As Washington remains deadlocked on the implementation of the Affordable Care Act, the US government’s shutdown has resulted in the furlough of nearly 70% of the Centers for Disease Control‘s (CDC’s) workforce. CDC Director Tom Frieden recently shared his thoughts in a tweet. We agree whole-heartedly. Although it’s all too easy to take the CDC staff for granted, they are the frontline sentinels (and the gold standard) for monitoring disease outbreaks. Their ramp-down could have serious public health consequences.
We are particularly concerned about the apparent temporary discontinuation of the CDC’s flu surveillance program, which normally provides weekly reports on flu activity. Although flu season typically begins in late fall, outbreaks have occurred earlier in previous years. In 2009, flu cases started accumulating in late summer/early fall. And given the potential for unique variants, such as the swine or avian flu, every season is unpredictable, making the need for regular CDC flu reports essential. We therefore hope to see the CDC restored to full capacity as soon as possible.
In the meantime, we would like to help by sharing data we have on communicable diseases, starting with the flu.
Because the athenahealth database is built on a single-instance, cloud-based architecture, we have the ability to report data in real time. As we have described in earlier posts, the physicians we serve are dispersed around the country with good statistical representation across practice types and sizes.
To get a read on influenza vaccination rates so far this season, we looked at more than two million patients who visited a primary care provider between August 1 and September 28, 2013 (Figure 1). We did not include data on vaccinations provided at retail clinics, schools or workplaces.
This year’s rates are trending in parallel to rates over the last four years, and slightly below those of the 2012-2013 season. However, immunizations accelerate when the CDC, and consequently the media, announce disease outbreaks and mount public awareness campaigns.
The Navy Yard shooting in Washington, D.C. has once again confronted us with the issues of guns and mental illness, but what we really should address is the inadequacy of mental health care in the United States. Since 2009 there have been 21 mass shootings and the perpetrators in over half of these were suffering from or suspected to have a serious mental illness like schizophrenia, bipolar disorder and depression. (The other killers with no signs of mental illness were ideological zealots, disgruntled employees and disaffected loners.)
After each incident there is a great hue and cry, and calls for action but no substantive action is taken. Our reflexive approach has repeatedly failed to provide care in a timely fashion to individuals in need. As a country, we continue to ignore the growing public health need for greater access and a more proactive approach to mental health care. It is time that we say enough is enough and do something to prevent future tragedies.
When you strip away the hype and politics, the causal factors in these horrific incidents are clear and solvable. Yet we’ve lacked the social and political will to fashion and apply the solution.
The plain truth of the matter is that we do not provide adequate services to the 26% of the U.S. population with mental illness. The scope of and access to mental health services available to most people are limited and fragmented. Moreover, insurance coverage is all too often lacking and discriminatory. Consequently, we do not provide the level and quality of care of which physicians and health care providers are capable. It is the equivalent of knowing that a woman has breast cancer but not offering the indicated treatment options of surgery, radiation and chemotherapy. The result is that many people go untreated or inadequately treated.
How do you tell the family members of a critically ill patient that their loved one is going to die because there are no antibiotics left to treat the patient’s infection? In the 21st century, doctors are not supposed to have to say things like this to patients or their families.
Ever since the discovery of penicillin in 1940, patients have expected a pill or an intravenous injection to cure their infections. But our hubris as a society with respect to antibiotics has been exposed by the rise of antibiotic-resistant “superbugs.”
The Centers for Disease Control and Prevention (CDC) recently issued a new study, entitled “Antibiotic resistance threats in the United States, 2013,” reporting that at least 2 million people become infected with bacteria that are highly resistant to antibiotics and at least 23,000 people die each year as a direct result of these infections. These estimates are highly conservative. Many more people die from other conditions that were complicated by an antibiotic-resistant infection.
Meantime, we have ever-decreasing new weapons to wage the war against such infections because the availability of new antibiotics is down by more than 90% since 1983.
Interventions are needed to encourage investment in new antibiotics, to prevent the infections in the first place, to slow the spread of resistance and to discover new ways to attack microbes without driving resistance.
