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Above the Fold

The Difficult Science, Part II

Dec 28, 2010• 19

By KENT BOTTLES, MD

“Despite their great explanatory powers these laws [such as gravity] do not describe reality. Instead, fundamental laws describe highly idealized objects in models.”

— Nancy Cartwright, “Do the Laws of Physics State the Facts?”

In Part I the limitations of science in helping us make wise choices and decisions about our health were examined.

Because of an inherent difficulty in establishing causation, absolute certainty is unattainable even in science. Medical knowledge follows Karl Popper’s theory of science because the right answer, whether about what causes ulcers or if you should take hormone replacement therapy, keeps changing with the publication of new studies. And most depressingly of all, a respected expert on evidence-based medicine concludes, “The majority of published studies are likely to be wrong.”

Part I ended with some suggestions that seemed to imply that savvy patients should enroll in a graduate level statistics class and understand the subtleties of observational studies, meta analysis, and randomized controlled clinical trials. Being an informed health care consumer is evidently difficult indeed.

Part II explores how we all have to change if we are to live wisely in a time of rapid transformation of the American healthcare system that everyone agrees needs to decrease per-capita cost and increase quality.

PATIENTS

When I talk to physicians about pay for performance programs, I am always asked why should doctors be responsible for patient behavior that they cannot control. Even if we were able to have health care access for all and eliminate every error in medicine, we would only account for 10% of whether an individual stays healthy. Environment and genetics account for about 35%, but the remaining 55% of whether one stays well depends on behavior (exercise, smoking, diet) and social support systems (families, communities, places of worship).

Tweetcasting @2011 : Health Reform Implementation, Mobile Health and Patient Safety

Dec 27, 2010• 8

By DAVID E. WILLIAMS

My crystal ball is a little foggy so I decided to ask my Twitter followers (@HealthBizBlog) to help compile a list of health care predictions for 2011. I’ve integrated my thoughts with theirs and organized the predictions into four themes:

Transparency will change from buzzword to reality
Information technology progress will be uneven, with the biggest breakthroughs in mobile
A culture of patient safety will begin to take root
Health reform implementation will advance despite some ugly battles

Transparency will change from buzzword to reality.

The health care industry is tremendously opaque. Patients and doctors don’t know the price of medical services, while pharmaceutical and medical device makers maintain secret financial arrangements with physicians.

Much is likely to change for the better in 2011.

Giovanni Colella, CEO of health care transparency company Castlight Health (@CastlightHealth) predicts, “Consumers will increase their demands for personalized information about health care cost, quality and convenience and will turn to innovative applications to address these needs.”

Bright lights will be trained on the interaction between industry and physicians.

The Affordable Care Act requires pharmaceutical and device companies to report payments to physicians starting in 2013; voluntary reporting is likely to pick up next year. Beyond that, @PharmaGossip predicts, “PharmaWikiLeaks will become a force for good,” citing a recent leak about Pfizer in Nigeria as Exhibit A.

Geolocate This

Dec 27, 2010

By DAVID HARLOW

As health care providers continue to wonder whether and how they should add social media to their mix of communications tactics, new tools — and new uses for those tools — continue to sprout up.

I’m quoted in the current edition of American Medical News in a story that looks at the question of whether and how health care providers should use geolocation services (e.g., Foursquare, Gowalla) as additional channels through which they may communicate with patients, colleagues and referral sources — or through which they may encourage patients and others to communicate among themselves.

I’ve touched on this issue in recent presentations on health care social media, and have noted that even “checking in” on line at an STD clinic — an activity discounted by Mark Scrimshire in the article — is something that people will do for a badge — check out this fall’s MTV/Foursquare Get Yourself Tested campaign. (Taking it to the next level, targeted sharing of STD test results is the idea behind start-up Qpid.me.)

Health care providers can leverage the general public’s interest in using geolocation services in a variety of ways. In the the article, Chris Boyer notes that his health system works to ensure that check-in data (addresses and phone numbers drawn from other online services) for each service location is accurate, but doesn’t necessarily encourage check-ins.

