The Health Care Blog – Page 371 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

The Patient-Centered Doctor

Apr 4, 2016• 10

By ROB LAMBERTS, MD

flying cadeucii I was talking with a few friends not long ago. Our conversation somehow got to the issue of authority, and what exactly respect for authority looks like. One of them, trying to make a point, turned to me and asked: “So you surely deal with people who don’t listen to what you have to say. What do you do when your patients don’t take the medications you prescribe?”

I totally wrecked his point, which made me glad because I didn’t agree with it anyhow.

Since I am in the midst of a series of posts on patient-centeredness in healthcare, I need to take a quick (1,200’ish word) detour to an important related question: what happens when the patient doesn’t cooperate? What does patient-centered care look like with non-compliant patients?

If you look up the word “compliance” in a thesaurus, the first synonym (at least in my thesaurus) is “obedience to.” This implies that non-compliant patients are, at least to some degree, equivalent to disobedient patients. This is borne out by the reaction many patients seem to expect of me when they “confess” they haven’t taken prescribed medications: they look guilty — like they are expecting to be scolded. I guess scolding is what they’ve had in the past. Certainly hearing my colleagues complain about “those non-compliant patients,” I am not shocked that they scold their patients. It’s as if the patient is not taking their medication with the express intent of irritating their doctor.

But this is a very doctor-centered view of things, not patient-centered. It assumes the doctor is the one who should be in control, and the patient’s job is to “obey” what they’ve been told. It is a “prescriptive” type of healthcare, telling people what they should do. Doctors, after all, give “orders” for things, and the Rx on our prescriptions translates to “take thou.” We are the captains of the HMS healthcare, aren’t we?

God and Statins

Apr 3, 2016• 10

By SAURABH JHA, MD

flying cadeucii Of life’s two certainties, death and cataracts, it seems statins defer one and prompt the other, although not necessarily in the same person. If you blindly love life you may be blinded by your love for life.

In the HOPE-3 trial, ethnically diverse people without cardiovascular disease were randomized to 10 mg of rosuvastatin daily and placebo. The treatment group had fewer primary events – death from myocardial infarction (MI), non-fatal myocardial infarctions, and non-fatal stroke. For roughly ten MIs averted there were seven excess cataracts. Peter may be blinded without being saved. Paul may be saved without being blinded. And then there is Rajeev who may be blinded and saved. But the very nature of primary prevention is that you don’t know you’re Peter, Paul or Rajeev. So everyone is grateful to statins. Not even God of the Old Testament had such unconditional deference.

Once you’re taking statins there is no way to disprove that any and every breath you draw is because of statins. Statins enjoy the metaphysical carapace, the immunity from falsification, which not even God enjoys. At least you can experiment with God. Don’t pray for a week and see if you’re still alive- you know if God really cares about prayer-adherence. Even if you die at age 55 on statins, you can never disprove that you wouldn’t have died sooner if you weren’t taking statins.

Research Bites Dog

Apr 3, 2016• 8

By JOSEPH KVEDAR, MD

Screen Shot 2016-04-03 at 10.42.56 AM We live in a headline/hyperlinked world. A couple of years back, I learned through happenstance that my most popular blog posts all had catchy titles. I’m pretty confident that people who read this blog do more than scan the titles, but there is so much information coming at us these days, it’s often difficult to get much beyond the headline. Another phenomenon of information overload is that we naturally apply heuristics or short cuts in our thinking to avoid dealing with a high degree of complexity. Let’s face it: it’s work to think!

In this context, I thought it would be worth talking about two recent headlines that seem to be set backs for the inexorable forward march of connected health. These come in the form of peer reviewed studies, so our instinct is to pay close attention.

In fact, one comes from an undisputed leader in the field, Dr. Eric Topol. His group recently published a paper where they examined the utility of a series of medical/health tracking devices as tools for health improvement in a cohort of folks with chronic illness. In our parlance, they put a feedback loop into these patients’ lives. It’s hard to say for sure from the study description, but it sounds like the intervention was mostly about giving patients insights from their own data. I don’t see much in the paper about coaching, motivation, etc.

