The Antidote: Counterspin for Health Care and Health News

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