More worrisome news about hazards of long term marathoning

I have written before about the troubling reports of certain test results following endurance events.

There is evidence that in the early hours after a marathon or an Ironman type triathlon there sometimes are elevations of troponin in the range seen in myocardial infarctions.There are also reports of echocardiographic changes that could be described as cardiac "fatigue". The changes are those of altered relaxation characteristics and a decreased contractility all of which, along with the elevated troponins returned to normal in 48 hours.There is the hope that all of this is just analogous to the sore leg muscles and raised total CK values that remit in a few days and is of as little consequence but there may be more to it that that.There is at least one report of some of the more subtle echo changes persist at least for one month after a race.

One post marathon study suggested that the above mentioned abnormalities were less marked in the better conditioned runners and another paper found the alterations more likely in first time runners versus more seasoned veteran marathoners. See here for my earlier blog entry discussing some of the issues involved in assessing the harm or absence thereof in marathoners.It should be noted that not all runners show the echo changes and there is a suggestion that the type of ACE gene pattern may play a role in that.

Well,all of the above really address the issue of over use damage that certainly is at least acute and some worry may lead to long lasting permanent cardiac damage, i.e. myocardial fibrosis or an endurance exercise induced cardiomyopathy.

Now for something completely different. There is a report suggesting that many years of marathon running may increase (not a typo) the risk of coronary artery disease at least as possibly indicated by increased coronary artery calcification.This seems counter intuitive as conventional wisdom tells us that exercise may decrease the risk of coronary disease but could this be an instance of " too much of a good thing".See here for that study.

Drs Robert and Jonathan Schwartz reported on a CTA (Coronary Computed Angiogram) study that involved 25 runners who had been running in the 26.2 mile races for 25 years or more and had completed 25 or more marathons.They found a statistically significant increase in calcified coronary plaques and an increase in non-calcified plaques that did not reach the level of statistical significance as compared with 25 controls.

If Health care planning is like green energy planning, hold on to your seats

In this article in Investor Business Daily we see how well government planning is working out in the Green area.

Here is in in a nutshell. The government gives a 527 million dollar loan guarantee to a solar panel manufacturing company whose business plan worked out badly and the company went broke.Now the employees have applied for a government funded jobs retraining program to cost another 14 million dollars.

On the one hand we have the government tossing away half a billion dollars on a company who was not viable in the market and on the other we have the government raiding and closing down ( hopefully only temporarily) a company on the basis on vague foreign laws.See here for DrRick's take on the Gibson Guitar Company raid by the Fish and Wildlife police and how that exemplifies the principle of Regulatory Speed Trap.

And speaking of regulations,it makes one feel warm and fuzzy and very secure to know that hundreds ( thousands ?) of government technocrats are working on the details that will give ambiguous and flexible operational meaning to the hundreds of pages of Obamacare. Yes, the very same government that gave us Solargate and raids a viable US company for using the wrong kind of wood is busy at work finishing the details that will shape health care for the country.What could go wrong with that??

Medical decision making moves to Washington

Every time I re-read a section of Thomas Sowell's Knowledge and Decisions I am more impressed with how brilliant it is,how filled with insights and how well written .

A central theme of the second half of the book is described by Sowell in this way: (my bolding)

Even within democratic nations,the locus of decision making has drifted way from the individual,the family and voluntary associations of various thoughts and toward government.And within government, it has moved away from elected officials subject to voter feedback,and toward more insulated governmental institutions, such as bureaucracies and the appointed judiciary.

The ACA (Obamacare) represents a major shift in the locus of decision making regarding medical care. One could consider Obamacare the poster child for that concept. Of course, the locus has already been shifted to a major decree away from the the individual physician and individual patient ( the "dyad" in Don Berwick's quirky terminology ) by the hegemony of third party payers and the virtual single-payer status of government finance health care administered through CMS (Medicare and Medicaid).


A major theme of the first half of his book is the following. One should analyze the decision making processes of institutions in terms of the incentives faced,the constraints in place and the likely outcomes and  whether the decision makers are immune from  or influenced  by  feedback mechanisms .Do not look at the "hoped for results" or the mission statements but rather at the mechanics of the decision making process.

Consider those mechanics in the context of ACA and how the myriad details which will make the lofty goals operational will be determined. Various governmental agencies and panels will deliberate and churn out the pages of rules and regulations that physicians and patients will have to live with. For the most part these rules makers will be immune from meaningful feedback but they will will not be immune to lobbying efforts by various special interest groups during the rule making process.

