Friday, December 12, 2014

Fewer hospital readmissions,the seen and the unseen and Goodhart's Law

One of the multiple provisions of the Affordable Care Act (ACA) is something called the Medicare Hospital Readmission Program.This provision links provider payments to 30 day readmission rates for three conditions-heart attack,heart failure,and pneumonia.More medical conditions are scheduled to be added to the list including chronic obstructive lung disease (COPD).

Writing in the December 4,2014 issue of the  NEJM Dr. Christine Cassel claims success for this program quoting that national readmission rates decreased from 19% to 17.5%.

 The French economist,Frederic Bastiat writing in 1850 advised his readers that a good economists not only looks as the visible effect,the seen, but needs to consider the unseen or what comes next.

What is seen here is the results of the reporting, what is unseen is the reason(s) for the decrease.

Did more patients end up in nursing homes, did more patients die at home,were more patients treated in ERs and not readmitted,what restraints , if any, were placed on ER doctors to not readmit folks recently discharged,.If someone was admitted to a different hospital did that count in the statistics?.What actions did hospitals take in a effort to minimize the likelihood of patients being readmitted?

The patients who were not readmitted are not seen. What  happened to them? Does this reported decrease in readmission rate reflect better care or just less care in the hospitals? Did more people die at home?Were more patients prematurely placed in a hospice care setting?

Thomas Sowell tells his readers that in the real world of limited resources and virtually unlimited desires that  most of times we are involved in trade offs and not solutions.What are the trade offs in this reported decrease in admission?

Has the hospital readmission program managed to be an exception to  Goodhart's'aw?

Charles Goodhart,a professor at the London School of Economics,wrote in a 1975 paper that when a measure becomes a target it ceases to be a good measure.

Although not discussed explicitly  as a example of Goodhart's law, Dr. Cassel also reviewed the ill advised six hour rule for the administration of antibiotics in patients with community acquired pneumonia.It turned out that ER personnel were too profligate in the administration of antibiotics so as to not get cited for poor care. They were like school teachers who "teach to the test".

Dr. Cassel said that the data validated the readmission policy approach. Can you claim that without knowing the mechanism(s) for the fewer readmission? Do we know if the decrease helped or harmed patients? There was less expenditures from CMS in the hospitalization category but what costs were incurred and by whom?

Friday, December 05, 2014

Does a JAMA viewpoint essay by Dr. Harold Sox reveal what population health really means?

Dr. Harold C. Sox writing in the November 13,2013 issue of JAMA in an article entitled  "Resolving the tension between Population Health and individual health care" says:( my bolding ).

"Perhaps the de facto organizing principle for US health care,,approaching each patient strictly as an individual is obsolete.The population health approach is an alternative."

This sentence seems structured to allow for escape mechanisms. He hedges by beginning with "perhaps" and then says that" approaching each patient strictly as an individual " , so he could later claim that, of course ,treat the individual but you also have to consider the interests of society.

The money quote is :

 " Must the Population health approach compromise the needs of the individual to benefit the community

It will take several generations to realize the full benefit of investments in disease prevention . In the short run,the investments may draw resources away from tests and treatment for some sick people.In the long run, disease prevention and better low cost technology could reduce the outlay for treatment.In the interim, skillful clinical decision making can make the most of limited resources"

He is answering  his introductory question in the affirmative by giving an example of how an individual would suffer for the allegedly benefit of a group  and incredibly does not express any concern about sacrificing the individual to some hypothetical future benefit to the community or society.In fact and amazingly  the only benefit he actually mentions is "reduce the outlay for treatment".

 Sox continues:

 " Are the needs of the individual and the population reconcilable?
Using the same method of value and the same decision making principle for patients and for populations would be an important step toward a system that fairly allocated resources between the healthy many and the sick few"

The traditional role of the physician has been the care of "sick few".Are they now being asked to allocate some of the resources away from the sick to the "healthy many"?

