Notes & Links: October 11, 2013

The court intervenes to save a child with cancer, and Make Adams lose his mind over it
Science Blogs Respectful Insolence examine the of an Ohio Court ruling that the hospital could not force a 10 year old Amish girl against the wishes of her parents to receive chemotherapy. This was later over turned by an Appellate Court. 

This is a longish article and an in-depth analysis of the case, the history, and the response of a one Mike Adams whose argument revolves around quotes like this…

The chemotherapy agents used today are, in fact, derived from the research of Nazi scientists and the chemical conglomerate known as IG Farben, which was later broken up into multiple companies, including Bayer, the modern-day pharma company. For example, the chemo drug thalidomide is actually an off-shoot of Nazi chemical weapons research.
Based on my research into all this, it is my opinion that the Akron Children’s Hospital is engaged in heinous crimes against children

WTF? If you need to get the blood pressure up read this. Or better yet if you want to see how the ignorant can use the internet to drive a message the kills jump to the link above. 

Getting estimated for insurance costs int he exchange, Indiana edition
Arron Carroll at The Incidental Economist looks at window shopping for health insurance in Indiana. I know I know yet another ACA ObamaCare post screaming from their individual position pulpit. Not so fast this is good stuff. Here is the money shot. 

Silver plans for an individual range from $278 to $301 a month (before subsidies). This is far less than what the state released a while ago. For a family like mine, silver plans range from $938 to $1018 a month (before subsidies). What’s more, even the gold plans range from only $1175 to $1329 a month.

Since we know that the average employer sponsored health insurance plan for a family in the US is $16,351, that means the most expensive gold plan on the exchange, at $15,948, is cheaper. Let me say that again: The most expensive plan I could find for a family line mine on the Indiana Health Insurance Exchange is less expensive than the average employer sponsored health insurance plan in the US.

How to cope with an aging population
The Lancet reviews data from Global AgeWatch Index 2013 with recommendations on what this means for the world. Some of their more interesting points are:

  • High-income countries did the best Sweden, Norway for all domains income security, health status, employment, education and an enabling environment. 
  • South Korea was 67th overall though ranked at 8th for health but crap income security
  • Interestingly life expectancy increased by 4.7 years for men and 5.2 years for women from 1991 to 2009. But healthy life expectancy stayed the same overall. So we may live longer but suffer more and cost more. 
  • Elderly patients are excluded from clinical trials
  • Consider the steep upward curve of older population in India, Indonesia, Mexico, and Russia. That population will double in the next 40 years. 

Better data are needed to gauge success (in terms of wellbeing) of interventions to address the long-term needs of an ageing population, and track progress on morbidity compression. Although a promising start, The Global AgeWatch Index was only able to provide rankings for 91 countries, including just seven from Africa. By 2050, more than 20% of the global population will be older than 60 years and 80% will live in low-income and middle-income countries. Success in other medical specialties means that the world’s population is getting old. To allow it to do so gracefully will require early investment and cooperation between health and social care.

CDC MMWR announcement in the face of the lapse in government funding.

Yet another victim of ass clown politicians. 

Academic Medical Centers and the The Coming Physician Shortage
David Kroll a contributor to Forbes is attending the Forbes Healthcare Summit: Empowering thePatient Revolution. The gist of Kroll’s article is large academic medical centers are in congestive areas, no parking, long drives, and dependent on Medicare. Great quote

I’d add that once they do find parking, patients are also frustrated by trying to navigate the complex array of buildings that have metastasized willy-nilly over the history of the institution. What academic medical centers must do, Rothman said, is go to the patient and pay more attention to customer convenience.

struggle with the idea of nice waiting area’s featuring WiFi and Miles van de Rohe designed furniture will not drive outcomes. Though I am in full support of the need to solve problems patients are seeking to solve as in convenience etc. So when Kroll says the following I would agree. It is about market expansion not market gloss

In my home, Durham, North Carolina, Duke University Medical Center has been aggressively opening primary care centers around the area. My walk-in urgent care clinic is barely a mile from my home, has plentiful, free parking, and I’ve never waited more than 30 minutes to see a healthcare provider. That’s the kind of thing that urban medical centers will need to do to remain sustainable.


