Thursday, February 26, 2009

Defining "Streetlight" Research

In my last post (“Quality and Chronic Disease Management”) I use the term “streetlight” research without defining it, so I thought that I should do that. It is based on an old joke:

A guy is walking down the street one night a finds another guy on his hands and knees searching in the gutter under a streetlight. He asks what he is doing, and the second guy says “I dropped my car keys.” So the first guy offers to help, but after some time they are unsuccessful, so he asks “Where exactly did you drop them?”
“Down the block,” the second guy says, pointing.
“So why are we looking here?” the other asks in exasperation.
“Well,” the second guy replies, “the light’s better!”

Streetlight research. You do the research that it seems feasible (cost, effort) even though it may not answer the real question that you have. (“Well, that would be much too difficult a study to do.”) It can get published, get you promoted, and even get you famous, but it still doesn’t answer the question you originally had.

Tuesday, February 24, 2009

Quality and Chronic Disease Management

JAMA (Feb 18, 2009) has an interesting commentary by Patrick Conway and Carolyn Clancy of the Agency for Healthcare Research and Policy (AHRQ) on “Transformation of Health Care at the Front Line”,[1] which tries to address issues of quality assessment and cost, and emphasizes the need for studies to be done at the “front line” of medical care – actual community-based practices, rather than only at academic health centers. AHRQ has funded much of this research, including funding of projects carried out by “practice based research networks”, networks of community based practitioners, usually coordinated at an AHC (frequently in departments of Family Medicine or Preventive / Community Medicine). They note the existence of a “multitude of quality organizations” that have developed standards and measures, but call on them to focus on “high priority measures such as those that influence outcomes on high-prevalence diseases, demonstrate baseline performance variability, and have potential mechanisms to improve results…measures should increasingly focus on patient-centered outcomes.” They also note that current measures, which focus on individual clinician-patient interactions, undervalue the importance of teams in care.

Conway and Clancy also address Health Information Technology, Comparative Effectiveness, Quality Collaboratives and Learning Networks, and very importantly, Clinician Training. This last includes what seems to be slightly odd: “This focus on quality improvement, coordination of care, and measuring results is especially critical for training future generalist physicians.” I am certain that this means to address the fact that generalist physicians will be critical in coordinating patient care, not to exempt subspecialists from quality improvement; after all, the effectiveness of standards implemented by and measured in the practices of generalist physicians will be completely negated if subspecialists are not subject to the same standards; if they are allowed to continue, as is very often the case currently, to provide procedures because they are available, may be effective, are profitable but not necessarily cost-effective, and done in isolation from an approach to the overall care of the patient.

One very large effort to address quality were the 15 randomized trials of care coordination for chronic disease in Medicare patients known as the Medicare Coordinated Care Demonstration, supported by the Centers for Medicare and Medicaid Services (CMS), and reported on by the independent evaluator, Mathematica Policy Research, Inc., in the Feb 11, 09 issue of JAMA.[2] Each of these trials was conducted by an institution (community hospital [3], academic medical center [3], integrated delivery system –i.e, hospital and associated practices [1], private for profit care-coordination agency [5], long-term care facility [1], retirement community [1]hospice [1]) and involved 15 states + DC (Iowa and Maryland were in two each, and one hospital covered patients in 4 states). The main effort was to use care coordination to try to decrease hospitalizations, and thus costs (as hospitalization is the main driver of cost) in various chronic disease populations. Most of these programs used nurses (usually RNs, though in one case LPNs, to call – with greatly varied frequency, or visit in only a few of the cases) patients with chronic diseases. The bottom line is that they didn’t work to reduce costs through reduced hospitalizations, although they do not really report on benefit to patient outcomes (as previously addressed in this blog, improved outcomes may not cost less). Two of the programs did have fewer hospitalizations, and two had significant increases in cost (one program was in both groups). Two (including the other program with fewer hospitalizations) had non-statistically-significant trends toward lower cost.