But the principles involved in treating patient who requests help from a physician and  and proposing preventive measures for a population are not the same. The population has not requested help and may have not even authorized the "treatment"  A key principle in treating the individual is to respect his/her values. How can one determine the values of a population? Do all member of the population have to agree.? Is disease prevention is only principle to value, do liberty, and avoidance of coercion not matter? Who is to judge what is the fair allocation? Is disease prevention more important than treating the sick which historically is what physician basically did ?What about the possible harms of a preventive program?Should the population members have to agree to the preventive measures? Is informed consent not to be part of population medicine?

Thursday, December 04, 2014

The coruption of medical practice

Drs Hartzband and Groopman hit another major home run..See here .

This husband and wife physician team  from Harvard Medical School have published cogent thoughts before  regarding serious issues in  current day medical practice.See here for their critique of the concept of quality adjusted life year (QALY) and here .

They contend that  medical care is being corrupted by the actions of several groups-insurers,hospital networks and regulatory groups.I would add that philosophical (ethical ) cover is provided by health policy experts who are attempting to change medical ethics from one in which the  physician has a strong,primary fiduciary duty to her individual patient to one in which the physician is obligated to act in the alleged benefit of the group.This attempt is exemplified by the New Professionalism initiative which is spearheaded by the American College of Physicians (ACP) and the American Board of Internal Medicine (ABIM and its foundation (ABIMF) and the Robert Wood Johnson Foundation (RWJF). Additionally, the movement for a "Population Medicine " approach  depends heavily on this sea change in medical ethics.Simply put- the population medicine approach is dead in the water unless physicians reject their traditional fiduciary duty to their patient.

Quoting the authors from their NYT article:

" Insurers, hospital networks and regulatory groups have put in place both rewards and punishments that can powerfully influence your doctor’s decisions.Contracts for medical care that incorporate “pay for performance” direct physicians to meet strict metrics for testing and treatment. These metrics are population-based and generic, and do not take into account the individual characteristics and preferences of the patient or differing expert opinions on optimal practice."

and later

"When a patient asks “Is this treatment right for me?” the doctor faces a potential moral dilemma. How should he answer if the response is to his personal detriment? Some health policy experts suggest that there is no moral dilemma. They argue that it is obsolete for the doctor to approach each patient strictly as an individual; medical decisions should be made on the basis of what is best for the population as a whole.

addendum: 12/27/14.Minor spelling and punctuation corrections made.

Friday, November 28, 2014

Does exercising efficiency decrease in cycists and walkers with aging but not runners?

The following will likely  only be of interest to older runners,walkers, cyclists and folks wfo like to talk about mitochondria.see here for a interesting commentary about muscular efficiency,aging and its effect of various kinds of exercise.

The mainstream current party line regarding the determinants of endurance exercise performance is that the major three factors are:

1Maximum oxygen uptake ( V02Max)there are conflicting data regarding whether regular endurance training over the years lessens that decrease with the older data supporting that idea.More recently Tanaka and others have shown that when expressed as per cent decrease from early adulthood, the rate of decline in VO2Max is not reduced in habitual aerobic exercisers.See page 58 reference no. 1.

2)Lactate threshold (LT).LT as a measure of the exercise intensity at which a person can sustain a high level of the maximal oxygen consumption.It is said to decrease with aging.Although data indicate that the absolute work rate or running speed at the LT decreases as a function of age, the LT does not change when expressed as a percentage of the 02 Max. Tanakia and Seals (ref 1) suggest that the decrease in LT is secondary to decreases in the 02Max.

3)Exercise economy .This is measured as the steady-state 02 consumption while exercising below the LT.A number of cross-sectional studies have shown that exercise economy does not change with aging.Most of the studies were done in runners but now we have a study that demonstrates a decrease in excise efficiency  in cyclists with aging.