Notes & Links: October 10, 2013

We’ll Soon Be Buried in Patient Decision Aids
Austin Frakt posting at The Incidental Economist speaks to the potential problems associated with Patient Centered Outcomes Research Institute (PCORI) goal to promote patient engagement and shared decision making. Frakt identifies the problem this way…

In fact, there are two. Think about it: If every comparative effectiveness research (CER) project develops its own patient decision aid we’ll have (a) a ton of decision aids of varying usefulness and in potential conflict and (b) relatively few decision aids that unify the findings of a body of work.
Therefore, we need (a) some way to assess the quality of decision aids and (b) organizations that can integrate across many CER studies to produce more robust and trusted ones

Two points I want to make. When my wife was dx with NSCLC her oncologist did a very simple thing. He drew a horizontal line on a chart note. On the left side he put the word ‘me’ on the right side he put the word ‘you’. He said to her on the line put an X where you want us to work together. All the way to the left I make all decisions all the way to the right you make all the decisions. That is shared decision making at its clearest and most effective. And it drove her patient decision making through discussion and evidence.

The second point is that I believe these decision aids are created based on the goal to position one treatment over another. Albeit based on evidence. What is missing is the determination of what problems the patient wants to solve specific to the disease or treatment they are facing. Patient decision tools should be less about shouting benefit and more about solving the problem the patient is seeking answers to. The tool should present the evidence while speaking to a problem say QOL or survival or cost. If we know what the patient wants to know the tools become effective at decision making.

The Cancer Treatment Centers of America Revisited: From “naturopathic oncology” to Burzynski-like Genomic Testing
ScienceBlogs Respectful Insolence takes an extended and in-depth review of The Cancer Treatment Centers of America (CTCA). I try to steer clear of the long and heavily analyzed posts. I am making an exception here simply because of my personal experience.

Donna was diagnosed with stage IV NSCLC told she had six months to live. We went to a local academic medical center where she received evidence based care that extended that six months to nearly three years. During that time and well after her passing I have seen on TV and in print advertising for CTCA. Their media buy is huge if you consider they are buying prime time news in NYC for the Philly center. Their print buy includes the NY Times Sunday edition. 

Watching and reading the media made me second guess our care and treatment. This article has had the desired effect to end my second guessing once and for all. 

Here is one long segment from a very long article.

It’s rather amazing here how so many of the things that are wrong with “integrative oncology” are right there on a single page. Look at the list of therapies. They range from the purest quackery (homeopathy) to what should be science-based medicine (physical therapy and exercise therapy) and everything in between. I realize that most readers of SBM know what homeopathy is and why it is quackery, but in case there are new readers seeing this, I’ll briefly recap. Homeopathy postulates two main ideas, both of which have no basis in science: First that you relieve symptoms by using a substance that causes the symptom being treated, and, second, that diluting a substance makes it stronger. Of course, the substance must be diluted with strong shaking (known as “succussion” in homeopathy lingo) between each serial dilution step. Most homeopathic remedies are diluted so much that there is almost certainly nothing left of the original remedy. For example, Avogadro’s number (the number of molecules in a mole of a substance) is on the order of 6 x 1023. A typical homeopathic dilution is represented as “C,” where each “C” equals a 1:100 dilution. So, a 1C dilution is a 1:100 dilution; a 2C dilution is a 1:10,000 dilution (100 x 100); and so on. If you get to 12C, you’re talking a 1024 dilution, which is already greater than Avogadro’s number. That means that it’s unlikely that more than one molecule of the substance remains, and that assumes the homeopath started with a mole of the substance being diluted, which is rarely the case. Usually the homeopath starts with much less. Now consider that typical homeopathic dilutions are 30C (1060), more than 1036 orders of magnitude greater than Avogadro’s number, and just how quacky homeopathy is comes into focus. Sure, homeopaths will wave their hands about the “memory or water” or “nanoparticles,” but in reality homeopathy is nothing more than magical thinking. The same is largely true for acupuncture, which is nothing more than a theatrical placebo, and studies claiming otherwiseare uniformly unconvincing.

This is an important article that we should all read in order to counter the huge media buy and messages of CTCA. Sometimes the fear and hopelessness of cancer blinds us.

For Whom Does it Work? Moderators of Outcome on the Effect of a Transdiagnostic Internet-Based Maintenance Treatment After Inpatient Psychotherapy: Randomized Controlled Trial.
Ebert, Gollwitz, et al published this study in JMIR studied who will benefit from Internet-based maintenance treatments for mental disorders. 

This is of interest because the study identifies who will benefit from this type of intervention. With the vast number of existing and new medical/healthcare apps appearing weekly few of them have studied what outcomes can be expected let alone studied who will most benefit. And this can be extended in part to Web based medical and healthcare applications. This study offer readers an in-depth understanding of who will out study benefit.

Conclusion: Transdiagnostic Internet-based guided self-help interventions may represent a cost-effective, far-reaching method for implementing maintenance phase treatments. Findings from the current study suggest that TIMT following inpatient psychotherapy helps patients differing in various characteristics to maintain treatment outcome. It is especially effective for participants with low education levels. Although some subgroups were identified as having profited less from the intervention than others, all subgroups benefited significantly. Future studies should replicate our results before clinical application.

