January 24, 2009
Newshour Health Updates
Question/Comment: What is the future of Social Security and Medicare in the next 20-years and how do you see it being changed to accommodate future generations?
Paul Solman: Medicare is a much bigger problem than Social Security. I think Medicare will be extended to all Americans at some point.
Nobel laureate economist George Akerlof convinced me, some years ago, that universal health insurance is inevitable because with genome testing, either you know that you're likely to have a serious disease but your insurance company doesn't, so you load up on insurance OR your company demands the test results and refuses you if the odds are bad. Either way, it's the death knell for a private insurance system; everyone has to be in the same UNIVERSAL risk pool.
But when that happens, and probably even before, Medicare will almost surely be changed in basic ways to further limit the procedures and pills it pays for. That's because the main reason health care costs will continue to rise steeply, as best I can tell, is technology. See my very personal take on this argument.
January 23, 2009
Clean Air Lead to Longer Life
The Boston Globe reports on a recent study in the New England Journal of Medicine showing that cleaner air in a number of our large cities has resulted in an average increase in life expectancy of five months. --- writes,
Cuts in air pollution increased life expectancy an average of five months in Boston and dozens of other American cities in recent decades, a study from Harvard and Brigham Young universities strongly suggests. The researchers looked at the amount of small-particle pollutants in 51 US cities - including Boston, Worcester, Springfield, and Providence - during the 1980s and '90s and found that the predicted lifespan increased most significantly in cities where air quality increased most dramatically.
The study, which appears in today's New England Journal of Medicine, signals that efforts to curtail the small, toxic particles spewed by power plants, factories, cars, and trucks and inhaled by city-dwellers had significant health benefits over those two decades. Several clean-air advocates and public health specialists said the results show that even stronger standards for air pollutants are needed.
"We had known with reasonable confidence for a while now that air pollution is bad for people's health," said Majid Ezzati, a professor at the Harvard School of Public Health and one of the study's authors. "The question still lingering was: Does lowering pollution have health benefits? The answer is yes." . . .
Other factors that have improved the predicted lifespan in recent decades range from medical advances, education, and income growth to changes in lifestyle, including healthier eating habits and quitting smoking.
Life expectancy does not directly indicate how long people live. Rather, it predicts how long the average person in a population would live if the death rate at a given time persisted for the person's lifetime. . . .
If cleaner air improves predicted lifespan, life expectancy has probably further increased in many parts of the nation during the past decade. Since 2000, air monitoring data show that the national average concentration of fine particles has decreased 11 percent, said Cathy Milbourn, spokeswoman for the US Environmental Protection Agency. . . .
FDA Approves Stem Cell Research
The New York Times reports on the FDA's approval of a stem cell therapy in humans. Andrew Pollack writes,
In a research milestone, the federal government will allow the world’s first test in people of a therapy derived from human embryonic stem cells. Federal drug regulators said that political considerations had no role in the decision. Nevertheless, the move coincided with the inauguration of President Obama, who has pledged to remove some of the financing restrictions placed on the field by President George W. Bush. The clearance of the clinical trial — of a treatment for spinal cord injury — is to be announced Friday by Geron, the biotechnology company that first applied to the Food and Drug Administration to conduct the trial last March. The F.D.A. had first said no, asking for more data.
Thomas B. Okarma, Geron’s chief executive, said Thursday that he did not think that the Bush administration’s objections to embryonic stem cell research played a role in the F.D.A.’s delaying approval. “We really have no evidence,” Dr. Okarma said, “that there was any political overhang.” But others said they suspected it was more than a coincidence that approval was granted right after the new administration took office. “I think this approval is directly tied to the change in administration,” said Robert N. Klein, the chairman of California’s $3 billion stem cell research program. He said he thought the Bush administration had pressured the F.D.A. to delay the trial. . . .
The F.D.A. approval comes a little more than 10 years after the first human embryonic stem cells were isolated at the University of Wisconsin, in work financed by Geron. Because the cells can turn into any type of cell in the body, the theory is they may one day be able to provide tissues to replace worn-out organs or nonfunctioning cells to treat diabetes, heart attacks and other diseases. The field is known as regenerative medicine. . . .
Geron’s trial will involve 8 to 10 people with severe spinal cord injuries. The cells will be injected into the spinal cord at the injury site 7 to 14 days after the injury occurs, because there is evidence the therapy will not work for much older injuries. The study is a so-called Phase I trial, aimed mainly at testing the safety of the therapy. There would still be years of testing and many hurdles to overcome before the treatment would become routinely available to patients. . . .
