Posts tagged health

Why Health Care Costs So Much

Samuelson:

Read Chaos and Organization in Health Care by James Mongan and Thomas Lee, both doctors. Mongan is the recently retired head of Partners HealthCare System in Boston, and Lee is a senior manager. Partners is a network of two Harvard-affiliated teaching hospitals, six community hospitals and 6,000 doctors. From personal experience and studies, Mongan and Lee describe an increasingly fragmented system that often raises costs and lowers quality.

A typical primary-care doctor has 2,500 patients and works 50 to 60 hours a week. By some surveys, doctors have increased the time they spend with individual patients; but it often feels like less because there is “so much more to do than a generation ago,” Mongan and Lee write. Paradoxically, medical “progress”—better diagnostics, drugs and treatments—fosters “chaos” by increasing specialization. Information-sharing becomes harder, and patients find the system more impersonal. A typical Medicare recipient sees seven doctors in a year. In 1986, almost half of internists performed treadmill tests in their offices; by 2004, only 29 percent did. Tests had shifted to cardiologists.

Hospitals and outside doctors often don’t coordinate. One study found that two-thirds of patients leave the hospital without proper “discharge summaries” detailing tests and drug treatments. In early 2008, fewer than 20 percent of doctors used “electronic medical records” in their offices. High start-up costs were a major obstacle.

In early January a friend mentioned that his New Year’s resolution was to beat his chronic depression once and for all. Over the years he had tried a medicine chest’s worth of antidepressants, but none had really helped in any enduring way, and when the side effects became so unpleasant that he stopped taking them, the withdrawal symptoms (cramps, dizziness, headaches) were torture. Did I know of any research that might help him decide whether a new antidepressant his doctor recommended might finally lift his chronic darkness at noon?

The moral dilemma was this: oh, yes, I knew of 20-plus years of research on antidepressants, from the old tricyclics to the newer selective serotonin reuptake inhibitors (SSRIs) that target serotonin (Zoloft, Paxil, and the granddaddy of them all, Prozac, as well as their generic descendants) to even newer ones that also target norepinephrine (Effexor, Wellbutrin). The research had shown that antidepressants help about three quarters of people with depression who take them, a consistent finding that serves as the basis for the oft-repeated mantra “There is no question that the safety and efficacy of antidepressants rest on solid scientific evidence,” as psychiatry professor Richard Friedman of Weill Cornell Medical College recently wrote in The New York Times. But ever since a seminal study in 1998, whose findings were reinforced by landmark research in The Journal of the American Medical Association last month, that evidence has come with a big asterisk. Yes, the drugs are effective, in that they lift depression in most patients. But that benefit is hardly more than what patients get when they, unknowingly and as part of a study, take a dummy pill—a placebo. As more and more scientists who study depression and the drugs that treat it are concluding, that suggests that antidepressants are basically expensive Tic Tacs.

When Samantha Burton started having complications in her 25th week of pregnancy, the Florida mom of two went to see her doctor. When he ordered bed rest for the remainder of her pregnancy—potentially 15 weeks—she wanted a second opinion. “I did not feel I was receiving the care I needed,” she told NEWSWEEK, in a prepared statement.

But Burton did not get a second opinion. She was not allowed to leave the hospital. After she protested her doctor’s orders, the hospital obtained a court order requiring her to comply with her doctor’s medical advice as to “preserve the life and health of Samantha Burton’s unborn child.” So Burton remained in the hospital where, three days later, she miscarried.

jayparkinsonmd:

Here’s a helpful tip. Next time you have surgery, ask the surgeon one simple question:
Will you use checklists as part of the procedure?
There are 40,000 commercial flights in America every day. And planes rarely, rarely crash. 100,000 people die in America every year due to medical errors. That’s the equivalent of a jumbojet with 273 people inside crashing every day. Minimize your risk when you enter our nation’s healthcare system. Print this checklist out and bring it to your doctor. Then ask the question. If they don’t use checklists, demand that they do in your case or find an institution that does.
For more information, see this article by Atul Gawande:

Pronovost recruited some more colleagues, and they made some more checklists. One aimed to insure that nurses observe patients for pain at least once every four hours and provide timely pain medication. This reduced the likelihood of a patient’s experiencing untreated pain from forty-one per cent to three per cent. They tested a checklist for patients on mechanical ventilation, making sure that, for instance, the head of each patient’s bed was propped up at least thirty degrees so that oral secretions couldn’t go into the windpipe, and antacid medication was given to prevent stomach ulcers. The proportion of patients who didn’t receive the recommended care dropped from seventy per cent to four per cent; the occurrence of pneumonias fell by a quarter; and twenty-one fewer patients died than in the previous year. The researchers found that simply having the doctors and nurses in the I.C.U. make their own checklists for what they thought should be done each day improved the consistency of care to the point that, within a few weeks, the average length of patient stay in intensive care dropped by half.
The checklists provided two main benefits, Pronovost observed. First, they helped with memory recall, especially with mundane matters that are easily overlooked in patients undergoing more drastic events. (When you’re worrying about what treatment to give a woman who won’t stop seizing, it’s hard to remember to make sure that the head of her bed is in the right position.) A second effect was to make explicit the minimum, expected steps in complex processes. Pronovost was surprised to discover how often even experienced personnel failed to grasp the importance of certain precautions. In a survey of I.C.U. staff taken before introducing the ventilator checklists, he found that half hadn’t realized that there was evidence strongly supporting giving ventilated patients antacid medication. Checklists established a higher standard of baseline performance.


Today in smart.

jayparkinsonmd:

Here’s a helpful tip. Next time you have surgery, ask the surgeon one simple question:

Will you use checklists as part of the procedure?

