Category: Blog

Notes & Links: August 21, 2013

How Obamacare Will Harm Cancer Patients

Scott Gottlieb, MD contributor to Forbes has a rather lengthy analysis of Obamacare and how It will hurt cancer patients. Dr. Gottlieb goes into great detail to make the point. 

 First, Obamacare is going to block the ability of patients to seek out the specialist doctors who are most likely to prescribe these cutting edge treatments.

Obamacare tries to coerce doctors to cut down on their use of costlier drugs and tests by changing the way that they’re paid. The law uses “bundled” payments, where doctors get lump sums of money to care for patients with particular medical problems. The idea is to pit the cost of the treatments doctors prescribe directly against their earnings and give doctors a potent incentive to use cheaper remedies.

Obamacare targets cancer drugs directly, by expanding a program called 340B, which siphons money away from drug developers in order to subsidize hospitals. The Obama Administration sees the program as a way to prop up the hospitals (a favored constituency) on the dime of less popular drug makers. But the oblique way the money is extracted from drug companies spawns a lot of harmful consequences that are increasing the cost of cancer care, and lowering its quality.

Gottlieb further makes the case that over 20 years total spending on cancer care was stable at 5%. And further how inpatient cancer admissions fell from 64% in 1987 to 27% in 2001 to 2005. 

His closing thoughts are focused on the cost of cancer drugs and the high cost of developing thuds drugs. 

Instead, Obamacare limits access to specialist doctors in order to cheapen insurance products, uses financial schemes that pay doctors more to do less, and targets the drugs that represent so much of our recent progress against cancer.

I agree with this thought and logic but I am not familiar enough with the 1,220 pages in the law to debate the overall message he is presenting. And I would trust his logic and data but I must say the conservative press has picked up on this and is running like crazy with the headline and not looking at the message of cost of drugs. If anyone out there has more information on this please share.

Use of Twitter Among Local Health Departments: An Analysis of Information Sharing, Engagement, and Action

Neiger, Thackeray, et. al from Brigham Young University Department of Health Science publishing in JMIR examined how local health departments (LHD) used Twitter to share information, engage with followers, and drove action behavior. In addition they looked at differences between LHD’s by size of populations served. 

While some evidence suggests that broad dissemination of information characterized by traditional mass media campaigns can improve population health, effective campaigns require simultaneous availability of and access to programs, services, and products that facilitate change [29]. Furthermore, broad dissemination of information ignores the fact that messages should be targeted to the intended audience. In the case of Twitter, LHDs may know nothing or very little about their followers unless they engage in dialogic communication to establish relationships. To indiscriminately post information on Twitter is inefficient. In fact, this contributes to what has been described as a fractured and cluttered media environment that can be resolved only through careful planning and testing of campaign content with intended audiences [29].

It was encouraging that at least one-third of LHD tweets attempted to engage followers, foster relationships, create networks, or build communities. These results are similar to those found by Lovejoy and Saxton in their analysis of how nonprofit organizations use social media [10]. Use of personal pronouns was present over a third of the time and more common among smaller LHDs. Additionally, evidence of effort toward dialogic communication included tweets that tended to be conversational in nature and may have used personal pronouns but were not necessarily intended for the purpose of engagement. This evidence of more conversational posting indicates LHDs may be trying to create a Twitter persona that is warm and friendly, thus making it more inviting for Twitter users to follow.

Are we beginning to see the fruition of social media (i.e. Twitter) in healthcare providing a welcomed and valued dialogue with health departments that improve the health of populations? I hope this data is only the start. 

Usage of a Generic Web-Based Self-Management Intervention for Breast Cancer Survivors” Substudy Analysis of the BREATH Trial.

van den Berg, Peters et. al from Radbound Rniversity Nijmegen Medical Center in the Netherlands publishing in JMIR have a fascinating and important look at how generic Web-sites are used and can be better designed for breast cancer survivors. This is an important study in my view because we are beginning to look at patients as learners based on usage statistics. This is providing ‘realistic estimation of exposure to intervention content“. Further the authors note “results suggest that investigating how generic fully automated Web-based interventions are used is far more informative than the amount of exposure. Usage statistics should be chosen accordingly.” 

 This is an important a first step. I believe we need to look at how these survivors are using this information to learn and what problems they are seeking to solve. 

