Medical Studies

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Surgical Complications and Mortality Rates

December 16, 2009 in Hospitals, Medical Studies, Surgery | No comments

Mortality during surgery is dependent on two factors.  The first is the probability of having complications during surgery.  The second is the probability of dying conditional on having a complication.  One would expect that hospitals with low mortality rates would have both fewer complications and lower probability of death conditional on a complication.  

A paper by Gheferi, Birkmeyer, and Dimick (NEJM 2009) shows that this may not be the case.  After risk adjustment complication rates were not significantly higher in high mortality hospitals.  However, conditional on there being a complication, mortality rates were much higher in high mortality hospitals than low mortality hospitals.  

 

In Hospital Mortality (Gheferi et al. NEJM 2009)

How can doctors decrease mortality due to complications?  Gheferi, Birkmeyer, and Dimick recommend “timely administration of antibiotics in patients with sepsis, the rapid transfer of a patient to an intensive care unit (ICU), and the availability of interventional cardiologists during an acute myocardial infarction.”

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H1N1: Do I have it? Do I need a vaccine?

October 20, 2009 in Contagious Disease, Public Health | No comments

Two weeks ago, the U.S. government released its H1N1 vaccine to the public.  Many people have had a number of questions about whether or not they should get the vaccine.  The CDC website has a list of Key Facts and a Q&A section that is helpful.  

There are five major groups who should have priority of getting the vaccine:

  • pregnant women,
  • people who live with or provide care for infants younger than 6 months (e.g., parents, siblings, and day care providers),
  • health care and emergency medical services personnel,
  • people 6 months through 24 years of age, and,
  • people 25 years through 64 years of age who have certain medical conditions that put them at higher risk for influenza-related complications.

There are a number of people who should NOT get the vaccine.

  • People who have a severe allergy to chicken eggs.
  • People who have had a severe reaction to an influenza vaccination.
  • People who developed Guillain-Barré syndrome (GBS) within 6 weeks of getting an influenza vaccine previously.
  • Children younger than 6 months of age (influenza vaccine is not approved for this age group), and
  • People who have a moderate-to-severe illness with a fever (they should wait until they recover to get vaccinated.)

The H1N1 vaccine is prepared using the same method as used for the seasonal flu.  However, because the H1N1 vaccine was developed too late, it could not be added to the seasonal flu vaccine.  Thus there are two flu shots available now, one for the seasonal flu and one for H1N1. 

If you think you have the H1N1 illness, you can use this self assessment tool to verify whether or not you should see a doctor.

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Medical Advances

June 7, 2009 in Medical Studies | No comments

The Economist’s Technology Quarterly reveals some recent advances in medical technology:

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Getting Naked

January 26, 2009 in Medical Studies | No comments

The physician-patient interaction can be a strange one.  Patients leave their most important possession–themselves–in the hand of strangers.  Typically conservative women will bare their naked bodies to physicians.   Although rare, the possibility exists for the physician to take advantage of this situation.  

In the U.S. “4 percent of the disciplinary order that state medical boards issue against physicians are for sex-related offenses…Seventy two percent of females medical students and twenty nine percent of male medical sudents have been victors of patient initiated sexual behavoir.”  I know of patients who slap cute medical assistants’ behind.  Physicians and patients can both act inappropriately.

How do physicians establish trust with their patients?

Atul Gawande gives some examples from around the world in Better: A Surgeon’s Notes on Performance.

  • Afghanistan: When a male physician examines a female patient, they are separated by an opaque screen with a two-inch circle cut into the screen. “Behind it, the woman is covered from head to toe by her burka. The two do not talk directly to each other. The patient’s young son serves as the go-between.” S
  • Iraq: Family members are present in the exam room whenever there is a male physician examining a female patient.
  • Venezuela: A nurse chaperone is present any time there is a breast or pelvic exam.  The exam will not take place without the presence of the chaperone.
  • England: A nurse chaperone is present any time a patient undergoes a breast, pelvic or abdominal exam.
  • Ukraine: A nurse chaperone or family member is rarely present in the examine room, but cultural mores help to maintain a professional tone.  Patients always address the physician as Dr. ____, and the physician addresses the patient as Mr. or Mrs. _____.

