percent of children and adolescents under 18 years of age were continuously uninsured.

Aviation safety revisited

2007-09-30T21:53:00.000-04:00

An article from today's New York Times describes a 65% drop in plane-crash fatalities over 10 years, accomplished in large part by identifying seemingly small problems that often precede crashes. Now that there are so few crashes, and data are sparse, the industry has reversed its learning patterns and analyzes flights that go well.

Apparently aviation is learning from its mistakes. Can hospitals - where, in an era of tens of thousands of deaths due to errors per year, data are not sparse - do the same?

Polypharmacy awareness

2007-09-27T20:46:00.000-04:00

The New York Times today had an article by Jane Brody describing the phenomenon of polypharmacy: simply put, too many drugs, whether prescription, over-the-counter, or both. It's a particular problem in elderly patients, who suffer from multiple conditions, and who often see multiple doctors who don't know what other drugs patients are taking. Those drugs often interact, producing additional morbidity and even death.

Here are some sobering data describing the incidence of polypharmacy:

Polypharmacy is responsible for up to 28 percent of hospital admissions and, he added, if it were classified as such, it would be the fifth leading cause of death in the United States.

Polypharmacy can even occur when doctors do know what other doctors have prescribed, but are afraid to override other doctors' decisions. There's an increasingly useful role for consultant pharmacists, who, despite their superior training in identifying potential interactions, often come into conflict with physicians when they question prescriptions.

I'm glad, however, that the term "polypharmacy" is now out there in the New York Times. Increased awareness of polypharmacy is one way in which patients and their families can be better advocates for their own care. Changing the culture of medicine and reducing the fragmentation of health care to reduce risk of polypharmacy are, again, as we all know, different stories entirely.

Massachusetts moves toward transparency on health care costs

2007-09-24T14:45:00.000-04:00

The California Health Care Foundation's ihealthbeat online newsletter today reported that Massachusetts plans to post payment data on hospitals online, based on a recent Boston Globe article. Specifically, each hospital will be required to post average payments made by each insurer for certain procedures, the idea being to allow consumers to comparison-shop for hospitals on the basis of costs. Hospitals will also post quality information on these procedures, but the specific procedures have not yet been decided upon.

New Hampshire has posted payment data, but not quality data, on a range of types of hospitalizations, some of which may be more feasible than others for comparison shopping.

Best science/politics article of the week

2007-09-20T10:38:00.000-04:00

President Bush, something of an "armchair physicist," discovered an error in a particle-physics article from Fermilab, and modestly described the error to scientists at the lab and to the press.

Thanks, Onion!

Senate passes mental health parity bill

2007-09-19T11:10:00.000-04:00

New legislation passed today by the U.S. Senate will ensure that all health insurance plans cover mental health care at the same level as coverage for general health issues.

This reform is long overdue. From my own perspective, I recently picked up temporary health coverage with a modest premium of about $230 per month, and noticed when I got the paperwork that it didn't include a mental health rider. When I inquired about the cost with the mental health coverage, I was told my monthly premium would be on the order of $800 per month. So I skipped it, and prayed for mental fortitude, though as far as I know, prayer is not an evidence-based preventive intervention against mental illness.

Pearlstein on Clinton's health care proposal

2007-09-19T10:45:00.000-04:00

Steve Pearlstein of the Washington Post writes today that Hillary Clinton's new plan, announced this week, is the best among those of the Democratic candidates. Of all, the candidates, in fact; Pearlstein says about the Republicans,

The knee-jerk response from Republicans was to smear her proposal as "socialized medicine," a fresh reminder of how illiterate, out-of-touch and irrelevant the Republicans have become on the most important domestic issue to voters.

Hey, he said it, I didn't.

Pearlstein cautions that Clinton has a lot of political work and voter education to do to sell the crucial nuances and inevitable tradeoffs of her proposal. Where I would start is by stressing that rationing is not necessarily a bad word; it doesn't have to be about profits for the insurance industry (though under Clinton's plan that will likely be the reality, at least in part), and it could actually improve health care both for individuals (by limiting the use of unproven, potentially risky procedures) and certainly for the population as a whole (by allowing more equitable distribution of resources). I'd like to see more details on modernizing Medicare in this regard.

But how can we get Americans with good health coverage to see that they may not need everything that they're currently consuming?

Free online evidence-based health care course

2007-09-18T19:02:00.000-04:00

The U.S. Cochrane Center at Johns Hopkins University's Bloomberg School of Public Health is offering a free online course in evidence-based health care. It's designed for consumers and consumer advocates who need to be able to distinguish high-quality research evidence from evidence that's not so reliable. The U.S. Cochrane Center is part of the worldwide Collaboration, comprising some of the world's gurus on evidence based medicine, and the course is taught by breast-cancer survivor and patient advocate Musa Mayer, and was co-developed by Kay Dickersin, Cochrane Center director.

A little quiz: I've attached the nifty logo of the Cochrane Collaboration. Would anyone care to describe what it represents? (Epidemiologists should hold back, at least for now.)

evidence-based medicine

Getting health care priorities in order

2007-09-10T22:46:00.000-04:00

Shannon Brownlee, whom I interviewed on this blog a few months ago, has an article in the new Washington Monthly on why we need to fully fund AHRQ (the Agency for Healthcare Research and Quality - remember it!), and all the reasons why it's important to insist on evidence in health care.

Bee science

2007-09-07T17:27:00.000-04:00

Researchers finally have a clue about the mass disappearance of pollinating honeybees from hives across the country and elsewhere, as reported in today's NYTimes: a virus, the presence of which was 62 times more likely in hives that had collapsed than in those that had not. Because the very strong association could still be a coincidence, however,

To try to clarify cause and effect, the researchers said they were preparing a new suite of tests in which isolated bee colonies would be intentionally infected with the virus, both with and without possible secondary causes like certain parasites.

I guess you could call it epiapiology (to mix Latin and Greek)...

Immigrants and mental health

2007-09-07T12:28:00.001-04:00

Just read this chat on washingtonpost.com about access to mental health among immigrants to the U.S., with Dr. Hochang Benjamin Lee of Johns Hopkins. Here's a related article from earlier in the week, which suggests (without a lot of hard data) that immigrant parents are likely to be in denial about their children's mental illness, among other barriers. Both of these are apropos of this week's state of Virginia report on the mental health of Seung Hui Cho, the Virginia Tech student who killed 32 people and then himself.

How Americans get information on health and cancer

2007-08-30T09:50:00.000-04:00

New results from a federally funded survey are out that describe trends in sources Americans use for finding health information. The survey revealed that we trusted our health care practitioners more in 2005 than in 2003, but the internet somewhat less between those two years. That, of course, is before this blog was born (August, 2006), so the internet trend may yet reverse ;-) .