Tim O’Reilly Discusses Collective Intelligence
A short video chock full of concepts and Ideas. Looks at the future think today and places it squarely into the context of medicine. 

Notes & Links: October 9, 2013

Deadly Disbelief
Kent Sepkowitz writing in Slate helps us revisit AIDS and HIV that many of us may have forgotten. Not what causes it and that it is deadly or that it is being effectively managed thanks to the hard work of the pharmaceutical industry being beaten senseless by AIDS activists before they realized market value. What Sepkowitz gets us to think about are the AIDS denialists who are still there. And the harm they do though is not half as damaging as the anti-vacination foilhat wearing crew.

This is a good read and one we need to perform annually.

Health Insurance Premiums in the Exchanges Pt. 1
Tim writing on Tim’s Stuff just published this post. Got to say what’s there not to love about a self-described boring Mormon economics grad student who is into insurance and health policy. And not to leave out cycling my fav. 

His post Part 1 is rather enlightening just because it speaks not in screaming advocacy or exploding hate about the ACA or ObamaCare depending on where you reside on your ‘I know more than you do scale’ but in quite calm fact based logic. 

There are two reasons why an individual’s insurance premiums might be rising this year. First, your plan may be changing. More likely than not, your plan is becoming more comprehensive. This is to comply with new regulations requiring plans to have an actuarial value greater than or equal to 60%. A plan’s actuarial value is the portion of health care costs the plan will cover for an average individual. Most individual plans currently fall short of the 60% requirement, so people currently holding individual policies will probably see their plans change to qualify, raising the price.1 This price increase does not come without corresponding benefits, however. Not many people are complaining about having to purchase more comprehensive coverage which they probably couldn’t get last year.

Second, new regulations require health insurance premiums to be “community rated.” No, this does not mean that everyone in your community has to go somewhere and rate every health plan. It means that plans can’t charge different people different premiums for the same plan. Now, the law does not require perfect community rating. Instead, it allows health plans to vary premiums by age, geography, and smoking status. Really, it just prohibits charging different premiums based on health status, i.e. a health plan can’t charge a sick person more than a healthy person for coverage via the same health plan.

he above is pretty much it for Part 1 but it opened my eyes. Tim has a bunch more on his site on insurance and health policy. Good reading someone’s got to write this stuff and make it accessible. 

40 Maps That Will Help You Make Sense of the World
This link is from Doc Searls Weblog and is brilliant, let me say that again BRILLIANT. One just for the content and execution of these maps but, the fact anyone doing a PowerPoint deck always needs a map. Well here ya go you will find a map just right to make your point dramatic and clear.

Just check this out. Boom that was my mind blowing up. And it is not only maps this site is sick.  

Notes & Links: October 8, 2013

Being in the Pink: Some Alternate Views

#$@*-Off For Breast Cancer Awareness
Cats & Cancer takes a hard critical look at October Breast Cancer Awareness month. All the Pink in the NFL?

Do NFL players wear pink wristbands because we aren’t aware of breast cancer, and watching 350-pound linebackers in pink accessories cause people to want to look into issues surrounding the disease?  Thank goodness the NFL has an online shop to sell NFL branded breast cancer awareness items.  Too bad their message is “A Crucial Catch:  Annual Detection Saves Lives” when it’s not totally true.  Some of the videos on their pink site, although compelling, do not support the message and are about self-diagnosing the disease and not annual screening.  And the NFL isn’t even putting any cash into this campaign.  You, as a supporter, can bid on the pink items the players wear in the game.  Then your money can go to…um…something.  Lucky us!

Think Before You Pink: Breast Cancer Awareness
At Healthcare Marketer another critical appraisal of Pinktober.

I Hate “Pinktober”
From Robin offers a radical view that cuts to the chase don’t buy pink merchandize or walking thill your feet bleed but, 

Consider this: instead of purchasing that pink t-shirt or that baseball cap with the pink ribbon on it, or raise that $2300 to walk the Komen, take that money and buy groceries for the woman in your church/school/neighborhood who is dealing with breast cancer.

Help her pay her light or heat bill.

Help her out with child care.



Friendship means the world to us.

These are sole voices but voices that should make the millions and millions of us blinded by pink this month to stop and think about cancer and not just breast cancer but all cancers including lung which kills more each year.

The Promise (And Reality) Of Healthcare
Goodman and Noorbeck contributors to Forbes addresses the economic truth about healthcare. Nothing here is new or surprising and has been part of the healthcare debate and fight for years. But it is worth another look and I would say we should all revisit this once a year to determine how well they saw the future. 