Gawande, Atul (2007) Better: A Surgeon’s Notes on Performance, Metropolitan Books, 288 pages.

Gawande A (2005) “Naked” NEJM, 353:645-648.

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Why do we die?

January 23, 2009 in Medical Studies | No comments

What factors predict how long we live?  What are the best ways to forestall death?

The determinants of premature death are 40% behavoiral, 30% genetic, but only 10% medical care.  It is important to remember that medical care and health are far from synonomous.

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700 billion reasons to read the Health Wonk Review

October 2, 2008 in Carnivals, Medical Studies | 6 comments

With the Senate passing a $700 billion Wall Street bail-out last night, the Healthcare Economist wonders who else needs a bail out.  The best and brightest health bloggers have your answer.  In this edition of the Health Wonk Review, we will examine six groups looking for help:

  • Wall Street
  • Health Insurers
  • Healthcare Reformers
  • Doctors
  • The Uninsured
  • Kids

WALL STREET

HEALTH INSURERS

HEALTHCARE REFORMERS

DOCTORS [Especially those owning MRI machines]

THE UNINSURED

KIDS

INTERESTING POSTS that I couldn’t tie in with the bail out theme

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Expectations and Prostate Surgery

September 3, 2008 in Medical Studies

The N.Y. Times Well Blog writes that 19% of men regretted having prostate surgery. What is interesting is that men who underwent a newer, less invasive, robotic surgery were four times more likely to regret the prostate surgery than those who underwent the older, more invasive “open” procedure.

Is this increase in regret due to worse outcomes?  This is likely not the case.  Instead, it may be that doctors are inflating the patient’s expectations of how life will be like after the robotic surgery:

“Part of the problem may be that doctors who perform robotic prostatectomies commonly cite potency rates as high as 95 percent and above among their patients, giving patients an unrealistic view of life after surgery.

But the data are highly misleading. Researchers often define potency as simply being able to achieve an erection that is “adequate” for intercourse — but for many men, that definition doesn’t capture their ongoing struggle to return to a normal sex life. Earlier this year, researchers from George Washington University and New York University used a more realistic definition of potency, showing that after surgery, fewer than half of the men studied felt their sex lives had returned to normal within a year.”

The success of a surgery may not only depend on the technical skill a physician exhibits, but also how they are able to control the patient’s expectations so that they are able to lead a satisfying life after their surgery.

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Americans have the best cancer survival rates

July 22, 2008 in International Health Care Systems, Medical Studies

On Friday I reported that the U.S. scored poorly on the Commonwealth Fund’s National Scorecard. Those in favor of universal health care are probably rejoicing. “The U.S. system is dysfunctional beyond repair and we need universal health care!”

Yesterday, the Economist reported on an article in The Lancet Oncology journal which found that the U.S. has the best five year survival probabilities for breast and prostate cancer. Score one for those against universal health care. “The American free market is always the best!”

How can this be? How can we reconcile these two results?

The Lancet Oncology article controls also for other covariates which are related to survival probabilities, but do not relate to the quality of health care. For instance, if Americans get cancer later in life than people from other countries this is taken into account since people who are older are more likely to die of almost all causes, including cancer. Further, if traffic mortalities or the homicide rate are higher in the U.S. than in other countries, this will likely decrease the probability a cancer patient survival for 5 years, but is unrelated to the quality of medical care. If Americans are more likely to be obese, this also will decrease their survival probabilities, but should not be an indictment against the health care system. For these reasons, the 5 year cancer survival probabilities are adjusted to take into account the age and death rates in the general population. After these effects are taken into account, the U.S. scores very well in terms of cancer survival.

Of course cancer survival is only one of a myriad of ways of measuring the quality of the American health care system. Further, the U.S. spends the most money on healthcare (in total and per capita) compared to any other country. While the U.S. may (or may not) be the best, it is certainly the most expensive.