Republican health care positions

2007-08-29T13:15:00.000-04:00

For the record, and posted without comment, here's a link to a Kaiser Family Foundation summary of a presentation on health care by Republican presidential candidates, sponsored by the Lance Armstrong Foundation.

Tough talk on improving health care in California prisons

2007-08-27T16:23:00.000-04:00

Today's NYTimes has a story about Robert Sillen, the court-appointed federal receiver chosen to overhaul health services in California prisons as the result of a class-action lawsuit. Sillen does not mince words with legislators in Sacramento and has no patience, for example, for political rhetoric about keeping felons off the street that elected officials must adopt.

He also dismisses the idea of setting goals and monitoring progress in health care improvement.

The Prison Law Office filed a complaint in federal court in June saying that Mr. Sillen’s plans have “no concrete details of how any of the goals or objectives are to be accomplished, no real timelines and no metrics.”

In an interview in his office in San Jose, Mr. Sillen dismissed the group’s assertions. “When people ask me how long and how much,” he said, “I have a stock answer: Long. Much.”

This, of course, is a mistake. I'll give him the benefit of the doubt and say he's just being contrary for the benefit of the media, but I'd be happy to help him with such a project.

The Receivership website is here.

More on (lack of) regulation of lead in toys

2007-08-22T14:21:00.000-04:00

Much more, from Slate.com.

The plot thickens.

Catching up on the health blogosphere

2007-08-21T21:47:00.000-04:00

Maybe all of you keep up better than I do with the health care sector of the blogosphere and this is a useless exercise, but here's the thing: sometime during my 6-week hiatus from blogging, my feed reader went dead, and I had stopped looking at it anyway. Today, though, I fixed it, and found a bunch of good stuff that seemed worth sharing. Here are some highlights (most of them, in fact, current).

At the Health Affairs Blog, a UK doctor writes about the ups and downs of pay-for-performance in the National Health System.

I didn't know, but I had wondered, what role the U.S. government might be playing in keeping China manufacturer-friendly; the Pump Handle blog today points to a McClatchy newspaper article alleging that the Bush administration has fought inspection rules that might have prevented recent lead poisonings from toys made in China. I found the article itself a little skimpy on facts, but I imagine - hope? - it's just the beginning of investigation on this issue.

This sounds like something I should be writing more about: the idea that a virus causes obesity, and the viral spread of the idea in the news. Read Knight Science Journalism Tracker's take on news coverage here.

Here's an obesity story I liked better, from Nature Newsblog, about how chimps practice dietary self-control; it's good to remember that, in the end, we are all apes. (Yes, even you, unless you happen to be that rare gerbil or komodo dragon who reads blogs.)

Thanks also to the KSJ Tracker for this cool science story (not about health, but I couldn't resist) about a juvenile sooty shearwater - a wide-ranging seabird, photo above - in New Zealand that had picked up a tiny tracking device implanted in a salmon in the Pacific Northwest of the U.S.

White Coat Notes, from the Boston Globe, reports that Harvard researcher and patient safety guru Lucian Leape approves of the new Medicare non-reimbursement rules, because, in Leape's words,

We’ve got a lot of solutions out there and the thing that is so frustrating is they haven’t been implemented.

Finally, Gary Schwitzer wrote about the increasing infomercialization of health segments on local TV news station. Scary.

Just trying to figure out...

2007-08-21T19:32:00.000-04:00

why this blog has a whole raft of hits today emanating from my interview with Nick Genes last December, when I hosted Grand Rounds.

So if you're coming from there, did someone else recently link to that interview?

Not paranoid, just wondering.

National Quality Forum request for public comments

2007-08-20T18:21:00.001-04:00

Just passing along a request for comments...

August 20, 2007 Update

Public Comments Requested for Three NQF Reports. NQF is pleased to announce that the following three draft reports are available for public comment. Comments must be received by Friday, September 7, 2007, 6:00 pm, EDT. NQF is now using a program that facilitates electronic submission of comments.

* National Voluntary Consensus Standards for Ambulatory Care: Cycle 3
* National Voluntary Consensus Standards for Ambulatory Care: Measuring Healthcare Disparities
* National Voluntary Consensus Standards for End Stage Renal Disease Care

Questions about the NQF and/or this email can be directed to info@qualityforum.org or 202.783.1300.

Preventing motor vehicle injuries in primary care

2007-08-20T17:27:00.001-04:00

The US Preventive Services Task Force has just issued its findings on counseling for seat belt use and on drinking and driving in the primary care setting. The Task Force basically identified critical research gaps for both: they concluded that there is insufficient evidence to assess whether physicians' counseling of patients on seat belt use or drunk driving adds to existing public health efforts such as legislation.

Such evidence gaps are, unfortunately, common amongst evidence-based primary care recommendations.

Anyone at NIH or CDC want to fund a study?

More bloggers weigh in on Medicare nonreimbursement

2007-08-20T17:13:00.000-04:00

The Physician Executive blog and Medpundit ("You Broke It, You Bought It") have posted their thoughts on the new Medicare rules stipulating that treatment of certain preventable adverse events and health care-associated infections will not be reimbursed. It's worth reading the comments on each, also those at Paul Levy's blog.

Mike Leavitt starts a blog

2007-08-19T17:13:00.001-04:00

US Department of Health and Human Services Secretary Mike Leavitt has a blog. Sounds like he's writing it himself, but will have help managing the comments, and therein lies, I imagine, the challenge. Cheerfully posting HHS news updates is one thing, confronting the masses head-on and transparently in this format will be quite another.

Preventing medical errors: an official incentive

2007-08-19T10:28:00.000-04:00

Medicare now says that it won't reimburse hospitals for hospital-associated infections, or the sequelae of serious adverse events, according to an article in today's New York Times. About 100,000 deaths per year are estimated to occur from hospital-acquired infections alone, and treating such infections is estimated to cost billions of dollars. The idea behind the new rules is that such events are preventable, and that non-reimbursement will further compel hospitals to take steps to ensure that they don't occur.

Hospital organization representatives interviewed in the article question the extent to which adverse events and infections are, in fact, preventable. (Paul Levy, CEO of Beth Israel Deaconess Hospital and blogger, believes that infections are preventable, and has written at length - e.g., here - about his hospital's goal of zero infections.) Hospitals also worry that they'll be have to spend more of their own money on tests of infection upon admission so that they can demonstrate that certain infections are community-acquired. It'd be an interesting economic analysis (that I'm not qualified to make) to see whether diligently working toward zero infections, in a climate of nonreimbursement for infections, pays off as well as investing dollars to try and prove that infections are not hospital-acquired, though the latter could provide interesting data if studied rigorously.

More details on this initiative soon.