Consider the mechanics of the Independent Payment Advisory Board ( IPAB) and how decisions will be made by its fifteen member presidential appointed panel and how lobbyists for various special interests will target this group and likely their efforts will be proportional to the power that IPAB has been given.

Addendum: Minor stylistic changes made 9/25/14

Victor Fuchs solves the "doctor's dilemma"-appropriate care is cost effective and ethical too

Victor R. Fuchs,Economics Professor Emeritus at Stanford, wrote a Perspective commentary in the August 18,2011 Issue of the New England Journal of Medicine entitled: The Doctor's Dilemma-What is "Appropriate" Care ?

The dilemma he describes is the following;

"How can a commitment to cost-effective care ( as physicians have been "committed" to that since the Physician charter and the New Professionalism) be reconciled with a fundamental principle of primacy of patient welfare"


Fuchs tell the readers if all the physicians in a given health care collective practice (as in HMOs and now Accountable care Organizations) cost effective medicine the resources saved can be used for the benefit of the defined population which includes the patients of the physician who seemingly may face a conflict. So, if all the physicians act in the same way all patients benefit.

I believe Fuchs conflates the good of group as indicated by some aggregate number with the good of each individual in a particular situation in which a particular individual may not enjoy the benefit and may actually be harmed. In fact cost effectiveness analysis involves aggregate data. With any outcome in a group some may benefit some may be harmed.

In his closing paragraph, Fuchs tells us that when a physician works in a health care collective in which there is a fixed annual budget the physician resolves the dilemma by favoring the cost effective option. This according to Fuchs become "appropriate". ( Why does Fuchs use quotes marks?) So,the cost effective choice is the appropriate choice and also the ethical one. It is ethical in the moral calculus of Kant "because if all physicians act the same way,all patients benefit" .

The basis of Kant's ethical precepts was the categorical imperative which is:

"Act only according to that maxim whereby you can,at the same time, will that it should become a universal law."

In other words, a person acts morally when he acts as if that conduct were establishing a universal law governing others in a similar situation.


I find it interesting and puzzling that Fuchs uses a Kantian based ethical argument to support cost effectiveness based decisions in health care as cost effectiveness analysis is typically justified using a consequentialist type argument. Philosophical support for the notion of resource allocation based on the best bang for the buck is supplied by this outcome based school of ethics.

Kantian ethics, on the other hand, is duty or rule based ,an approach called deontological in the literature of ethics.Kant believed that the individual should be considered an end in himself not as a means to an end. In the medical collective the individual's interests are subjugated to the aggregated good of the group;the individual functioning as a means to achieve the greater good of the collective whether or not a particular member of the collective enjoys the benefit.

In the moral conflict between the physician's fiduciary duty to do what is right for the individual patient and the imperative to serve the best interests ( by what ever aggregate parameter that is being used) of the group as a whole, would not Kantian rule-duty based ethics support the rule of do what is best for your patient and patient is a singular noun. If Fuchs is suggesting that cost effectiveness analysis should be determinative in medical decisions and that it is justified by Kantian ethics, I suppose the "rule" would be always do what is cost effective.Never mind that pesky notion of a person being considered an end in himself and not as a means.

Once again price control in medicine results in shortages,this time cancer drugs

There has been and continues to be shortages in some of the older well proven cancer drugs. See here for an explanation of what is happening there.

Dr. Ezekiel J. Emanuel blames much of the problem of the 2001 Medicare Prescription Improvement and Modernization Act.

Here is a quote from Emanuel's opinion piece in the August 6,2011 NYT Sunday Review:

The act had an unintended consequence. In the first two or three years after a cancer drug goes generic, its price can drop by as much as 90 percent as manufacturers compete for market share. But if a shortage develops, the drug’s price should be able to increase again to attract more manufacturers. Because the 2003 act effectively limits drug price increases, it prevents this from happening. The low profit margins mean that manufacturers face a hard choice: lose money producing a lifesaving drug or switch limited production capacity to a more lucrative drug.

The economist Arnold Kling is fond of saying that they teach all the important stuff in Econ 101 not saving any big secrets for more advance study.I'm fairly sure Econ 101 explains the effects of wage and price controls and that incentives matter.

