Monday, January 31, 2011
David Henderson, writing in the Concise Encyclopedia of Economics,says this about the economic concept of opportunity cost. "Its [the term] value is to remind us that the cost of using a resource arises from the value of what it could be used for instead." In this case what could the physician's time be used for instead. If she spend less time keying stuff into the clinical record, she could be seeing and evaluating more patients in a given time period and in the language of the administrators- generating more income.
Investipedia put it this way : Opportunity cost is the cost of an action that must be forgone to pursue a certain action. The physician is forgoing caring for patients in the time she takes to enter in the data, even if she is can enter data at a world class speed, it does not make economic sense for the doc to spend time typing. Economists love to say things like "economics is just about incentives"
I still get updates from placement agencies regarding locum tenems. A recent one described a position at a VA hospital. One of the job requirements was the ability to key in information .In this setting the above economic incentives may not apply.The doctors gets a set salary and he will not generate more income for the VA (they don't generate income at all) by seeing more patients so why not have the doc spend his time typing.
Some emergency departments (EDs) apparently caught on and not just recently. See here for an article on that topic as early as 2009. The EDs are hiring scribes to sit in on the physician-patient encounter and key in the relevant details freeing the doc to do all those doctor things and not appear distracted with his computer while he talks to the patient. Of course this would also work in other practice situations.
Many physicians who may have never hear the term opportunity cost when introduced to the notion that they would key in clinical encounters said in effect " why should I waste my time doing that" operationally knew all about that concept.However, some of the suits in HMOs and large clinics "run like businesses" who hired self appointed experts in IT must have slept through the economics course they must have taken to get the MBA.
From the article linked above which quoted comments made at a recent meeting of the Society of Thoracic Surgery
.. minimally-invasive strategies, such as ablation, to treat small lung tumors without radical resection or even lobectomy are under development [ ed ; and threaten the chest surgeons]
Maybe 'under development" but don't we have a long way to go to treat (remove?) lung cancer through the bronchoscope? But I think one of the participants in the conference linked in the first paragraph above was saying why can't chest surgeons do those things with the bronchoscope if and when those developments get ready for prime time.
This multi-institutional study involved a follow up of 697 patients who presented with an acute coronary syndrome (ACS) treated with an invasive catheter procedure ( percutaneous coronary intervention or PCI). The patients underwent coronary angiography and coronary artery intravascular ultrasound imaging.
Over a three year period 20.4 % had another adverse coronary event . The authors analysis indicated that about half of these events were due to obstruction at the location of the culprit lesions ( i.e the obstructive lesion that was treated by PCI) and half were due to non-culprit lesions. Most of the non-culprit lesions were considered angiographically mild (typically with an obstruction less than 70%) and were described as "thin-walled fibroatheromas" with a large amount of plaque . I suppose if those lesions were not thought to be mild by the cardiologist that they would have been "fixed".
According to the authors, a lesion with a thin wall, a lumen area of less than 4 mm,and a plague burden of 70% has a three year risk of causing a coronary event of 17%.
Potentially useful information not provided in the article would include to what extent patient with these non-obstruction lesions were treated with medications thought capable of stabilizing plaques, e.g. clopidogrel, aspirin, and statins. You have to believe (hope?) that the percentage would have been higher if patients had not been treated with drugs that "pacify the platelets" and decrease inflammation.
The authors emphasize that the intravascular imaging techniques used in this study are not ready for prime time, everyday clinical use because the specificity of lesions with the most predictive risk characteristics is low and there were serious side effects (including rupture of a cornoary artery) .Further, data was only obtainable on the proximal portion of the major epicardial coronary arteries ( about 6-7 cm) so what was going on more distally is unknown.
Thursday, January 27, 2011
"Thiazide-type diuretics should be used for most patients with uncomplicated hypertension either alone or in combination with other drugs."
The ALLHAT trial has been used in support of that recommendation although that trial has generated hundreds if not thousands of pages of rebuttal and re-rebuttal. See here for an ALLHAT summary.We reassured later that the diabetes that sometimes might be precipitated by thiazides is a different and really benign type of diabetes, so not to worry about that.
The European approach is arguably less dogmatic that JNC's emphasis on diuretics.Here is the ESH/ESC 2007 update on hypertension treatment.
Now we have this meta-analysis ( yes, I am very skeptical of MAs in general but when they suit my biases, I shamelessly quote them).See here.
The authors included 14 studies that used 24-hour blood pressure monitoring and concluded"
Conclusions: The antihypertensive efficacy of HCTZ in its daily dose of 12.5 to 25 mg as measured in head-to-head studies by ambulatory BP measurement is consistently inferior to that of all other drug classes. Because outcome data at this dose are lacking, HCTZ is an inappropriate first-line drug for the treatment of hypertension.