More on aging in For Better or For Worse

2007-08-16T06:34:00.000-04:00

Today's For Better or For Worse comic strip (go to August 16, 2007, in the archive if it's not visible when you look) addresses the issue of polypharmacy: the grandfather, who is working to recover from aphasia caused by a stroke, is apparently depressed, and when his daughter suggests upping his meds, his wife replies that he's already taking too many.

Tough one. It'll be interesting to see how the strip, which takes place in Canada, resolves this issue. Will they bring in a consulting pharmacist to review all Grandpa's meds? Will they find a way, given that he can't talk, to engage him in psychotherapy (e.g., instant messaging)? Or will he be miraculously and glibly cured - maybe even of the aphasia - from an insight experienced, say, in the presence of one of his grandkids or great grandkids?

In any case, the thread is a refreshing break from the saccharine and highly annoying romance of Anthony and Lizard Breath (see, for example, August 11 in the archive).

Grand Rounds

2007-08-14T18:58:00.000-04:00

Please check out medical blogging's Grand Rounds hosted this week at Med Journal Watch.

It's been much too long since I submitted anything to Grand Rounds; I really need to get with the program.

Kids brainwashed by advertising

2007-08-14T08:15:00.000-04:00

This article in today's NYTimes describes how kids prefer foods that come in McDonald's packaging to the same foods in plain wrappings. Apparently the official McDonald's response is to add healthier foods - with the proper appealing packaging - to their lineup, rather than cop to the brainwashing.

As summed up by one of the researchers,

“We often hear that parents are the ones responsible for their kids’ nutrition,” Dr. Robinson said, “but in reality there are these other factors, created by a tremendous amount of advertising effort, that undermine parents’ ability to make healthy choices.”

Evidence is the main issue for supplements

2007-08-09T19:59:00.000-04:00

Interesting perspective on prioritization of research on dietary supplements, from Mark Moyad, Director of Preventive and Alternative Medicine at the University of Michigan. Thanks to The C.A.M. Report blog for pointing this out.

Raw milk: "Russian roulette" is right

2007-08-08T07:32:00.000-04:00

My usual morning newspaper routine includes reading the health sections on Tuesdays, and the food sections on Wednesdays. I gather the raw milk people have been plastering news outlets with press releases recently, because Sally Squires' Lean Plate Club column yesterday in the Washington Post health section was pretty direct about the risks of drinking raw milk, and the Times reported on it in today's Food section (see below).

Squires' column reports a number of recent cases of milk-borne bacterial illness in humans (there are a number of pathogenic bacteria specific to milk), and gives good data on the extent of the problem: raw milk from a quarter of the farms tested had disease-causing bacteria in it. Particularly telling regarding public understanding is Squires' online chat yesterday, where a number of people wrote in to say, basically, that they drank raw milk all the time growing up and never got sick. As I always say, though, the plural of anecdote is not data. People, did you read Squires' column?

Today, the New York Times reports in the food section on raw milk, and the struggle over whether it should be legal or not. Writer Joe Drape interviews a number of raw milk fineshmeckers, some of whom even feed it to their kids, who have apparently fallen for the improved healthfulness arguments cited in Squires' article. More enzymes? Sorry, they're destroyed as soon as they hit the stomach. Maybe it tastes better but, as the Center for Science in the Public Interest points out in the Times article, universal pasteurization led (early in the 20th century) to a precipitous drop in the proportion of food-borne illness caused by milk. Otherwise, the Times does not offer any data on risks, just perceptions.

I think many people are more likely to fall back on their own experience than to pay attention to hard numbers. Some consumers, those who are more likely to prefer small, organic farmers over large industrial farms, for example, (and I sympathize, but for other reasons) may prefer to take their chances with "natural." They might believe the hokum spouted by the Sally Fallon, who is trying to promote consumption of the who says that non-industrial dairy-produced milk has its own antimicrobial properties. Is that so? Well, until you submit your magic milk for bacterial testing along with everyone else, I'm not touching it. In this case, I'll side with the National Dairy Council official quoted by Squires, who said that that drinking raw milk is "like playing Russian roulette" - it's hard to argue with that.

Update from Health News Review

2007-08-07T20:18:00.000-04:00

Gary Schwitzer, who runs a site called Health News Review that systematically reviews the quality of health news, has posted highlights from the site over at the World Health Care Blog. Gary points out a number of disappointing stories in recent national health news.

I, for one, am grateful that Gary has continued to mind so ably the quality-of-health-news store while I've been off investigating new directions (nothing terribly exciting to report as a result, I'm afraid) and noticing what it's like not to blog regularly (was harder to stay away than I expected).

Where are the standards?

2007-08-07T10:13:00.000-04:00

I was surprised this morning to find that the Washington Post had published this piece. It's about a biochemist who is promoting manuka honey from New Zealand as a wound-healing agent, and it also does a pretty good job of promoting manuka itself.

But the article presents almost no evidence that manuka works. Instead, it interviews other honey experts, who lament the slowness of the medical community in accepting alternative treatments. The writer does, to his credit, quote researchers in the field who acknowledge that more research is necessary - including in vivo studies. One small, unpublished study is described: it's not clear whether it was s randomized, and though 7 of 10 wounds colonized with MRSA were no longer colonized at the end of the study, no comparison result is offered.

Apparently the FDA has approved manuka as a wound dressing, but what does that mean? that they don't think it will kill you? and if so, how do they even know that? Are the standards different for wound dressings from, say, anti-cholesterol drugs?

Why so much fuss about something that hasn't even reached the level of credible research? The article has that alternative-medicine air of "let's take back medicine from evil Pharma, and go back to natural remedies used for thousands of years" - even if there's really no good evidence that those natural remedies were actually effective or safe.

Hospital Compare adds patient outcomes

2007-06-22T10:11:00.000-04:00

The Centers for Medicare and Medicaid Services (CMS) has just added 30-day mortality measures for heart attack and heart failure patients (separately). These are the first actual patient outcome measures to be included in this national, voluntary, hospital-specific public reporting database. In addition to the rates themselves, the site compares the rates to the national average (better, about the same, or worse).

The rates are also risk-adjusted to even out differences in the underlying morbidity of patients. The 30 days include patients who die outside the hospital, because there are also differences in how quickly hospitals discharge patients. This is, however, a potential source of error, because it's fairly difficult to capture deaths that occur outside the hospital. Last time I checked, there was a substantial time lag before such information was available via national data sources. If readers know how hospitals typically get such information, I'd be interested.

Top 100 health care blogs

2007-06-15T10:16:00.000-04:00

(Warning: potentially confusing cross-referencing ahead...)

Thanks to Tony Chen of Hospital Impact, and one of my fellow World Health Care Bloggers, for pointing out the Healthcare 100 blogs, indexed by rankings in Google, Bloglines, Technorati, and eDrugsearch. The World Health Care Blog is number 47, and The Antidote is number 58! Lots of other blogging colleagues/buddies of mine are there as well; check it out.

