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Archive for the ‘Public Health’ Category

Saturday, October 19th 2013

Volume Makes Better Outcomes

Don’t listen to Lombardi. Practice eventually makes people good at a skill. Even over practicing. I used to have this impression in surgical training that the learning curve was steep but then tapered off. That perhaps, once you reached a relatively low threshold that improvement beyond that would happen but be marginal. That perhaps there wasn’t much of a difference between the 100th brain tumor and the 500th brain tumor from the same approach for a medical system – the surgeon and the OR staff and the nursing caring for the patients.

I don’t believe that anymore.

Some of the most important questions you can ask a proceduralist are how many of your type of surgery he’s done (being specific) and how often he performs them at whatever hospital or surgical center you’re going to be at.

Just more evidence for such in the NEJM. For six index surgeries,

Hospitals with high surgical volume and low surgical mortality have lower rates of surgical readmission than other hospitals.

Kind’ve obvious but worth reminding. The literature is full of evidence that volume makes better outcomes whether it’s in heart attacks or colon surgery.

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Saturday, September 28th 2013

It Only Seems The Summer of Naegleria

I know its just me but it seems the summer of Naegleria Fowleri, the “brain eating” amoeba, that each year makes headlines in the American south. In short order there have been at least three cases I can think of that have gotten significant media attention. It seems more prevalent in the news than I remember it in previous years. And yet the disease remains as rare as ever. Perhaps its just the coverage of Kali Hardig, the first survivor of the meningoencephalitis caused by the amoeba in decades.

I will say she looks remarkably non-devastated neurologically for having gone through this infection.

N. Fowleri enters the brain through the nose. It lives in warm, shallow, still, fresh water.

The symptoms of its meningitis occur within a week of infection. Rare cases of survival are probably related to early diagnosis. Mainstay treatments are highly ineffective but center on amphotericin B plus or minus steroids. The CDC is handing out miltefosine this summer as a new possible treatment for amoebic meningoencephalitis. But all three of the cases I know about got it and two of them didn’t survive. Not a massive shift in prognosis but considering where we’re starting from any other therapy options are probably welcomed.

Luckily this remains an incredibly rare disease.

Saturday, September 28th 2013

The Risk of Exposure In Healthcare

Prions, the misformed proteins behind the various spongiform encephalopathies (including Mad Cow disease), are difficult things to sterilize for. They’re not “living” and so the typical techniques used to sterilize surgical instruments before they’re use in the next surgery are ineffective. These prions are infective. You can transmit these fatal, horrific encephalopathies from one patient to another via organ transplants or contaminated surgical equipment. Contaminated equipment may have exposed a number of people undergoing spinal procedures in Massachusetts recently, it was revealed earlier this month.

Five patients underwent spinal surgery at Cape Cod Hospital with the same potentially contaminated instruments used on a New Hampshire patient who likely died from CJD, a rare and fatal brain disease. Dr. Alfred Delmaria with the MA Dept of Public Health says, “The instruments are so specialized, they were carefully tracked, know exactly where they went.”

I remember once doing a stereotactic brain biopsy where, amongst the differential was Creutzfeldt-Jakob disease. It turned out not to be that but before the surgery everyone sat down in a conference room and talked about the steps we were going to take to only use equipment that could safely undergo the sterilization techniques needed to rid prions without destroying the equipment and the quarantine techniques that were going to be used to make sure all the used equipment got to the right place for proper sterilization.

This case in Massachusetts isn’t the first time there has been a scare over prion contaminated surgical equipment as a transmission vector. It won’t be the last despite commercial products coming on line to try to reduce such risk.

Monday, May 27th 2013

Does It Matter Where You Die?

Injury to the brain continues to be a unique thing in medicine. These injuries are scary and unfamiliar to many health care providers. There is a finality to them. Their consequences are hidden a little bit; the asystole is easy to figure in the emergency room but the suppression and brain death isn’t something so easily recognized.

They’re what you might imagine, along with polytrauma, as poster child conditions for tertiarization and transfer to a higher level of care.