A very important factor is that the participants in these studies were different from the mean for all Medicare beneficiaries. They were had higher educational levels, and were less likely to be Hispanic, younger than 65 (since people who are on Medicare < 65 must be disabled, this would potentially select for healthier people, or at least exclude a large number of sick ones), or on Medicaid (a proxy for poverty). They also had nearly three times higher costs/beneficiary in the year prior to entry into the study ($1555 vs $552). An even more important issue is that the programs were allowed to set their own criteria for entry into – and exclusion from – their study populations:

“Four programs explicitly excluded beneficiaries younger than 65 years [who, as noted above, would be particularly sick] and 13 programs excluded those patients with end-stage renal disease or receiving dialysis. Fourteen programs excluded beneficiaries with certain other conditions, including terminal illness, conditions that affected their ability to learn self-management (e.g., serious mental illness or dementia), or conditions that were complex to manage but unrelated to target diagnoses (e.g., human immunodeficiency virus/AIDS)…”

Such exclusions make the studies easier to conduct, and would tend to make the outcomes look better (although they still didn’t) but make them less useful to apply to the real world, where people do have mental illness, HIV/AIDS, end-stage renal disease, and even more, have multiple chronic diseases, not just one or two. Many of them are also poor, on Medicaid, disabled, and Hispanic. Thus, while these studies, in multiple settings, seem to fit the criterion of “front line” that Conway and Clancy describe, the exclusions and the differences in the study populations from all Medicare beneficiaries would limit their applicability even if they were effective; they are still “effectiveness” than “efficacy” studies.

In this regard, this study is another illustration of the problems of most research studies, whether laboratory, clinical, or even (as this one) community based. They are “streetlight” studies that set out to answer questions that are possible, or easy, to answer, rather than the actual questions that we need answers to. By excluding participants, paying them, providing free benefits (all of which may be components of ethical research, ironically), by setting conditions not replicable in the entire community, their usefulness can be very limited. The Medicare studies, based in the community and involving sick people are, even with their limitations, more useful than most. Unfortunately, they did not demonstrate savings, but savings alone cannot be the only criterion (we have addressed cost-effectiveness, Feb. 13). Conway and Clancy speak of “patient-centered outcomes”, but we really need more – patient-important outcomes, by which really we mean mortality and quality of life.

Finally, as I have to note so often, studies of quality, and of cost, and even of cost-effectiveness, are taking place in the context of our current non-system of health care, with ridiculous financial motivators for practice and no coordinated national approach to health or health policy, and are therefore extraordinarily limited. A national health financing system, single payer or otherwise, will not guarantee quality or cost control, but its absence will virtually guarantee failure when pilot programs, even “successful” ones, are moved into the general population.

[1] Conway PH, Clancy C, “Transformation of health care at the front line”, JAMA 18Feb09;301(7):763-5
[2] Peikes D, Chen A, Schore J, Brown R, “Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials”, JAMA 11Feb09;301(6):603-18.

Thursday, February 19, 2009

Performing procedures: Who is capable and how should we pay?

A recent article in the British Medical Journal reported on a comparison between physicians and nurses performing endoscopy in the UK.[1] They specifically looked at “upper endoscopy” (esophago-gastro-duodenoscopy) and flexible sigmoidoscopy, not full colonoscopy which has largely replaced flexible sigmoidoscopy as a screening tool. Their conclusions show that there were no differences in outcomes at 1 day, 1 month, or 1 year in the two populations, and that the patients of the nurses indicated greater satisfaction, particularly with the teaching and explanation that they received. This study is consistent with the findings of one published in 1994 in the New England Journal of Medicine by William Maule.[2] Nursing journals and other advocates have pointed to the latest study as indicating that nurses are, or can be, as “good as” doctors[3]; certainly within the limits of the study it does provide such evidence. The editorial accompanying the BMJ article discusses many of the limitations of the study, which I will not go into here, except to say that none of them particularly indicate that nurses trained to do endoscopy do not perform as well as physicians.[4]