Chemotherapy: profits vs. questionable benefits to patients

2007-06-12T10:06:00.000-04:00

A story in the NYTimes today reports that oncologists are still trying to find ways to profit from treating their patients with expensive drugs, even though Medicare has cracked down on such profits two years ago (by limiting the markups docs can charge to 6% above the cost of the drug).

Doctors can get around the limitations in reimbursement by simply offering drugs to more patients, whether or not they'll benefit from them.

“There’s pretty good evidence at this point,” said Dr. Richard Deyo, professor of medicine at the University of Washington and an expert on health care spending, “that there are plenty of patients for whom there’s little hope, who are terminally ill, whom chemotherapy is not going to help, who get chemotherapy.”

Some doctors claim that the Medicare limitations are going to result in a lack of access to needed drugs for patients in rural areas, for example, although an unspecified federal commission cited by the article found this not to be the case.

In such a climate, how common are honest conversations between doctors and patients about the risks and benefits (not to mention the costs) of chemotherapy in terminally ill patients? I'd like to see studies on utilization of chemotherapy in settings where oncologists can't profit from use of the drugs (and I'm not sure where those are, given multiple payers, including Medicare, available in most care settings in the US), compared to those where they can. The extra-credit part would be comparing real health outcomes - not 5-year survival! - in different settings.

The fog of medicine

2007-06-12T09:14:00.000-04:00

Baffling news from the recent American Society for Clinical Oncology meeting, about which the public should probably not yet make too much of a fuss; however, the NY Times chose to report on it, so there you are. Here's my take on what I've read in today's article.

Researchers presented an analysis of pathology samples from a study that had previously shown that breast cancer patients classified as positive for the HER-2 gene allowed them to benefit from treatment with trastuzumab (Herceptin). Another look at the HER-2 positive samples showed that 20% of them were actually HER-2 negative - and yet half of those women benefited from treatment with trastuzumab, a drug that specifically targets HER-2.

This could mean any (or more than one) of three things, none of which we have enough information at this point to be confident:

- the tests (immunohistochemistry - for the protein - and fluorescence in situ hybridization - for the gene) are worse than we thought
- the threshold for classifying a patient as HER-2 positive is wrong
- trastuzumab is not as specific to HER-2 as we thought (suggesting that women with HER-2 negative tumors could also benefit)

The studies described are small, and even those at the meeting (including the Times writer) did not have the benefit of all the methodological and data details we would in a peer-reviewed, published paper. In other words, these findings are meant to be chatter amongst investigators, and to suggest directions for more definitive research: for example, why did the women in the early studies test positive for HER-2, and negative now? were there other genes involved that could affect the results of the tests and/or the activity of trastuzumab? I'm not a molecular biologist, or an oncologist, so I'll stop there.

Regarding the NYTimes story itself, if it had fallen clearly into the excitement-of-science category, perhaps - perhaps - I'd have been OK with it, but there's a little too much hype offered up front by a National Cancer Institute scientist, suggesting that the results are potentially "practice-changing."

Democratic candidates: debate excerpts

2007-06-06T13:09:00.000-04:00

The Kaiser Family Foundation has posted a compilation of health care-related excerpts from the recent Democratic candidate debate in New Hampshire.

Early detection of cancer

2007-06-04T15:28:00.001-04:00

My fellow blogger Orac, an oncologist, has a great post (from back in April; somehow I missed it) on why screening for cancer is a complicated issue that should be approached with cautious weighing of risks and benefits. And here's his Part 2, with specific reference to breast cancer.

Be sure to read the comments - surprisingly, all were supportive - and check out the 9-minute video offered in the first post by Tracy of Dr. Barry Kramer (full disclosure: he's my former boss).

Cuba vs. the US on the health front: what do we know?

2007-05-27T07:15:00.000-04:00

Today's New York Times has a thought-provoking little piece on health care in Cuba, where life expectancy is longer than in the U.S. apropos of Michael Moore's forthcoming movie "Sicko."

After presenting possible reasons for lower infant mortality (more abortions) and longer life-expectancy (failing to take account of the death of refugees), the article muses as to whether Cubans' relative privations (fewer cars=more walking, less [but adequate] food=less obesity) might actually improve their health. A Cuban doctor who defected and now works in Miami points out that there are actually two health care systems in Cuba, one for public officials and visitors, which has everything, and one for everyone else. The second-tier system is pretty bare-bones, but begs the question - not asked by the article - of what are the essential elements of a functioning health care system that actually improves health?

As always, it's hard to separate the impacts on longevity of lifestyle (and socioeconomic) factors from that of health care itself. However, there's certainly lots more to be learned about the Cuban system(s), which we may not be able to learn, given restrictions on access.

Clinton gets it

2007-05-25T13:04:00.000-04:00

In today's New York Times: Finally, a democratic presidential candidate who's not just touting universal health care as the be-all and end-all, but recognizes that such approaches as broader preventive care and Medicare drug payment negotiation are part and parcel of lowering health care costs. I trust there's more detail forthcoming; she has been leading in this area in Congress from the beginning.

Moore's "Sicko": I can't wait.

2007-05-22T08:21:00.000-04:00

Michael Moore's documentary on health care in the U.S., which is getting good reviews at the Cannes film festival, is due out the end of next month. As pointed out today by the New York Times (who interviewed a number of health care experts who'd seen a preview), it could promote the national dialogue on health care. Why not? We're overdue for a fight, not just among policy wonks and presidential candidates (though a real argument would be nice there, too). I'm still waiting for mass protests on the Mall.

A friend of mine argues that Moore is such a polarizing personality that he'll be a distraction. I'll take his point, but counter that (1) we're getting used to him, and (2) raising the issues in a popular/populist format such as this is exactly the kind of exposure the topic needs to set the ball rolling. I'm more worried that the argument will devolve into anecdotes. But that in itself could be a useful opportunity for analysis (e.g., Moore says X, data says Y).

And yes, I will probably take the cost of my ticket as a tax deduction.

News coverage of screening tests

2007-05-14T22:20:00.000-04:00

My colleague Gary Schwitzer has a new article on the Poynter Institute website in which he discusses how much news coverage on screening tests contradicts evidence-based recommendations from the U.S. Preventive Services Task Force and the American College of Physicians. He also includes some useful insight from health journalists on why screening gets the kind of coverage it does.

Important step for anti-smoking efforts

2007-05-11T11:08:00.000-04:00

The Motion Picture Association of America, which makes recommendations on the suitability of movies for young viewers, has now decided to include smoking alongside violence and sex in its ratings. (Here's a NYTimes article.) Even though the prevalence of smoking portrayed in movies has come down a bit in the past few years (under lots of pressure from anti-smoking advocates, as was this ruling, for sure), there are still lots of films in which smoking is portrayed as glamorous, sexy, or appealing in some ways.