If it is true that the interactivity/coaching/motivation component was light, that may explain the lackluster results. We find that the feedback loops alone are relatively weak motivators. It is also possible that, because the sample included a mix of chronic illnesses, it would be harder to see a positive effect. One principle of clinical trial design is to try to minimize all variables between the comparison groups, except the intervention. Having a group with varying diseases makes it harder to say for sure that any effects (or lack of effects) were due to the intervention itself.

Dr. Topol is an experienced researcher and academician. When they designed the study, I am confident they had the right intentions in mind. My guess is they felt like they were studying the effect of mobile health and wearable technology on health (more on that at the end of the post). But you can see that, in retrospect, the likelihood of teasing out a positive effect was relatively low.

Telemedicine: Competition and Coopitition

Apr 3, 2016

By ALAN PITT, MD

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In 1985 I had the good fortune to study in Sweden. I made many good friends and loved the natural beauty. I also learned a lot about healthcare in what is essentially a socialist country.

Sweden was (and is) by no means perfect. Progressive taxation had disincentivized hard work leading to something of a brain drain. Many of the physicians I met were looking to emigrate. On the flip side, Swedish healthcare was accessible and high quality. The government viewed healthcare as a responsibility and right rather than an option. The relatively small and homogeneous population (8 million in 1985) allowed central planning. On the campus of the Karolinska Institute, their version of the NIH, there were regional specialty hospitals: a hospital for the heart, the G.I. tract, the nervous system, etc.

This contrasts with American healthcare where hospitals offer specialty services on nearly every corner. Here in Phoenix, a patient with cancer can choose from Banner / MD Anderson, Mayo Clinic, Dignity Health / UA Cancer Center, and Cancer Treatment Centers of America, along with several other institutes. How did such choice come about? As a nation, we hold certain truths to be self-evident. Near the top of the list, we believe competition is a good thing. In just about every business open markets lead to higher quality goods and services and ever decreasing prices. Right? So how come on almost every measure Swedish healthcare trumps the American system? Sweden spends half as much per capita

[JL1] but on average its citizens live four years longer.

The Thing About the IoT

Apr 2, 2016

By BROOKINGS INSTITUTION

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In the coming years, the number of devices around the world connected to the Internet of Things (IoT) will grow rapidly. Sensors located in buildings, vehicles, appliances, and clothing will create enormous quantities of data for consumers, corporations, and governments to analyze. Maximizing the benefits of IoT will require thoughtful policies. Given that IoT policy cuts across many disciplines and levels of government, who should coordinate the development of new IoT platforms? How will we secure billions of connected devices from cyberattacks? Who will have access to the data created by these devices? Below, Brookings scholars contribute their individual perspectives on the policy challenges and opportunities associated with the Internet of Things.

The Internet of Things will be Everywhere

Humans are lovable creatures, but prone to inefficiency, ineffectiveness, and distraction. They like to do other things when they are driving such as listening to music, talking on the phone, texting, or checking email. Judging from the frequency of accidents though, many individuals believe they are more effective at multi-tasking than is actually the case.

The reality of these all too human traits is encouraging a movement from communication between computers to communication between machines. Driverless cars soon will appear on the highways in large numbers, and not just as a demonstration project. Remote monitoring devices will transmit vital signs to health providers, who then can let people know if their blood pressure has spiked or heart rhythm has shifted in a dangerous direction. Sensors in appliances will let individuals know when they are running low on milk, bread, or cereal. Thermostats will adjust their energy settings to the times when people actually are in the house, thereby saving substantial amounts of money while also protecting natural resources.

With the coming rise of a 5G network, the Internet of Things will unleash high-speed devices and a fully connected society. Advanced digital devices will enable a wide range of new applications from energy and transportation to home security and healthcare. They will help humans manage the annoyances of daily lives such as traffic jams, not being able to find parking places, or keeping track of physical fitness. The widespread adoption of smart appliances, smart energy grids, resource management tools, and health sensors will improve how people connect with one another and their electronic devices. But they also will raise serious security, privacy, and policy issues.

Unicornius Gorus: There’s More to the Theranos and Zenefits Story

Apr 1, 2016• 1

By FRED GOLDSTEIN

flying cadeucii A Correction to Unicornius Gorus – Theranos and Zenefits

I have a confession to make, my previous piece entitled Unicornius Gorus –Theranos and Zenefits, which identified these two companies as a new species in the Unicornius genus was not correct.