I don’t doubt that this is encouraging to nurses, and to nurse educators, who have frequently been disparaged by implications that their education and training did not provide them with the background to perform as well as physicians. However, the important point here is not a nurse/doctor one, but rather the fact that endoscopy, like many medical procedures, is essentially a psychomotor skill, which should be able to be successfully taught to anyone who is moderately intelligent and moderately dexterous. In Britain, they have taught this skill to a large number of nurses, who apparently do it very well, as did the nurses in the US reported upon by Maule 15 years ago. But why should such training be limited to nurses? It is obvious that many procedures, including endoscopy, require significantly less psychomotor skill (and probably knowledge) than complex automobile mechanics, such as, say, rebuilding a transmission. Yet our automobile mechanics, even transmission specialists, while well trained, are not required to even attend college, not to mention receiving education and training as rigorous as nursing or medical school. Not to mention the 4 years of college, 4 years of medical school, 3 years of internal medicine residency, and 2 years of gastroenterology fellowship that are required in the US for a physician to become a GI specialist, the primary group doing endoscopy. For those who wish to note that working on a car is less serious than working on a person, I suggest that there is likely much greater risk to the health of the people riding in a car with a poorly rebuilt transmission or other major mechanical work than from a poorly done colonoscopy.

It seems obvious that adequate – even excellent – training could be received by those attending a two-year community college course, comparable to those training our radiology and laboratory technicians. A well-trained technician doing 10 or 20 endoscopic procedures a day would be very good indeed, and would free the well-trained gastroenterologist to make the complex medical decisions that do require a great deal of medical knowledge, skill and experience rather than spend their time performing relatively simple procedures. So why don’t we do it that way? Why do superbly educated gastroenterologic physicians choose to spend their time doing these procedures?

The answer, of course, is money, and the perverted, inappropriate and nonsensical way that we reimburse for health care in this country, in which the value assigned to procedures of any kind far exceeds that assigned to thinking and caring and talking and decision making (so-called “evaluation and management”, or E&M, care). In the US system of assigning value to different numeric codes, representing the work done for a patient, E&M “codes” are routinely, and absurdly, assigned a lower number of “relative value units” (RVUs) and thus reimbursed at much lower rate than procedural “codes”. For example, for approximately 30 minutes spent by a physician doing a visit with an established patient Medicare (2007) would pay $94.20, while the payment for a colonoscopy would be $203 and for a cataract removal, $670! This does not just apply to major surgical procedures, or even relatively large non-surgical procedures such as endoscopy. A physician can collect more money for cleaning the wax from a person’s ears (a procedure!) than for the entire well-person visit! Spending 5 minutes wrapping a gel-infused elastic bandage (“Unna’s boot”) around a foot with an ulcer on a person with diabetes will pay several times more than the entire visit listening to, examining, educating, and prescribing treatment for the patient. What utter nonsense!

The most important point made about the article in BMJ is a relatively minor sentence in the editorial: “Nurse led services in the United Kingdom have been encouraged by government policy, a shortage of doctors, a willingness of nurses to adopt expanded roles, and a salaried NHS workforce where professionals re not in competition for income from patients” (my emphasis). This is the heart of the matter. Where absurd reimbursement systems are not driving inappropriate use of resources, incenting highly trained physicians to do what could be done by nurses or, as I suggest, by well-trained technicians, we could actually decide what kind of care should be done by whom, and how much time should be spent on it, by what was in the best interest of people’s health.

[1] Williams J, Russell I, Durai D, et. al., “Effectiveness of nurse delivered endoscopy: findings from randomized mult-institution nurse endoscopy trial (MINuET), BMJ 2009;338:b231
[2] Maule WF, Screening for Colorectal Cancer by Nurse Endoscopists, NEJM Jan201994;330(3):183-87.
[3] Lomas C, “Endoscopy nurses 'equal' doctors”,, Feb 16, 2009
[4] Norton C, Grieve A, Vance M, Editorial: Nurse-delivered colonoscopy, BMJ 2009;338:a3049

Sunday, February 15, 2009

New Orleans: Have we still no shame?

