Monday, March 30, 2009

Should "preventionists" treat the population and real docs treat individuals?

I had not heard the term "preventionist" before reading this excellent entry by Dr. Michal Accad. His thoughtful essay in part delves into a topic that has interested and bothered me for years, the individual versus the collective and in the medical context population health versus individual health.One of my rants on this topic can be found here. (One indicator that you probably have run out anything to say is frequently quoting yourself.)

I quote his final paragraph wherein the term "preventionist" appears, I think tongue in cheek.

... But since population medicine has little to do with individual medicine, and since the application of primary prevention requires no diagnostic skills to identify the subjects of predilection, the advocated intervention need not be practiced in the doctor’s office. I propose that JUPITER’s precepts be promoted in specialized “Centers of Excellence,” public health dispensaries where competent preventionists could directly indoctrinate the public to the many values of the modern wisdom, un-distracted by the chaotic environment of a clinical practice. And thus relieved from the burdens of a task at which they are so woefully “inefficient,” the primary care physician could then return to their humble original calling, the care of a patient with a chief complaint.

The primary care physician increasingly is called upon to to be a preventionist under the threat of being accused of not practicing quality care and not receiving his bribe (aka P4P ).

My favorite P4P quote continues to be:
"He hands you a nickle.He hands you a dime.He asks you with a grin are you having a good time"...Dylan from Maggie's Farm.

Prevention is one of the holy trinity (along with EMRs and quality systems) that will bring the new age of greater health for all, less money spent and really good care for everybody. In terms of the world of the internist, it is the office internist (one variety of the officist) upon whose shoulders falls the obligation to ensure his patients (clients, customers) have been quizzed and then instructed to do whatever they are supposed to do to strive for wellness from submitting to colonoscopies and flossing and using their seat belts.The other sub-species of internist (the hospitalist) can still for the most part manage sick patients leaving the administrative tasks of prevention to his 8-5 office cousins and increasingly to their extenders.

Wednesday, March 25, 2009

If you get Universal health care with a single payer you better have a "safety value"

In Great Britain, at least for some, the safety value for the NHS is private health care. In Canada, if you can afford it, the safety value is to leave and get the care in the United States or overseas, perhaps in India.

Here is a reference to comments made by the Director of Trauma at McGill Hospital Centre in regard to the events surrounding the death of Natasha Richardson. He said in part:

"It's impossible for me to comment specifically about her case, but what I could say is ... driving to Mont Tremblant from the city (Montreal) is a 2 1/2-hour trip, and the closest trauma center is in the city. Our system isn't set up for traumas and doesn't match what's available in other Canadian cities, let alone in the States,...

The system is not "set up" for trauma in part because there were no air evac helicopters in that area. As pointed out by others capital investments in the health care system in Canada are costs to the system that cannot be recouped. In the US, the purchase of,for example, an MRI, is also a cost to the hospital or clinic but it can be recouped and typically is a profit center. So hospitals under which system are likely to have MRIs readily available?

It is important to recognize that "universal health care coverage" and "single payer" are not the same thing.

David Henderson of the econlog blog has this to say about the single payer system in Canada:

The essence of "single payer" medicine is that no one other than the government is allowed to pay for medical care. Thus the term "single payer." There are a few exceptions in Canada but, by and large, the more serious the ailment, the more stringent the ban. So, for example, if you want to be treated for cancer in Canada, you can not do so legally and any doctor or hospital that tries to charge you faces serious penalties, up to and including a prison sentence. In that sense, Canadian health care is one of the most totalitarian systems in the industrialized world and is far more extreme than the National Health Service of Britain.

When rationing by waiting turns into health care denied by health care delayed ( as numerous anecdotes or case reports indicate) as occurs in Canada the single payer may in effect work directly counter to the promise of universal care that the single payer system promises. There are many problems of single payer system as a cursory study of the health care in Canada and Great Britain will show, but a single payer system that outlaws private care is, as David Henderson says, about as totalitarian as you can get since your life is in the hands of the state.

Tuesday, March 24, 2009

Tight glucose control in ICU seems hazardous

In the March 24,2009 on line issue of NEJM the results of the Nice Sugar trial are published and shows that conventional treatment ( target glucose less than 180) as opposed to tight control (defined as 81-108 glucose target) is better. This was a very large trial with over 3000 patients in each arm.

In the tight control group 27.5 % died versus 24.9 % deaths in the conventional treatment group.Severe hypoglycemia (less than 40) occurred in 6. 5 % of the intensive treatment group versus 0.5 % in the conventional treatment group illustrating once more that more insulin may drive the blood sugar too low and be harmful.

Even though meta-analysis have generated conflicting results regarding the efficacy and safety of tight glucose control, both the American Diabetes Association and the American Society of Clinical Endocrinologists have recommended tight control.