Aggregate Healthiness, Gross Body Health,Keynesian Medicine

I have ranted and sometime more reflectively argued quietly against the morality of the aggregate as it applies to medical practice. Rules,pay for performance (now re branded as value based purchasing) rely on the statistical aggregates and often overly simplified guidelines. I know, aggregates can be useful in a number of contexts but the individual patient ( what other kind of patient is there?) may have her interest devoured by obsession with rules based on the statistical abstractions.

Here, George Mason Economist,Don Boudreaux, tells a satirical tale about a medical analogue to Keynesian aggregate demand.

No, the fictional gross body health is not exactly what I argue about with the guideline-P4P thrust in clinical medicine but Boudreaux's commentary is worth reading.

MIT Prof discovers people like to spend other people's money

Amy Finkelstein,a PhD economist from MIT,has "discovered" that people when given a card that lets them buy something cheaper than they could otherwise buy more stuff. Thanks Dr. Michel  Accad at the blog, Alert and Oriented,for calling this discovery to my attention.

This link from a news story on the discovery briefly discusses her findings and the mind boggling claim that this finding will change thinking about health care spending. Yeah, it is that old
"demand curves slope downward" thing again. Note: this is not breaking news as her report and news items on it date back to 2007 but I have fallen way behind on my health wonk literature reading.

Here is a quote from the news report:

Already, Finkelstein's analysis is shaking up views across the political spectrum. "This is pathbreaking work," says Joseph R. Antos, a health economist at the conservative American Enterprise Institute. Adds the more liberal MIT economist Jonathan Gruber: "This really changes the whole landscape in the way we think about health economics." 

Wow! The economist ( Gruber)  who advised in regard to Romney-care and Obamacare seemingly was unaware that people tend to buy more of something when it costs less.

Wow again,  path-breaking work.Apparently no one heard or remembered what Milton Friedman had said about the ways people can spend.See here for that concept in Dr.Friedman's own words.The key point here is that when you spend someone else's money on yourself , you are not very careful about how much you spend.

Dr. Finkelstein work supports the notion that health care costs have increased in no small measure because millions of older American have Medicare insurance and they realize that they can get medical services much cheaper than otherwise when they show their card to various health care providers. The fact that some health care wonks thought her findings will change the way people will think about health care policy seems to mean that until now some health care experts believed that demand curves slope upward. Some admirers of Milton Friedman are celebrating the 99th anniversary of his birth. See here. Maybe health care economists might browse through some of his work.Perhaps an econometric demonstration of the absence of a free lunch might be forthcoming.


Addendum: 11/12/14 Minor changes  made re style , spelling  and one factual error in regard to Dr. Accad's first name.

Health Care and Education-the new "commanding heights -"Kling and Schult

An interesting and insightful commentary by Arnold Kling and Mick Schult is found in the Summer issue of "National Affairs" and is entitled "The New Commanding Heights".The title is a play on the title of the book by Daniel Yergin and Joseph Stanislaw "entitled "The Commanding Heights:The battle for the world economy". See here for the Kling essay.

The term Commanding Heights was used by Lenin in a 1922 speech in which he refers to the dominate industries in Russia at the time indicating that they would be target of the central control of the communists. He gave up trying to control everything so he decided to control the key industries.These included heavy manufacturing,mining,electric generation and transportation.

Kling and Schult contend that those industries are now largely not controlled by the state in the United States and in western countries generally and while these sectors are important they present data showing they are no longer the major growth sectors in our economy.They argue convincingly that education and health care are the growth sectors in the United States.

History has made it clear that markets work. Market economies lead to prosperity,economic growth and innovation while central planning results in dismal and often tragic failures. Lenin promised to do what capitalism did plus eliminating waste, recessions, and inequality:what was produced was mass starvation and mass murder.

However, the authors warn markets advocates against premature celebration. Their thesis is that in the U.S., both in education and medical care, the new commanding heights, governmental controls are prevalent and growing and if the U.S. is to continues to grow and prosper, we need innovation in these areas? How much innovation occurs in government controlled economic sector?

Many (most?) discussions of the medical economy emphasize the overall
cost" of medical care and its growth ( it is a growth sector) and that it is a bad thing. Two comments are appropriate: 1) often overall costs are conflated with government costs ( i.e. Medicare and Medicaid) with overall costs 2) Costs are only one side of the accounting, one person's costs are another's income stream.