A major reason for the “market failure” of antibiotics is that they are taken for short periods of time, so they have a lower return on investment than drugs that are taken for years (such as cholesterol-lowering drugs). The Food and Drug Administration can help reverse the market failure by adopting new regulatory approaches to encourage development of critically needed new antibiotics.
Porn stars all across San Fernando were told to put their clothes back on and go home a couple of weeks ago on the news that a 29 year-old adult actress named Cameron Bay tested positive for HIV.
Shortly thereafter, the Internet lit up. News, judgments, and jokes shot left and right in newsrooms as freely as bodily fluids fly on set. Countless reporters and pundits surely worked overtime to do the deep background: who were Ms. Bay’s co-actors, who did what to whom, and inquiring minds want to know: were condoms used? Imagine the frenzied speculation, all those sticky keystrokes.
Don’t get me wrong: the details of the whodunit have medical import. Public health workers need to find who is at risk. Those who are at risk need testing and education including reminders that early tests can be falsely negative and must be repeated. Since this isn’t the first case of HIV among the scantily clad actors of San Fernando, CA, Ms. Bay’s diagnosis demands we try again to get porn stars to practice safer sex. My guess is legal maneuvers will never do much to affect the sex lives of the nude and infamous, but if porn viewers could learn to have fun even with a condom on set there might be a hope.
Twitter captured all this and more. It showed the diversity of our reactions to Ms. Bay and people like her. Some tweets expressed a sense of inevitability:
Some were judgmental:
The American Psychiatric Association recently published a new version of the Diagnostic and Statistical Manual (DSM). The DSM-5 is what medical, mental health, and chemical dependency professionals use to diagnose developmental, mental health, substance abuse and dependence, learning, and personality “disorders.” Now in its 5th edition, the DSM was first published in 1952. At that time, the DSM was 129 pages containing 106 diagnoses.
Now, 61 years later, the DSM-5 consists of approximately 950 pages and roughly 375 diagnoses. The DSM-5, while researched far more than previous editions, is based on the medical model or the model of disease. Simply put, the medical model finds the causes of disease and illness and then prescribes a treatment to cure the disease or illness. This means a person has a pathology or pathogen that needs to be treated and cured.
The questions that eat at me during my day as a psychologist and at night as a person searching for answers are:
- Is it possible to accurately identify mental health “issues,” “illness,” or “disorders?” versus extreme ranges within the sphere of the human condition?
- Even if it is possible to identify these conditions, does it determine the course of “treatment” or “intervention?”
- If so, is there a “treatment” for every identified “condition?”
- Does it mean there is a treatment that works?
- Do you need a diagnosis to get help?
Over the years, many have been critical of this approach to mental “health” issues. Referring to mental “health” is actually a newer name as people have historically been thought to have mental “illness.” This makes more sense for people who are unfortunately compromised by severe conditions termed schizophrenia, bi-polar (manic-depressive), and severe depression and anxiety. But does this make sense for children, adolescents, and adults who are challenged with some other, and possibly less severe, aspect of their functioning and development? Do all human problems warrant a medical or mental health diagnosis? When did a weakness become a “disorder” that requires “intervention” and/or “treatment?”
To be fair, the DSM provided structure and guidelines for approaching the complicated business of determining who had a “problem” that required help. However, it seems things have gone too far. Critics of the DSM believe that this latest edition has taken the business of diagnosing to a new level, one where approximately 50% of the population can be diagnosed with something. Critics also believe that this pathology finding approach supports the continued trend of medication prescribing as the number one mode of treatment, and continued trend of increased health care costs and premiums with increased utilization of individuals who need a “diagnosis” to meet “medical necessity” to receive services. What does that mean? It means if you don’t have a diagnosis, you don’t get help. It means you have to have a problem (pathology) to get help (treatment and intervention).