The problems at Theranos, as reported by John Carreyrou at the Wall Street Journal, just keep getting worse. While its now very clear Theranos has a serious problem with their Edison technology and its ability to produce accurate results, what is perhaps even more glaring is their complete disregard for operating a lab within standards.

Along with the measurement errors, the report by the Center for Medicare and Medicaid Services found Theranos:

used unqualified staff,

allowed unlicensed workers to review patient test results

did not properly operate equipment as per manufacturer recommendations,

lacked proper documentation and signatures and

failed to meet quality control standards.

Repealed or Repaired?

Mar 31, 2016• 17

By PAUL KECKLEY

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Last Wednesday marked the sixth anniversary of the passage of the Patient Protection and Affordable Care Act. As of this week, the five Presidential aspirants have each articulated key changes they’d propose, though polls show interest in the law is largely among Democrats who consider healthcare a major issue along with national security and the economy.

GOP candidates Trump, Cruz and Kasich say they will repeal the law; Democratic frontrunner Clinton says she will repair it, and her challenger, Bernie Sanders, promises to replace it with universal coverage. Some speculate that candidate Clinton’s plan will ultimately mirror her Health Security Act of 1993 that parallels the Affordable Care Act in many respects. But the law gets scant attention on the campaign trails other than their intent about its destiny if elected.

I have read the ACA at least 30 times, each time musing over its complexity, intended results, unintended consequences and hanging chads. At the risk of over-simplification, the law purposed to achieve two aims: to increase access to insurance for those unable to qualify or afford coverage, and to bend the cost curve downward from its 30 year climb. It passed both houses of Congress in the midst of our nation’s second deepest downturn since the Great Depression. Unemployment was above 10%, the GDP was flat, and companies were cutting costs and offshoring to adapt.

The “Patient Protection and Affordable Care Act” soon after became known as the “Affordable Care Act”, and then, in the 2010 Congressional Campaign season that followed its passage, “Obamacare”. It was then and now a divisive law: Kaiser tracking polls show the nation has been evenly divided for and against: those opposed see it as “the government takeover of healthcare” that will dismantle an arguably expensive system that works for most, while those supportive see it as a necessary to securing insurance coverage for those lacking.

The Case for Case-Based Reasoning

Mar 30, 2016• 1

By FRANK MEISSNER, MD

flying cadeucii Case-based reasoning has been formalized for purposes of computer reasoning as a four-step process^[1]:

Retrieve: Given a target problem, retrieve cases from memory that are relevant to solving it. A case consists of a problem, its solution, and, typically, annotations about how the solution was derived.

Reuse: Map the solution from the previous case to the target problem. This may involve adapting the solution as needed to fit the new situation.

Revise: Having mapped the previous solution to the target situation, test the new solution in the real world (or a simulation) and, if necessary, revise.

Retain: After the solution has been successfully adapted to the target problem, store the resulting experience as a new case in memory.

The complexities associated with programming and implementation of a knowledge management system based on case histories is both non-obvious and difficult, but ironically this is the actual process that an expert physician uses in his day to day clinical work.

Torture the Data Until it Confesses

Mar 29, 2016• 9

By TOM EMERICK

flying cadeucii Did you ever hear the old joke where the boss says floggings will continue until morale improves? Torturing the data until results improve…or the data confesses…is not uncommon. Which is a pity.

In my career I’ve worked with companies with over 100k covered lives the claim costs of which could swing widely, from year to year, all because of a few extra transplants, big neonatal ICU cases, ventricular assist cases, etc.

Here are just a few of the huge single case claims I’ve observed in recent years:

$3.5M cancer case
$6M neonatal intensive care
$8M hemophilia case
$1.4M organ transplant
$1M ventricular assist device

This is not a complaint. After all this is what health insurance should be about, huge unbudgetable health events.

All plans have one organ transplant every 10k life years or so, most of which will cost about $1M over 6 years. A plan with 1k covered lives will have such an expense on the average of every 10 years. Of course the company may have none for 15 years and two in the 16th year. The same goes for $500k+ ventricular assist device surgeries.