  • There is currently a shortage of physicians and nurses in the US and that will only get worse as all of age. We all know age means illness. And just to add injury to insult the ACA is trying to recruit 30 million new Americans to the luxury of healthcare.
  • Accountable Care Organizations are in reality just extensions of large hospitals and will in the end drive prices up because they are buying physician practices up and are in reality a nightmare of red tape
  • Affordable Care Act is 20,000 pages long and so unwieldy it will crush us all. Additionally individuals buying health insurance don’t have to verify employment status, income, etc. Can you say fraud?
  • Affordable Care Act will mean new and higher taxes.

The authors end with the following recommendation that I agree could help with the economic issues. But I want to know how these truths hold up in one, two, or three years?

One solution that has received scant attention is to establish an advisory panel of real practicing physicians – who treat patients every day – to review, evaluate and make recommendations on which regulations improve patient care and which ones just increase government bureaucracy.  Another solution is to truly reduce rules and government red-tape instead of writing new regulations at the rate of 68 per day.  For some foolish reason, all of the proposals for healthcare reform projected over the past few decades have excluded the voice of the practicing physician. 

How Much More Evidence do You Need?
Aarron Carroll at The Incidental Economist gives us word up on probiotic supplementation, necrotizing enterocolitis, and preterm infants. This is an excellent analysis of the data from the likes of JAMA and a Cochrane review. He ends the post with the following…

It also attacks the way that probiotics seem to be held to a standard that traditional medicine is not. Look, I will be the first to slam any practices, traditional or alternative, that make claims that go beyond evidence. I will be the first to mock those that refuse to engage in studies because they think they might find something they don’t like. Neither applies here. This is a problem that needs fixing, now.

HealthcareDIY: An Old Idea Made New
Jane Sarasohn-Kahn writing on The Health Care Blog introduces a new site HealthcareDIY and wraps the discussion around what the current new black in patient care the ePatient. She writes about her mother Polly

…who died 34 years ago this month. She was my first role model for an engaged patient. When she was diagnosed with Hodgkins lymphoma in 1971, there was no internet for her to tap into for a patient network, a clinical trial, or a directory of oncologists or centers of excellence that were Top Doctors for treating the condition

This is a must read for anyone who is interested in or wants to become an ePatient. It is also a must read for the simple reason it is not yet another post about how our healthcare system, the ACA, our economy because of healthcare is all going to hell in a hand basket. This is about what small steps taken by individuals can add up to a movement that improves care and lowers cost. But I’m just a pollyanna who some days is longing to take a dirt nap. 

Notes & Links: October 7, 2013

Why Are ObamaCare Opponents So Vehement?
David E. Williams posting on HealthWorks Collective gives us perhaps the most rational answer to the above question I have seen. Short and sweet but cuts to the chase in all this insanity of stopping ObamaCare even if we destroy our economy and the global economy. 

Why they feel the way they do

  1. They feel the legislation was rammed down their throats and they were disenfranchised
  2. They honestly feel ObamaCare will be the ruination of the world’s greatest health care system 
  3. They believe ObamaCare will bankrupt the country
  4. The bill is too complicated
  5. They want to appeal ObamaCare and replace it with something better

I buy those. Williams shows why none of those reasons hold water in a clear and on point fashion. But for me the most telling reason is the one he ends with…

A more objective read is that some opponents have whipped themselves into a lather over their revulsion to all things Obama and are living in an echo chamber where these views seem rational. It would be better for everyone if they went back to the Birther madness.

Security Concerns to Be Considered When Downloading Human Immunodeficiencey Virus/Sexually Transmitted Disease Related Smartphone Application
A letter to the editors of JMIR from Brito-Mutunayagam addresses a recent article reviewing Mobile Phone Apps for the care and prevention of HIV and other STDs. The article addressed security concerns. Brito-Mutunayagam says the bigger concern is that if an app is not developed by a a named professional health care body or organization. 

It is a great letter and fits with the current trend of showing data regarding medical apps and the outcomes they deliver. Well worth the read. 

A Web-Based Tool to Support Shared Decision Making for People with a Psychotic Disorder: Randomized Controlled Trial and Process Evaluation
Van der Krineke, Emerencia, et al out of the University of Groningen Leeuwarden, Netherlands published this RCT. There has been a great deal written and studied on shared decision making. Here is a good overview on the topic for some background. 