Controlling the amount of money that the government spends on health care or farm subsidies or foreign wars is one thing and is well within legitimate government activity, attempting to limit private spending on healthcare or cosmetics or anything other legal activity is quite something else.So with GDP not snapping back to previous more healthy levels do we really want to decrease activity in one of the two major economic growth centers?

Surprise-economic principles apply to old folks and Medicare costs

See here for a report on some data gathering that should be filed under the heading of "very bloody obvious". The link is to the 7/16/2011 blog entry from Dr. Mark J.Perry which tells us 1)Medicare utilization is about 50% higher than private health insurance utilization and 2) why Medicare patients see their doctor so (too?) much. Hint:it has something to do with spending someone's else money and the law of demand.

Economists are fond of saying "demand curves slope downward" which is their jargony way of saying that people buy more when the prices is lower and less when it is higher. Milton Friedman has been quoted as saying that economics is simple- just remember there is no free lunch and demand curves slope downward.

Economists ,for some obscure reason possibly found deep in the history of their discipline, place the dependent variables on the X-axis and the independent variable on the Y-axis. This is just the reverse of the practice of physicists and engineers and most other people who like to draw graphs. So they place price on the Y axis and quantity demanded on the X axis and thus the demand curves slope downward because folks buy more when the price is cheaper.

Medicare patients "buy" more health care because of the way Medicare works they get a really good deal on the price that CMS allows to be charged. It gets better, Medicare generally pay 80% of a significantly lower "allowed price" and many seniors have supplemental insurance which further amplifies the illusion of a free lunch.So,of course,Medicare users utilize more services and the reason is not that fee-for-service doesn't work. Blaming fee-for-service is the current battle cry on many in Congress and many of the organizations who allegedly represent the practicing physicians.

Some would conflate fee-for-service with free markets in medicine but there has been no free market in medical care for many years now (except for a few markets such as lasik surgery and some plastic surgery and much of alternative medicine) and the Medicare system is characterized by price controls and the demand side characterized by folks buying services with someone else's money,both of which are the products of central planning. What could possibly go wrong with that circumstance?

The list of problems in medical practice are not due to fee-for-service but rather what happens in a nominal fee-for-service setting when there are price controls namely shortages,long waiting lines,poor quality and various other forms of rationing by other than prices.As is often the case, the results of central planning are blamed on that heartless,run-away greed all the way down, free market.And as is also often the case the solution is more central planning,which is what Obama care is all about.

More on IPAB and the risk of regulatory capture

See here for a recent report on views of the IPAB.

Particularly interesting were comments of someone who has been there and done things in the setting of a very important and powerful governmental appointed post.

Bruce Vladecks, the former head of CMS under Bill Clinton, had this to say :

"In the short term, it might theoretically work," he said. But the history with other independent regulatory agencies, like the Interstate Commerce Commission and the Civil Aeronautics Board is that over time "the regulated industries tend to capture them; and they tend to do more to protect the regulated industries than they do to protect consumers."


Considering the legislative hurdles that Obamacare put in place for Congress to over ride the edicts of IPAB, capturing IPAB would be prize well worth capturing.

What is the moral case for Obamacare?

Is there one at all?This commentary by the economist John Goodman argues there is none. After Dr.Goodman made his case he invited readers to offer such a moral justification.I could find none in the forty reply to his article.

Several commentators ( including spokesmen for the ACP and the AMA ) claimed that Obamacare furthered social justice. So could that be the moral justification for Obamcare?

In regard to social justice Thomas Sowell said the following:

Their passionate arguments for particular results tend to obscure or distract attention from the question of the social processes by which these hoped-for results are to be pursued.


Goodman,in this most recent cited commentary, and in numerous others posting on his blog gives great detail of the various social process set in motion by Obamacare and the numerous apparently unintended consequences

In short, the various elements of this outlandish long bill do just about anything other than the putative hoped-for results which is "affordable , accessible health care for all" and instead offer a mind boggling array of counterproductive results and bizarre inequities and the frightening promise that many more such dystopian outcomes will arise from the hundreds ( more likely thousands) of pages yet to be written by agencies created by Obamacare and the incredible discretionary powers given to the Secretary of HHS.

Perhaps,spokesmen for the medical organizations who champion (yes, they still support it in spite of the increasing evidence that the bill is a very bad idea) can offer a moral justification .

Meta-analyses-money well spent?

I have blogged more than once ( see here and here )about meta-analyses (MA) and quoted Steve Goodman MD PhD more than once when he said that MAs are just observational studies in which the observed elements are studies. I would add and we just don't know what went on behind the curtain.