I don't want to be too cynical here, but I do question whether giving a movie an R rating actually keeps (younger) teens from seeing it, or whether it actually increases its allure, and hence the exposure. Particularly now, in the DVD era, I imagine it's a lot easier for teens to have access to forbidden stuff. But that's just a guess, and a different question.

On the whole, I think the new rules are a good thing, particularly as they increase awareness of the issue.

Storefront clinics: good or bad?

2007-05-11T09:46:00.000-04:00

You'll want to have a look at a great discussion - be sure to read the comments - on the convenient clinics that CVS and similar stores are developing, to be staffed largely by nurses and physicians' assistants.

News-critique feature at Ben Goldacre's blog

2007-05-08T22:23:00.000-04:00

Ben Goldacre, wickedly smart - and funny - health writer for the Guardian and blogger at bad science, has added a new mini-blog feature (which you can access via rss feed). In it, he simply responds to tenuous health stories with sassy one-liners (or in many cases less than one-liners).

For example:

Headline: Researchers uncover genetic link to obesity
Ben: Is it the gene for the muscle that opens the mouth?

Science for the OCD in all of us

2007-05-08T22:06:00.000-04:00

Harold McGee has moved his column on food safety to the New York Times, and in this week's column he examines the five-second rule, which has now been addressed by a real study that involved pouring Salmonella broth on different flooring surfaces and then dropping bologna slices on them for varying lengths of time.

Yep, it's for real, and it's great stuff.

Genetics blog has moved

2007-05-05T12:56:00.000-04:00

Hsien Hsien Lei's genetics blog, formerly Genetics and Health, is now Eye on DNA. Looks great!

This week's primary health care roundup from Australia

2007-05-03T00:56:00.000-04:00

Here's another edition of PHC RIS, from the Australian Primary Health Care Research and Information System...

International comparisons of health care systems

2007-05-02T12:35:00.000-04:00

Ezra Klein has an article in the May issue of The American Prospect comparing efficiency - what you get for what you pay - in Germany, France, Canada, Great Britain, and the Veterans' Health Administration, with reference to what we get in the US. Thoughtful and well worth reading.

Antidote Interview #3: Shannon Brownlee

2007-04-29T21:46:00.000-04:00

I'm pleased to have the opportunity to interview Shannon Brownlee, a leading health and health care journalist, and a Senior Fellow at the New America Foundation. As you'll see, she has a lot to say about the direction of health care in the U.S., health care reform, how evidence-based medicine can help, and the role of journalism. Look for her forthcoming book on health care, to be released this fall.

I'd like to start with the topic of health and health care journalism, because I think you've been a particularly influential voice in this regard. What is your training, and how did you come to appreciate and learn about evidence-based medicine? Was there a defining moment?

I have a master's in marine sciences, and I trained as a behavioral biologist. I started writing about medicine in 1989, when I got a job with U.S. News & World Report. I was reporting on basic biomedical research, and had never heard of evidence based-medicine. Like most of Americans, I assumed the medicine was all scientifically based. Then I began researching the history of high-dose chemotherapy for breast cancer, a treatment that was used on some 40,000 breast cancer patients before it was shown to be no more effective than standard treatment. (High-dose chemo was also known as bone-marrow transplantation.) High-dose chemo killed thousands of women before the trials were completed in 1999, showing that it didn't work. I was shocked by the realization that a dangerous, experimental treatment was used so widely on the basis of so little evidence. That was the first time I really thought about the lack of evidence, and the tendency for U.S. medicine to plunge ahead into new therapies before doctors or patients really know whether the novel treatment was any good.

We now have a more recent, and far more costly, example in elective angioplasty and stents for heart disease. These two procedures, which are the tools of interventional cardiology, have been highly effective in the treatment patients in the midst of an acute MI. But the vast majority of angioplasties and stents are given not to the patient in the throes of a heart attack, but to patients who are suffering from the symptoms of heart disease. A few maverick cardiologists have been saying for years that there's no evidence that these procedures are any more effective than medical management in relieving the pain of angina or preventing heart attacks. Recent results from a randomized, controlled clinical trial, the gold standard of evidence based medicine, showed that the mavericks were right. That means we've been spending on the order of $40-$50 billion a year on invasive procedures that don't work any better than aspirin, beta blockers, and improved diet.

I was at a Cochrane Collaboration meeting with you a few years ago at Brown University where proponents of evidence-based medicine were reaching out to, well, evidence-based health journalists. The hope was that you and your journalist colleagues would "partner" with them in plugging systematic reviews, etc., in the mass media. This language raised some hackles about the appropriate role and function of journalists. What is that role? Is use of and reporting on best evidence a bias (to the extent that you're relying on groups like Cochrane and AHRQ), a tool, or something else? And what about editorial pressure to provide consumer-oriented health recommendations?

I don’t think it's my job to partner with the Cochrane Collaboration or AHRQ or anybody else, but I do think medical journalists should be more aware of resources like the Cochrane when they report on medical developments. Most medical journalism isn't very good, largely because most medical journalists are poorly trained when it comes to assessing the medical literature. (They're in good company. Doctors aren't trained to critically appraise the medical literature, either.) What journalists lack in critical skills could be made up for in more skeptical reporting, but that doesn't happen often enough. In any area of medicine, there's always a credible source who will offer an opposing view to the prevailing wisdom. But all too often, medical journalists don't seek out those critics, or they discount them as cranks.

The fact is, most of medicine is based not on evidence but on hunches and supposition, and on what's profitable. What I discovered in researching the history of high-dose chemotherapy was there were two driving forces pushing the therapy, even though the evidence for efficacy was based on historical controls, which is generally considered poor quality evidence. First, high dose chemo made much sense. If a little chemo could get rid of most breast tumor cells, a lot might offer a cure. This was part of the belief system in cancer treatment, and it proved to be a powerful motive. Two, transplanting breast cancer patients was hugely profitable, both for physicians and for hospitals. All too often, in American medicine, profitable procedures are done at the expense of effective medicine.

What would you like to see health journalists covering more? Are there gaps in coverage that you think could be filled usefully?

I'd like to see us following the money a little more assiduously. There are remarkably few investigative journalists in medicine, and there's so much to cover. I'd also like to see more skepticism. Where were the really critical journalists when researchers announced recently that CT-scanning for lung cancer could save lives? That research was full of holes, and any reporter who had the sense to go to one of several experts in screening epidemiology would have learned there was more to the story than met the eye. Yet most reports made CT-scanning out to be the greatest thing since sliced bread, and early detection the answer to fewer lung cancer deaths. I can understand why we make this mistake. I used to think all doctors understood how to analyze science, but many if not most of them aren't much better at it than a decent science journalist. So when journalists simply follow what the medical establishment is saying, they can fail to serve their readers.