The stated objective 
To gain insight into meaningful usage parameters to evaluate the use of generic fully automated Web-based interventions by assessing how breast cancer survivors use a generic self-management website. Final aim is to propose practical recommendations for researchers and information and communication technology (ICT) professionals who aim to design and evaluate the use of similar Web-based interventions. 

Conclusion
This study underscores the added value of evaluating usage statistics of generic Web-based interventions as a realistic estimation of exposure to intervention content. To the best of our knowledge, the present study gained first insight into the design of technical usage evaluations of generic fully automated Web-based interventions. Overall, and in concordance with research on more interactive eHealth applications [38], results suggest that investigating how generic fully automated Web-based interventions are used is far more informative than the amount of exposure. Usage statistics should be chosen accordingly. Further, it is recommended to collect both singular and composite usage statistics, include self-reported usefulness, and to pilot test a variety of usage statistics to aid decision making of meaningful usage parameters. Last, shared knowledge about ICT and conducting research is helpful in developing a meaningful rationale of technically recorded usage statistics of generic Web-based interventions.

Notes & Links: August 20, 2013

Why Health Insurance is So Expensive

Ya gotta love the title of this contribution by Sandra Mills on HealthWorks Collective. Even more to love is an amazing, clear, and well designed info graphic. One of the best I’ve seen but the topic keeps you focused and shocked. 

The seven most significant causes to increasing cost are:

  1. New medical technology
  2. Provider price inflation
  3. Low primary care use
  4. High spending on specialists
  5. Aging population
  6. Increase of chronic illnesses
  7. Fraud

Take a look at the graphic a lot of pictures tell a sad story.

Vintage Typefaces

John Gruber of Daringfireball.com fame had this link. For those of you who are into design and type. Take a look. Type is the most critical element of good design just ask Jonathan Ive.

How to Start A Conversation About Estate Planning

Forbes has a nice 8 panel set of facts about discussing estate planning. This is important so is the Will, end of life planning etc. I think Everplans.com has this and more covered so very very well it is worth a look. No it’s worth the time to do it. 

Notes & Links: August 19, 2013

iPad Applications in the Healthcare Industry: Fad or Future?

Todd Riddle posting to Healthworks Collective takes a look at apps on the iPad and its utility for both patient and HCP. There has been a huge growth of iPad apps in healthcare albeit slower due to legal, medical, and patient issues. But it is changing rapidly and growing. Riddle quotes data that states by 2015 there will be 500 million smartphone users accessing healthcare application. Pretty impressive. 

Advantages of iPad healthcare apps

  • Patient safety
  • Easy access to information
  • Increases efficiency
  • Minimizes costs
  • Effective use of audio, video, visual communications modes

Challenges

  • Not always accurate and consistent (I believe we need to expect studies on apps and outcomes
  • Security and confidentiality 
  • Regulatory challenges

Top iPad healthcare applications

  • Medscape
  • MedPage Today Mobile
  • AHRQ ePSS
  • Radiology 2.0: One Night in the ED
  • Calculate by QxMD

 Riddle concludes with

Since healthcare apps are extremely sensitive, it is developer’s responsibility to rigorously test app. Quality compromises could be costly. It is equally important that user conducts a thorough due diligence of app such as checking developer’s bio, user feedback, and its reputation on the net before actually installing/using it. 

Jenny McCarthy and the Selling of e-Cigarettes

Orac on ScienceBlogs points out Jenny McCarthy is now hocking blu eCigs. Now this is the same Jenny McCarthy who is anti vaccine since it is an unproven cause of autism. Let’s think about this. No evidence based proof of the link between vaccinations and autism but there are clear causative data about tobacco and disease. Orac goes into great detail to examine the data on eCigs and clearly we don’t know yet. 

Although short term studies of e-cigarettes appear not to have found any evidence of significant harms, there are currently no solid long term data regarding the effects of inhaling the vapors produced by e-cigarettes. A recent review concluded that the vapors are likely safe, but did so based on primarily on a review of chemical analyses of e-cigarette vapor. A more recent analysis finds some toxic chemicals in e-cigarette vapor butat much lower levels than in tobacco smoke. Again, however, there are no long term epidemiological or observational data in actual humans using e-cigarettes.