They are not super randomized trials as the prefix "meta" might imply but should rightly reside significantly under RCTs in the hierarchy of clinical research methods.

Since the views expressed conform nicely with my biases I was drawn to this commentary by Dr Wes.

"Wise Legislators " pass ACA with IPAB,their "good deed"

Henry J.Aaron,of the Brookings Institute, has written three commentaries in the Perspective section of the NEJM in the last year. He seems to be their go-to guy for IPAB issues.Here is a link to his latest.

He praises Congress for their willingness to "abstain from meddling in matters they are poorly equipped to handle." He seems to be aware of Public Choice theory (he has a PhD in Economics from Harvard) when he talks about the temptation of Congress to spend money for political ends but seems to have missed the point when he apparently assumes that the IPAB panelists would be immune to lobbying efforts.Clearly, he believes it is a good and desirable thing for Congress to delegate its powers to agencies and other bodies- a view somewhat in opposition to how James Madison thought things would work out.

This is in stark contrast with the friend of the court brief that the Pacific Legal Foundation has filed to challenge the constitutionality of the creation of IPAB. See here for their comments on IPAB and a reference link to their brief challenging IPAB.

Aarons likens the creation of IPAB to the creation of the Federal Reserve which was to be an entity not subject to congressional control.

This may not be the best analogy with the increasing efforts of Congress (and not just Ron Paul ) to at least exert some surveillance of what the Fed does.

July 4th, all about the right to vote or much more than that?

This commentary from the Coyote Blog is good fourth of July reading.

Warren Meyer,a libertarian entrepreneur and prolific writer, who writes the blog as well as being a contributor to Forbes list three principles more important than the right to vote. Here is the first one he discusses:


"The Rule of Law. For about 99% of human history, political power has been exercised at the unchecked capricious whim of a few individuals. The great innovation of western countries like the US, and before it England and the Netherlands, has been to subjugate the power of government officials to the rule of law. Criminal justice, adjudication of disputes, contracts, etc. all operate based on a set of laws known to all in advance and applying equally to all."

Meyer then points out the obvious contempt for the rule of law with the exemptions to certain provisions of the health care law .

More of the "social justice" fallout from ACA

As more and more inequities and unintended consequences of Obamacare are revealed as we learn more and more about the bill,we can see that the social justice Obamacare advocates (you know who you are )boasted about following its passage is a very strange type of justice.

See here for one of the latest revelations about how basically unfair various aspects of the bill turn out to to be. As the AP article explains two families with same income would pay significantly different health insurance premiums to the exchange based on what type of income they receive.This problem seems to be tied to the definition of income used in the statute.

But it gets even worse, more folks become eligible for Medicaid based on the law's wording.

Medicare's top number-cruncher is warning that up to 3 million middle-class people in households that get at least part of their income from Social Security could suddenly become eligible for nearly free coverage through Medicaid, the federal-state safety net program for the poor. Chief Actuary Richard Fosters says that situation "just doesn't make sense."

The progressive mind set worries about inequality just about everywhere

See here for David Henderson's remarks about a commentary from former white house adviser and Director of OMB and now VP of global banking at Goldman Sachs.Peter Orszag.

Here,Orszag worries that high tech advances will worsen the gap between the rich and poor in longevity. The various (endless?) parameters that can be used to illustrate the fact that the rich and the poor are different is many ways provide much source of professed worry and endless calls to action from the progressives.

His move to Goldman Sacs should do much to insure that he will be at the top of that gap so that any "solution" to this problem must involve raising up the poor and not lowering the rich although his commentary seemed to offer no practical solution to this worrisome gap .

We will never run out of gaps.Market economics is the engine of prosperity and also the engine of inequality according to Milton Friedman.

There is a body of literature and discourse which emphasizes the notion that inequality is a major problem in the western world, as least in the U.S., and the inequality per se is bad and harmful and therefore there should be continuing policy efforts to shrink the gaps. Here is a well reasoned counterargument to that notion.

Platonic Medicine and the ACA with its IPAB

 A recent commentary by one of favorite bloggers,Dr. Robert Centor, spoke favorably about IPAB, one of many,many provisions of ACA.See here.I made a brief reply to his entry. I recalled this earlier blog entry and if Dr.Centor's comment stirs up much furor  I want to add this earlier blog post to the kerfuffle.Originally published  6/22/11 and now submitted with little editing.

