Unbiased Analysis of Today's Healthcare Issues

Will a VA scandal happen in England?

Written By: Jason Shafrin - Jun• 08•14

The VA scandal of long wait times is now well-known. Part of the reason why patients were left off official wait lists–ironically–was because VA senior staffers wanted to reduce wait times. Senior VA staff monitored wait times closely to check for any upticks. Some of the VA management at the Phoenix hospital believed the only way to hit their wait time target and save face with upper management was to keep a separate, off-the-books waiting list.

The VA, however, is not the only government organization that monitors wait times. In the UK, the National Health service also closely monitors wait times and sets wait time performance targets for all English hospitals. Like the VA in the US, hospitals in England are incentivized to reduce official waiting times for procedures such as elective surgery.

Using data from the Hospital Episode Statistics between 2006 and 2009, Marques et al. (2014) find that:

…although official waiting times decreased drastically in our study period, total waiting time in secondary care has not declined. Patients with shorter official waits spent a longer time in a ‘work-up’ period prior to inclusion in the official waiting list, and socio-economic inequities persisted in waiting times for joint replacement. We found no evidence that target policies achieved efficiency gains during our study period.

For the VA in the US and the NHS in England, wait time targets do not appear to be successful means of increasing access to care.


HWR: Wonkers Hard at Work Edition

Written By: Jason Shafrin - Jun• 06•14

Joe Paduda has posted  the latest & greatest Health Wonk Review at Managed Care Maters  - he says this issue is quick but not dirty!

End of week links

Written By: Jason Shafrin - Jun• 05•14


Brazil’s Health Care System and the World Cup

Written By: Jason Shafrin - Jun• 04•14

The World Cup starts June 12 in Brazil.  Although the event is sure to draw attention around the world, protesters have taken to the streets demanding that Brazil use the money for these events to improve the countries, health care and education services it provides to its citizens.  Brazil’s projected budget for hosting the World Cup is $13.3 billion, and this figure does not even count the $18 billion Brazil is estimated to spend to host the Olympics


Today, I review Brazil’s health system.  My initial post on Brazil’s health care system is here, but this post adds more recent content and updates some health care statitsics.


New Apple iOS adds Health

Written By: Jason Shafrin - Jun• 03•14

Typically, when Apple unveils a new operating system much of the talk is about new features, faster processing speeds and new visualizations.  Apple’s unveiling of their most recent operating system is no different.  However, this release has a unique focus: health.

Apple is getting into the quantified self health movement with their new Health app.  The app will collect data on your heart rate, activity, blood pressure, calories burden and other health dimensions.  Engaget reports:

The initiative works with companies like Nike to bring all your health information into one place, under the Health app in the next update to iOS. It looks a lot like Passbook, using cards to identify various stats. Thusly, it enables customization of the stats you want tracked and how you want it presented.

In addition to Nike, the Health app is also being developed with consultation from the Mayo Clinic.  One question is, who owns this data?  The user?  Apple?  Nike?  Right now it appears the answer is Apple and this data will likely be highly valuable.

Personalized, portable, electronic health records have long been a dream for many in the Health IT world. This app is not a replacement for electronic medical records (EMR), it  does not appear to contain information from physician, hospital or other health care provider visits. Nevertheless, it is a step in the right direction towards reliable health monitoring.

Correction: Apple’s HealthKit actually does plan to be intergated with EMRs.  Apple is working with Epic and the Mayo Clinic to develop this capability.  HealthKit is a standard way to store information (that can later be used with other apps).  The information will presumably work with data from Epic’s My Chart system.  However is HealthKit just another failed attempt at personalized health records along the lines of Google Health (RIP ‒ 1/1/2012), Revolution Health (RIP ‒ 2/1/2010) and then “last-PHR-standing,” Microsoft’s Healthvault?


Organ Donation: World Cup Edition

Written By: Jason Shafrin - Jun• 02•14

What do organ donation and soccer (or football or fútbol) have in common?  Typically, not much.  However, one Brazilian soccer team, Sport Club do Recife, though otherwise.  The BBC reports:

“Every Brazilian is born with football in the soul,” says Jorge Peixoto, of Sport Club Recife, one of the top teams in the north-east of the country.

For the last two years though, he has been more concerned about what happens to fans’ bodies when they die.

The club decided it “must look beyond the 11 players on the field and use its power for bigger things,” says Peixoto, the club’s vice-president for social programmes.