Without going into detail about some of the changes in the newest edition of the DSM, some diagnostic categories have been added and some diagnosis “thresholds” have been lowered. This means that you need fewer symptoms to “meet diagnostic criteria.” Here are some examples of concerns with the new DSM-5:
- Temper tantrums will now be diagnosed as Disruptive Mood Dysregulation Disorder
- Normal forgetting will now be diagnosed as Minor Neurocognitive Disorder
- Gluttony will be diagnosed as Binge Eating Disorder
- Grief will be diagnosed as Major Depression
- First time substance users and college partiers will get a diagnosis of Substance Use Disorder
- Everyday Worry will be diagnosed as Generalized Anxiety DisorderContinue reading…
The dangers of texting while driving recently received renewed attention thanks to a public service video produced by German film director Werner Herzog. The National Highway Traffic Safety Administration estimates that driver distraction results in approximately 3,000 deaths per year, as well as an additional 400,000 injuries. Experts have estimated that the risk of a crash may increase by more than 20 times when texting, exceeding the risk associated with intoxication.
Texting while driving is just one example of a larger phenomenon of our age, often referred to as multitasking. The term was coined by IBM engineers in the 1960s to refer to the ability of a microprocessor to perform multiple tasks at once. Today the term is more often applied to human beings attempting to do more than one thing, such as simultaneously watching television and folding laundry, or answering emails while talking on the phone. Many health professionals pride themselves on their multitasking.
In fact, however, the term multitasking is a bit of a misnomer, even in the domain of computing. At least where one microprocessor is concerned, a computer does not so much multitask as it switches back and forth between tasks at such a high rate of speed that it appears to be doing multiple things at once. Only more recently, with the advent of multicore processing, has it become possible for computers genuinely to multitask.
The same thing applies to human beings. Health professionals and others who think they are multitasking are typically switching back and forth between different tasks over short periods of time. And in most cases, multitaskers are not able to perform any of the activities in which they are engaged as well as they could if they concentrated on them one at a time. It takes time and effort to re-focus on each task at hand, and this tends to degrade the effectiveness and efficiency of each.
To be sure, multitasking is not impossible. In one sense, simply remaining alive requires us to multitask all the time. Our hearts are continuously pumping, lungs exchanging gases, kidneys filtering the blood, immune system fighting infections, and all the while we are also digesting our last meal. Add to this the ceaseless multitasking of the brain, which is monitoring the environment and maintaining our posture while simultaneously walking and chewing gum, and the complexity multiples.
The hype over mobile health is deafening on most days and downright annoying on some. So it is with some reluctance that I admit that mobile has the potential to be a game-changer in health. I’ve professed enthusiasm before, but that was largely around the use of wireless sensors to measure physiologic signals and SMS text as a way to deliver messages to patients and consumers. For several years, the industry has been awash with smartphone apps (by a recent count more than 40,000). At the Center for Connected Health, we started looking at mobile health as far back as 2008 and could not justify the excitement around smart phones and apps at that time, mostly because our patient population did not demonstrate significant enough adoption of smartphones to justify development in this area.
I felt very unpopular at all of the major conferences. I talked about our success with text messaging as a tool for engaging pregnant teens in their prenatal care and helping patients battling addiction to stick with their care plan, while others were touting the virtues of their various apps.
It’s worth noting that our primary focus at the Center for Connected Health has been patients with chronic illness. As such, we are every bit as concerned about the 85 year old with congestive heart failure as we are about the young professional with hypertension. However, across the population of people with chronic disease, smartphone adoption has lagged. I felt like our strategy was vindicated when my friend Susannah Fox published research showing that folks with two or more chronic illnesses (independent of other variables such as age and socioeconomic status) use technology in the context of their health less than others.
The world of patient care appears to be catching up to the rest of mobile. Not that I would ever endorse the irrational exuberance shown for mobile health apps in general, but some recent data points that changed my thinking are worth noting.
A controversial study published earlier this year in the Journal of the American Medical Association shows that overweight people have significantly lower mortality risk than normal weight individuals, and slightly obese people have the same mortality risk as normal weight individuals.
This meta-analysis, headed by statistician Katherine Flegal, Ph.D., at the National Center for Health Statistics, looked at almost 100 studies that included 3 million people and over 270,000 deaths. They concluded that while overweight and slightly obese appears protective against early mortality, those with a body mass index (BMI) over 35 have a clear increase in risk of early death. The conclusions of this meta-analysis are consistent with other observations of lower mortality among overweight and moderately obese patients.