I had been sketching out some comments about what I was going to call "Platonic Medicine" referring to the "leaders with ideas" who will lead the way to transform medicine based on the underlying premise that "medicine is too complex and important to be left to the individual physician and the individual patient" and therefore it should be controlled and directed by the wise medical elite who will determine the collective utility of a given approach and its value.I have commented before about Don Berwick's advocacy of that view.

However, someone had written something in that regard better than I could.See here.

Hat tip to the Pacific Legal Foundation who filed a friend-of-the-court brief to challenge the constitutionality of IPAB on the grounds of violation of the non-delegation doctrine and for the above mentioned link which alerted  me to Jost's frightening comments.

It turns out that an outspoken advocate and supporter of Obamacare,law professor, Timothy Jost has already praised that legislative act in part because of what the IPAB will provide. He said:

A board of “Platonic Guardians” to govern the health care system or some aspects of it. The cost of health care is spinning dangerously out of control…. [O]ur traditional political institutions—Congress and the executive administrative agencies—are too driven by special interest politics and too limited in their expertise and vision to control costs. Enter the Platonic guardians…an impartial, independent board of experts who could make evidence-based policy determinations based purely on the basis of effectiveness and perhaps efficiency.

Incredibly Jost is asserting that this board will be immune to the influence of special interests and will make decisions rationally and in a proper evidence based manner.From what planet will these board member be chosen? Philosopher kings in charge,what could go wrong with that?

The PLF commentary pointed out that a Platonic government was definitely not what the founding fathers had in mind and Jefferson and associates were not big fans of Plato.

In the commentary that I was considering I thought perhaps calling the panel members Platonic Guardians would earn me the accusation of being overly dramatic and hyperbolic, but now we see an IPAB advocate using the same characterization and believing that to be a very good thing.

Dictating the coverage to control the cost for Medicare and Medicaid may not be enough for the medical Platonic elite as is illustrated by this quote from Dr. Robert Berenson:

"we ought to consider setting all payer-rates for providers." He continues "but the country's antigovernment mood renders such a discussion unlikely,at least for now".

I wonder who the "we" is that Berenson references.

Finally, another chilling quote from Mr. Jost:

"In the long run, Congress may not be able to cap Medicare expenditures without addressing private expenditures as well. If the IPAB opens the door to rate setting for all payers,it may well be the most revolutionary innovation of the ACA".

Yeah, it just might be.

Why is there a shortage of certain drugs?

When faced with a shortage in some good or services a good first guess as to what might be going on is to see if there are price controls at work?

Go here to read a detailed analysis by John Goodman of what factors are at work in the ongoing shortage of over 200 hundred medications. It turns out that at least a contributing factor to the shortage is price controls which are part of a 1992 Federal 340B drug rebate program to certain medical facilities.

Another, perhaps more important governmental factor is at work in the form of the the output controls put in place by the FDA which limits the production of product by drug companies and diminishes their ability to quickly react to market conditions with increased production.

No, price controls are not the entire explanation but government price controls and other regulatory actions impeding market process are playing a role. The situation is more complicated that the two factors mentioned above and some of the other contributing factors are discussed here. But,as the various shortages play out, I'll be it won't be long until we hear that the free market has failed again and more governmental controls are necessary to protect the public.

Peripheral arterial disease (PAD) and smoking, now there is a real relative risk

While I thought there was little doubt remaining about the relationship between cigarette smoking and PAD, a recent study published in the Annals of Internal Medicine (see here for abstract) provided more convincing data, this time in women. Yes, cigarettes are bad for women's peripheral arteries as well.

This study from the Women's Health Study generated some robust, relative risk numbers.I am not talking about the puny 1.2-1.4 relative risks (RRs) we often see in the typical data dredging articles and certainty not the ridiculous RR of 1.01 (not a typo) that was the alleged increased risk of death from vitamin E use.See here for that silliness.

Here are the age adjusted incidence numbers for symptomatic PAD

0.12 never smoked
0.34 former smoker
0.45 smoked less than 15 cigarettes per day
1.63 smoked greater than 15 cigarettes per day

1.63/0.12 =13.6

You are not likely to see RRs greater 10 from the typical data dredge and the WHS data also demonstrated a dose-response effect.

So, how large should a RR be before one worries about it or seriously believes we may have a causal relationship?