Their last sentence could not be more in opposition to JNC. Let the games begin again.
Wednesday, January 26, 2011
I think he is saying in part that the "problem" isn't some mysterious regional variation in how doctor practice medicine ( i.e greed seems to distributed geographically by some as yet undiscovered mechanism); the problem is it costs more to care for poor sick patients. Changing doctor's practice patterns won't fix poverty. Somehow, I think electronic medical records (EMRs) won't either.
Here is his nutshell paragraph:
"MedPAC, the IOM and countless other organizations are on a quest to explain geographic variation in health care. Yet the puzzle has been solved, and it is solved again here. Geographic variation in health care is a manifestation of geographic variation in poverty. The logic is obvious to all of us in our every day experiences. Poverty is associated with more disease, and poor people cope with disease more poorly. And poverty is geographic. So it should not be surprising that health care utilization and spending are geographic."
Tuesday, January 25, 2011
They include in the overall cost of obesity the increased cost of food and of purchasing extra sized clothing. somehow they consider purchases of food and clothing to be some mythical "cost to society". I wonder if someone at McKensey actually sat in on economics 101 and learned that one person's cost is another's stream of income. Buying food, regardless of one's BMI, is not a cost to society but just a market transaction just as it is when the thin person buys a car. However, economics can be such a subtle and counter intuitive discipline.Apparently giving folks money to buy new cars was thought to stimulate the economy (remember cash for clunkers) but some "incremental" money spent by the obese on extra food and big shirts is a cost to society.
McKensey speaks obesity as a pandemic, the whole world is getting more obese and they contend that the problem is so vast and important than "governments must lead the fight against obesity" Well at least they didn't call it a war.
The McKensey group has been knee deep in health care policy matters for some time. Dr. Robert Kocher has been in and out of the group serving in between with President Obama's Council of Economic Advisers. He was a co-author of this fluff piece promoting Obamacare that appeared in the Annals of Internal Medicine and will be long remembered for this incredible quote; "It (Obama care) guarantees access to health care to all Americans."
While it has become dogma that the obese increase health care costs because of their increased incidence of such things as heart disease and arthritis and that by mitigating obesity there will be cost savings ,one should be aware of a attractive counterargument .Simply put that argument is that the obese will die at a younger age and therefore it is at least logically possible that they will consume less health care service overall. This is exactly what this article from Dutch authors concluded based on a series of simulation mathematical model scenarios. Here is a quote:
As with all mathematical models such as this, the accuracy of these findings depend on how well the model reflects real life and the data fed into it. In this case, the model does not take into account varying degrees of obesity, which are likely to affect lifetime health-care costs, nor indirect costs of obesity such as reduced productivity. Nevertheless, these findings suggest that although effective obesity prevention reduces the costs of obesity-related diseases, this reduction is offset by the increased costs of diseases unrelated to obesity that occur during the extra years of life gained by slimming down.
Over ten years ago I did some consulting to a large intentional petrochemical company. One day a group came by hawking their employee wellness packet .After their presentation, a Human Resources manager asked will not their pension expenses go up if we keep future retirees healthy longer. A refreshingly honest presenter said yes- that was probably so and added that the best thing for a pension plan would be for employees to be healthy productive workers, then retire and die the next day without a prolonged expensive illness .Of course we would never want to do that.
So if cost to "society" is behind the movement to fix the obesity problem maybe we should at least keep the topic on the drawing board even if anti-obesity advocates aren't ready to consider going back to the drawing board.
A public health initiative that improves people's health is a goal many would support but the claim that prevention necessarily saves money is one that is based more on faith than sound empirical evidence.
The first time I came across this general thought was when I was discussing a case with a psychiatrist to whom I had referred a patient I thought might be chronically depressed.He said she was not depressed but in his view she was just a very unhappy person. I can't recall if he then proposed to treat her with the antidepressant flavor of the day or just talk her out of being unhappy or what.
While non psychiatry medicine which I will refer to as "real medicine" (somewhat tongue in cheek) sometimes uses a symptom counting method of diagnosis ( e.g use of a number of symptoms in the a major or minor category to reach a diagnosis) it has the cognitive luxury of being able to rely on physical findings, imaging techniques, sometimes fairly definitive blood tests and often definitive biopsy results.