I don’t usually post things about me, and what I did – it isn’t that kind of blog – but sometimes I come across things that do relate to issues of social justice.

I just returned from a meeting in New Orleans. I hadn’t been there since several months before Hurricane Katrina; that visit, in May, at a lovely time of year in New Orleans was a very pleasant memory in contrast to the devastation that I know occurred, that I have seen pictured. Three and a half years later, the French Quarter, where we stayed, looks ok. Ten days before Mardi Gras, there are even big parades, to show New Orleans is “back”. But it is not back. On the way to and from the airport the devastation is still apparent, the ruined buildings and blue tarps on the roofs of the Ninth Ward obvious even from the highway. Our group spent an afternoon working, planting, well, plants at City Park, a 1300 acre (compared to 800 acres for NYC’s Central Park) largely privately supported venue that is near to Lake Ponchatrain and was devasted by the storm. It felt good to do the work, to know that in some small way we were contributing to the rebuilding of New Orleans.

But why has it taken so long? It seemed that, with all the articles published, all the criticism of FEMA, and Homeland Security, and GWB, and “Heckuva job, Brownie!” that there was no more to know. But there is. Two experiences in particular. My friend Pat, talking to a ranger at a local park, asked why the Dutch, with their expertise in dikes and land reclamation, had not been consulted. They had, he said, and had arrived two days before. Two days before! Three and a half years late! But the Army Corps of Engineers didn’t think it needed to learn from anyone. Of course, they – the Corps – just handed in their plan for rebuilding the levees two weeks ago. The one that was due in December, 2007. (The ranger noted, as a sidebar, that he had been in Biloxi, MS after the storm, and that the Dutch Army landed on the beach and helped to feed people. Thank you!)

The other involves the attached photograph, not very clear as it was taken with a cell phone of a sign pretty high on a wall. If you can’t read it, it says:

Tulane Community Health Center at Covenant House. Sustained through a generous gift from the People of Qatar.” And to the right of the logo: “Qatar Katrina Fund.”

Very generous of the people of Qatar. I am certain that the Tulane Community Health Center is providing vital health care services to the people of that community thanks to the funds from the People of Qatar.

But I am the only one who feels just a little bad, a little nauseous, that the “richest country in the world”, the home of all those multibillionaire financiers and bankers who are still rich, even after the collapse of the economy that they engineered with the able assistance of the US government, must rely on the generosity of the people of Qatar to fund a clinic in one of its own cities, three and a half years after a major natural disaster?

Where are our priorities? Where have they been? Is it possible that anyone could feel a government, a nation, that pursued policies of socialism-for-the-rich while ignoring the most basic human needs of its own people, is not worthy of shame? And that anyone who doesn’t feel that way, the people who actually made and make up the government, the policy makers and the talking heads who supported them and still support the same disastrous policies, are not evil and probably criminals?

Where is our shame?

Friday, February 13, 2009

Economics and Disease Prevention

In a brief, less than 3-page commentary in the February 4, 2009 JAMA, (“A closer look at the economic argument for disease prevention”),[1] Steven Woolf systematically, succinctly, and thoroughly addresses the breadth of issues surrounding assessment of prevention methods and their cost, and the comparison to treatment. It is a “must read” for anyone interested in health, prevention, medical care, or health economics. I have nothing to add to this excellent presentation, but for any readers who cannot get JAMA, I will attempt to identify and summarize some of the key points, below.

· Framing the question as “whether preventive strategies save money” is incorrect. Some may, indeed, but for others, as for any goods and services we purchase, the question is what value we, as individuals or a society, get for our expenditure (cost-effectiveness), particularly in comparison to other options (most commonly disease treatment). Often this is measured in QALYs (quality-adjusted life years; see post January). “Services ordinarily are considered to have reasonable cost-effectiveness if they cost less than $50,000 to $75,000 per [QALY], but payers routinely cover treatments that cost more than $100,000 per QALY.”