Methods: The study was carried out in a Dutch mental health institution. Patients were recruited from 2 outpatient teams for patients with psychosis (N=250). Patients in the intervention condition (n=124) were provided an account to access a Web-based information and decision tool aimed to support patients in acquiring an overview of their needs and appropriate treatment options provided by their mental health care organization. Patients were given the opportunity to use the Web-based tool either on their own (at their home computer or at a computer of the service) or with the support of an assistant. Patients in the control group received care as usual (n=126). Half of the patients in the sample were patients experiencing a first episode of psychosis; the other half were patients with a chronic psychosis. Primary outcome was patient-perceived involvement in medical decision making, measured with the Combined Outcome Measure for Risk Communication and Treatment Decision-making Effectiveness (COMRADE). Process evaluation consisted of questionnaire-based surveys, open interviews, and researcher observation.

Conclusions: The development of electronic decision aids to facilitate shared medical decision making is encouraged and many people with a psychotic disorder can work with them. This holds for both first-episode patients and long-term care patients, although the latter group might need more assistance. However, results of this paper could not support the assumption that the use of electronic decision aids increases patient involvement in medical decision making. This may be because of weak implementation of the study protocol and a low response rate.

Shared decision making is important and there have been any number of reviews, analysis, and RCT herehere, and here. And here is a great site in Canada using SDM. It is simple in its concept and offers important and critical outcomes for patients. But at times it strikes me that we are making this far more complex and involved. Donna’s oncologist at our first meeting drew a horizontal line on a chart note. On the left side of the line he wrote me on the left side of the line he wrote you (Donna). He said ” Place an X how you want to work together to make decisions regarding your care. On the left I will make all decisions. On the right you make all the decisions.”

This is shared decision making succinctly presented and adhered to. This may not fit all patients but what it does do is open the discussion and create a sense of engagement and empathy which is the foundation for SDM. 

Notes & Links: October 4, 2013

Assessing the Internal and External Validity of Mobile Health Physical Activity Promotion Interventions: A Systematic Literature Review Using the RE-AIM Framework

This is good less from the study and more from the fact the authors have demonstrated that we can review and critical appraise mobil apps. It’s hardly perfect but it is a step in the direction of helping patients and HCP know what works and what doesn’t. 

Blackman, Zoeliner, Berrey, et. al writing in JMIR have performed a Cochran Review on mobile apps. This is fascinating from the simple fact it begins to establish a methodology to review mobile apps for physical activity. 

Despite the popularity of commercially available health-related applications, there is little evidence that mobile phone-based interventions with demonstrated efficacy have been translated beyond the research setting and been broadly adopted [19]. Some potential reasons for the lack of translation of these interventions into more widespread use are that the scientific approach typically emphasizes high internal validity at the expense of external validity [20] and that the traditional research pace impedes the flow of disseminating relevant findings [21]. To date, reviews of mHealth interventions have evaluated the quality of studies through the lens of internal validity and emphasized improved reporting on potential confounding factors [22]. As a result, the conclusions are largely limited to factors related to intervention efficacy and the extent to which these mHealth interventions report on or achieve external validity to different settings and populations is unclear [1317,23]. 

This study used RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) to inform investigators who will do research on mHealth applications. This is the first I’ve seen on standardizing how we determine the value across a broad measure for mHealth applications. They also clearly show current limitations and where we as an industry need to improve. Mobile health applications are becoming the center piece to our healthcare in many regards. Also we know that they are bought, downloaded, and frequently forgotten about. Using RE-AIM along with other metrics can help determine the clinical value of apps and how to design better one not only from a shinny toy with bells and whistles perspective but from a patient outcome point of view. This sorely needed. 

The authors conclude

There is an emergent body of literature reporting on mHealth PA interventions. On average, the studies provide initial evidence that these interventions may have promise in helping participants initiate PA. However, few studies report on key internal (eg, delivery as intended) or external (eg, descriptions of participants, settings, and delivery staff) factors. As a result, the degree to which these findings are robust and generalizable cannot be determined. Improved reporting across RE-AIM dimensions and the use of intention-to-treat, tracking of costs, and mixed methods approaches are recommended to ensure mHealth PA interventions are developed that can be broadly applicable across target populations, intervention delivery locations, and staff of differing levels of expertise.

Health care in the USA hanging in in the balance
The Lancet offers some editorial insight and comment on healthcare in the US of A. The editorial is an excellent review of Obamacare with no hyperbole and written simply in plain Queens English. I am sure from their vantage point they are missing all the hairs growing out of each ACA wart. This is a great easy read to wrap your head around. 

The closing paragraph offers insight on what the world sees.