This is an excellent review of eCigs but more important how the hell can Jenny McCarthy do this while trashing vaccinations? 

What Americans Don’t Know About the Affordable Care Act

Danyell Jones posting to HealthWorks takes a look at where we as a nation stand with our knowledge of ACA and offers ways we can learn more and be better informed. 

There is the chart from Kaiser Family Foundation showing that country feels we will be worse off. 

Notes & Links: August 18, 2013

Drug or Snake Oil?

Dan Munro of iPatient contributing to Forbes takes a look at the new black in healthcare ‘patient engagement’. His article gives us a chance to pause and consider what it should mean and how it should be measured. I am an advocate of outcomes and how to measure if what we are doing is working and improving patient care. 

Dan quotes Leonard Kish Principle and Founder of VivaPhi

Actually, it’s surprising that it has taken us this long to focus on patient engagement because the results we have thus far are nothing short of astounding. If patient engagement were a drug, it would be the blockbuster drug of the century and malpractice not to use it.

Dan provides the reader with some metrics (outcomes) from patient engagement

Kaiser Permanente HealthConnect™ / Collaborative Cardiac Care Case Study (here):
1) Prevented 135 deaths and 260 costly emergencies

2) Patients meeting cholesterol goals went from 26% to 73%

3) Patients screened for cholesterol went from 55% to 97%

4) “Clinical care teams reduced overall mortality by 76 percent and cardiac mortality by 73 percent”

Dan’s advice, patient engagement is in place and is working while we all need is to be careful we are not being fed BS by believing what is passing for engagement is actually a way for systems to lower utilization cost at our expense. It is a short but excellent read. 

From my view patient engagement is key and should be build around an understanding of the problems patients and caregivers want to solve. Here, here, here and here are my thoughts on how to achieve patient engagement and what it does to drive improved patient care. 

Follow-Up: Google Scholar vs. PubMed

I post a summary of an article from the JMIR this week examining the relative strength of Google Scholar vs. PubMed for medical searches. What struck me on the article (here) was the authors contention that GS provided more free citations. Well today I had the chance to try GS out and was gobsmacked that many many of the citations that came back were behind a pay wall. So I wrote to the lead author. He quickly got back to me very quickly with the following:

In our study, we found that on average only ~25% of the relevant articles (understanding this was a strict definition of relevance – usually RCTs) per search were available for free from Google Scholar and ~16% from PubMed. Unfortunately free access is more an artifact of the journal that published the article than the search engine. However, Google Scholar almost always provides a link to the publisher’s site, while PubMed is hit or miss. Unlike PubMed, Google Scholar also links to non-Journal websites where a full-text article may be posted (may not always be legal).  

One trick I use is to maximize the chance of finding the full text of an article is to always click on the “All X Versions” (X representing a number) link at the bottom of the citation beside “Related Articles” in Google Scholar and trying all the links. Additionally, sometimes searching for an  article’s title surrounded by quotes in Google proper and limiting to pdf documents can help.

I hope this helps any of you using GS. 

Notes & Links: August 16, 2013

The Adopt One! Challenge

Changing how physicians are being motivated to improve their communications skills look at Adopt One! It’s a simple challenge to physicians to adopt techniques and tools to engage and satisfy their patients. The program offers participating physicians a baseline assessment of their communications skills with patients and benchmarks it against best practices and their peers. It will then offer online access to assessment, recommendations, and tools to develop and improves patient-centic communications skills.

Here are the benefits:

  • More productive visits
  • More engaged and activated patients
  • Higher level of patient trust, information sharing, and adherence
  • Fewer patient request ion for unnecessary tests
  • Fewer medical errors and malpractice claims
  • Exceptional patient experiences

I buy each benefit but do busy stressed and hard pressed HCP have the time to do this? If these benefits are accomplished even in a few practices it will support and expand the changes we are seeing with online patient learning and the desire for more and better engagement. Take look and let me know what you think?

Metaphor in Video: Simple Ways to Improve Patient Education and Boost ROI

 Now that is a promise. I mean a whopper of a promise. 

Andrew Angus writing on HealthWorks offers pharmaceutical marketers a way to eliminate the use of jargon to help patients become better involved in their healthcare. Already the hair on my neck is standing up thinking about pharma improving communications to patients. 

