Medical Studies

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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 | Permalink

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 | Permalink

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 | Permalink

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 | Permalink

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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Shingles Vaccine

February 20, 2008 in Medicaid/Medicare, Medical Studies | Permalink

The USA Today reports on the development of a shingles vaccine. According to the article, “The vaccine reduced shingles cases by 51% in people given the vaccine vs. those given the placebo. Vaccination reduced the burden of illness, a measure of pain and discomfort, by 61%.”

So why aren’t people getting this vaccine? One reason is how the vaccine is paid for. The vaccine, priced around $150 by the manufacturer, is covered by the part of Medicare that pays for prescriptions, not doctor visits. That means doctors are not automatically paid for shots given in their offices. Some send patients to pharmacies to get the shots or pick up prescription vials, adding steps that may reduce use, Oxman says. Others stock and give the vaccine, but require patients to pay upfront and seek their own reimbursement.

What questions should you ask your doctor?

February 13, 2008 in Medical Studies | Permalink

Last night I saw an encore presentation of an interview with Jerome Groopman on the Newshour with Jim Lehrer. I have written posts in the past about Dr. Groopman (see 16 March 2007). Dr. Groopman notes that doctors often misdiagnose patients. Physicians are often anchored to a prior belief and have trouble changing their diagnosis even when new evidence appears. Dr. Groopman advises that there are three important questions that patients should ask their physicians after they receive a diagnosis:

  1. What else could it be?
  2. Could two things be going on at once?
  3. Have you found anything–any laboratory test, or X-ray, or physical finding–that isn’t in sync with your presumption…that contradicts what seems to be the diagnosis.

The full interview is available on YouTube: part 1, part 2.

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Pittsburgh has more MRI Machines than Canada

February 11, 2008 in Medical Studies | 7 comments

There is an interesting article at Forbes describing that the housing boom is not the only bubble that may need to burst. Scans per thousand insured people went from 85 to 234 in the U.S. between 1999 and 2007. Author David Whelan describes what happened to one radiologist in Connecticut after Medicare and HMOs cut scan reimbursement rates this year:

Radiologist David Gruen used to spend millions of dollars to replace his General Electric MRI and CT scanners every three years. It was money well spent because the machines were always busy. But a year ago Medicare cut the price it pays for imaging, so Gruen gets paid 15% to 50% less for each order, depending on the type of scan. Health insurers got wise, too, and started imposing a 48-hour review on imaging orders. The doctor hired clerks to battle the HMOs, but his office volume was flat last year, down from 10% growth in prior years. Gruen was forced to take a 20% salary cut. Now his Norwalk, Conn. practice is holding off on buying new machines and stretching the old machines’ life span to five years. “We really do face a crisis,” he says.

In additional, General Electric’s (disclaimer: my former employer) medical division has seen declining profits for the first time in years.

Are Medicare and HMO cuts to imaging hurting patients? The New England Journal of Medicine thinks not. There are side-effects to these scans including increased levels of radiation exposure, especially dangerous for kids. As with any test, there is the probability of a false positive (i.e., that patient does not have the disease, but the test claims they do). “A study from the National Institutes of Health found that 17% of patients getting tested for cancer had at least one false positive chest X ray over a four-year period, and 8% of women had at least one false positive ultrasound for ovarian cancer.” These figures lend some more evidence that Americans may be Overtreated (see my post on Shannon Brownlee’s book of the same name).

Forbes also finds that “a doctor who owns his own machine is four times as likely to order a scan as a doctor who doesn’t.” Financial incentives do make a difference (for more information on how physician financial incentive affect surgery rates, see my working paper “Operating on Commission“).

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How to reform Med School

February 7, 2008 in Medical Studies | Permalink

Is the current medical school curriculum optimal in terms of teaching doctors-to-be how to best practice medicine? DB’s Medical Rants blog says no.

“One cannot really understand most diseases if one cannot correlate the physiology. We should focus our anatomy teaching on the big issues, not the 3rd branch off the 2nd artery (hopefully you get my point.) We need not have students be able to identify dried out cadaver structures. Rather we should learn functional anatomy – e.g., the structures and causes of shoulder pain, the types of knee injuries, the correlation of DVT with clinical findings, intra-abdominal anatomy, how specific brain lesions impact patients.

To support these 2 very important courses we need to learn enough cell biology and histology to understand the cellular components of disease. We also need to know enough biochemistry to support the physiology course.”

Sounds like good advice to me.

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Doctors figure out what house movers, wedding planners, and tax accountats figured out ages ago

December 11, 2007 in Current Events, Hospitals, Information, Medical Studies | Permalink

A New Yorker article (“The Checklist“) recounts Peter Pronovost’s efforts to improve the delivery of medical care. One of his simplest ideas was to invent a 5 step checklist to reduce line infections:

Doctors are supposed to (1) wash their hands with soap, (2) clean the patient’s skin with chlorhexidine antiseptic, (3) put sterile drapes over the entire patient, (4) wear a sterile mask, hat, gown, and gloves, and (5) put a sterile dressing over the catheter site once the line is in.

All doctors know these 5 steps, but in the distraction-filled world of the I.C.U., it is very easy for the physician to forget any one of the steps. Dr. Pronovost’s checklist idea has extended to other treatment areas as well. Yet he believes that Americans are still not getting serious about treating medical care as a science.

“The fundamental problem with the quality of American medicine is that we’ve failed to view delivery of health care as a science. The tasks of medical science fall into three buckets. One is understanding disease biology. One is finding effective therapies. And one is insuring those therapies are delivered effectively. That third bucket has been almost totally ignored by research funders, government, and academia. It’s viewed as the art of medicine. That’s a mistake, a huge mistake. And from a taxpayer’s perspective it’s outrageous.â€? We have a thirty-billion-dollar-a-year National Institutes of Health, he pointed out, which has been a remarkable powerhouse of discovery. But we have no billion-dollar National Institute of Health Care Delivery studying how best to incorporate those discoveries into daily practice.

Checklists are not the solution to every problem.  A large portion of medicine deals with complex condition with large uncertainties and many disease interactions.  Further, it may be more difficult for an insurance company to institute checklists than a hospital manager or someone further down the chain of command.  Nevertheless, standardization in medicine should help to dramatically improve quality.

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