In truly catastrophic injury to the brain however, I’m not sure that’s a good thing.

My institution has had a small discussion lately on just what ethics and the law requires of us as a place with full neuro specialty coverage.

I’ll make up an example:

A 61 year old man comes into a small community hospital’s emergency room. He was found down at home by his wife and last seen normal four hours previously. He wouldn’t wake up and he was breathing slowly and shallowly. The ambulance crew intubated him. In the emergency room his pupils are large and don’t react to light and he doesn’t do anything when the doctor hurts him. He’s in a very deep coma. If the physician working the emergency room felt comfortable doing a brain death exam, which he doesn’t, the patient might have some very primitive reflexes left but his condition is very serious.

A CT scan of the head is performed and shows a large bleed within the brain.

The bleed was probably caused by high blood pressure. In reality however, the patient’s condition is essentially terminal and the cause of the bleed isn’t important at this point.

The small hospital has an intensive care unit and an open bed. It however has no neurosurgeons, nor indeed even neurologists who round at the hospital. And so the physician in the emergency room starts trying to transfer the patient to a hospital where a neurosurgeon can see the patient.

There are really two issues here. The first is a legal issue concerning a law called EMTALA. EMTALA is a law that dictates transfers for higher care amongst hospitals that accept Medicare (virtually all hospitals). In very broad terms it puts responsibilities and requirements on both the hospital trying to transfer the patient and the hospital that might accept the patient. The former has a responsibility to stabilize a patient. They cannot refuse care in an emergency as a matter of lack of payment or inquire about payment prior to treatment to stabilize. Nor can they transfer a patient after stabilization merely as a matter of lack of ability to pay. The latter has a non-discrimination requirement, that specifically reads,

A participating hospital that has specialized capabilities or facilities (such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers as identified by the secretary in regulation) shall
not refuse to accept an appropriate transfer of an individual who requires such specialized capabilities or facilities if the hospital has the capacity to treat the individual.

Case law on the non-discrimination provision is scarce but in catastrophic injury, where no specialized intervention will alter the course of the patient’s condition, I would argue that the patient doesn’t require specialized care. And not merely cases where the patient is brain dead at the time of the transfer request but also in situations where brain death is inevitable or the condition is otherwise not survivable. The patient and family can proceed to comfort measures at any hospital, there is no specialization about such care.

The second issue is an ethical one. Do hospitals with specialized capabilities owe something to patients and families to transfer as a matter of finality and closure. In that we’re saying, “Watch, we did everything we could…”?

While I’m somewhat empathetic to such an argument I have trouble with it. I think it reflects a problem in both the expectations we have of health care as patients and how physicians are trained to deal with end of life. Really it is a shame for physicians to come out of training without basic palliative and communication skills. Even the physician in the small rural emergency room should have such a skill set. The capability to have an end of life discussion with families, even if the medical issue falls somewhat outside their scope of specialty.

I’m also somewhat disappointed in how some referring physicians appear to place priority in getting the patient off their hands over the patient’s well being. I’ve had cases where even after discussion with the consulting physician at an outside hospital and having seen the films and described in no uncertain terms to the other doc that the injury is not survivable that they continue to press for transfer.

I may be wearing blinders here but, and I think much of this is subconscious, I can only draw a single conclusion from such arguing. The continued pressure to accept the patient in transfer, after I’ve explained there is nothing to do for them, is a condemnation of my analysis of the situation. They’re basically calling into question my competency; my faculty’s compentency.

And I’m okay with that in the sense that I’m not going to take offense. What I have trouble with is they’re now trying to transfer their patient to a consultant who they don’t think is competent.

I don’t know how they can have the patient’s best interests in mind and work to transfer them to another physician they’ve basically said they don’t trust.

The issue gets more complex of course and I could continue writing. What if the patient was 6 months old instead of 61 years but the situation, in terms of the finality of the condition, remained the same? How many physicians on the line at the accepting hospital are literally too lazy to accept the transfer and work for any reason not to?

