July 2010

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Atul Gawande’s Latest Article

July 30, 2010 in Nursing Homes, Supply of Medical Services | 2 comments

Atul Gawande has written yet another excellent article in the New Yorker.  This one about end of life care.  In the debate surrounding health reform, many politicians hijacked the serious discussion of end-of-life decisions and decisions to use non-invasive medical treatment were termed death panels.  But end-of-life decisions merit further investigation.  Not only can giving patients end-of-life treatment options lower cost, but it can also improve the patient remaining quality of life.  For instance:

“Coping with Cancer project published a study showing that terminally ill cancer patients who were put on a mechanical ventilator, given electrical defibrillation or chest compressions, or admitted, near death, to intensive care had a substantially worse quality of life in their last week than those who received no such interventions. And, six months after their death, their caregivers were three times as likely to suffer major depression.”

One reason that palliative care has not been adopted by more patients is that most hospice facilities compel patients to agree to forego more intensive services.  One innovative program convinced more terminal patients to use hospice facilities by allowing access to more intensive treatment while in hospice care.

“In late 2004, executives at Aetna, the insurance company, started an experiment. They knew that only a small percentage of the terminally ill ever halted efforts at curative treatment and enrolled in hospice, and that, when they did, it was usually not until the very end. So Aetna decided to let a group of policyholders with a life expectancy of less than a year receive hospice serviceswithout forgoing other treatments…A two-year study of this “concurrent care” program found that enrolled patients were much more likely to use hospice: the figure leaped from twenty-six per cent to seventy per cent. That was no surprise, since they weren’t forced to give up anything. The surprising result was that they did give up things. They visited the emergency room almost half as often as the control patients did. Their use of hospitals and I.C.U.s dropped by more than two-thirds. Over-all costs fell by almost a quarter.”

NPR’s Fresh Air also has an interview with Dr. Gawande.

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Penile Exorcism

July 29, 2010 in Books | No comments

Here is one more excerpt from the book, The Spirit Catches You and You Fall Down. The book often discusses the intersection between Westernized medicine and more traditional healing arts.  Since mental/spiritual well-being often affects physical well-being, it should be no surprise that more traditional ritual ceremonies should offer some health improvement.  This is one of the more “interesting” cases where traditional healing arts improved both spiritual and physical outcomes.

  • Complaint/Symptomatology: The client’s penis had been swollen for about a month.  He reported that he’d been treated by licensed physicians, but that the treatment had only given intermittent relief from pain and swelling.
  • Assessment: The Neng determined that the client had offended the stream spirits.
  • Treatment Plan: The Neng called upon the Neng spirits to effect a cure and release the pain.  The Neng used a bowl of water to spray from the mouth over the infected area.  The offended spirits were offered payment of five sticks of incense to release the pain and relieve the swelling.
  • Result: The client got better after the ceremony.

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Cavalcade Of Risk: Colorado Rocky Mountain High Edition

July 28, 2010 in Carnivals | No comments

The latest edition of the Cavalcade of Risk is up at Colorado Health Insurance Insider.

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Maximum Empathy

July 27, 2010 in Books | 2 comments

I just completed reading a very interesting book about cross-cultural medical care.  The book, The Spirit Catches You and You Fall Down, and deals with the problems physicians face when treating one Hmong girl in Merced and the problems the parents of this child face when dealing with Western medicine.  One interesting describes the progression of physician empathy levels over time.

The desnsitization starts on the first day of medical school, when each student is given a scalpel with which to penetrate his or her cadaver: ‘the ideal patient,’ as it is nicknamed since it can’t be killed, never complains, and never sues.  The first cut is always difficult.  Three months later, the students are chucking pieces of excised human fat into a garbage can as nonchalantly as if they were steak trimings.  The emotional skin-thickening is necessary–or so goes the conentional wisdom–becuase without it, doctors would be overwhelmed by their chronic exposure to suffering and dispair.  Dissociation is part of the job…

At Stanford Medical School, in an admirable attempt to fight this trend, students are informed during the first semester that their empathy may already have peaked; if they succumb to the norm, it will plunge steadily during their four years of medical school and their first year of residency.

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Hospital Quality

July 27, 2010 in Hospitals, Quality | 1 comment

The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) is a standardized survey instrument and data collection methodology for measuring patients’ perceptions of their hospital experience.  HCAPHS is the first national standard for collecting and reporting hospitals quality data.

The survey asks discharged patients 27 questions about their recent hospital stay.  The survey is administered to a random sample of adult patients across medical conditions between 48 hours and six weeks following discharge.

Although CMS publicly reports the results of the HCAPHS survey, the sample is not restricted to Medicare beneficiaries.  However, hospitals are allowed to collect their own data which begs the question of whether they manipulate the data.  For instance, they may prefer worse satisfaction scores to have a low baseline or prefer high satisfaction scores to attract more patients.  Although I do not know if this occurs, one could envision a patient conveniently being dropped from the survey if they give the hospital a bad review.