The way to do this is to replace jargon with metaphor. Let’s take a look at the example:

“Insulin is a hormone that treats diabetes by controlling the amount of sugar (glucose) in the blood…It’s important to space your insulin doses throughout the day to keep your blood sugar levels within the normal range despite eating habits and activity patterns.”
Prepare to watch as your patient’s eyes glaze over as first confusion, then boredom, set in. Or you could put it in terms he already understands:

 
“Okay, Jimmy. Think of your pancreas as a refrigerator. Refrigerators keep food cool so it doesn’t spoil, right? A chemical called Freon is what helps fridges stay cool. Think of that Freon as insulin. If a fridge runs out of Freon, the food will go bad. Your body needs a consistent stream of Humalog so its food doesn’t go bad.”

 
What you need to realize is that your story has to solve someone else’s problem, so you need a way to express it concisely. The trick is to know what your consumers will understand. Everyone has used a fridge, but there are as many metaphors as there are drugs, so don’t be afraid to get creative.

 
I think I get the Freon metaphor but the money shot is that last paragraph. I agree in learning if you speak about someone else that the learner can relate to they will improve their uptake of knowledge. “Know what you consumers will understand’ is the issue to learn what they know what they don’t is a Herculean task for a busy HCP. 

Now how do you put this in practice. Well of course with a 60 second video. Find a metaphor that covers all your patients and do a video for everything from hemorrhoids to hematoma is no mean feat. Let me know if I’m being mean. 

Staging Dementia From Symptoms Profiles on a Care Partner Website

Rockwood, Richard, et. al from Dalhousie University published a paper in JMIR looking at how symptoms of dementia tracked on by a partner/caregiver online relate to dementia stage. They used the Artificial Neural Network to find relationships between the dementia stages and individualized profiles of people.

The results were:

The ANN model was trained in 66% of the 320 Memory Clinic patients, with the remaining 34% used to test its accuracy in classification. Training and testing staging distributions were not significantly different. In the 1930 Web-based profiles, 309 people (16%) were classified as having mild cognitive impairment, 36% as mild dementia, 29% as moderate, and 19% as severe. In both the clinical and Web-based symptom profiles, most symptoms became more common as the stage of dementia worsened (eg, mean 5.6 SD 5.9 symptoms in the MCI group versus 11.9 SD 11.3 in the severe). Overall, Web profiles recorded more symptoms (mean 7.1 SD 8.0) than did clinic ones (mean 5.5 SD 1.8). Even so, symptom profiles were relatively similar between the Web-based and clinical datasets.
 

This is where the authors end and it speaks to the need and benefit of using the Internet to drive healthcare knowledge and improve patient care. 

Finally, especially as disease-modifying drugs are developed that modify the course of dementia (and thereby its stages), it could lead to the creation of a more robust clinical staging methodology that considers symptom profile composition as important to understanding dementia severity and potential treatment effects.

Efficacy of a Text Message-Based Smoking Cessation Intervention for Young People: A Cluster Randomized Controlled Trial

Haug, Schaub, et. al from the Swiss Research Institute Public Health and Addiction publishing in JMIR show how texting can do more then take down a politician it can impact smoking in adolescents. 

A 2-arm cluster randomized controlled trial, using school class as the randomization unit, was conducted to test the efficacy of the SMS text messaging intervention compared to an assessment-only control group. Students who smoked were proactively recruited via online screening in vocational school classes. Text messages, tailored to demographic and smoking-related variables, were sent to the participants of the intervention group at least 3 times per week over a period of 3 months. A follow-up assessment was performed 6 months after study inclusion. The primary outcome measure was 7-day smoking abstinence. Secondary outcomes were 4-week smoking abstinence, cigarette consumption, stage of change, and attempts to quit smoking. We used regression models controlling for baseline differences between the study groups to test the efficacy of the intervention. Both complete-case analyses (CCA) and intention-to-treat analyses (ITT) were performed. Subgroup analyses were conducted for occasional and daily smokers.

This study demonstrated the potential of an SMS text message–based intervention to reach a high proportion of young smokers with low education levels. The intervention did not have statistically significant short-term effects on smoking cessation; however, it resulted in statistically significant lower cigarette consumption. Additionally, it resulted in statistically significant more attempts to quit smoking in occasional smokers.