In general however, in an honest physician-to-physician phone call, with terminal conditions, where nothing will be done at the accepting hospital, no matter the patient’s age, I’m not sure transfer is a good thing. It significantly contributes to costs, provides false hope and contributes to our societal expectations at the end of life.

Monday, May 20th 2013

Financial Toxicity In Cancer Care

I wouldn’t know what to tell patients if they raised the issues of the cost of care. Let me correct that, I don’t know what to tell them. Questions like: “How much will this cost?” or “Are there any resources to help pay for this?” do come up in my patient encounters. I can do little more than shrug ignorantly and suggest a call to the social worker on the floor or in the clinic.

Now some limited research out of Duke looks at how discussions about cost in oncological care impact such,

The people who did talk about financial issues told the researchers it was helpful to do so. “They said it helped decrease their expenses,” Zafar says.

[...]

“I treat colon cancer, and I have the option of giving a drug as an IV or an oral pill,” he says. “If I give the pill form, the patient faces a copay even if they have insurance, and that copay goes away if I give the intravenous version.”

[...]

“We can’t necessarily give the best care to patients unless we address cost,” Zafar says.

Cost and the taboo about discussing such is obviously an obstacle to care. I wish I was better informed on resources for my patients. I’ve grown better over the course of my training but still feel pretty impotent in pointing them in the right direction.

Monday, May 6th 2013

Like All Insurance, Medicaid’s Role In Health Debated

Last week you could watch liberals scramble in response to a New England Journal of Medicine published study.

In 2008 Oregon found resources within the state budget to expand Medicaid. There were far more eligible for the expansion than funds available. Oregon held a lottery to enroll 10,000 new people onto the Medicaid rolls. Harvard, MIT and RAND have a group who saw that lottery as a great playground for studies. The first of these studies has now published its results. The study followed approximately 6,000 people who got Medicaid in 2008 and 6,000 who didn’t and looked at how their blood pressure, cholesterol, diabetes and depression did post randomization. Here’s the important quote from the conclusion that has so many talking,

This randomized, controlled study showed that Medicaid coverage generated no significant improvements in measured physical health outcomes in the first 2 years

As the Affordable Care Act promises the greatest increase in covering the uninsured by Medicaid expansion, if states take it, the study is important.

I linked to Mother Jones above. Here’s what Kevin Drum had to say,

It’s more likely that access to Medicaid did improve health outcomes than that it had zero or negative effects. It’s just that the study was too small to say that with certainty. For laymen, as opposed to stat geeks, the headline result of the Oregon study was “Possibly positive but inconclusive,” not “Had no effect.”

Here’s Jonathan Cohn at The New Republic,

Of course, even if Medicaid isn’t improving health, it’s certainly not making health worse, as some critics have claimed. Meanwhile, it’s improving mental health and providing economic security to some of the most economically vulnerable people in the country.

Justin Wolfers resorted to hypotheticals,


And, as a final example, here’s Matt Yglesias,


There are many nuances that need to be realized about the this study. The measures in the Oregon study where all surrogates for long term health. Admittedly hardly definitive quantities. And it “trended” towards significance in those measures. And we don’t know what the study’s power was.

I concede that significance is a relative crude tool in research. See here for a good explanation of such. But I think that fact plays poorly for this study. The reality is that asking to find a significance defined as a p <0.05, depending on pre-test probabilities, is not asking a lot.

Even without knowing the power with specificity, if this study couldn’t find signifigance at that level then to raise policy questions based on this study is not unreasonable. The beneficial effects of Medicaid on these quantities must be small if they’re real.

And so, only Kevin Drum in hindsight realized the real question this study raises,

Even if they’re real, are these results worth the money spent? That’s a different question, and there’s just no way to answer it with this study. That would require a much larger, longer-term research project.

I strongly disagree with the assertion this study doesn’t help answer that question.

The fact that most proponents of the Affordable Care Act are loathe to discuss, in my limited experience, is the fact that insurance status is not a terribly strong influencer of health. Sure, it influences health utilization and some surrogate markers. But I’m with the studies that imply its effect on major things like mortality is negligible conceding that such is debated.