Your forthcoming book is about the quality of health care. Have you learned anything about the topic that really surprised you? And without giving away the punchline - unless you want to! - is there a core message the book will convey?

I'm happy to give away the punchline, because it speaks directly to the questions you've been asking. The book will be out this fall, and the title is Overtreated; Why Too Much Medicine is Making Americans Sicker and Poorer. As the title suggests, the book focuses on the $700 billion worth of unnecessary care that's delivered annually in the U.S. There are many forces behind all this overtreatment, but they aren't the usual suspects that are trotted out, like malpractice, and patient demand. Yes, malpractice worries cause doctors to deliver unnecessary care. And yes, Americans do demand a great deal of treatment and drugs they don’t necessarily need. But there are two far more powerful effects at work. One is the over-supply of medical resources--beds, specialists, catheterization labs. Two, uncertainty and lack of evidence, the topic we're discussing here. Because so much of medicine has so little science to support it, much of what doctors do is based on supposition, on where they trained, what they believe, and how they're compensated for what they do.

Our health care system is also over capitalized. We have too many specialists in certain locations, too many hospital beds, too many devices like CT scanners. This overcapacity helps drive excess care, in part because medicine is so fragmented.

I just read in the Washington Post that each of the declared Democratic presidential candidates is in favor of universal health care, and the buzz around the topic is obviously huge. Senator Clinton has also sponsored legislation on health care quality and patient safety, but is anyone in Washington really thinking strategically about universal coverage and quality at the same time? Do you think universal health coverage - say, along the lines of Canada's system - will result in improvements in quality, or could it multiply the effects of a broken system with regard to delivery of high-quality care, or neither or both? (I hope this doesn't sound like a leading question; I'm honestly curious and am asking as many people as I can.)

I think Senator Clinton understands the need for improving quality and bringing down costs in conjunction with universal access, but it’s a lot easier politically to talk about covering everybody than it is to talk about how to rein in runaway costs and poor quality due to unnecessary care. Americans' perception of their health care is at odds with the idea that they are getting too much of the wrong kind of medicine (and too little of what could really improve their health). We try to get an appointment and we have to wait months. Once we get to the doctor's office, we cool our heels in the waiting room, and then we get all of seven minutes with the doctor before she rushes off to the next patient. We want the drugs we see advertised on television, and our doctor says we can't have them. The doctor recommends a surgery and the insurer turns it down. It's very hard for many Americans to wrap their minds around the idea that a lot of the care we're getting is not only unnecessary, but also harmful.

Medicare for everybody is not the solution. Universal coverage on its own will not solve our quality and cost problems; in fact, it will make them worse. Costs obviously won't go down when you cover more people. Extending coverage to everyone will simply provide hospitals and physicians with more paying patients to whom they can deliver more poor quality, expensive care.

Don't get me wrong. I'm all for universal coverage. It's a crime that we spend $2.1 trillion and can't seem to cover everyone. A little boy just died in Washington, DC, of a brain infection that developed from an abscessed tooth, all because his mother didn't have Medicaid or the $80 to pay for getting his tooth extracted. And it isn't just the poor who are going bare. I know a highly educated professional couple in their fifties who have been turned down by insurers on the individual market. They make enough to buy a nice house, but they've made the decision not to buy health insurance.

But the idea that covering everybody will magically solve our quality and cost problems is pure fantasy. Unfortunately, very few policy makers and lawmakers have grasped the enormity of overtreatment, and until they do, we won't be able to move forward on a coherent plan for improving quality and bringing down costs.

Because my readers would be shocked if I didn't ask you, what are your thoughts on rising health care costs? How do costs fit in with quality, who's responsible, and what can we do about it? OK, I know this is another book in itself, so is there anything in particular that stood out in your research regarding costs?

We have all sorts of misconceptions about what drives costs in health care. The silliest reason I've heard recently for our spiraling costs is illegal immigrants who get free care. Give me a break. We also imagine that malpractice is the problem, but malpractice amounts to about $20 billion a year, a mere 1 percent of the total. We think the problem is high priced drugs, and while it’s true, Americans do pay the highest prices in the world for pharmaceuticals, drugs amount to 11 percent of total costs. It's also important to remember that many of those drugs help us live longer, more comfortable lives. Then there's bureaucratic overhead. About 30 percent of our total costs go toward paper pushing. The Canadian system, by contrast, spends about 16 percent on overhead. Obviously we could cut down on overhead, but we can't eliminate it. Some economists blame the fact that American doctors make more money than their peers in Canada and Europe, particularly such specialties as interventional cardiology and orthopedics. Physician fees account for a quarter of the total costs. But we certainly can't eliminate doctors.

The one thing we can get rid of that adds absolutely nothing to our health is overtreatment. Finding ways to cut out $700 billion of unnecessary care would simultaneously improve the quality of care and cut costs.

But think, for a moment, about what cutting out $700 billion worth of care really means. For one thing, it means less money for doctors and hospitals, which often profit handsomely from unneeded procedures. Interventional cardiology and cardiothoracic surgery are two of the most profitable departments of any medical center. For some hospitals, interventional cardiology is the sole source of profit. If we could wave a magic wand and get rid of all of the several hundred thousand unnecessary cardiac interventions that are performed each year, it would be good for patients and it would save a lot of money. But think of all the downstream effects it would have. Some hospitals could go bankrupt. Device makers will lose sales. There will be fewer jobs for hospital workers because fewer patients will be hospitalized. Interventional cardiologists will see their incomes drop precipitously. The winners here, if we start treating heart disease patients medically? Patients, of course, payers (which is to say, you and me), and the drug industry.

Here's another example. French researchers recently released results from a study showing that a device called a vena cava filter does nothing to reduce mortality in patients who are already on a blood thinner. (Vena cava filters are meant to prevent blood clots from reaching the lungs and causing a pulmonary embolism.) If doctors stopped putting in unnecessary vena cava filters, we'd all save money, and patients wouldn't be subjected to unnecessary, invasive surgeries. But device makers would lose sales, and surgeons' incomes would drop.

You can see pretty quickly that improving quality and bringing down costs is not going to be painless. But we have to do it. There are some economists who are now claiming that we can afford to see health care eat up 20 percent of GDP. They argue that there's nothing wrong with that because health care provides jobs and profits as well as health. But this view fails to take into account the stunning inefficiency of our health care system. There's a huge opportunity cost to wasting a third of our health care dollars on care that not only does us no good, but also can cause harm. Elliott Fisher of Dartmouth estimates that 30,000 Americans die each year from unnecessary care. That's almost as many deaths as are caused by breast cancer.

