Grab Bag 2

Scorecards on state health care performance.
Not surprisingly, this shows that the south and Nevada are relatively bad at caring for their citizens. If the those states acted more like the best performing states, they would help a lot more of their people with better quality care at lower prices. They don't, though, because they have a predominant culture of blind belief in their superiority and refusal to engage in progressive change.

CT scans cause about 30,000 cancers per year, half of which will be fatal. This is not to say that we should never use CT scans. We do need to be more vigilant about the overprescription of tests and procedures, and this is a great example of that need. CT scans are typically overpriced and overprescribed because too many hospitals bought CT scanners by issuing debt and have to pay off those debts by increasing the prices to consumers and performing more tests than the population needs. Doctors with financial stakes in their clinics are especially prone to prescribing unnecessary tests and procedures because they profit from them. People will unnecessarily die early from expensively-treated cancer caused by unnecessary tests ordered for personal and hospital profit, as well as for the sake of defensive medicine. We need more oversight, more restrictions on the purchases of expensive equipment (some states restrict, but the outcomes are mixed because of the different standards used), and an absolute ban on doctors being in conflict-of-interest situations. "First, do no harm," right?

Speaking of defensive medicine, it is one component of the Congressional Budget Office's estimation that tort reform could effectively save America over $50,000,000,000 over ten years. The report suggests that the measures would also result in better health outcomes, perhaps due to a reduction in unnecessary tests and procedures that carry health consequences. Reform is of course heavily opposed by the deep, deep pockets of the lawyers who make piles of money no matter which side of the lawsuits they're on. Politicians are getting lobbied by the greedy lawyers who profit from the policies that hurt real people in our country.

Grab Bag 1

Here's just a bunch of topics I've pulled aside and not gotten around to posting.

Teen pregnancy and STD rates got worse under G.W.Bush's watch, especially in the South. No surprises, there. When you take money away from programs that work and give it to programs that don't work, the outcomes suffer. When you have a culture that uses evidence-based practices, you see returns on your investments.

Putting stents in arteries may be unnecessarily done 240,000 times per year. Dr. Teirstein is an obvious example of the big problem with many doctors. He is biased towards something he has experience with and makes a fortune from, which leads him to discount real research. He doesn't care what really works best for people. He doesn't want to be told what to do. He wants to do what he likes and effectively defraud insurers. Fee for service is a terrible way to pay doctors. We need fee for outcomes. They need to be accountable.

Stupid Americans will not vote for politicians who would actually make the best decisions for our country. Rationing is not bad. Every health system has rationing. In fact, every system that involves money or resources has rationing. It's a fact of life. Get over it. Right now, insurance companies ration the Hell out of people's health care, and the uninsured get nothing at all. The British system is brilliant. The British try to make sure they get the most pop for the pound. With finite resources, they try to do the most good that they can for everyone. Only complete idiots would take the American route and deprive children and workers from basic care while spending the bulk of resources on people who are going to die soon. Also in this article is the idea that we should find out what treatments work best in which situations, then NOT require doctors to use that information. I sure as Hell want my doctors to do what's been shown most effective instead of whatever else they feel like.

Infant Mortality Revisited

Continuing from before. An article on the ABC news website discusses factors related to infant mortality in Memphis, TN, which has the highest infant mortality rate among US cities. The article also reminds us that the US has the highest infant mortality among the 23 richest countries in the world.

"Premature birth is the primary medical cause of infant mortality." American doctors try really hard to turn premature births into living babies, spending massive resources on NICU treatment, then sending them home to still die at high rates compared to other wealthy countries. I used to challenge international infant mortality comparisons on the basis that other countries didn't include deaths of babies born after less than, say, 30 weeks gestation, while the US counted anything over maybe 24-27, depending on who's reporting. Lately, though, the comparisons have been careful to use the same gestation criteria across countries, I think with five hold-outs. What I do not know is the proportions of births by country that are premature. If America has higher rates of premature births, that could explain much of the higher infant mortality rate.



I believe that race washes out as a factor when the model includes SES, parenting, education, religion, and geography. Children develop into healthier, smarter, better-thinking people when they have affectionate, stable parents. Girls who grow up without dads, or without affectionate parents, make bad decisions about relationships, and are more likely to get pregnant early by another poorly raised teen or an exploitative adult. Remember to look at this model pangenerationally. The young people having kids that survive are the bad parents of the next generation of young parents; with poor brain development, making bad decisions, working poor jobs if at all, poorly educated, stressed out because they are incapable of managing effective lives. Religion contributes to ineffective education about birth control, and to preventing abortions. It is notoriously difficult for teens to get abortions in some areas of the US (like the South), so many babies are born to parents who do not want them and/or are completely unable to properly raise them. A recent TIME magazine chart showed that the South and Southwest have vastly higher teen pregnancy rates compared to other regions (New England has the lowest), and the chart was nearly identical to the earlier chart on infant mortality. Despite the media frenzy about the Massachusetts "pregnancy pact", the teen pregnancy rate in that area is very low for the US. Interestingly, mortality is only higher for the first-born of teens.