Even as some researchers hailed the onset of clinical trials, others expressed trepidation that if the therapy proves unsafe — or even if it is safe but does not work — it could cause a backlash that would set the field back for years. “It would be a disaster, a nightmare, if we ran into these kinds of problems in this very first trial,” said Dr. John A. Kessler, the chairman of neurology and director of the stem cell institute at Northwestern University. Dr. Kessler, whose own daughter was paralyzed from the waist down in a skiing accident, said he thought Geron’s therapy was not the ideal candidate for the first trial. He said results showing the therapy worked in moderately injured animals might not apply to more seriously injured people. “We really want the best trial to be done for this first trial, and this might not be it,” he said. . . .
The main safety concern is that if raw embryonic cells are put into the body, they can form tumors. Even though most such tumors do not spread like other cancers, any unwanted growth in the spinal cord can further damage nerves. . . .
January 22, 2009
Social Determinants of Health
Gail Wilensky, former administrator of the Health Care Financing Administration, during the presidency of
George H.W. Bush, and David Satcher, former surgeon general and assistant secretary of health during the presidency of Bill Clinton, have a piece in Health Affairs discussing improving health care provided to children - with a focus on social issues. Here is the abstract:
The Obama administration faces daunting challenges to reform health care.
The authors, commissioners on the World Health Organization’s Commission on the Social
Determinants of Health, believe that strategies to improve health by affecting the social determinants may gain bipartisan support. These determinants—including the effects of poverty,
education, the treatment of women, employment opportunities, and limited access to
medical care for some—are as important in promoting health, if not more so, than the direct
medical determinants of health. Focusing on these determinants makes more sense than
waiting until people become sick and seek care, and it often costs much less.
Rating Hospitals by Death Rates in California
The LATimes reports the results of a rating system for California hospitals. Lisa Girion writes,
Some hospitals are better than others. But for many years all patients had to go on was reputation, doctors' advice, word of mouth and advertising. Today, California follows some other states, the federal government and a few private groups in offering a window on hospital quality.
The study by state officials of hospital death rates shows that for eight common conditions and procedures -- including stroke, hip fracture and brain surgery -- the rates vary widely.The study looked at mortality rates for 2007 and 2006. It found that, in 2007, 25 hospitals had death rates that were significantly better than the state average on at least one indicator, while 94 were significantly worse in at least one area.
In 2006, 33 hospitals had mortality rates that were significantly better on at least one indicator, while 98 hospitals rated significantly worse on at least one indicator. Los Angeles County hospitals fared especially well in acute stroke care, based on mortality statistics in 2007. Of 97 hospitals in the county, 13 had significantly better than average mortality ratings for stroke, while only one was worse than average on the indicator. . . .
Officials plan to post the study today at www.oshpd.ca.gov and said they hoped it would help improve care. "It is our hope that the timely release of these new indicators will encourage California's hospitals to examine their practices and improve their quality of care and help inform consumers and patients about their healthcare choices," said David Carlisle, director of the Office of Statewide Health Planning and Development.
But the study was immediately criticized. Torrance Memorial Medical Center, which received a worse than average mortality rating for gastrointestinal hemorrhage, said the information was badly flawed. The hospital's own review of the 40 deaths in 883 gastrointestinal hemorrhage cases during the two-year study period "revealed a startling result: 15 of the 40 patients did not expire at Torrance Memorial," the hospital said in a statement. "In fact, many of the patients listed by OSHPD as deceased are still known to us to be alive." The hospital said it discovered a programming error in the electronic data transfer from its medical record system to the state. A recalculation without the 15 cases inadvertently classified as deaths would result in a mortality rate well within the state average, the hospital said. . . .
Neil Romanoff, vice president for medical affairs at Cedars, said the study offered a limited view of hospital care because it failed to take into account deaths that occurred shortly after hospitalization. "If a hospital . . . transfers their patients out alive earlier and they die at the next level of care, what does that tell you?" Romanoff said. "These are complicated questions that are not clearly answered by one measure of quality."
Joseph Parker, director of the statewide health office's Health Outcomes Center, said a study that took into account deaths after hospitalization would be less timely. "There's a trade-off here," he said. "We wanted to get information here that is more recent and actionable."