What is clear is that, even under optimal conditions, the health insurance marketplace is a work in progress, involving the commitment of thousands of civil servants, administrators, consultants, programmers, and, ultimately, consumers. As part of risky manoeuvring to extract political concessions, gutting the ACA and scrapping the state exchanges is an irresponsible and short-sighted assault on the promotion of the health and wellbeing of Americans. Irrespective of meeting arbitrary deadlines, the efforts of these individuals converge on the vital goal to overhaul the health-care system in the USA. Health-care reform is a process that must start somewhere and will adapt and evolve over time. The ACA offers that starting point—there should be no turning back now.

Vaccine Conspiracy Theorists More Likely To See Conspiracy Everywhere
File this under the biggest tin foil hat wearers are the vaccine conspiracy theorists. Leaders of the pack. I am of the age I still think there was a shooter on the grassy knoll but, I am not grabbing huge real estate on the Web to drive my theory. 

Emily Willingham a contributor to Forbes gives a nice review of current thinking about vaccine conspiracy theorists and specifically autism. She notes research results from PLOS ONE that found conspiracy theories are lock stepped with a rejection of science. The authors also find that vaccine conspiracy theories have a political flavor and fit libertarian leanings and those not as conservative reject immunization because of the pharmo industrial complex. Who can trust anyone that sell a drug proven to be equal to placebo?

Least we forget there are health consequences to the continued vaccine-autism conspiracy crap. It harms others and the child. The woman who was killed in Washington DC had her 1 year old daughter in the car. Some have said that she put that child in direct danger and harm. Not vaccinating does the same. 

What can we do? Not much. 

Lewandowsky and co-authors close their paper almost dejectedly, noting that because “conspiracist ideation” leads believers to resist evidence contrary to their conspiracy theory, presenting them with scientific evidence tends to amplify that rejection. They recommend affirming the competence and character of the conspiracy theorist and kind of leaving it at that. Please, consider yourself affirmed.

Not so much it seems. But we can not let those to are anti vaccination not drive the message or control the voice online. Reason and science must prevail since we are seeing outbreaks of measles, mumps, etc. 

Notes & Links: August 2, 2013

Read the Fine Print Before You Burn Your Obamacare Card

A guest post by Aaron Carroll on The Incidental Economist speaks to the conservative organizations pushing young adults to skip joining ACA and pay the penalty. 

People pushing young adults to skip the exchanges aren’t saying, “Don’t enroll now… but hey, if you get sick in a few months, we’ll understand if you have a change of heart.” They’re saying, “Don’t enroll now; pay the penalty instead. And if you fall ill, or become pregnant, or get stabbed while doing a good deed and you can’t buy a plan, well, them’s the breaks. That’s the gamble we asked of you.”

Some of these young adults must have seen their parents loose jobs, loose coverage, loose their homes, and life without healthcare coverage. I would think that is enough motivation to want healthcare insurance. It would be for me. I know when I had a bunch of employees working for me I made sure healthcare insurance was offered at a great price and for many many years with no employee contribution. I believed in its value. Hopefully these young adults see the value as well. We’ll know soon enough. 

Countdown to The Physician Sunshine Act: Gloomy Days Ahead

Jonathan Govette posting on HealthWorks Collective speaks to the Sunshine Acts and its August 1, 2013 start of data collection. The title kind of says it all about his position and attitude. And the site is sponsored by Siemens a medical device manufacturer. 

So basically every doctor in the country will now have to report his private financial information to the world.  Seems like this is a complete waste of time and will cause more harm than good.

I would agree about flashing personal income all over the web. But these are payments that have been well documented and associated with prescribing and often not associated with evidence based medicine or the best Rx for that patient. Patients and colleagues should know what the financial association with pharma or device manufactures are. That’s why they call it transparency. 

Sunlight as Disinfectant

Professor Meredith Rosenthal Ph.D. and Michelle Mello, J.D., Ph.D writing in the NEJM have a much better and more salient review of the Sunshine Act and its benefits vs. the problems. They capture two key point here:

Disclosure rules aim to influence the behavior of both the subjects of reporting and those making decisions about whether to do business with them. Thus, one mechanism through which the Sunshine Act could reduce health care costs is that patients, having learned of a physician’s involvement with industry, might alter their view of the physician’s trustworthiness. They might be less inclined to accept treatment recommendations from these physicians or even to receive care from them. Given the evidence that greater physician financial involvement with manufacturers is associated with higher utilization of expensive, brand-name products, such dynamics could reduce costs.

Experience gives reason for skepticism about the potential force of patients’ response to disclosures, however. Decades of public reporting of provider quality information have underscored the difficulty of engaging consumers in seeking even the most salient information about their providers, such as a cardiothoracic surgeon’s predicted mortality rate, from a passive report.3Consumers are typically unaware of these data and, even when they know about them, tend to choose their providers on the basis of other factors. The payment data are also complex, and even with the educational information CMS plans to provide, patients may have difficulty evaluating the undesirable and beneficial aspects of various types of payments.