· Many preventive measures have been demonstrated to be very cost-effective – “Among 25 recommended preventive services 15 cost less than $35,000 per QALY and 10 services cost less than $14,000 per QALY”, while others actual do save money – “childhood immunizations, smoking cessation, and aspirin prophylaxis among patients at increased risk for cardiovascular disease”. However, some are not: “…offering services to low-risk patients, frequent rescreening, and pursuing aggressive targets (e.g., reducing low-density lipoprotein cholesterol levels to <100mg/dL).”

· Some services can be shown to be cost-effective in comparison to doing nothing, but are not when compared to an alternative intervention. This is parallel to the requirement that new drugs only need to be shown to be superior to placebo to be approved, not to alternative existing therapies (my comment, not his).

· The adoption of behaviors by individuals (such as smoking cessation or exercise) may be of great benefit and cost-effectiveness in themselves, but programs to induce such behaviors may or may not be. For example, physician counseling to patients to stop smoking is cost-effective (<$5000 per QALY) but physician counseling for patients to exercise is of uncertain effectiveness and cost/benefit.

· Econometrics doesn’t capture everything; “Even if prevention and treatment cost the same per QALY, patients prefer the former to avoid the ordeal of illness.” Of course, but not always considered!

· What level of effectiveness are we looking at and, importantly, who pays? “…some community…preventive services (e.g., tobacco taxes, immunization requirements, seatbelt requirement) offer low cost per QALY or net savings.”, but may not be as important to, or even considered by, physicians, hospitals and health plans concerned with medical care, and require social or governmental intervention. “Community interventions may outperform clinical interventions, on both effectiveness and economic value. Opening a new cardiac center may cost more and do less for the health of local citizens than banning smoking in public places.”

· While prevention only accounts for 2% to 3% of health care expenditures, preventive interventions are (rightly) scrutinized for effectiveness and cost-effectiveness, treatment interventions (wrongly) rarely are. “Policy makers will rightly deny coverage for cancer screening until trials demonstrate an effect on mortality, but they readily extend coverage for new diagnostic tests simply because they boast greater accuracy or are advocated by specialists….The question that dogs prevention – will it save money? – is rarely posed for a new imaging device, a new antibiotic, or a surgical procedure.” Woolf persuasively argues that, whatever the origins of this “double standard” may be, it must disappear if we are ever to control health care spending. “The same questions posed for prevention must now be applied to disease treatments: does the intervention improve health outcomes, and how strong is the evidence? If the intervention is effective, is it cost-effective (a good value)? Can other options achieve better results, or the same results at lower cost?”

I have quoted extensively from the piece because it is so well-written and clear. Although based on the work of many researchers, it provides an outstanding expostulation of the issues it covers. It should be read and pondered by all health systems, providers, and policy makers.

[1] Woolf SH, “A closer look at the economic argument for disease prevention”, JAMA 4Feb2009; 301(5):536-8.

Monday, February 9, 2009

Masters of the Universe: They need a long fall

The Sunday (February 8, 09) New York Times had an (as usual) excellent column by Frank Rich, “Slumdogs Unite!”. It addresses the issues of tax problems, conflict of interest, especially in the financial sector, and confidence of the public in the new Obama appointees. I would add only one thing: when I read the sentence “Most ‘ordinary Americans’ still don’t understand why banks got billions while nothing was done (and still isn’t being done) to bail out those who lost their homes, jobs and retirement savings.”, I initially misread “bail” as “jail”. Maybe that was wishful thinking. I suspect most “ordinary Americans” would think, as do I, that jail would be a good place for these financial “titans”!