Alex Hutchson in his Runner's World column,"Sweat Science", discussed several articles that demonstrated that older cyclists became less efficient with age but that deficit compared to the younger cyclists  was abolished by a several week period of quadriceps resistance exercises . In one study a 3 week training period increased leg strength by about 18% and cycling efficiency by about 16%.

As early as the 1980s there was experimental evidence that resistance exercise could increase mitochondrial bio-genesis and improve oxidative capacity even in a person habitually doing endurance exercise. 

1)Tanaka,H and Seals DR, Endurance exercise performance in masters athletes.
J Physio 586 1 (2008) pp 55-63

Friday, November 14, 2014

Eight high school football deaths from head or neck injury in 2014 equaling the number in 2013.

The Annual Survey of Football Injuries 1931-2013 (first author Kristen Kucera)l was published in March 2014.See here for the full report.

The report distinguishes between direct death (basically brain or neck injury) and indirect death which includes a cardiac cause or heat stroke among others.

In 2013, there was 8 directs deaths ,all in high school, and nine indirect deaths seven of which were related to high school football. Of the direct deaths 6 were from brain injury and 2 were from neck injuries.There are approximately 1.1 million participants in high school football. So there were 16 death related to football in 2013 in that population.News report indicate that there have been 8 apparent direct deaths from high school football in 2014 .

Of the 8 direct deaths in 2013, 3 occurred in running backs, 2 in defensive backs and one  in wide receiver and one in line backer and the position of the eighth player was not known.

In 1976, a major football  rule change was put into place and review of the deaths tabulated by year indicates it was an important contributor to overall fewer deaths from head and neck injury but has certainty not eliminated them There were further rule changes in 2005 and 2007 designed to eliminate the use of the helmet as a weapon.. In 1976 it became illegal to make initial contact with head and face while blocking or tackling (so called "spearing").The decrease in cervical spine injuries is greater than that seen in fatal head trauma following that rule change and the increased emphasis of not hitting with the helmet.Still from 2003 through 2013, 23 high school players died from head or neck injuries and 103 died from indirect causes ( largely heat stroke and cardiac causes).

 What is thought to be the mechanism(s) involved in  the football related. fatal brain injuries . The likely candidates  are 1)acute subdural hematoma and 2)and those  of the second hit syndrome. See here for Dr. Robert Cantu's description of ten cases of the second hit  syndrome.The second hit syndrome is thought to be at least in part a disorder of cerebral blood flow auto regulation occurring acutely after a second blow to the head in a player who is still symptomatic from an earlier (perhaps unrecognized) concussion and may result in fatal herniation and brain stem compression which can occur within a few minutes of the second  head blow.

Better helmets,greater awareness of concussion and the efforts to restrict play for a concussed athlete and rule changes since 1976 are thought to have decreased fatal had  and neck injuries. Things did look like they have gotten better. From 1968 through 1971, 44 high school players died from head and neck injuries and 12 died in sandlot type football  and 12 died playing college ball and 2 died in pro and semi pro leagues.In that 4 year  time frame 70 people died from playing football .

 The reports states that data from the decade 1985 - 1994 showed reduction in those injuries.However, the data from 1995-2004 show an increase in brain fatalities over that in 1985-1994 ,namely 11 more deaths during 1995-2004 representing a 33% increase.In the latest nine year period  analyzed (2005-2013) 25 brain deaths have been recorded in high school players.

Football continues to be a sport in which there are high impact collisions which place the head and neck at a non trivial risk. It may be that the mitigating factors mentioned above (rule changes etc) have done what they can do but a very troublesome residual exists and young athletes continue to die while cheerleaders and family members gather on Friday nights to celebrate the rituals of high school football. Judo has been made mandatory part of  high school education in Japan and a number of athletes die every year as a result of head trauma associated with that sport. Understandably parents in Japan have raised  justified protests.Just imagine what protests would be raised if high school football were a mandatory part of high school education.It has become common ( mandatory?) for an ambulance to be on hand at high school football games.I wonder if their presence is reassuring to parents or a troublesome reminder that medical tragedies continue to occur in spite of the considerable effort that has been made to avoid them.