However, our psychiatry brethren- as best I can tell as an outsider- depends on a symptom counting based diagnostic paradigm outlined in excruciating- to- read- details in the powerful DSM. For example,if a patient has five out of the nine official symptoms of depression over a two week period then they are diagnosed with major depression.Apparently for a while there was a "bereavement exclusion" for depression diagnosis but with the newest classification that has been removed, exemplifying how fluid the definition of a given disease can be.This descriptive diagnosis system was heralded as a marked improvement over the situation in the old days in which psychiatrists of different psychoanalytic schools would differ as to the diagnosis of a given patient.
Symptom listing,counting and matching was considered more scientific and importantly became available to non-psychiatrist physicians ( or any clinical health care provider). With a check list type diagnostic paradigm generally available and multiple psychiatric drugs being promoted by big pharma, primary care docs might conclude that "this psychiatry stuff is easier than I thought" and I suspect many did.Numerous dinner CMEoid sessions with primary care docs featured as the "thought leader"showing their fellow PCPs ( and NP and PAs) that psychiatric diagnoses were not something to be afraid of probably paid off for the sponsoring drug companies.
Friday, January 21, 2011
New taxes kick in in 2013 for households with incomes over 250K ( 200 for a single filer); a 0.9% wage and salary tax and a 3.5% tax on some investment income.The article's authors walk the reader through what happens to families in three income ranges and oddly enough those in the middle of the three ranges are taxed more than the higher range group for an increase in their income, as might occur if one of the two spouses receives a job promotion or work extra. Nothing like a good partially regressive tax to sock folks in the face with some some hard hitting anti-productive social justice.Readers might recall that after PPACA was signed, we were told by Senators and some medical organizations ( you know who you are) that social justice was served.
A broader analysis of taxes and PPACA is offered by the Harvard economist,Greg Mankiw. His plan to decrease the deficit is for the government to give him one billion dollars and increase taxes by three billions.This reduces the deficit by 2 billion. He then relates this scheme to the arguments made about PPACA.
"Healthcare reform, its advocates tell us, is fiscal reform. The healthcare reform bill passed last year increased government spending to cover the uninsured, but it also reduced the budget deficit by increasing various taxes as well. Because of this bill, the advocates say, the federal government is on a sounder fiscal footing. Repealing it, they say, would make the budget deficit worse."
Professor Mankiw, in a more serious moment, refers readers to this article that explains how repeal of PPACA will not increase the deficit.That a repeal will increase the deficit is the latest argument from some of those who continue to support PPACA, the social justice argument getting a bit stale,now that the bill is passed and we are finding out what is in it.
Thursday, January 20, 2011
My hunch is that both would have much less trouble with that question when they were in their Internal Medicine training programs. ( in fact Dr. RW made that point in his commentary ).
I know I had little doubt about what an internist was and what an internist did when I was a resident in IM. An internist was someone who was respected and called upon to deal with the diagnosis and management of complex medical problems and of critically ill patients. That was what a general internist did.General practitioners would consult with an internist for difficult cases and their expertise and knowledge was respected by both the GPs and surgeons.
Major changes in medical practice has brought about the current ambiguous nature of the internist's identity.
The general internist's role has been bifurcated into an office doctor and a hospitalist, with a rapidly decreasing number of internists playing both roles. While the hospitalist role more closely resembles the internist of 30-40 years ago the office internist is becoming harder and harder to be distinguished from the family practice physician.They both spend a significant part of their day doing preventive medicine,an activity particularity suited to guidelines and flowsheets and readily adaptable to delegation to nurse practitioners and physician assistants and likely ultimately to NP assistants or PA assistants.
The family practice physicians has evolved from the GP s of years ago and while the GPs were a source of referrals to the internist the Family Practice docs are more often than not competitors in the fairly recently defined world of what has become to be known as "primary care practice" . Both FP and IM docs will face more competition from NP and PAs if and when Obamacare plays out as demand from the number of insurance card carrying patients increasingly outpaces the supply of FPs and general IM docs and likely NPs as well.
The earlier version of the internist practiced in a very different world. He took call at night and would go to the hospital to see his patients in the ED and if they had problems in the hospital and some went to nursing homes.
The modern version so often now signs out at five o'clock with a telephone answering device informing the caller to call back during regular hours or if "an emergency" go to the Emergency Department.
I found the following paragraph from Dr RW's commentary as on target as it is depressing to someone who spend many years training to be an internist and more years practicing internal medicine as it used to be and now watching it change almost to the point of being unrecognizable.
The American College of Physicians slogan “Doctors for Adults” is unfortunate because it defines Internal Medicine as Family Practice without Pediatrics. This view has led to a proposal, published in the Journal Academic Medicine, that IM and FP be merged. It would mean the dissolution of general IM as a specialty. It's little wonder so few trainees want to go into general IM anymore. Who in their right mind would sign up for a specialty that's slated for dissolution in the next decade.