The state plans to update the study annually and to expand the categories. The federal Centers for Medicare and Medicaid and about 15 states publicly report various hospital quality indicators. Some report how well hospitals adhere to model practice standards, while others look at mortality and other outcomes.
January 21, 2009
Health Care in the Inauguration Speech
We, focused as ever, listened for any tidbits about health care and heard two. First, there was an acknowledgment of the expense of health care in a long list of woes the nation now faces.
That we are in the midst of crisis is now well understood. Our nation is at war, against a far-reaching network of violence and hatred. Our economy is badly weakened, a consequence of greed and irresponsibility on the part of some, but also our collective failure to make hard choices and prepare the nation for a new age. Homes have been lost; jobs shed; businesses shuttered. Our health care is too costly; our schools fail too many; and each day brings further evidence that the ways we use energy strengthen our adversaries and threaten our planet.
Later, in keeping with Obama’s seemingly ceaseless message of hope, health came up again as the president talked about how the U.S. can “lay a new foundation for growth.”
For everywhere we look, there is work to be done. The state of the economy calls for action, bold and swift, and we will act - not only to create new jobs, but to lay a new foundation for growth. We will build the roads and bridges, the electric grids and digital lines that feed our commerce and bind us together. We will restore science to its rightful place, and wield technology’s wonders to raise health care’s quality and lower its cost. We will harness the sun and the winds and the soil to fuel our cars and run our factories. And we will transform our schools and colleges and universities to meet the demands of a new age. All this we can do. And all this we will do. . . . .
Faith v. Medicine
The New York Times has a story today on the tension between faith and medicine that exists for some families. Dirk Johnson reports,
Kara Neumann, 11, had grown so weak that she could not walk or speak. Her parents, who believe that God alone has the ability to heal the sick, prayed for her recovery but did not take her to a doctor. After an aunt from California called the sheriff’s department here, frantically pleading that the sick child be rescued, an ambulance arrived at the Neumann’s rural home on the outskirts of Wausau and rushed Kara to the hospital. She was pronounced dead on arrival.
The county coroner ruled that she had died from diabetic ketoacidosis resulting from undiagnosed and untreated juvenile diabetes. The condition occurs when the body fails to produce insulin, which leads to severe dehydration and impairment of muscle, lung and heart function. “Basically everything stops,” said Dr. Louis Philipson, who directs the diabetes center at the University of Chicago Medical Center, explaining what occurs in patients who do not know or “are in denial that they have diabetes.”
About a month after Kara’s death last March, the Marathon County state attorney, Jill Falstad, brought charges of reckless endangerment against her parents, Dale and Leilani Neumann. Despite the Neumanns’ claim that the charges violated their constitutional right to religious freedom, Judge Vincent Howard of Marathon County Circuit Court ordered Ms. Neumann to stand trial on May 14, and Mr. Neumann on June 23. If convicted, each faces up to 25 years in prison.
“The free exercise clause of the First Amendment protects religious belief,” the judge wrote in his ruling, “but not necessarily conduct.” Wisconsin law, he noted, exempts a parent or guardian who treats a child with only prayer from being criminally charged with neglecting child welfare laws, but only “as long as a condition is not life threatening.” Kara’s parents, Judge Howard wrote, “were very well aware of her deteriorating medical condition.”
About 300 children have died in the United States in the last 25 years after medical care was withheld on religious grounds, said Rita Swan, executive director of Children’s Health Care Is a Legal Duty, a group based in Iowa that advocates punishment for parents who do not seek medical help when their children need it. Criminal codes in 30 states, including Wisconsin, provide some form of protection for practitioners of faith healing in cases of child neglect and other matters, protection that Ms. Swan’s group opposes. . . .
In the last year, two other sets of parents, both in Oregon, were criminally charged because they had not sought medical care for their children on the ground that to do so would have violated their belief in faith healing. One couple were charged with manslaughter in the death of their 15-month-old daughter, who died of pneumonia last March. The other couple were charged with criminally negligent homicide in the death of their 16-year-old son, who died from complications of a urinary tract infection that was severely painful and easily treatable.
“Many types of abuses of children are motivated by rigid belief systems,” including severe corporal punishment, said Ms. Swan, a former Christian Scientist whose 16-month-old son, Matthew, died after she postponed taking him to a hospital for treatment of what proved to be meningitis. “We learned the hard way.”