Quality report cards

2007-04-20T08:54:00.000-04:00

Steve Pearlstein, business columnist for the Washington Post, writes today about hospital quality report cards. He discusses at length some of the pros and cons of HealthGrades, which compiles risk-adjusted data on health outcomes. Unfortunately, HealthGrades reports are based on coded administrative data, which have been shown to correlate poorly with actual quality of care received.

Pearlstein largely dismisses the process measures reported at HospitalCompare.gov in favor of outcomes measures. Process measures describe processes of care that are linked closely to outcomes, and those on the HospitalCompare site have been carefully vetted and validated to ensure that they represent quality of care. Outcome measures (such as hospital infection rates), while potentially of greater interest to consumers, require substantial standardization and risk adjustment in order to provide data that comparable between hospitals. And despite Paul Levy's assertions, patients want to be able to compare hospitals directly, not just track a given hospital's progress over time. State governments are moving toward mandatory reporting of hospital infection data; those already reporting such data are Missouri and Pennsylvania, and Missouri's data are the only ones thus far to be risk-adjusted (and thus comparable).

More reliable measures of quality than HealthGrades' can be found, for free, at http://QualityCheck.org, which is produced by the Joint Commission, the organization that accredits medical facilities. These measures are exhaustively tested and vetted, like the HospitalCompare measures (with which they overlap).

More on mental health and gun laws

2007-04-19T07:32:00.000-04:00

In today's New York Times, thoughts from two sides of the issue:

“A guy like that probably shouldn’t have been able to buy a gun,” said Mike McHugh, president of the Virginia Gun Owners Coalition. “But my point is, that’s not going to stop a guy like this.”

Gun control advocates conceded that an array of issues would complicate efforts to tighten such laws, including privacy concerns and difficulties in determining whether someone is mentally unstable.

“If you cataloged every American who has been depressed, you’d probably have a majority of the population,” said Ladd Everitt, a spokesman for the Coalition to Stop Gun Violence.

But Mr. Everitt added: “I think it’s something that should be looked at. That’s as far as I would go. I think it’s a debate we should have.”

I would add that the doc who evaluated Cho at the institution did not judge him to be a danger to himself or others, so they had to let him go. What's up with these evaluations anyway? What can you do if the person doesn't answer truthfully?

And I imagine that the evaluation took place out of the context of the rest of Cho's life. Did the evaluator even know about all the violent stuff he'd been writing, the video games, etc.? That gets back to the privacy issues alluded to above.

Obviously these are issues I don't know a lot about. As I find out more, I'll share, and as always, discussion is welcome.

VA Tech, April 16, 2007

2007-04-18T11:23:00.000-04:00

I can't stay away from all the news about the massacre. Now it turns out that the shooter, Cho Seung Hui, was questioned by campus police about harrassing women students and had even admitted to a mental health facility for evaluation. It's not clear whether he accepted a plea, from a professor who reached out to tutor him one-on-one in writing poetry, to seek counseling. Apparently university officials felt there was nothing they could do legally to prevent Cho from being on campus because he hadn't made direct threats. Would restraining orders even have worked with someone so troubled? Would intensive therapy have helped? There's no way to know.

What I do know is that it was remarkably easy, in the state of Virginia, for Cho to buy the weapons he used in the shooting, because he passed a criminal background check: I think this means he hadn't been convicted of a felony, an awfully high bar.

What's wrong with health research in the US

2007-04-17T15:56:00.000-04:00

I liked Nick Jacobs' post this morning at the World Health Care Blog, in which he questions the academic research model as a target for addressing big health problems such as cancer. A little heavy on the innuendo, perhaps, but great food for thought.

Orac takes on TV docs

2007-04-12T11:55:00.000-04:00

My fellow blogger Orac at Respectful Insolence has a new post on examples of non-evidence in TV news that are likely to hold sway with viewers because they're proferred or at least tacitly endorsed by MDs, specifically Sanjay Gupta and Holly Phillips.

An antidote to bad TV medical news reporting is Dr. Maria Simbra, a colleague of mine at KDKA-TV in Pittsburg. She's a practicing neurologist, is on the board of the Association of Health Care Journalists (she also has an advanced degree in journalism), and is committed to promoting evidence-based journalism.

The problem of overdiagnosis

2007-04-10T10:20:00.000-04:00

Here's a great article in today's Washington Post about the dilemma of screening for cancer. It focuses on MRI screening for breast cancer, which I discussed last week.

Chit-chatting with corporate America on health care costs

2007-04-09T12:57:00.000-04:00

Today's New York Times has an article in which leaders of corporations that have been absorbing health care costs are interviewed. Overall, they view the current focus on employer-based coverage as unsustainable. On the other hand, they don't think the government should be responsible for coverage either.

But much of the coverage issue - at least as described here - is not about the costs per se, but where they should be shifted.

I was about ready to hurl my laptop again when, blessedly, the discussion finally moved after the jump to the costs themselves, with some anecdotes about the beneficial effects of employer-sponsored prevention programs on cost increases. As I've pointed out before, reducing the slope on an increase is not the same as eliminating the slope or making it negative (i.e., reducing costs); still, I'll allow that the single-digit increases cited for Pitney-Bowes are better than double-digit increases. (Is that the best they can do?)

Prevention is, of course, an important goal that benefits everyone, except for those who actually - yes, let's admit it - profit from illness, and from overuse of interventions. And there's precious little willingness to look at the profit variable in the cost equation.

World Health Care blog

2007-04-03T18:55:00.000-04:00

See the square banner ad to the lower right? I've been invited to contribute to the World Health Care blog, which brings in a number of health care bloggers to cover two international conferences of the World Health Congress. My first post is here. Please come by and join in the discussion!

Coverage: MRI screening recommendations for breast cancer

2007-03-28T22:36:00.000-04:00

The New England Journal had an editorial today by Robert Smith, Director of Screening for the American Cancer Society, in which he presented the recommendation that women deemed to be at high risk of breast cancer should be screened by magnetic resonance imaging (MRI) directed at the breast. MRI is 10 times more sensitive than mammography - in other words, it picks up a lot more small tumors - but it's also less specific - i.e., there are more false positives. Furthermore, MRI screening is expensive, on the order of 10 times the cost of mammography, so the ACS is not recommending it for all women.

What's still missing is long-term, randomized studies that show a mortality benefit from MRI screening for women at high risk - or, indeed, any risk - of breast cancer.

I chose a convenience sample of articles on this topic in the three newspaper health sections I look at regularly, the Boston Globe, Washington Post, and New York Times. Each of the articles did a good job of presenting the pros and cons. The Times focused, in particular, on the cost issue. The writers' choice of quotes from experts added interesting nuance to the arguments. To wit, from the Times:

“Just to figure out who should have it will be the hardest thing,” Dr. Morris said. “A lot of that onus is put on the referring physician. A lot of women are going to think they’re high risk, and they’re not.”