The number of hospitals that publicly report HCAHPS results has increased from 2,521 in March 2008, to 3,711 in March 2009.

Timeline:

  • 2002.  CMS partnered with the Agency for Healthcare Research and Quality (AHRQ), another agency in the federal Department of Health and Human Services, to develop and test the HCAHPS survey.
  • May 2005.  National Qualify Forum endorses HCAHPS
  • December 2005.  Office of Management and Budget (OMB) approves HCAHPS
  • October 2006.  CMS implements HCAHPS survey
  • July 2007.  The Deficit Reduction Act of 2005 requires IPPS hospitals to submit HCAPHS data to receive full IPPS annual payment update.  Non-IPPS hospitals, such as Critical Access Hospitals, may voluntarily participate in HCAHPS.
  • March 2008. CMS publicly reports HCAHPS survey results on Hospital Compare.

Source: HCAHPS Fact Sheet, March 2009.

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Off to NYC

July 21, 2010 in Miscellaneous | No comments

I will be out of town until Monday night.  Blogging will resume Tuesday.

Links

July 21, 2010 in Current Events | No comments

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Medicare Part D’s Effect on Drug Use, Other Medical Services, and Health

July 21, 2010 in Uncategorized | 2 comments

Medicare Part D increases beneficiary utilization of drugs, but does not decrease utilization of other medical services or improve health.

That is the conclusion Kaestner and Khan (2010) reach using data from the Medicare Current Beneficiary Survey.  Many other studies have found that prescription drug insurance plans increase drug use.  After Medicare Part D drug insurance was enacted, Lichtenburg and Sun (2007) found a 12.8% increase and Yin et al. (2008) calculated a 5.9% rise in drug use.  The Kaestner and Khan paper, however, finds that “Medicare Part D was associated with an 63% increase in the number of annual prescription.”  Even among individuals in poor health, whose demand for pharmaceuticals may be more inelastic, “gaining prescription drug insurance was associated with a 56% increase in the number of annual prescription.”  The direction of these findings should not be surprising, but the magnitude maybe shocking.

If the large increase in pharmaceutical consumption is offset by decreased hospitalization rates or use of other medical services, Part D may still be cost saving.  In fact, Zhang et al. (2009) found that individuals covered by Kaiser Permanente, “gaining prescription drug use was associated with a 7% decline in medical (non-pharmacy) spending.”  Kaestner and Khan, on the other hand, find that increased drug utilization has little effect on the use of other medical services for most beneficiaries.  In the case of outpatient visits, however, gaining prescription drug insurance decreased outpatient visits among those in poorer health. “For this group prescription drug insurance was associated with three less outpatient visits per year, which is approximately 40% of a standard deviation fewer visits.”  Thus, Part D could create some cost savings in other areas of Medicare.

Finally, the authors find that Part D has no effect on health in terms of either functional status or self-reported health.  [The authors measure functional status as the number of ADLs and IADLs.] In fact, the authors note the following: “If anything, estimates suggested that gaining prescription drug insurance was associated with worsening health.” Could this be because some physicians overprescribe drugs which could actually worsen outcomes?  Is functional status and self-reported health sufficiently precise to capture the benefit of these drugs?  Are the benefits of pharmaceuticals generally confined to short-run benefits?

Generalized Linear Models (GLM)

July 20, 2010 in Econometrics | 1 comment

The generalized linear model (GLM) is a flexible generalization of ordinary least squares regression. OLS restricts the regression coefficients to have a constant effect on the dependent variable. GLM allows for the this effect to vary along the range of the explanatory variables.

The basic structure of GLM estimator is as follows:

  • g(Y) = Xβ + ε
  • E(Y) = μ = g-1(Xβ)

To estimate the model, one needs three components:

  1. Random component, specifying the conditional distribution of the
    response variable, given the explanatory variables.  Typically, this distribution is from the exponential family.
  2. A linear predictor which is a linear function of the regressors: η = β0 + β1X1 +…+ βkXk = Xβ
  3. A link function which transforms the expectation of the response to the linear predictor.  In other words, the link function describes the relationship between the linear predictor and the mean of the distribution function.  The link function must be invertible.

Read the rest of this entry »

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Marketing Cocaine

July 19, 2010 in Regulation | No comments

An energy drink called Cocaine has received a lot of press.  Texas has barred the sale of the drink in the state. The FDA made the manufacturers of Cocaine change the label so it looked less like white powder.  To comply with FDA directives, the cans now declare “This product is not intended to be an alternative to an illicit street drug, and anyone who thinks otherwise is an idiot.”

Peru has also banned the sale of Cocaine.  To market the drink in Peru, the manufacturer would need to add extract of coca leaf.

Source: Wilson Quarterly, “Marketing Cocaine” Summer 2010, p. 15.

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