I know I would not.
Wednesday, January 19, 2011
AND this entry from the same blog gives some very revealing insights as to who can get what from electronic medical records.Hint- it won't always be the patient or the physician. Dr. Scot Silverstein deserves much credit for his seemingly untiring efforts to educate us all about some of the really harmful ( and hypocritical) things going on in the EMR business.
Monday, January 17, 2011
See here for the entire column.
Will says in part:
"The eclipse of Congress by the executive branch and other agencies is Congress' fault. It is the result of lazy legislating and lax oversight. Too many 'laws"actually are little more than pious sentiments endorsing social goals-environmental,educational,etc.-the meaning of which are later defined by executive-branch-rule-making."
The "etc." could well include the recently passed health care bill. The phrase "the Secretary (of HHS) shall determine" occurs repeatedly in the bill.If ever the phrase " the devil is in the details" applies it is in Obamacare.
Federal bureaucrats will write the rules that will be the very essence of the program. Congress endorsed a social goal ( health insurance for all-well, all but some 14-23 million, depending on whose estimate you believe) and abrogated the defining details to various federal agencies .
Will points out that the Federal register is a more important guide to governance than is the Congressional record.
To describe the belief that health care in this country will be improved by thousands of federal regulations patched together by scores of agencies, each subject to lobbying pressures and the risk of regulatory capture, requires a modifier stronger than the word "panglossian".
Sunday, January 16, 2011
Several clinical research papers concluded that a number of children recovered from AOM without antibiotic treatment and seemingly without sequelae. Those findings were amplified by a couple of meta-analyses which derived the number needed to treat with antibiotic (NNT) and claimed that at least 7 children need to be treated (NNT) to shorten the illness of one child.
Perhaps encouraged by policies regarding antibiotic treatment in Europe and the growing concern about bacterial resistance caused by widespread and at times imprudent antibiotic use, several medical professional bodies issued guidelines that said antibiotics need not always be given to a child with AOM.
Now, two articles in the January 13, 2011 issue of NEJM present evidence from which one may reasonably conclude that antibiotic treatment is a good thing after all.An accompanying editorial supports a pull back from the current guidelines. The editorialist and authors of at least one of the two NEJM articles point out serious flaws in the clinical trials which lead to the current guidelines including ; imprecise criteria for the diagnosis of AOM,inclusion of children with minimal disease,ambiguous endpoints,small sample size and improper choice and dosing of the antibiotics used.
If the trials were as poorly done as implied about you have to wonder how repacking them in the fancy wrapping of meta-analyses strengthened the argument that lead several medical organizations to recommend a watchful waiting approach to AOM.A meta-analysis is only as good as the underlying studies that are included in the data set. I have repeatedly argued that meta-analysis should not rest at or near the top of the hierarchical structure of doctrinaire Evidence Based Medicine.
The specter of antibiotic resistance or rather the concern over the resistance may have played a role there. It is interesting that in regard to the treatment of AOM, it seems that resistance has not actually become a major factor.Apparently there has been a unexplained shift in the bacteria that cause AOM.Previously beta-hemolytic streptococcus was the major player and now the less invasive Hemophilus influenza ( H.Flu) and Moraxella catarrhalis are more common.
Although dissenting views were offered in 2003 by Dr. E.R. Wald ( one of the authors of one of the two NEJM articles) from the pediatrics department at the University of Pittsburgh in 2003, both the AAP and the AAFP issued guidelines in 2004 recommending initial observation in some cases ( described as nonsevere) rather than immediate treatment with antibiotics.Other groups joined the parade as well.
It will be interesting to see if these two publications lead to changes in recommendations and if so how much of a lag time there will be.
Monday, January 10, 2011
Does the increase represent myocardial cell necrosis or could the increase be due to "leaky muscle membranes" also known as "cytosolic release". The authors of this recent article suggest the second mechanism may be responsible. I hope they are right as I have not given up running marathons just yet. See here for an abstract of that research.
A 2009 paper by Knebel et al investigated biomarkers and echocardiographic changes in 28 older marathon runners ( aged 60-72) and found no changes suggestive of systolic dysfunction but confirmed the finding previously reported of transient right ventricular diastolic dysfunction.These changes were no different from a group of younger marathoners. See here for abstract. So at least here the older runners were no worse off.
A 2002 paper by Shave,RE et al reported left ventricular systolic and diastolic dysfunction in 11 bikers after a 2 day mountain bike marathon.See here for abstract.