Read both articles and see which one rings as a true well balanced examination of the Sunshine Act and which one is grinding a whinny ax?

Spike Lee Shares His NYU Teaching List of 87 Essential Films Every Aspiring Director Should See

Thanks to Doc Searls for this link. I would love to be an aspiring director but I am more of a film freak so I wanted to see what was on his list. I’ve seen 62 of the 87 and need to revisit most of them (memory sucks) besides what I haven’t seen. Guess me and Netflix will be busy this year.

You Don’t Have To Be A Data GeekTo Love Consumer Health Devices—But It Helps

David Shaywitz writing on writing about capturing health data from phones, devices, and apps. I think for some of us he captures what and why for these devices 

In other words, my gadgets don’t provide essential information I couldn’t get elsewhere, but they motivate me to pursue and sustain activities I might otherwise avoid – like regularly checking my blood pressure, or finding time for a run.  They facilitate data sharing, whether with my doctor, as I’ve described, or with friends and family who can offer encouragement and motivation

I agree because on my bike I have a HR monitor and a computer to capture speed, cadence, max and average speed. I just love the data and comparing one ride to another. I no longer make a spread sheet with it. Maybe I will start again. But the bigger question is who are the others that capture data? What do they do with it? Do they share it with their physician? To what end?

We need to know more about the new world of consumer data. 

Hamptonites Are All Smiles Over Newest House Call

For the fee of $999, more than double what it costs for services in their office, the husband-and-wife dental team of Dr. Jeffrey Rappaport and  Dr. Michelle Katz will perform professional teeth whitening in the comfort of a client’s living room.

The only thing that comes to mind here is “Qu’ils mangent de la brioche“. But we live in a free market for some.

Notes & Links: October 1, 2013

Is Your Hospital Website Costing You Revenue?
Nicola Ziady posting at HealthWorks Collective points out that 8 out of 10 consumers are visiting hospital websites but 90% are going somewhere else making an appointment. The reasons for this are:

  • Competition
  • Confusion
  • Dissatisfaction

The lead in to the dissatisfaction bullets is the statement that “8 out of 10 Prospective patient will visit your website before converting.” 

I shared this with a good and wicked smart colleague Scott. His thoughts on this were:

Since it is impossible that 83% of hospital patients are going in for elective reasons where they could choose, and the primary driver is physician privileges at a particular institution, the reason consumers are visiting hospital websites before converting into patients has to be to fill out paperwork, or gain more information about what to expect – not to choose a hospital.

I agree with that and I would add that conversion is the wrong goal. The goal for the hospital especially going forward is improving outcomes since that is what and where they will be competing. The forward facing message for a hospital to patients should be to continually engaged with them so they learn, improve self care, and drive improved outcomes. I would look at improving expanding retaining and showing GREAT outcomes from current patients. Current patients are where your message to new patients should come from. 

Remember hospitals have spent millions to buy physicians practices. Half the patients in those physician practices do not need hospital care. And when they do since that MD is an attending w/privileges will get them. My goal would be to get current patients engaged w/the hospital as a healthcare knowledge provider because that meta data from those active and engaged patients I am currently treating will inspire conversion. Make sense?

Patient Engagement, Negaclaims Can Rehabilitate Health Insurance
Dave Chase a contributor to Forbes has a deep dive on cost for care and patient engagement and how HCP are ‘selling’ care in the fee for service model. Chase introduces the concept of Negaclaim which is TM’d. And what is that? It is when patients are fully educated on trade-offs with interventions and they choose the less invasive approach which is generally less expensive. Chase lists a number of examples showing the benefit of curbing unnecessary care while improving patient experience. 

  • Direct Primary Care
  • High Cost Procedures
  • End of Life

Clearly incentives driven by a flawed reimbursement system is driving waste in spending. And another confounding factor are health insurance providers. Most people consider them the Darth Vader of healthcare. Most people consider health insurers to only want to deny deny deny. They need to fix that image. 

Chase ends on a topic near and dear to me. 

Leonard Kish made the case that if patient engagement was a drug, it would eclipse all blockbuster drugs before it.

 Chase offers this interesting insight. Insurers should stop denying claims and invest in getting customers to engage in healthcare and with their physicians because these customers would self-deny their own claims. 

As I said this is deep dive but rewarding in that Chase is looking at the value of patient engagement not only it being the new black in healthcare.

The issue is summed up nicely in an AP story by Marilynn Marchione:
Obese people are less likely to survive cancer, and one reason may be a surprising inequality: The overweight are undertreated.