There are no HIPAA issues raised by patients “checking in” on line, since it’s a voluntary act by the patient, and doesn’t really involve the provider. Providers might decide to encourage check-ins (but not repeat visits — we want to keep people healthy, right?) as a way to drive patients to links to targeted health information, or even, perhaps, coupons for coffee or something (as long as we don’t bump up agianst limits on financial incentives … though I think that would not be an issue under most circumstances.

Playing Tetris Cuts Flashbacks in PTSD

Dec 26, 2010• 2

By GLENN LAFFEL, MD

Flashbacks are vivid, recurring, intrusive and unwanted mental images of a past traumatic experience. They are a sine qua non of Post-Traumatic Stress Disorder (PTSD). Although drugs and cognitive/behavioral interventions are available to treat PTSD, clinicians would prefer to utilize some sort of early intervention to prevent flashbacks from developing in the first place.

Well, researchers at Oxford University appear to have found one. Remarkably all it takes is playing Tetris. Yes, Tetris!Continue reading…

The Difficult Science

Dec 25, 2010• 21

By KENT BOTTLES, MD

“The mind leans over backward to transform a mad world into a sensible one, and the process is so natural and easy we hardly notice that it is taking place.” Jeremy Campbell

On the same day in November, headlines from the Wall Street Journal and the New York Times reported on the same story about a federal panel’s recommendations on consumer intake of vitamin D.

“Triple That Vitamin D Intake, Panel Prescribes” read the WSJ story;

“Extra Vitamin D and Calcium Aren’t Necessary, Report Says” stated the New York Times. (http://ow.ly/3tJMe) Since I had recently started taking vitamin D daily, I was interested in what the experts in Washington, DC were recommending.

How should you decide what advice to follow about the relationship between your diet, lifestyle, medications, health, and wellness?

Is this just another example of how the media does a terrible job? Many of us resonate with the view of media watchdog Steven Brill who said, “When it comes to arrogance, power, and lack of accountability, journalists are probably the only people on the planet who make lawyers look good.” (http://ow.ly/3tKdM)

The media does play a role here and needs to improve, but it turns out that it is really complicated to figure out what the “truth” is about diet, exercise, medicines, and your individual well being. Everybody (journalists, government panel members, scientists, patients, physicians, and nurse practitioners) needs to change.

Hospitalist Co-Management Of Neurosurgery Patients

Dec 24, 2010• 3

By ROBERT WACHTER, MD

In this month’s Archives of Internal Medicine, my colleagues and I report the results of our early experience with hospitalist co-management of neurosurgery patients. We found stratospheric satisfaction among neurosurgeons and nurses, as well as impressive cost reductions ($1400/admission). At the same time, there was no impact on quality or safety, at least as judged by hard end-points such as mortality and readmission rates.

While these results might seem like a mixed bag, I believe that the overall impact of this service has been fantastic, for patients, surgeons, and our own hospitalists. Let me explain, beginning with a brief history of hospitalist co-management, folding in the history of our neurosurgery co-management effort (which we call the “Co-Management with Neurosurgery Service”, or CNS), and ending with some of the more subtle outcomes that lead me to feel that this is one of the most important things our hospitalist program has done since its inception in 1995.

A Brief History of Co-Management

When the hospitalist field took off in the mid-1990s, we projected that its growth would largely reflect the degree to which hospitalists assumed the care of inpatient internal medicine (and later, pediatrics) patients: those with pneumonia, heart failure, sepsis, GI bleed, and the like. Sure, I recognized that there would be increased opportunities for traditional medical consultation – we come when you call us – but I completely underestimated the siren call of co-management.

It turns out that once there are hospitalists in the house, the notion of having them actively co-manage surgical patients is hard to resist, for several reasons. First, many of the problems such patients experience before and after surgery are really medical, not surgical. Secondly, just as a hospitalist can provide on-site availability that the primary care physician can’t match for medical patients, he or she can do the same for surgical patients. (In this case, it’s not that the primary care doc is stuck in the office, but rather the surgeon is stuck in the OR.) Third, in an era of more widespread quality measurement and reporting, it seems likely that a hospitalist will improve quality measures such as DVT prophylaxis and evidence-based management of CHF more than a surgeon, flying solo, would be able to.