The Institute of Medicine’s estimate that lack of insurance leads to 18,000 excess deaths each year is almost certainly incorrect. It is not possible to draw firm causal inferences from the results of observational analyses, but there is little evidence to suggest that extending insurance coverage to all adults would have a large effect on the number of deaths in the United States.

The link in the quote is my own.

There are two associations that stunningly are a matter of debate.

The first is the association between insurance status and health care access. Especially with the Medicaid population there are other impressive obstacles to utilizing health care. Those include education and understanding of health issues, time constraints, literacy rates, angst at interacting with providers of different socioeconomic status amongst others. No matter their insurance status those of lower socioeconomic status utilize less health care and have poorer health.

The second is even more stunning, the association between health care access and health. It is true access to care is sometimes associated with secondary measures of health – some of the same measures in the Oregon study and others – but its association with the big quantities such as life expectancy is hardly unequivocal.

I find that personally a little bit shocking.

No doubt health care saves lives and improves health. Our own anecdotes tell us that. But it may very well be doing that on the margins. On a population level how much it effects such, especially as compared to things we might label under the umbrella ‘public health’ is questionable. And so we’re expanding Medicaid at considerable costs and for, perhaps, limited benefit. To what such limited benefit this study may help elucidate. And that is certainly something worthy of policy debate.

The issue is complex. There are cost savings and cost shifting in expansion and there are benefits to consider other than large population based health measures. But to pretend that such doesn’t deserve debate and that this Oregon study doesn’t inform that debate is silly.

The Oregon study is a blow to the logic behind Medicaid expansion.

Sunday, April 28th 2013

The Government Telling You What Drugs You Can Take Is A Balancing Act

What’s the substantial difference between hydrocodone or dihydromorphone or diacetylmorphine? Beyond their manmade designations. Their potential risks versus their potential benefits are difficult things to quantify. In some studies diacetylmorphine is a better analgesic than morphine; nowadays, at least in the United States, only the criminal can tell us anecdotally. The various governments of our federal republic nominally weigh the risk versus reward of all controlled substances in determining under what conditions they will allow them.

It is true that government regulatory behavior appears to influence clinical providers utilization of opiates. But considering physicians can’t even agree on the appropriate use of the opiates the government does lend them to use,

It is unlikely these standards will be developed until there is a consensus among pain specialists about opioid use for nonmalignant pain because boards/agencies have no consistent, reliable source of expert information: Pain specialists should initiate efforts to develop this consensus.

Long term opiates for nonmalignant chronic conditions remain a controversial subject. I say that despite their wide use. Many factors including many psychological and social and financial factors that favor benefit from opiates play into any improvement (or lack thereof) in such pain. And the long term benefit from opiates in a condition like chronic back pain is questionable at best despite the fact such drugs may be the only thing that seems to make your loved friend or family functional. To be fair, not as dubious as surgery itself often.

Nor, as above, is the utilization of opiates, even amongst pain specialists, standardized for such conditions. It is remarkable both the variations amongst clinicians in opiate use for nonmalignant pain and the factors that influence such use. So a belief your personal health care providers know best for your pain may be an inadequate argument against government regulation of opiates.

I’m not a fan of government regulation of opiates whether in a medical setting

My wife suffers from chronic pain…she…requires daily narcotic pain medication to manage her pain.

[...]

My wife is not the criminal. Colorado and the DEA are forcing her to live in pain as they restrict her legal access to pain relief. No one should have to watch the person they love suffer in unimaginable pain just because of bureaucratic hurdles put in place to slow illegal drug use.

…or for personal treatment or other reasons. The point of this post is the distinction is smaller than you may imagine. “[I]llegal drug use” is whatever the government says. Philosophically is there much difference between restricting the hours when you can get morphine from a pharmacy and making the very possession of heroin out of the lab illegal?