Monday, November 10, 2014

The Great Health Information Technology Flim-Flam explained in plain english

Margalit Gur-Arie has hit another out of the park on her blog "Health Care Technology". Everyone should read her recent entry entitled "Technology for Onesies-Twosies". See Here.

Her comments are aimed at the almost one half of U.S. physicians who are still in private practice, most of which are in medium or smaller groups.The topic isthe government program to "help"private docs obtain and use electronic health records (EHRs) and its "Meaningful Use" Program which is a carrot and stick approach to get  recalcitrant physicians on the program.


"Case in point: Meaningful Use is a voluntary program. The maximum incentive per Medicare physician is equivalent to seeing one more patient per week. The maximum penalty for a typical Medicare physician can be recuperated by seeing one more patient per week. The cost of using a Meaningful Use EHR, in both cash and physician time, far exceeds one weekly visit. Can someone please enlighten me on why there is no market (and trust me, there isn’t) for non-government sanctioned technology that is purposely built to serve doctors? Remember, you own more than half the market."

Bottom line- signing on to the government subsidy EHR program is not just a bad idea it is much worse than that. Note, the computer programs that are government sanctioned are for the most part not meant to help the physician practice medicine nor to help the patient receive better care.Read her entire article and find out who really benefits.Spoiler- it ain't the patients and physicians.

Friday, October 24, 2014

Does much of the blame for sarcopenia rest on the satellite cells of the fast twitch muscle fibers?

Well, at least some of the blame anyway.

Dr. LB Verdijk and coworkers at the Masstricht University in The Netherlands have published several articles contributing insights into at least some of what goes on with the age related loss of muscle size and strength.See here and here.

Their work deals with satellite cells (SC), so called because in their resting form they hang out on the periphery of skeletal muscle cells, wedged between the basement membrane and the sarcolemma.They are the muscle's stem cells. They are poised to multiply and to differentiate into myofibers when signaled by damage such as occurs with strenuous exercise.

Their 2007 publication  gives a good summary in the article's title, "Satellite cell content is specifically reduced in type II skeletal muscle fibers in the elderly" The authors did muscle biopsies in the lateral thigh in 80 elderly subjects (age 76 +/- 1 yr) and 80 twenty year olds. The proportion and mean cross-sectional area of type II fibers was reduced in the elderly  as were  the number of satellite cells per fiber .A similar pattern was not noted in the slow twitch (type I) fibers.The type II fibers were smaller and fewer in number and contained fewer satellite cells per fiber .

Now for the sorta  good news.

A more recent article from the same  research group in the Netherlands reported that a 12 week program of resistance exercise training significantly increased both muscle fibers size and satellite cell count in type II fibers in elderly subjects. This was part of a more comprehensive study which examined muscle fiber type and satellite cell content in 165 subjects in various age ranges. 49 of which were 70-86 years of age.Also a subset of elderly subjects took part in a 12 week resistance exercise program .Muscle biopsies after the training program demonstrated increased type II fiber size and satellite cell content.

It seems plausible that the satellite cell awakening induced by resistance exercise was instrumental in muscle cell growth.There are , of course, many other factors in the muscle loss of aging including loss of sex hormones,increase in inflammatory cytokines,inactivity,poor nutrition and loss of anterior horn cells,among others. Resistance exercise in the setting of adequate protein intake  is not the fountain of muscle youth but so far it seems the best we've got.

A final word.writing as someone who has run more ( much more ) than can be justified  based on reasonable  concerns of improving health .Running will not prevent sarcopenia. While running on level ground the quadriceps does little more than stabilizes the patella. I suppose running up and down hills may activate some type II fibers but basic jogging will not prevent the age related loss of muscle size and strength.That requires resistance exercise and adequate protein intake.