U.S. Health Care & U.S. Productivity: A Dissent

Dec 23, 2010• 39

By JOHN R. GRAHAM

One of the great myths about American society is that our lack of a “universal” health plan harms our competitiveness. The masters of this refrain, of course, are the American automakers. Years before driving themselves into bankruptcy and the unwelcoming arms of their new owners, the American taxpayers, they used to claim that they spent up to $1,600 per car on health care. This was more than they spent on steel, and a multiple of what they claimed their foreign competitors spent. In her well received book, Who Killed Health Care? America’s $2 Trillion Medical Problem – And the Consumer-Driven Cure (New York, NY: McGraw-Hill, 2007), Professor Regina Herzlinger of Harvard Business School claims that these complaints are inflated (pp. 104-105).

Furthermore, we don’t hear Mark Zuckerberg complaining that Facebook’s health care costs are preventing him from competing against foreign social-media businesses. Indeed, while all Americans complain about health costs, the argument that our health “system” reduces our competitiveness versus other countries with “universal” health care is actually quite weak. Indeed, the percentage of all firms offering health benefits actually increased from 66 percent in 1999 to 69 percent in 2010, and a greater number of smaller firms have begun to offer health benefits, according to the Kaiser Family Foundation.

One oft-cited metric is that the United States spends far more on health than other countries as a share of Gross Domestic Product (GDP). But this measurement can mislead. It is a ratio composed of a numerator and a denominator. The numerator – the real cost of medical care – has grown slightly slower in the U.S. than Europe. Advocates of government monopoly health care point out that Canadian and U.S. health spending as a share of GDP was about the same before the Canadian government took over health care, but diverged starting in 1970, soon after the government completed its takeover. They present this as evidence that the state can control costs better than the private sector. However, real GDP growth in Canada dramatically outpaced U.S. growth between 1969 and 1987, meaning that the denominator of the health spending per GDP ratio grew much faster in Canada, not that the numerator grew much slower, according to research by Professor Brian Ferguson.

Who Cares?

Dec 23, 2010• 3

By PETER KRUGER

The father of a wireless engineer, who made a good living designing mobile devices, contracted a rare and chronic form of athlete’s foot. Over the course of a few months, the father’s condition worsened and eventually he died. Vowing he would make sure that no-one suffered the way his father had during the last few weeks of his life, the engineer set about developing a wireless athlete’s foot detector.

After obtaining the backing of a venture capitalist, he licensed technology from a university spinout that specialised in bio-sensing and embedded it onto a wireless chipset, which he then packaged into a simple mobile device. The athlete’s foot monitor is now on the market and our wireless engineer is talking to a number of healthcare providers, including the NHS.

There are two important things about this story; first it is complete fiction – and second; anyone who has been involved in the wireless and mobile industry, will have come across real life examples of personal quests masquerading as business plans.

THCB Recommends …

Dec 23, 2010

New Law Lets the Feds Sponsor Prize Competitions

Dec 23, 2010• 2

By GLENN LAFFEL, MD, PhD

The repeal of Don’t Ask Don’t Tell and the ratification of a brand-new START treaty represent milestone achievements for the suddenly prolific lame duck Congress, and the press has covered these developments accordingly. But Congress passed another law amid this flurry of activity—the America COMPETES Act—and although the media didn’t cover this move nearly as vigorously, it is potentially quite significant and praiseworthy in its own right.

America COMPETES authorizes continued growth in the budgets of the Department of Energy’s Office of Science, the laboratories of the National Institute of Standards and Technology, and the National Science Foundation, 3 agencies focused on incubating and generating innovations designed to keep our country at the forefront of an increasingly competitive global economy.

Beyond this, in what many hope will become a bona fide turning point in the effort to leverage American ingenuity and innovation, America COMPETES empowers all federal agencies to sponsor prize competitions to spur innovation, solve particularly vexing problems in their domains, and advance their missions.

Prize competitions are proven to be an effective strategy for energizing our country’s innovators. The private sector and philanthropists use them increasingly. According to a study by McKinsey in fact, more than 60 prizes valued at $100,000 or more were introduced by such organizations between 2000-2007. Total prize money associated with these competitions approaches $250 million.