Friday, April 26th 2013

Why You May Have Less To Fear From Superbugs Than You Think

Infectious disease is the most hyperbolic of all medical fields, at least when the media gets ahold of such. Right now we are to fear a new avian influenza virus. Previously there was another avian influenza strain whose outbreak threatened the world and of course SARS and, more distantly, the ebola virus and the threat of bioterrorism. And on the periphery, as these acute threats come and go, is the persistent threat of super bugs; bacteria resistant to multiple antibiotics. Sometimes all antibiotics.

I remember my pharmacology professor in medical school claiming that within our practice lives we would reach the useful end of antibiotics. A claim, literally, that physicians would no longer have any use for antibiotics by the time I reached the end of my career.


via The Hamilton Project

Scary stuff but evidence that such outrageousness sells pharmacology in a classroom as much as it does magazines on a news stand. Time magazine a post called “The End of Antibiotics?” referencing a Guardian article along the same lines. This followed a similar 2009 scare article in Time.

And recently in the New York Times, this,

Scientists all over the globe are in a race with evolution, scrambling to understand the underlying mechanisms of antibiotic resistance and to discover new ways to fight bacteria. We must diversify our methods for treating bacterial infections and simultaneously reduce the amount of antibiotics we use, says Brad Spellberg, an infectious-disease specialist at U.C.L.A. This has led to a renewed interest in treatments from a world before penicillin.

In the United Kingdom tabloids took to tracking down individual MRSA victims and sensationalizing their stories, prompting this response from the BMJ,

Raising public awareness can be helpful, but the creation of a climate of fear among patients entering hospital is more likely to increase newspaper sales than to provide a solution.

And while that is part of the issue of the hysteria around antibiotic resistant infections, obviously media is not the sole driver of such. The director of the World Health Organization said antibiotic resistance meant “an end to modern medicine as we know it.” The Infectious Disease Society of America has this publication called, “Bad Bugs, No Drugs.” Sensational quotes.

In 2007 multiantibiotic resistant bacteria were attributed as the cause of 25,000 United Kingdom deaths a year. In the United States the CDC estimates that 90,000 people die from hospital acquired infections every year, a significant portion of those likely from multiantibiotic resistant bacteria. Terrible numbers, but even if they’re on the rise, they continue to pale in comparison to other health care risks and this more than 5 decades after the first great superbug came into the mainstream consciousness.

Infection continues to register weakly as a cause of mortality in the United States compared to heart disease or cancer or chronic respiratory disease or trauma or suicide even. Even when you add all the infections up; the majority of them hardly attributable to multiantibiotic resistant bacteria.

I know we spend much time focussing on the risk factors for cardiac disease and lung disease and the public health issues of such. And the media aids such, but certainly not on the order of magnitude more you might imagine such would demand considering the true risks these non-communicable diseases pose for you and me. And not with the hysteria with which media covers infectious diseases.

This is a serious problem but one that despite its growth will long pale in comparison to other public health issues. And it is not an insurmountable issue. Old therapies, new therapies, prevention are all reasonable strategies for checking the threat of multiantibiotic resistant bacteria. Any public disaster that can be anticipated with any permeance of common knowledge and with any foresight can be stopped.

To be fair, media coverage serves the purpose of informing an important step in fixing any problem but, perhaps, with some measure to the coverage.

Friday, April 19th 2013

The Studies Are All Bad

One of my fellow residents might be a Ben Goldacre disciple except amongst all his citations in conversation I’ve never heard him reference the English Physician. I’ll call Dr. Goldacre the ‘Bill Nye’ or the ‘Neil Degrasse Tyson’ of the antagonistic medical epidemiology circle. But it’s a growing group. Amongst them as well the Greek epidemiologist, John Ioannidis.

There is a horrific set of facts about what we know in medicine.

1) Most medical research is so poorly designed that conclusions you can draw from it are…limited

2) The medical research we are conducting is low yield

3) Most medical research performed never comes to light because it fails to meet the hypothesis of those who conducted it

4) There is strong incentive to falsify results

Ioannidis has a famous paper entitled “Why Most Published Research Findings Are False,”

[T]he majority of modern biomedical research is operating in areas with very low pre- and post-study probability for true findings. Let us suppose that in a research field there are no true findings at all to be discovered.