Some of this suspicion is highlighted by an even more pointed column by Eugene Robinson, a member of the Washington Post Writers Group, which appeared in my local Kansas City Star on Monday, February 9, 09. Quoting liberally from Sen. Claire McCaskill’s “These people are idiots,” speech (referring to the financial executives who have been paying themselves billions from the federal (read: your money) bailout, Robinson cautions them to “…pay attention to those citizens outside, the ones with the pitchforks and torches.” Going beyond, but not missing the opportunity to discuss at length, the horror people feel at the arrogance and greed of our “masters of the universe”, including the craziness of the average CEO making 344 times what the average worker makes, Robinson adds the following:

“No longer does it make any sense to reward those who work in the financial industry so lavishly compared with the way we compensate those who, say, build tractors or write software or teach our children. Salaries should be reasonable and bonuses – much more modest ones – should be reserved for those who actually, you know, make money. If some of Wall Street’s vaunted “talent” balks and flees, terrific. It was “talent” that got us here.”

Couldn’t say it better. Maybe, if we insist on not jailing them, and not taking away all their money and using it for balancing the national debt and having them live in surplus FEMA trailers (all of which I advocate), they can learn an honest trade doing something truly necessary. Like collecting trash. But maybe they don’t deserve such a good job.

Saturday, February 7, 2009

Universal Health Insurance or Universal Quality Health Care?

Jonathan Gruber, an MIT economist, has a piece in the January 29 issue of the New England Journal of Medicine entitled “Universal Health Insurance Coverage or Economic Relief – A False Choice”.[1] He clearly delineates the case for proceeding with health reform even in – perhaps especially in – these difficult economic times. He argues that rather than “Universal coverage…” being “…a luxury that we must do without in order to make way for other programs that will stimulate the economy”, that it is not only necessary for people’s health, but will in itself stimulate the economy. He suggests that “broad subsidies that make affordable health insurance available to lower-income families would improve not only the health of these families but the health of our economy, by freeing up funds that the families could spend on other consumer goods.”

Other ways it would stimulate the economy include elimination of “job lock”, the common (he states as much as 25%) circumstance in which people are afraid to leave their jobs, even for new and exciting opportunities (and “the most productive positions”), for fear of losing their health insurance, especially when they have pre-existing conditions. He notes that universal health insurance, if it required electronic health records and other methods of information sharing, would also be a great economic stimulus to the information technology industry. He cites the “white paper” issued by Sen. Baucus (D-MT), calling for dramatic investment in primary and preventive care, and the creation of the “patient centered medical home”, both things I have written about and strongly supported in previous posts. Finally, he discusses how having universal health coverage will allow us to focus on controlling spiraling health care costs: “I have witnessed this effect firsthand in Massachusetts, where for years our advocacy community focused exclusively on expanding coverage for medical expenditures and therefore opposed most initiatives that might have put that goals at risk, even those that might have meant controlling costs. Since Massachusetts passed its universal-coverage plan, this powerful advocacy community has shifted its attention to controlling costs as a means of preserving the program’s affordability to the state.”

These are all important points, and Dr. Gruber’s case for moving ahead with health reform as expeditiously as possible is on target. However, his position is inadequate, incomplete, and likely doomed to not achieve the goals he articulates because of several major misconceptions or issues insufficiently thought through. While his endorsing primary care and prevention is great, he goes on to state that “Such an approach would shift the focus of the health care system from specialists to preventive care practitioners with much lower barriers to entry, such as those for nurse practitioners and registered nurses.” This is a deeply flawed concept on several levels.