The study authors of the NICE trial offered this understatement "Our findings suggest that a goal of normoglycemia for glucose control does not necessarily benefit critically ill patients and may be harmful",

This seems to be another example of the ready, shoot, aim approach to guidelines bringing to mind the ill advised rush to give everyone beta blockers peri-operatively which was probably laid to rest with the publication of the POISE Trial. Let me repeat what I said after that trial was published.

If there is a lesson here it is not just that a large randomized clinical trial gives results opposite to earlier smaller trials-that is a story we have heard more than once before. The lesson is not that expert committees sometimes have to revise their recommendations as new information becomes available.The lesson I think that should be emphasized is that overzealous quality rule writers and enforcers can be a hazard to your health ( and I have said that before). Read Dr. Devereaux's comments regarding how many patients may have been harmed by taking peri operative beta blockers and then wonder how many patients received them simply because premature quality guidelines were in place and physicians were caught up in the rush to treat even though it seems clear now that the evidence for such zealous efforts was inadequate. Dr. DB (AKA Dr. Robert Centor) nailed it when he recently spoke about in this regard " the performance and quality movement which has a 'ready,fire, aim' philosophy".

The other side of the health Care "debate"

As for as the main stream medical journals (JAMA, NEJM, Annals Internal Medicine) the health care issue is largely already decided with certain conclusions reached and as such now exist beyond debate or refutation. The conclusions are :U.S. health care costs too much, many folks are "denied" access to care and the care is of inferior quality to that received in the other developed countries.

There are cogent arguments to the contrary and those can be found here.

The authors include John Goodman , a Phd in Economics and a prolific author on the subject of health care economics but unlike Uwe Reinhardt is rarely quoted in the big three journals mentioned above. (It seems to help to be on the board of a managed care company to get quoted in JAMA).

Another author is Dr. Robert M Sade. I first heard of Dr. Sade when he published a NEJM article in support of the proposition that health care is not a right. The type of fire storm that his article elicited was not unexpected and included a blistering admonition from the editor of the journal. Dr. Sade, a trained heart surgeon, later left practice and has devoted some of his energies to biomedical ethics and health policy and organ transplantation issues.

Dr. Wes gives his views on the "broken health care system" here.

Monday, March 23, 2009

The new HFA inhalers may or may not help the environment and drug companies but are the users the forgotten men?

Here is on article discussing the possible cons of the introduction of the HFA inhalers and the outlawing of the older CFC type (except for Maxair).

Some patients complain they do not work as well and more complain about the increased costs and more than a few physicians have spent time educating patients regarding their use and offering reassurance.

If you wonder, as I do, about how much effect the CFC pulmonary inhalers have on ozone depletion and how much good this prohibition will generate, this reference might offer some information and opinion in that regard.

When I wrote about this before I said:

.. I think this is the first time that the FDA [has banned] a medication or group of medications not because they are thought or proven to be harmful to those who use them but because they are thought to possibly harm folks who do not use it. (OK, the purported skin carcinogenic effect of increased sun rays from the purported decrease in ozone layer thickness would affect everyone- even asthmatics.) Since the task of determining harm to medication users has proven much harder that the FDA or anyone ever thought, it is admirable that the FDA will take on an even more difficult task.

I don't have a tracking on the course this regulation took through the regulatory mechanisms and who supported it, but I cannot help but wonder if we are dealing with still another instance of the "Baptists and the Bootleggers". Since there are no generic versions of the HFA inhalers, guess who the bootleggers would be and would the Baptist role be played be the more radical environmentalists?

Friday, March 13, 2009

Wait-Maybe electronic medical records might not save money.

We have been told by President Obama that we cannot fix the economic mess without fixing health care (and education and the environment, for that matter). OK, some of us think that may rank as the non sequitur of the year (decade?) but let us look deeper. Electronic medical records (EMR) has been heralded as one of the ways we can simultaneously improve quality,provide medical care for all and save money. One prominent medical blogger and a fairly well known medical author both suggest that might not be true at least in regard to money part.

KevinMD, see here, offers a interesting take. Hospitals may get more proficient at maximizing coding techniques with computers and therefore increase their share of the medicare and insurance pots and thereby increase costs.With the stimulus plan the government will give money to the hospitals to get the computer systems to code better and get more payments.

Dr. Jerome Groopman whose writings on medical cognitive tricks and traps has now taken on the topic of putative savings from EMR and challenges the often quoted Rand study that claims EMR would save huge amounts of money.See here.The study needs to be analyzed on its own merits as Dr. G. apparently has done but it did not go unnoticed that the study was founded by HP and Xerox, who could be described as interested parties. We all know how the money behind drug studies always raises a red flag and a reflex skepticism of the results but here only now ( at least I can't find other references) does someone make that point with the Rand study.

Sunday, March 08, 2009

What does universal health care have to do with the economic mess?