Sackett ,of McMaster EBM fame, asked one of the giants of epidemiology that question. Sir Richard Doll said that if the RR were 20 or greater that would be almost sufficient to indicate causality.Sackett was not quite that cautious and indicated that a RR of greater than 3 was "convincing".

Some courts use a RR greater than 2 to reach the threshold of "more likely than not".This is the current level of proof in most tort cases.

Michale Thun, who at the time was vice-president of epidemiology and Surveillance at the American Cancer Society, said:

With epidemiology you can tell a little thing from a big thing.What's very hard to do it to tell a little thing from nothing at all.

With cigarettes and PAD, we have big thing and we will not likely see battling statisticians debating the data. However, we did see that when Nissen's NEJM article claimed a RR of 1.43 for of Avandia and heart disease and we will likely get to see another again with the current breaking news of a RR around 1.4 with Actos and bladder cancer.

Independent Payment Advisory Board (IPAB)-what could go wrong with that?

The IPAB which was inserted into Obamacare at the last minute without anything approaching proper legislative review and contemplation establishes a 15 member panel appointed by the President which will beginning in 2014 ( if a cost limit trigger is met) have unprecedented power to control medical spending in the country with almost no significant or likely effective congressional oversight.

Now what could possibly be wrong with that?

James Madison had some thoughts about that.He was concerned about what he referred to as "factions' which today would be thought of as special interest groups.Special interest groups have developed a potent skill set to influence government bodies to focus benefits on themselves while the cost are diffused.

In general, the founding fathers of the country has some thoughts about what could be wrong with that sort of entity.They tried to design a government not so that wise leaders could do great good but rather one that would limit the damage done by fools,thugs and would be despots who might(most assuredly would) find their way to influential posts in government.

Their wisdom seemed brushed aside as the view of a benevolent and wise government assumed the default position as it was persistently promoted by a cadre of progressive minded academia intellectuals and high school civics texts which visualized a government that would wisely recognize problems,devise safe and effective solutions and then without special favors execute remedial plans marvelously bereft of significant unintended consequences.

Fortunately, James Buchanan and Gordon Tullock resurrected Madisonian wisdom, enlarged upon it and explicated the theory of public choice which basically asserts that government officials and bureaucrats display the same characteristics as other humans, namely a proclivity to look after their own self interest. They definitely had some thoughts about what could possibly go wrong with something like  IPAB.

The economist, George Stigler,who did much to develop the concept of regulatory capture might have some to say about what could go wrong with the IPAB.Governmental agencies and organizations can be subject to the influence of the very groups that they are  nominally created to regulate and control .

Mafia dons and wise guys alike know the explanatory value of the "follow the money" and could explain simply what could go wrong with the IPAB.

Big Pharma had supported the passage of ACA but it is hard to believe that their support would have been forthcoming had they realized what IPAB would be.They certainly recognize the danger now.

The American College of Physicians (ACP) also supported Obamacare but now express opposition to the IPAB section "as written".Although (unfortunately in my view) they do not recommend repeal of IPAB but instead want certain changes that would make the entity acceptable.See here for ACP's position which objects to the exemption of hospitals and hospices from IPAB's edicts until 2019,the absence of primary care physicians on the panel,the lack of a mechanisms for significant congressional oversight and for preserving quality while decreasing costs.

So, much can go very,very wrong with IPAB but it gets even worse. Go here to read a recent commentary by George Will which discusses the chilling thought that the IPAB may not be stoppable. It may well be " entrenched".

Entrenchment refers to one legislative body passing a law that contains provisions that prohibit later legislatures from repealing the law.

Can a legislative body really pass a law that contains a wording to prohibit further changes in that law?Is the IMAB really an immutable entity?

Eric Posner discusses it here and, as best I can translate it from the legal dialect academic lawyers speak into everyday English is that the Supreme Court has decided that they cannot allow that but as with anything that might be litigated there are at least as many sides to the issue as there are interests who can loose or gain from a decision and Supreme Courts sometimes change its mind.

It is hard to find a better summation that the one penned by Mr. Will in his above cited recent column:

"The essence of progressivism, and of the administrative state that is progressivism’s project, is this doctrine: Modern society is too complex for popular sovereignty, so government of, by and for supposedly disinterested experts must not perish from the earth. "

And the corollary for progressive medicine is that "medical care is too important and complex to be left to the individual physician and the individual patient."

minor editorial changes and typo correction changes made 8/17/14.
more corrections made 11/29/14