Twenty-seven athletes were studied with echocardiography after what was described as a ultra-endurance triathlon. In all, right ventricular dysfunction was demonstrated and while LV ejection fraction was normal and unchanged in most . However,in the 7 who demonstrated post exercise LV wall motion abnormalities there was a decrease in average LVEF from 57.8% to 45.9%. The authors described also that the "integrated systolic strain decreased from 16.9 to 15.1." I have no idea of the significance of that index nor if that degree of decrease mean anything.See here for abstract.
More elaborate cardiac echo testing was carried out on twenty 2003 Boston marathon finishers pre and post race and one month later. They used regular TTE (trans thoracic echo) but in addition used a technique called "spectal and tissue doppler (TD"). While systolic ejection fractions were unchanged, TD derived indices of LV and RV systolic function were said to be abnormal with at least some of the diastolic dysfunction indicators remaining abnormal one month later.See here for abstract.
Neilan and co workers published detailed results from extensive echo and biomarker studies on 60 finishers of the 2004 and 2005 Boston marathon. See here for full text. They reported elevations in cTnT and NT-ProBNP and similar echo findings to those reported in the previous article from the 2003 Boston marathoners.They noted more marked changes in biomarkers and echo changes in the group who trained less ( less than 35 miles per week in preparation for the race .) So maybe the better trained runners were less susceptible to whatever it is that long events bring about with heart function which is also suggested by the following reference.
A slightly optimistic note is sounded in this paper which describes echo findings of dysynchrony only in first time participants in a long distance event and not in more experienced distance runners and that a predictor of the echo changes was the type of ACE gene polymorphism.
More recently, a review also expressed an optimistic,reassuring note while a rebuttal letter to the editor offered the opposite view proposing the term " exercise induced right ventricular dysplasia" suggesting that the elevation in troponin post endurance events actually reflects tissue death and not just leakage. Both views lack the support on longitudinal follow up data. See here for the two letters.If troponin elevation does signal cell death would we see some type of clinically apparent cardiomyopathy in older endurance event participants after years of beating up their hearts or perhaps myocardial fibrosis noted on autopsy. I wonder if anyone has investigated cardiac function or reported autopsy data on the prolific running Tarahumara Indians.
At least so far there do not seem to be cases of what might represent endurance exercise induced cardiomyopathy.
Thursday, January 06, 2011
He discusses three commentaries on the same broad subject, two by physician bloggers and one by a health care insurance industry executive. The physicians are Dr. Richard Fogoros, aka DrRich of Covert Rationing Blog and Dr. Scot Silverstein of the blog Health Care Renewal and of another blog devoted to issues involving medical information systems.see here.
The important message ( there are other messages as well and all three blog entries are well worth reading) from these blogs is best summarized by a concluding paragraph from Dr. Perednia;
Together these articles cover an enormous amount of ground, but the central message is that we’re making a big mistake if we think that coercing our doctors into using expensive and complex information technology and following the edicts of centralized “panels of experts” is going to get us where we want to go as patients. These are the obsessions and grand managerial plans of people who really don’t know much about doctors, patients and the real-world of delivering and receiving healthcare services. People in government bureaucracies, insurance companies, think tanks and academic medical centers, whose livelihoods depend upon claiming to be smarter, better informed and more creative than clinicians who actually deliver the care. These regulators and technocrats have now been in charge and working their will on healthcare for over 20 years.
Saturday, January 01, 2011
One case in point was elucidated in this commentary by Reason Foundation Senior Policy analyst,Shika Dalmia. She tells the reader about something called the "exchange recapture subsidy".
Under this provision, the government will go after low-wage families to return any excess subsidies they get under the Patient Protection and Affordable Care Act...
When the government hands out subsidies, it will use a household’s income in the previous year as the basis for guessing what the household is qualified to get in the current year. But if the household’s income grows midyear, the subsidy recapture provision will require it to repay anywhere from $600 to $3,500, compared to the $450 that the law originally called for.So, if a poor working family manages to somehow increase its income higher than the number which the government guessed to be their income for the purpose of handing out a subsidy they are hit with higher taxes with the result being that the marginal tax rate on their incremental gain in income is insanely high. If much or most all or economics is about incentives, what will that do to efforts to move up to the next level of income.
In the interest of fairness, it has been pointed out (see here) that this recapture mess was apparently added on to the last minute doctor-fix in an effort to scrounge up money to help pay for the subsidies and was part of an amendment authored by Republicans. So, maybe Obamacare set up the subsidies and Republicans tried to help pay for it and that was enacted by a legislature nominally controlled by Democrats and made it even worse. In any event, it is a bad deal thanks to those darn unintended consequences. Central planning might not be as easy as its advocates claim.