The Post article got an unfortunate headline: "Annual Breast MRIs Urged For Women at Cancer Risk." I think you can safely say that most women are at some risk of breast cancer; the high-risk part really is crucial here. But it's probably not the writer's fault. Here's my favorite quote from the Post:

"You can find a lot of cancer, but that's not the same thing as helping people live longer or better," said Russell Harris of the University of North Carolina. "It's unclear how many women really will be helped and how many will be hurt by over-diagnosis and overtreatment."

Finally, the Globe gave the last word to a breast screening advocate:

Dr. Daniel Kopans, a radiologist at Massachusetts General Hospital, said studies of MRI's usefulness in the broader population are urgently needed.

"The real question . . . is whether we should be screening all women with MRI," said Kopans, noting that nobody knows how many of the 40,910 breast cancer deaths expected this year in the United States could be prevented with MRI. "What if MR screening could knock it down by 90 percent? Is that worth $800 apiece to do MR screening for everyone? These are very important questions, and somebody is going to have to bite the bullet and do a very large, expensive study" to find out.

Is that the real question? At least he's recommending a study, rather than recommending that we just screen everyone now... And 90%? Is that an evidence-based guess? Would any of my very smart friends out there like to take on Dr. Kopans' fondest hope?

Patient safety with Paul Levy

2007-03-26T23:01:00.000-04:00

Passing on another post at Running a Hospital, this time on forbidden abbreviations for writing prescriptions and making entries on charts.

I don't know how many of my readers are also keeping up independently with Paul's blog, so if it's unnecessary for me to keep linking to him, let me know.

But I have an ulterior motive here, which is that he'll let me interview him one of these days if I stay on his radar screen and provide him with a few extra hits. What do you say, Paul? Have I annoyed you enough yet?

Evidence against overtreatment of heart attacks

2007-03-26T16:10:00.000-04:00

The Washington Post reports today on a new randomized trial showing that medication is as good as angioplasty with stenting in treating patients who are stable after a heart attack. Angioplasty is one of those expensive procedures that shows wide regional variation in use, begging questions about whether it's better to do a lot, or fewer. Now we have a better idea. I hope, though, that the study authors follow up and publish their findings in a peer-reviewed journal, so that everyone can have their own look at the data.

Not doing angioplasty could save a lot of money. So I wonder: is Medicare listening?

Elizabeth Edwards' breast cancer: Orac responds to the media

2007-03-23T11:03:00.000-04:00

Orac, over at Respectful Insolence, is an oncologist and has provided extensive, helpful comments to help put the news on Elizabeth Edwards' breast cancer metastasis into context.

The Joint Commission

2007-03-18T09:25:00.000-04:00

Over at Paul Levy's blog, Running a Hospital, an enlightening, frank discussion of the accrediting organization's role in patient safety and quality improvement. It includes an excerpt from a Boston Globe article that consists of a memo from the CEO of another hospital, Mass. General, to that hospital's staff in response to recent Joint Commission findings, and another of the commenters notes how, even though these proposed "duh" solutions seem so obvious, they're actually quite difficult to implement, and often require culture change.

I agree, and this isn't just nihilism or whining. For example, just because everyone supposedly knows that they're supposed to wash their hands between each patient encounter, it's not going to happen immediately, and the hospital has to play an active role in making it easier for staff to remember and providing more convenient, usable handwashing facilities.

It's not just me.

2007-03-16T15:36:00.000-04:00

According to a Wall Street Journal survey, I'm not the only one who:

- has thrown prescriptions in the trash (27%)
- has thrown lab slips in the trash (13%)
- thinks doctors offer interventions (a) out of fear of litigation (52%), (b) to make more money (45%), or (c) to meet patient demands (44%)
- has switched doctors because they consider their doctor's recommendations overly aggressive (7%) (but what do I know?).

It's good to see the flip side to the conventional wisdom that patients demand x, y, and z from their docs, and will switch docs when they don't get what they ask for.

But what does all this say about communication between patients and caregivers? Maybe a Meyers-Briggs-type instrument is what we need, so that we can match patients and doctors by their aggressiveness-of-care/CYA personalities and beliefs.

Primary care news resource

2007-03-15T09:29:00.000-04:00

Here's a website I found that covers research and other news in the primary care arena. It's in Australia. It's a little hard to read - the font is a little small and fuzzy on my screen - but it seems up-to-date and comprehensive. Anyone know of a similar resource in the U.S.? And why is it that the British Commonwealth always seems to be a few steps ahead of us on this stuff? Heck, they even cover the NIH.

Screening for lung cancer

2007-03-12T10:40:00.000-04:00

I'll probably follow up with some of the news coverage on this story, but fellow blogger Medpundit has written a very useful summary of the new study last week showing that there is overdiagnosis in lung cancer screening.

Teamwork in health care - evidence-based?

2007-03-08T18:31:00.000-05:00

Does teamwork in health care improve health outcomes? Nobody really knows.

Here's a 13-minute video by health journalist Ray Moynihan, who's a stickler for evidence, and filmmaker Miranda Burne. Moynihan is Australian and works a lot in the British Commonwealth, where evidence-based medicine is taken pretty seriously (see groups such as NICE and Cochrane). This film was funded by the Canadian Health Services Research Foundation, a policy group (though that's an oversimplification) that works with provider and government organizations to try and increase the uptake of research evidence into practice.

The film focuses on a program to integrate care for stroke victims. It raises some good questions: do you really need evidence when it's so obvious that an approach like team care is a good idea? My answer would be yes, if it's something that requires a lot of resources to bring about, and could have other hidden downsides. How do you get that evidence? Do you need a randomized trial? My answer: That's the best way, and you needn't rule out an RCT just because you are in a "complicated" setting with a lot of variability. Randomization takes care of a lot of that. Finally, shouldn't providers always work together as a team, just as a part of good practice, and what does "good practice" mean anyway? I'll leave that one open, but after reading some anecdotes recently about lack of coordination in hospital care, where patient charts became a sort of wastebasket for notes and lab slips that no one bothered to consult, I'd hazard that, yeah, some level of coordination probably makes sense.

What I would have liked to see more of in this film is an idea of what was meant by teamwork - is it just a series of case meetings like the one shown? How many such meetings were there? What sort of follow-up was there clinically? What does it actually mean to accumulate evidence on teamwork, and what outcomes would you look at?

Overall, though, the video is worth your 13 minutes, and provides food for thought.

Meet Don Berwick

2007-02-20T20:42:00.000-05:00

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

2007-02-20T10:58:00.000-05:00

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

2007-02-20T09:47:00.000-05:00

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

2007-02-14T14:59:00.000-05:00

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.