It asked them to become “immortal fans” donating their organs after they die so that their love for the club will live on in someone else’s body.

It’s nice that a soccer club in Brazil wants to give back. The question is, did it work?

The answer is yes. Over 65,000 people have signed up for an organ donor card. In fact, the organ transplant waiting list in Recife was reduced to zero within 1 year. In fact, mega-clubs PSG and FC Barcelona are interested in adopting a similar program.


Friday Links

Written By: Jason Shafrin - May• 30•14

What is hypertension?

Written By: Jason Shafrin - May• 28•14

What is hypertension?  How is it treated?  Below is a primer from a clinical guidelines paper from Weber et al. (2013).

Classifying Hypertension

  • Prehypertension: Systolic blood pressure between 120 mm Hg and 139 mm Hg, or diastolic pressures between 80 and 89 mm Hg.  Patients with this condition should not be treated with blood pressure medications; however, they should be encouraged to make lifestyle changes in the hope of delaying or even preventing progression to hypertension.
  • Stage 1 hypertension: patients with systolic blood pressure 140 to 159 mm Hg or diastolic blood pressure 90     to 99 mm Hg
  • Stage 2 hypertension: systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥100 mm Hg

Primary vs. Secondary Hypertension

  • Primary: About 95% of adults with high blood pressure have primary hypertension (sometimes called essential hypertension). The cause of primary hypertension is not known, although genetic and environmental factors that affect blood pressure regulation are now being studied.
  • Secondary: About 5% of individuals have secondary hypertension where the cause of is due to chronic kidney disease


Additional questions physicians ask about.

  • Previous stroke, coronary artery disease, chronic kidney disease, diabetes, peripheral artery disease, or heart failure.  Certain anti-hypertensive medications may be preferred  based on patient comorbidities.
  • Sleep apnea.  Additional medication may be needed to improve blood pressure control.

Goals of hypertension treatment.

  • Generally systolic blood pressure is usually <140 mm Hg and for diastolic blood pressure <90 mm Hg



  • Non-pharmacologic: Weight loss, salt reduction, exercise, limit alcohol consumption to 1-2 per day, and stopping cigarette smoking.
  • Drug treatment.  Typically started if blood pressure is >140/90.  Pharmaceutical treatment is especially important for  Stage 2 hypertension.  Treatments include: angiotensin-converting enzyme  (ACE) inhibitor, angiotensin receptor blockers (ARB), alpha-blockers, beta-blocker, calcium channel blockers (CCB), and thiazide diuretic.  If none of these drugs works on its own, drug combinations can be used such as ACE inhibitors plus CCB or diuretics.

CoR at III

Written By: Jason Shafrin - May• 28•14

Claire Wilkinson of the Insurance Information Institute (iii) presents this week’s Cavalcade of Risk, focusing on the assessment side of the equation. From hurricanes to hamburgers, there’s sure to be a post to pique your interest.

CPS updates its health insurance question

Written By: Jason Shafrin - May• 27•14

The Current Population Survey (CPS), a large monthly survey administered by the Census Bureau, is not only designed to measure labor force participation and employment, but is also used to measure health insurance coverage.  Health insurance coverage information is  collected once each year through the Annual Social and Economic Supplement (ASEC), which is administered February through April.  However, a RWJ brief reports that the manner in health insurance status was asked in the CPS may over-estimate uninsurance rates.

To address issues of recall and other errors, the CPS revised its health insurance question in the ASEC.  Specifically, in the revised CPS: “the respondent is first asked about their current coverage and is then asked when that coverage began and if other coverage was held in any month from the start of the previous calendar year through the date of interview.”

Additionally, uninsurance was overestimated because only one person in the household answered all the questions for the whole household.  In the revised CPS:

To improve accuracy without increasing respondent fatigue, a hybrid of the household and person level design was developed. Questions are first asked at the person-level with follow-up questions to determine if others in the household also have an identified coverage type. For the additional household members their coverage is verified, if already identified, and they are asked if they had any additional coverage. The full question series is only asked of additional household members if they have not had any coverage identified in the first-pass through the question series.

The CPS has also been updated for the post Obamacare world. Now, individuals are asked whether their coverage was purchased through a health insurance exchange and if their premiums are subsidized by the government.

For researchers who seek a more consistent time series where the health insurance question changes less frequently over time, other survey options include: the American Community Survey, the Medical Expenditure Panel Survey, and the National Health Interview Survey.