Tell me again why we cannot get out of this economic mess without fixing health care? I have read over twenty putative explanations for why and how we got where we are in one scary recession and so far none of the financial pundits nor card carrying economists have suggested that lack of medical coverage and too high health care costs caused the problem or was even a major contributing cause.

I have read that we had first a housing boom and then a bubble and then a crash whose effects were hyper-amplified beyond most analysts' wildest fears by a situation in which: entities that made loans sold them to others who packaged them in ways few understood, many of the loans were made to people who could not afford them,mortgage based securities (MBS) based in part on bad loan were markedly overvalued by rating companies,financial entities who bought and sold MBSs were dangerously over leveraged and according to one school of economic thought (the Austrian School) a major driving force was the artificially low interest rate driven down by the Federal Reserve system in this country and by other central banks around the world.

If one plows through a lucid and laboriously documented academic discussion by Marcus Brunnermeier from Princeton's economic department you will be treated to a discussion of how he suggests the housing bubble was made possible by cheap credit supplied both by a surplus of foreign ( mainly Asian) money looking for a good return on investment and an expansionary Federal Reserve Policy,of lowered lending standards ,of major changes in the banking system (i.e. going from loan and keep , to loan and sell off the loans), of various actions by banks to establish a "shadow banking"system involving off balance sheet investment vehicles exposing them to liquidity risk, of investments entities relying more and more on a borrow short and loan long arrangement . In short he describes elements of the events that took place as a mortgage crisis was amplified into a severe finanacial crisis.

If medical costs and folks without medical insurance played a role in any of this he and every other economists and financial analysts and pundits who has written about it really missed the boat.

Yet, we told by the new administration that we cannot get out of this financial mess without fixing the health care system. We are told that for recovery we will have to simultaneously cut medical care costs and ensure that everyone has medical care and improve quality of care. Of course, there are good arguments to the point that we do spend a lot of medical care and thoughtful people have a legitimate concern that some folks do not have health insurance and that there is a great deal that needs fixing but what do those concerns have to do with a housing bubble,burst, and mortgage crisis amplified into a financial crisis and why is a health care fix a necessary part of recovery?

Dr. Krauthammer hammered away at what he describes as Obama's glaring non-sequiturs in his Washington Post commentary dated 3/6/2009 entitle "The great Non-sequitur"

President Obama has asserted that the mess we are in relates to the country failing to obtain universal health care, green energy and better education. Dr. Krauthammer gives us this quote from the President's speech in which we are seemingly finally told why the real reasons of why we are where we are now:

"Our economy did not fall into decline overnight," he averred. Indeed, it all began before the housing crisis. What did we do wrong? We are paying for past sins in three principal areas: energy, health care and education -- importing too much oil and not finding new sources of energy (as in the Arctic National Wildlife Refuge and the Outer Continental Shelf?), not reforming health care, and tolerating too many bad schools.
Krauthammer says in reply:
.. the list of causes of the collapse of the financial system does not include the absence of universal health care, let alone of computerized medical records. Nor the absence of an industry-killing cap-and-trade carbon levy. Nor the lack of college graduates. Indeed, one could perversely make the case that, if anything, the proliferation of overeducated, Gucci-wearing, smart-ass MBAs inventing ever more sophisticated and opaque mathematical models and debt instruments helped get us into this credit catastrophe. .......
Clever politics, but intellectually dishonest to the core. Health, education and energy -- worthy and weighty as they may be -- are not the cause of our financial collapse. And they are not the cure. The fraudulent claim that they are both cause and cure is the rhetorical device by which an ambitious president intends to enact the most radical agenda of social transformation seen in our lifetime.

Whether on not you agree with Dr.K's characterization of what Mr. Obama's agenda really is, it is very hard to accept the claim that fixing his big three initiative is necessary for the economic repair.To be fair I have to recuse myself regarding expressing an opinion on the carbon cap and trade issue,I have not researched that enough to justify comment but if the lack of a universal health care plan in this country is a cause of the economic downturn, it must be the best keep secret on the century. Should not Great Britain have been spared the economic turmoil since they have had a universal health coverage system in place for years?

Thursday, March 05, 2009

Two (three) must read articles on clinical guidelines

Clinical guidelines,virtually non-existent a few decades ago now have reached hyper-epidemic proportions. Two of the best medical bloggers have recently penned commentaries that are must reading. DM,know in the real world as Dr.Robert Centor published a great editorial in JAMA

DrRich, known in real life as Dr. Fogoros wrote the blog postings linked below and as usual gives a take on the guidelines issue that should make physicians and other interested readers sit up and notice and one that I'll bet you won't see elsewhere. Dr. Fogoros is a card-carrying cardiologist (well maybe, he does not carry his card any longer and after they read his Part 2, they may try to take the card away) and with the credibility that should go with that dives into the subject of cardiology guidelines.Part 1 is good but Part 2 should knock your socks off and offers a great insight into what we might expect from comparative effectiveness research even if the government sponsors it as long as they use humans to do the work.