Text messaging reaches adolescents very well it speaks directly to where they participate but more importantly it speaks to lower socioeconomic groups more effectively. And remember the more one trys to quit the greater the chance of success.

Teaching Medicine Requires Teaching Thinking

I couldn’t resist this one just for the doh factor. But with due respect this is a well considered piece that looks at how do we assess diagnosis accuracy but db looks at how to teach a thought process. What can be done to help medical students learn how to critically appraise learn how to approach a medical problem 

This works for me:

Great medicine does not come from following scripts.  Great medicine occurs when the clinician knows enough to either proceed or know that they need another physician to help.  Algorithms are not the answer.  Excellent thought processes are the answer.

Notes & Links: August15, 2013

Retrieving Clinical Evidence: A Comparison of PubMed and Google Scholar for Quick Clinical Searches

Shariff, Math, et. al. publishing in JMIR compares the performance of PubMed vs. Google Scholar. It was a well designed study and the data was interesting to the point that Google Scholar may be my go to search, well quick search. To bad it has the word Google in it with all the associated tracking and saving of your personal data. It’s good know another search tool works well in healthcare. 

Compared with PubMed, the average search in Google Scholar retrieved twice as many relevant articles (PubMed: 11%; Google Scholar: 22%;P<.001). Precision was similar in both databases (PubMed: 6%; Google Scholar: 8%; P=.07). Google Scholar provided significantly greater access to free full-text publications (PubMed: 5%; Google Scholar: 14%; P<.001).

Our findings are consistent with those of previous studies [12,14,15,20,21]. In preliminary testing within targeted areas of respiratory care, sarcoma, pharmacotherapy, and family medicine, Google Scholar provided better comprehensiveness (recall) but worse efficiency (precision) compared with PubMed. Similar results were seen in our study when we considered all records that were retrieved and not just the first 40. However, previous studies tested only a small number of searches (range: 1-22), compared with the 100 searches in the current study. In addition, the search queries used in previous studies were created and tested by researchers in idealized settings, which may not generalize as well to searches generated by physicians in busy clinical settings

Practicing Medicine and Practicing Social Media

Mark Senak writing on Eye on FDA revisits and interview a physician Ph.D. he met in 2010 Bertaln Mesko, MD, PhD who is a medical futurist. The links from the post above to the various sites of Dr. Bertain are nothing short of a rich rich vein of knowledge that we can all use as references or just link to now and then for newbies to learn from. Take a look at Eye on FDA page and just to all the links provided. 

Here is an section from that interview:

While social media use among those in medical practice is growing, there are a lot of concerns on the part of practitioners that range from potential lapses of privacy to concerns about the return on investment.  How would you characterize the “risk-benefit” ratio of social media use by physicians?

 
I think there aren’t many essential differences between real-life and online communication.  I teach my students they should behave online just like they do in the offline world.  Therefore, social media can only make processes faster and more interactive, although if your offline communication as a doctor is bad, it’s going to be the same on any social media platforms as well.

There are risks, obviously, but if you know the limitations and potential problems related to the active use of social media, you know what you can do and what you should never do online.  That was the basic concept behind writing this handbook so then medical professionals worldwide would get a clear picture about the online channels and ways of communication.

 
Teaching tricks and rules about the Internet should get a huge emphasis in medical school, but it doesn’t get that kind of attention.  This is why I thought there is a niche for such a handbook which includes step-by-step instructions and tutorials focusing on all the major social media channels.

Lack of Information Synthesis: One of the Most Important Causes of Medical Errors

Val Jones, MD writing on Health Policy and picked up by Better Health makes a great case on ways to reduce errors slow down and listen. Here are his three recommendations: 

The solution to the healthcare cost crisis is not to increase the speed of the assembly line belt when our physicians and nurses are already dropping items on the floor. First, stop asking them to step away from the belt to do other things. Second, put a cap on belt speed. Third, insure that you have sufficient staff to handle the volume of “product” on the belt, and support them with post-belt packaging and procedures that will prevent back up. 

Now can we use this idea and help patients improve their ability to uptake, understand, and use data/information and turn it into healthcare knowledge? Perhaps if we slow the belt down and allow the HCP to engage and pay for engagement we can drive improved outcomes. 