Doctors often short them on chemotherapy by not basing the dose on size, as they should. They use ideal weight or cap the dose out of fear about how much treatment an obese patient can bear. Yet research shows that bigger people handle chemo better than smaller people do.

Even a little less chemo can mean worse odds of survival, and studies suggest that as many as 40 percent of obese cancer patients have been getting less than 85 percent of the right dose for their size.

Now, the largest organization of doctors who treat cancer, the American Society of Clinical Oncology, aims to change that. The group has adopted guidelines urging full, weight-based doses for the obese.

Orac presents a lot of data and logic on why clinical oncologist may feel it is necessary to dial back dosing for obese patients with comorbidities etc. Further there is some great information where in healthy weight patients dose reduction was 9% to 37% in obese patients. This was from a study in 2005 Jennifer Griggs, MD from University of Michigan. And from that study this finding:

Interestingly, Griggs also found that severe obesity was actually associated with a lower likelihood of being admitted for febrile neutropenia (fever with a low white blood cell count, indicating potential infection in an immunosuppressed patient), was actually less common (odds ratio, 0.61; 95% confidence interval, 0.38-0.97) in the severely obese even in patients who received full dose, and there was a trend towards less admissions for febrile neutropenia associated with increasing body mass index that only became statistically significant at a BMI ≥ 35.

There is a considerable amount of data here which is well presented and documented. It is a great place to continue your education on weight and chemo. 

Dermatology Smartphone Apps No Substitute for Doctor’s Visit
Bill Crounse posting on Healthworks Collective gives us some solid advice which comes on the heels of the FDA guidance for medical apps. I would give you a link to it but since those morons in Congress shut down the government in order to ensure only the privileged have healthcare the FDA site is working like crap.

Crounse makes the case for seeing a trained dermatologist and not leaving possible life and death decisions to an app. He has cred having been diagnosed with three of the most common types of skin cancer, basal cell, squamous cell, and melanoma. His melanoma was caught early and he was cured. 

Researchers tested four different smartphone skin cancer apps. One of the apps sends photos to board certified dermatologists for review. In the research study, that particular app was, as you might expect, quite good. It missed diagnosing just one of 53 pictures of melanoma that were used to test its accuracy. However, taken together the accuracy of all four smartphone apps was determined to be just 33 to 42 percent.

His primary point is that a smartphone app should not replace a trained dermatologist. I concur because I am reminded of a comment at a dermatology advisory board I ran with some nationally KOLs. One physician chair of her department said that when they are offering residents and fellows a position they have found those with an interest or background in art are better at diagnosis since their eyes are well trained and tuned by an art background. When you think about that it rings true. The majority of dermatology diagnosis is based on visual not lab values or listening to the heart or an MRI. I would not trust me to look at an app and my skin and say nah that is not that. Would you?

Cancer Chemotherapy and Obesity
Orac writing on ScienceBlogs takes a long hard well balance look at this recent mainstream press topic of obese patient and cancer chemotherapy. 

The topic is straight forward enough most chemotherapy is dosed based on weight and obese patient are not always getting full weight-based doses.

The issue is summed up nicely in an AP story by Marilynn Marchione:
Obese people are less likely to survive cancer, and one reason may be a surprising inequality: The overweight are undertreated.

Doctors often short them on chemotherapy by not basing the dose on size, as they should. They use ideal weight or cap the dose out of fear about how much treatment an obese patient can bear. Yet research shows that bigger people handle chemo better than smaller people do.

Even a little less chemo can mean worse odds of survival, and studies suggest that as many as 40 percent of obese cancer patients have been getting less than 85 percent of the right dose for their size.

Now, the largest organization of doctors who treat cancer, the American Society of Clinical Oncology, aims to change that. The group has adopted guidelines urging full, weight-based doses for the obese.

Orac presents a lot of data and logic on why clinical oncologist may feel it is necessary to dial back dosing for obese patients with comorbidities etc. Further there is some great information where in healthy weight patients dose reduction was 9% to 37% in obese patients. This was from a study in 2005 Jennifer Griggs, MD from University of Michigan. And from that study this finding:

Interestingly, Griggs also found that severe obesity was actually associated with a lower likelihood of being admitted for febrile neutropenia (fever with a low white blood cell count, indicating potential infection in an immunosuppressed patient), was actually less common (odds ratio, 0.61; 95% confidence interval, 0.38-0.97) in the severely obese even in patients who received full dose, and there was a trend towards less admissions for febrile neutropenia associated with increasing body mass index that only became statistically significant at a BMI ≥ 35.

There is a considerable amount of data here which is well presented and documented. It is a great place to continue your education on weight and chemo.