What can we do?
Obviously, a good start would be to get the areas with the worst problems to do more of what the areas with the best outcomes do. It blows my mind that the South wallows in problems while trash-talking New England. It also blows my mind that America wallows in problems while trash-talking Europe. Stop being blindly arrogant. Look at the outcomes. Apply best practices. Stop abstinence-only sex-ed. Promote safe sex. Provide social services that work. Make welfare-recipients buy vegetables (make them accessible, too) instead of chips and cigarettes. Make abortions and condoms accessible to teens. Provide drug rehabilitation instead of throwing addicts in jail. Provide incentives for the populations of people who can't make good decisions and resist being told what to do, so that they are more subtly influenced to do what is good for them. Not only would these things reduce infant mortality, but also reduce teen pregnancy, crime, and poverty, increasing national productivity and overall quality of life for the citizens of our country.

HR 676 - The Good and the Bad - Part 4

Continued from Part 1, Part 2, and Part 3.

Health care delivery facilities must meet regional and State quality and licensing guidelines as a condition of participation under such program, including guidelines regarding safe staffing and quality of care.

Good
This is a measure to appease people who oppose federal involvement in state affairs.

Bad
Some states insist on having unnecessarily low standards. "Best Practices" is the idea that everyone should do what has been shown to lead to the best outcomes. We are constantly measuring health care outcomes related to different policies, and it blows my mind that there are factions out there who refuse to do what is best for the people in their care. Mississippi's quidelines for quality of care are not the same as Connecticut's, and Mississippi has significantly worse health care outcomes. A single-payer has a great opportunity to use its leverage to require uniformly high standards instead of allowing states to choose whether or not they will slack off. Residents of Mississippi are still Americans, and the American government has a responsibility to them.

Participating clinicians must be licensed in their State of practice and meet the quality standards for their area of care. No clinician whose license is under suspension or who is under disciplinary action in any State may be a participating provider.

Good
Pretty standard.

Bad
Same as above about variance in state standards, but with an added gripe. It is a pain in the tuchas for clinicians to move from one state to another because licensure requirements are all different. Clinicians who live near a border are either stuck working in one direction, or have to go through multiple licensure procedures. I don't know if this constitutes an undue burden on interstate-commerce or what, but it is ridiculous. There should be at least the option of satisfying a single, high standard that would allow clinicians to move without getting a new license. There is a similar situation with gun laws, and many states accept a Florida license because it is more difficult to get than their own. Some states are easier to move to than others.

The complaints in this post are about our current system, and not about HR 676 in particular. It is just that HR 676 is accepting of these problems, and they are included in the bill. Causing as little turmoil as possible will help the bill's progress, though our system really does need some improvements.

Acupuncture - A Study with Toothpicks

I came across this article today reporting on a study comparing four types of lower back pain treatment over 7 weeks: individualized acupuncture, standardized acupuncture, "sham" acupuncture using toothpicks, and a control group that just used painkillers and anti-inflammatories (all groups were allowed to use drugs). Though I don't have the original journal article (May 11 Archives of Internal Medicine), the sample size seems large enough that the effect size mentioned should be statistically significant. 40% of the control group reported "significant improvement in disabilities brought on by back pain", and 60% of each of the other three groups reported the same. What might this mean for recommended treatments and third-party payment?

First, keep in mind that the participants all knew that this was a study on acupuncture treatment in order for the study to get informed consent. Only people willing to receive acupuncture were involved, which means the study had self-selection biases. Then they were randomly assigned to the four groups. So, the control group knew it was not getting the treatment that the study was testing. This would definitely have led to expectation biases in reporting disability. This study compared people willing to try acupuncture who got what they were told was acupuncture to people willing to try acupuncture who were then not given it. The chances that the effect seen is due to the placebo effect are very high.

The placebo effect is real and practically significant. It is really amazing how thoughts and beliefs, activity in the pre-frontal cortex, affect other parts of our brains and bodies, stimulating immune response (or inhibiting it) among other phenomena. What is also nifty is that we can intentionally generate these effects in ourselves without being tricked. Once we understand that a placebo effect exists, we can mimic the effect on purpose through mindful concentration or meditation. Recent studies using MRI, PET, and SPECT scans have revealed many brain processes that we can harness to benefit ourselves.

Jonah Lehrer, in How We Decide, cited research that reported that 90% of cases of non-specific lower back pain go away with just 7 weeks of rest. That would make rest far more effective than acupuncture or drugs. Perhaps having an active treatment encouraged these participants to continue physical activities that aggravated their back problems. With the expectation that they would be better with acupuncture or drugs, maybe they pushed themselves harder than they should have.

Based on this information, and in the interest of best practices, it seems that the answers to our questions are that Doctors should prescribe seven weeks of rest before moving on to other treatments, and that third-party payers still have little to no call to reimburse for acupuncture. The evidence is not compelling that acupuncture works according to its theories, and the high likelihood of a placebo effect suggests that similar benefits could be achieved through optimism, which is free.

I am interested in any well-done, valid, peer-reviewed studies demonstrating real benefits to acupuncture beyond a placebo effect. Since one in twenty studies may fall prey to a type I error (alpha is usually 0.05), meta-analyses are preferred. Send them my way if you've got 'em.