Is Your iPad The Technological Equivalent of Typhoid Mary?

Standardized, App-Based Disinfection of iPads in a Clinical and Nonclinical Setting: Comparative Analysis

It didn’t long for someone to look at iPads and infections. Urs-Vito Albrecht, et. al. publishing in JMIR and asked the question how the hell do you clean an iPad, etc. in a clinical setting. 

We discovered a 2.7-fold (Mann-Whitney U test, z=-3.402, P=.000670) lower bacterial load on the devices used in the clinical environment that underwent a standardized daily disinfection routine with isopropanol wipes following the instructions provided by “deBac-app”. Under controlled conditions, an average reduction of the mainly Gram-positive normal skin microbiological load of 99.4% (Mann-Whitney U test, z=-3.1798, P=.001474) for the nonclinical group and 98.1% (Mann-Whitney U test, z=3.1808, P=.001469) for the clinical group was achieved using one complete disinfecting cycle.

Well the data is in clean your iPad with and isopropanol pad, pad to pad. This is a very detailed and well designed study so it should not be laughed at, well maybe a little bit

Notes & Links: August 14, 2013

We Don’t Have the Best Healthcare System in the World But We Could

The Incidental Economist makes an interesting argument until he closes with this:

“We don’t have the best health care system in the world. But we could. I long for the day when we can start talking about getting that instead of whether we should give Medicaid to people making less than the poverty line.”

I’m not sure if he saying hell with the poor and their health or let’s stop bitching about it do it, and move on to the issue at hand making what we have work better for all. Perhaps I should ask?

A Glut of Antidepressants

Roni Caryn Rabin writing in NY Times Well blog offers some insights to depression and why we have a ton o antidepressants.  (At this time NYTimes.com is down)

Over the past two decades, the use of antidepressants has skyrocketed. One in 10 Americans now takes an antidepressant medication; among women in their 40s and 50s, the figure is one in four.

 So if you think the reason is overdiagnosed well you are right according to a study in the journal of Psychotherapy and Psychosomatics. 

“…nearly two-thirds of a sample of more than 5,000 patients who had been given a diagnosis of depression within the previous 12 months did not meet the criteria for major depressive episode as described by the psychiatrists’ bible, the Diagnostic and Statistical Manual of Mental Disorders (or D.S.M.).

So we are prescribing more antidepressants more quickly for longer periods of time. The article is rich in its analysis and thought but the best part of it are the comments which just speaks to medicine, science, research, and the Internet. Oh boy.

How Much of a Subsidy Will You Get in Obamacare? Here’s an Estimate.

Julie Appleby in the Washington Post (aka Amazon’s in house newsletter) presents work from the Kaiser Family Foundation they looked at the subsidies and stated they will average $5,548. 

Because that figure is an average, some families will get more and some will receive less when they enroll through new online marketplaces, which open Oct. 1.

Here is the link to  Kaiser Family Foundation

With a Name Like That and Mission It Can’t Miss

Frank H. Netter, MD School Of Medicine: Developing A New Breed Of Medical School Faculty To Change The Way We Educate Doctors 

Coming up through the ranks in advertising during the late 70s you quickly learned who Frank Netter was. His medical illustrations were revered and respected by agency art directors, creative directors, and anyone who could rub two brain cells together. So when I saw this article about a new medical school called Frank H. Netter, MD School of Medicine I stopped and had to read. 

Dr. Koeppen clearly acknowledges that the greatest need for doctors in terms of clinical service is centered around primary care. This will be a major emphasis of his school’s goals, accomplishing this in partnership with other health-related programs at Quinnipiac—Nursing, Physician Assistant, Physical Therapy, Occupational Therapy.

Dr. Wikel believes that “providing problem solving exercises in which students gain confidence an experience in their ability to solve problems ultimately helps them to be more comfortable with their ability to acquire knowledge on their own, and subsequently to become self- directed learners.”

There is great hope for this school of medicine just from the fact over 965 applications for 22 full-time faculty members and many of thos applications gave up tenure and were from the likes of Harvard, University of California, Brown, etc. 

I hope they succeed but we’ll need to wait a bunch of years to see. I wish them luck. The school logo should be a Netter illustration.