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Doctors are very empathetic…until they start seeing patients

February 29, 2008 in Medical Studies

According to InsideHigherEd.com (“Tomorrow’s Doctors…“) medical students are very altruistic, empathetic people…until the start medical school.  The article describes the findings of a study titled “Is There Hardening of the Heart During Medical School?” in March’s Academic Medicine. 

The longitudinal study finds significant decreases in “vicarious,” or emotionally driven, empathy, during the course of medical education. Significant drops happen after the first year and after the third, clinical year when “students,” the article notes, “were seeing patients they had, presumably, looked forward to helping.”  (The drop at that point of first patient contact in the third year is particularly concerning, the lead author, Bruce W. Newton, said in an interview Thursday)…

The authors find, for instance, that students who choose the “core” specialties, where they see many of the same patients (i.e. internal medicine, family medicine, pediatrics, obstetrics-gynecology and psychiatry), manage to better maintain their empathy throughout medical school compared to those who choose “noncore” specialties (like radiology or surgery), where continuous contact with specific patients is limited.

[Hat tip to Marginal Revolution]

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Doctors, Patients, and the Racial Mortality Gap

February 28, 2008 in Academic Articles, Medical Studies

Differences in the health outcomes between white and minority patients has been well documented in the medical and economics literature. Reasons for this difference could be:

  • Unequal access to treatment. Minorities are poorer and less likely to be covered by insurance than whites.
  • Unequal treatment – Minorities are less likely to have a regular doc, which leads to discontinuities in care.
  • Unequal quality of care available to minorities – For instance, doctors who treat blacks are less likely to be board certified.

A recent paper by Emilia Simeonova tries to dig deeper into what is causing the racial mortality gap for chronic heart failure (CHF). CHF is one of the leading causes of death for the elderly and one of the major components of the racial mortality gap.

Methods

Ms. Simeonova uses a six-year panel data set from Veterans Affairs [i.e.: the VHA Medical SAS inpatient and outpatient datasets,the Beneficiary Identification Records Locator Subsystem (BIRLS) death files, the VHA Enrollment files, and the Veterans Service Support Administration (VSSA) clinic performance measures database]. The data allow the author to compare treatment within facilities rather than just between them. This is important because it is possible that blacks go to bad doctors and whites go to good doctors and this may constitute the entire mortality gap. By comparing outcomes within a clinic or within the same doctor, the author can better analyze what is causing the mortality differences.

The author calculates 3 year survival probabilities conditional on surviving two years. This should help to eliminate different CHF severity levels. In her regression, Simeonova uses patient and clinic characteristics, as well as clinic fixed effects, and time and cohort dummies. Simeonova measures doctor quality as the probability the doctor prescribes beta blockers and ACE inhibitors to patients with chronic heart failure (CHF). However, another aspect of the quality of medical care is patient compliance. Patient compliance is calculated as the number of prescriptions filled on time divided by the total number of prescriptions filled.

Results

Simeonova finds that doctor quality accounts for 5% of the CHF mortality gap and socio-economic factors account for 20% of the differences in CHF mortality. However, the vast majority of the mortality differences are due to the fact that blacks are less likely to take their medication than whites.

“I show that doctor quality significantly influences patient outcomes. While minority patients visit slightly less competent doctors, this does not explain the large gap in survival. Individual doctors are found to treat their patients similarly regardless of race. On the patient side, I demonstrate that variation in compliance triggers a racial mortality gap. Differences in patient response to treatment significantly alter survival probabilities. Considerable reductions in medical costs could be achieved by convincing patients of the importance of strictly following the therapy regimen. I estimate that targeting compliance patterns could reduce the black-white mortality gap by at least two-thirds.”

Also interesting is that the paper found that when blacks have a regular doctor, they end up seeing a lower quality doctor. Nevertheless, compliance rates and mortality decrease for blacks when they have a regular doctor despite the fact that this doctor may be of a somewhat lower quality.

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