Many public health practitioners are concerned with the ways these findings are being presented to the public. Virginia Hughes in Nature explains “some public-health experts fear…that people could take that message as a general endorsement of weight gain.” Health practitioners are understandably in disagreement how best to translate these findings into policy, bringing up the utility of BMI in assessing risk in the first place.
Walter Willett, chair of the nutrition department at the Harvard School of Public Health, told National Public Radio that “this study is really a pile of rubbish, and no one should waste their time reading it.” He argues that weight and BMI remain only one measure of health risk, and that practitioners need to look at the individual’s habits and lifestyle taken as a whole.
The late Dr. C. Everett Koop was the most revered Surgeon General in history, perhaps even the most revered Cabinet member. His calling card—indeed, his claim to fame – was his integrity. A Reagan appointee, he acted as though he reported to no one other than the American people and his own conscience. His penchant for candor and scientific independence fueled the federal government’s groundbreaking steps to raise public awareness about HIV/AIDS at a time when the tendency was to demonize and diminish. He resisted incessant political pressure and refused to take positions or produce data that he knew to be false.
This drew strong support from both sides of the aisle, and even his detractors never questioned his honesty. (Exhibit A: The two authors of this posting, whose political views have little else in common other than respect for strong, independent-minded politicians.)
Dr. Koop’s legacy stands in sharp contrast to the eponymous award dispensed by The Health Project, whose committee members have turned their back on their founder. The last thing Dr. Koop would have expected is to see is *his* award bestowed upon people who know that they don’t deserve it. The 2012 award was given to three recipients for work done in Nebraska: a vendor that claims wellness programs don’t even have to exist to save money, an outfit that can’t even spell the name of its own founder, and a state employee benefits plan that is under investigation for sky-high administrative costs.
Among the extravagant statements that formed the basis for the award (like claiming more than $20,000 in savings for every person who reduced their risk factors for a year, even though per-person spending is only $6,000), they claimed to have made 514 “life-saving catches” on employees with otherwise undetected cancer. This data was obviously wrong to begin with — that cancer rate would have been at least 40 times greater than Love Canal’s. Nonetheless, it sure sounded good, and the Governor of Nebraska himself was all-in too, so an award was issued.
Recently, there was a bit of a dust-up over whether it was appropriate for the Secretary of Health and Human Services (HHS) to engage the National Football League (NFL) to help HHS with the process of drumming-up enrollment for health insurance exchanges. In the end, the NFL and other sports leagues decided they were not going to be involved fearing the appearance of taking political sides.
In our view HHS is better off with this outcome. To our way of thinking the exercise would not have delivered the desired results and would have left individuals confused and created a political distraction. At the heart of most public health communication plans are three main functions: create a message, deliver the message and get people to act on the message (many variations: example
, and example
). The HHS/NFL combo would likely have failed the test: What exactly does someone who catches a football for a living say that would make the uninsured purchase insurance on an exchange? While it’s easy to single out HHS and the administration, the opposition party also thinks messaging alone
will solve all of its ills but that is far from correct assumption in our view.
In terms of creating a message, our first instinct would be to recommend a governmental agency like the FCC but for healthcare. We would call it something like the clinical communications clarification committee (CCCC). However, given recent concerns about “Orwellian” government information gathering, perhaps a more open-source, crowd-sourced approach to communicating may be more readily accepted. What we have in mind is a something like Pubmed meets Wikipedia where the information is readily available, credible, and based on updated facts. Inevitably something like this would need to be proctored to keep unreliable information out. Many crowd-sourced communities do a good job of self-policing but it couldn’t hurt to have an adult watching just in case.
Assuming we can create information (the message) in a way that is understandable and credible, how to transmit this information (the medium) becomes the next challenge. While we are pretty sure the “wired generation” who wear body monitoring devices are getting the “right” information via mobile devices, the web etc., we think that more important populations that are not technologically savvy may be missing out. Dual-eligibles for example, who are major drivers of cost and poor outcomes in the system, are not in our view, easily able to access useful information via high-tech gadgetry.