All states give social service authorities the right to go into homes and petition for the removal of children, Ms. Swan said, but cases involving medical care often go unnoticed until too late. Parents who believe in faith healing, she said, may feel threatened by religious authorities who oppose medical treatment. Recalling her own experience, she said, “we knew that once we went to the doctor, we’d be cut off from God.” . . . .
Thanks to Jim Hart for bringing this artice to my attention.
January 20, 2009
Change Has Come
Here is the newly updated whitehouse.gov website. Looks good.
January 19, 2009
Happy Martin Luther King Day
Atul Gawande on Health Reform
Atul Gwande has an interesting article in this week's New Yorker discussing health reform. He provides a history lesson on how other countries came to embrace universal health care and talks about the prospects for reform in the United States, He writes,
Yet wherever the prospect of universal health insurance has been considered, it has been widely attacked as a Bolshevik fantasy—a coercive system to be imposed upon people by benighted socialist master planners. People fear the unintended consequences of drastic change, the blunt force of government. However terrible the system may seem, we all know that it could be worse—especially for those who already have dependable coverage and access to good doctors and hospitals.
Many would-be reformers hold that “true” reform must simply override those fears. They believe that a new system will be far better for most people, and that those who would hang on to the old do so out of either lack of imagination or narrow self-interest. On the left, then, single-payer enthusiasts argue that the only coherent solution is to end private health insurance and replace it with a national insurance program. And, on the right, the free marketeers argue that the only coherent solution is to end public insurance and employer-controlled health benefits so that we can all buy our own coverage and put market forces to work.
Neither side can stand the other. But both reserve special contempt for the pragmatists, who would build around the mess we have. The country has this one chance, the idealist maintains, to sweep away our inhumane, wasteful patchwork system and replace it with something new and more rational. So we should prepare for a bold overhaul, just as every other Western democracy has. True reform requires transformation at a stroke. But is this really the way it has occurred in other countries? The answer is no. And the reality of how health reform has come about elsewhere is both surprising and instructive. . . .
January 18, 2009
Your Kids as Research Subjects
Interesting and thought-provoking story in the New York Times today about researchers using their children in research. Pam Belluck reports,
At a birthing class, Dr. Sinha, a neuroscience professor at the Massachusetts Institute of Technology, stunned everyone, including his wife, by saying he was excited about the baby’s birth “because I really want to study him and do experiments with him.” He did, too, strapping a camera on baby Darius’s head, recording what he looked at. Dr. Sinha is among a new crop of scientists using their children as research subjects.
Other researchers have studied their own children in the past, but sophisticated technology allows modern-day scientists to collect new and more detailed data. The scientists also say that studying their children allows for more in-depth research and that the children make reliable participants in an era of scarce research financing. . . .
Arthur Toga, a neurology professor at the medical school at the University of California, Los Angeles, studying brain change, scanned his three children’s brains using magnetic resonance imaging. . . . And Deb Roy, at M.I.T., embedded 11 video cameras and 14 microphones in ceilings throughout his house, recording 70 percent of his son’s waking hours for his first three years, amassing 250,000 hours of tape for a language development study he calls the Human Speechome Project.
Some research methods are clearly benign; others, while not obviously dangerous, might not have fully understood effects. Ethicists said they would consider participation in some projects acceptable, even valuable, but raised questions about the effect on the child, on the relationship with the parent, and on the objectivity of the researcher or the data.
“The role of the parent is to protect the child,” said Robert M. Nelson, director of the Center for Research Integrity at Children’s Hospital of Philadelphia. “Once that parent becomes an investigator, it sets up an immediate potential conflict of interest. And it potentially takes the parent-child relationship and distorts it in ways that are unpredictable.”
Researchers themselves acknowledge the challenge of being simultaneously scientist and parent. “I don’t want them to feel uncomfortable, like I’m invading their privacy,” said Dr. Linebarger, who ultimately set some boundaries. “When you mix being a researcher with being a parent, it can put your kids in an unfair place.”
Children have been subjects for some well-known scientist-parents, including Jean Piaget, the child-development theorist. But some past examples would probably not pass ethical muster today. Jonas Salk injected his children with his polio vaccine. Clarence Leuba, a psychologist, wondering if laughter in response to tickling was learned or innate, forbade tickling of his infant son and daughter, except when he tickled them, wearing a mask to hide his expression. . . .