There are 40,000 commercial flights in America every day. And planes rarely, rarely crash. 100,000 people die in America every year due to medical errors. That’s the equivalent of a jumbojet with 273 people inside crashing every day. Minimize your risk when you enter our nation’s healthcare system. Print this checklist out and bring it to your doctor. Then ask the question. If they don’t use checklists, demand that they do in your case or find an institution that does.

For more information, see this article by Atul Gawande:

Pronovost recruited some more colleagues, and they made some more checklists. One aimed to insure that nurses observe patients for pain at least once every four hours and provide timely pain medication. This reduced the likelihood of a patient’s experiencing untreated pain from forty-one per cent to three per cent. They tested a checklist for patients on mechanical ventilation, making sure that, for instance, the head of each patient’s bed was propped up at least thirty degrees so that oral secretions couldn’t go into the windpipe, and antacid medication was given to prevent stomach ulcers. The proportion of patients who didn’t receive the recommended care dropped from seventy per cent to four per cent; the occurrence of pneumonias fell by a quarter; and twenty-one fewer patients died than in the previous year. The researchers found that simply having the doctors and nurses in the I.C.U. make their own checklists for what they thought should be done each day improved the consistency of care to the point that, within a few weeks, the average length of patient stay in intensive care dropped by half.

The checklists provided two main benefits, Pronovost observed. First, they helped with memory recall, especially with mundane matters that are easily overlooked in patients undergoing more drastic events. (When you’re worrying about what treatment to give a woman who won’t stop seizing, it’s hard to remember to make sure that the head of her bed is in the right position.) A second effect was to make explicit the minimum, expected steps in complex processes. Pronovost was surprised to discover how often even experienced personnel failed to grasp the importance of certain precautions. In a survey of I.C.U. staff taken before introducing the ventilator checklists, he found that half hadn’t realized that there was evidence strongly supporting giving ventilated patients antacid medication. Checklists established a higher standard of baseline performance.

Today in smart.

The CDC’s Misleading Advice on Swine Flu

Begley:

In the federal government’s explanations of swine flu, through its Web site and public-service announcements, one message has come through loud and clear: seniors can rest easy. Children face a much greater risk from this disease, and they are dying from it in numbers never seen with regular, seasonal flu. Maybe seniors even have some special immunity to H1N1.
There’s only one problem: according to a new analysis, the CDC’s own numbers show clearly and unequivocally that H1N1 is more than twice as deadly to seniors as to children.

Around 4 p.m., I saw a weird Facebook status update from a friend, a journalist turned lawyer whose writing is usually smart, grammatical, and comprehensible. The update read, “rose and lavender paisley.” Huh? Over the next seven hours, more than half the status updates in my feed turned out to be colors, mostly pink, beige, and black. I figured out that these were colors of bras. Then I chuckled a little at my friends who had written “nothing” and “pink” (that friend was a man) and “harvest gold” (him, too).

You know what I didn’t do? Think about breast cancer. That, however, was supposedly the point of the exercise. No one yet knows who started the meme, but apparently, someone kicked it off a few days ago with a chain-letter-style Facebook message to a bunch of women, asking them to virtually flash the world in the name of supporting medical research, and to forward the note only to other female friends, and to be aware of breasts. Sorry, breast cancer. Right.

In which Mary Carmichael is at once racy and reproachful.
The message is not “Here’s your destiny. Get used to it!” Instead, it’s “Here’s your destiny, and you can do something about it!” Diseases result from a combination of genetic vulnerability and lifestyle. If you know you have high risk of certain diseases, it’s in your interest to know and practice the lifestyle that reduces your risk—and the younger, the better.
I had this ‘Oh my God’ moment, thinking, how many kids have been produced?" he says. "I thought the doctors were keeping track of each birth, but when I realized they weren’t, I began to worry. What if they start dating one another?" He also began to worry about their genetic health. "I wanted to know if I have anything totally lethal or deranged or recessive in my genes that I may have passed along.
Kirk Maxey, who donated his sperm at a Michigan clinic twice a week for for 15 years. The whole story is pretty great.

The fact that Republicans and Democrats differ on whether health-care reform should include a public option is no surprise. That they differ on setting a date for exiting Afghanistan, sure. On Sarah Palin, of course. But on physics? And biology? That the growing list of issues where there is a partisan divide now includes the accuracy of scientific findings may be lamentable for a democracy (if we can’t agree on facts, how can we agree on policy?), but it’s a gold mine for research on how personality and other psychological factors influence political ideology.

The red-blue split on mammograms is particularly striking. In a recent poll, the Pew Research Center asked 1,002 American adults about a preventive-health task force’s conclusion that most women can safely begin mammograms at age 50, not 40, and have one every two years, not annually. (Large studies have found that earlier mammograms save almost no lives; since the radiation can cause cancer, it therefore makes sense to minimize them.) Among Republicans, 15 percent agreed with that. Among Democrats? Twice as many.

tanya77:

How Will You Die?

Interesting. One depressing bit stands out: HIV is the leading cause of death among black men and women age 25-34.

tanya77:

How Will You Die?

Interesting. One depressing bit stands out: HIV is the leading cause of death among black men and women age 25-34.

Research has linked genes to intelligence, social skills, neuroticism, risk taking, impulsivity, and more. In most cases, “linked” means determining that the behavior is partly inherited, but not how the gene brings about the behavior. What if the gene affects a trait known to be strongly heritable, such as appearance or temperament, and what if that trait in turn elicits particular behaviors from parents and teachers: behaviors such as responsiveness, paying attention to, interacting with, speaking to—things that affect how a child turns out academically and socially? If so, we are mistakenly attributing these outcomes to genes “for” intelligence and the rest, when in fact all the genes do is give a child looks or temperament that elicits, for instance, IQ-boosting responses from adults.