A Huffington Post article by Dr. Ida Sim,

About 80 percent of clinical trials are funded by the commercial sector, but the commercial sector disproportionately studies drugs, and understudies behavioral treatments or older treatments that can’t be patented or profited from. When 75 percent of our medical costs are for chronic diseases that are largely due to poor lifestyle habits, where are the studies on prevention? On behavior? On effective patient-doctor or public health strategies? Where are the studies that examine the balance of benefits and harms, that guide patients and doctors on side effects and cost-effectiveness?

In England a researcher working for Aptuit is set to serve a prison sentence for falsifying lab results for a cancer drug.

Steven Eaton, from Cambridgeshire, has become the first person in the UK to be jailed under scientific safety laws.

[...]

Sheriff Michael O’Grady said: “I feel that my sentencing powers in this are wholly inadequate. You failed to test the drugs properly – you could have caused cancer patients unquestionable harm.

“Why someone who is as highly educated and as experienced as you would embark on such a course of conduct is inexplicable.”

Speaking after the case, Gerald Heddell, the Medicines and Healthcare Products Regulatory Agency’s director of inspection, enforcement and standards, said he welcomed the conviction.

He added: “This conviction sends a message that we will not hesitate to prosecute those whose actions have the potential to harm public health.”

Biomedical research is difficult to call science. What you can assume your doctor or surgeon knows about your condition is surprisingly less than you think. They will certainly act like they know and truly believe that they do but such knowledge is based on a limited amount of reliable data. In Dr. Ionnaidis’ essay there are some suggestions on making medical research better. And of course as Dr. Goldacre calls for all results of all medical research should be public. Even if that disincentivizes some research we may not be missing out on much.

Monday, April 15th 2013

Iranian Medicine & Sanctions

Like many I have mixed feelings about sanctions against horrific places like North Korea, Iraq and Iran. Muting the costs of the sanctions on the local populace is a difficult task. Loathe to link to anything Alex Jones the article on his site has a number of good links and a number of legitimate points.

They imposed a medieval embargo and tried to starve the nation into submission. The result was over 500,000 dead children, which Clinton’s Secretary of State, Madeline Albright said was a price worth paying. Over the span of ten years, child mortality in Iraq went from one of the lowest in the world, to the highest.

And now, similar things are happening in Iran. For lack of supplies Iran’s health care system is struggling.

Starting last fall, however, Iran appears to have run out of basic surgical supplies, owing to sanctions designed to limit the country’s nuclear program. Despite a “humanitarian assistance” loophole built into the sanctions, reports from inside Iran, some in English and some in Farsi, claim shortages of anesthetics have threatened closures of operating rooms.

[...]

Though it’s legal to sell medicine to Iran, the sales must pass through a byzantine process of currency transfers and third-party banking, to avoid doing business with Iranian financial institutions—most of which are sanctioned. The result is a massive disincentive to do business, her report argues. Pharmaceutical companies, turned off by the risk, simply turn their attention to less demanding markets. “A Western company that wants to sell medicine to Iran has no legal assurance of being paid,” Slavin said.

[...]

Because banks can’t do deals in direct ways with Iran, it’s extremely risky for a pharmaceutical company to extend credit there. But pharmaceutical deals are huge, and almost always conducted on delayed payment.

“Novartis and Pfizer used to give their distributors something like 20 to 50 million [dollars] in credit,” said Namazi. “From the day you needed the medicine to the day it was in the pharmacy was three weeks. If you needed it fast, DHL would get it to you the next day.”

Instead, Iran’s entire national health system has to operate on a cash-and-carry deal. And DHL no longer services Iran, he said.

The United States should have a stated goal of preventing Iran from gaining nuclear power and indeed more, regime change in Iran. I don’t support a unilateral strike to achieve such. And apparently I don’t support sanctions either. Do I contradict myself? Well then, I contradict myself.