First, there is a major qualitative distinction between the skill set and practice role of registered nurses and nurse practitioners. Glossing over this is the most obvious indication of a fantastic lack of understanding of medical care and health care delivery. As documented by my guest author Robert Bowman in the January 15 entry “Ten Biggest Myths Regarding Primary Care in the Future”, nurse practitioners do not provide enough “standard primary care years” of practice to meet our needs, and without a more comprehensive approach to addressing the primary care/subspecialist imbalance, NPs (and physicians’ assistants) are likely to continue to move from primary care into higher-paying positions in subspecialty care. This leads to the third flaw, the idea that we can increase the number of practitioners in the primary care / preventive specialties without limiting the production of subspecialists. These “partialists” are paid an enormous amount for caring for “pieces” of people and are paid especially well for providing procedures, many of which involve mainly psychomotor rather than cognitive skill. Not every procedure is “brain surgery”; many are routine activities that could easily be done by technicians trained at a community college level (as are X-ray and laboratory technicians). However, they are so highly reimbursed that there is great pressure to 1) keep the entry level high (physician subspecialist), and 2) increase the volume of these procedures – many studies have demonstrated that in the weird inverted “market” of medical care, it is the availability of subspecialists and technology that drive demand rather than vice versa. Only by dramatically decreasing the financial incentives to enter subspecialties while increasing incentives to enter primary care can we reach the proper ratio of primary care to subspecialty care providers. (If our goal is to have 50% primary care providers, while we currently have 30% or less, we will need to have a much greater than 50% primary care provider output or it will be more than 30 years before we achieve this goal.)

Finally, Gruber’s flip comment plays directly into the idea, entrenched in the medical profession and medical trainees, that subspecialties, because they earn so much more, require greater skill and intelligence and thus merit higher “barriers to entry” than primary care. This is absolutely not so. In addition to the issue of high reimbursement for relatively simple psychomotor procedures noted above, “partialists” only care for one aspect of a person’s health. Thus, an individual’s care is not only spreading among many providers, increasing fragmentation, but dramatically increases cost by multiple subspecialist referrals for conditions (“I’m a cardiologist; I do hearts. If your knee hurts, see an orthopedist”). The specialty of primary care (I am aghast that Gruber is inane enough to contrast “primary care provider” and “specialist”) provides care for the whole person. Rather than managing a single condition or organ system, the primary care provider manages many chronic diseases, sometimes with help from consultants whose recommendations s/he has to coordinate and rationalize in his/her role as the primary consultant to the patient. S/he also cares for acute problems. And provides preventive care, counseling and screening. And understands the impact of the family and community of each person, and on their health and their ability to address their health needs. And “asks for trouble”, even when the patient doesn’t complain of a problem (“Are you feeling safe at home?). And, most importantly, recognizes that the role of primary consultant to the patient means working hard to understand the patient’s world-view, to speak their language, and realize that “knowing the right answer” is absolutely meaningless unless it can be translated into health benefit for the patient. This is a skill set that is exceedingly complex, difficult to develop and maintain, and requires the highest level of cognitive and interpersonal skills, and requires constantl improvement over time. In Gruber’s Massachusetts, health reform has been stymied by the insufficient number of primary care providers to care for all the newly-insured despite a wealth of subspecialist / partialists. His comments implying the simplicity of primary care do nothing to advance the quality of health care to our population, which is after all the goal of health reform -- not coverage but access to high quality care for all.

Beyond these issues with primary care, Gruber’s analysis is fatally flawed in its assumption that expanding insurance coverage – with the government paying for it – is the solution to universal coverage. He only tangentially addresses the issue once, saying “Other countries, such as the Netherlands and Switzerland, have demonstrated that it is possible to have both universal coverage (even coverage provided through private insurance companies) and much lower health care spending.” As clearly noted in T.R. Reid’s “Frontline” piece “Sick around the world”,[2] Switzerland’s insurance companies are – and were even before universal coverage – not for profit. This makes a tremendous difference.

To suggest that we should have universal coverage paid for by the government through for-profit insurance companies, is exactly equivalent to giving enormous government bailouts to the financial sector that they can use to pay stockholder dividends and executive bonuses! (Whoops, we did that!) It is absolutely wrong and misguided. It is morally and logically bankrupt, and, ultimately, financially bankrupting.

[1] Gruber J, “Universal Health Insurance Coverage or Economic Relief – A False Choice”. NEJM 29Jan,2009;360(5):437-9.

Monday, February 2, 2009

Prevention and Cost

Health Affairs, Jan-Feb 2009, has several articles on preventing chronic illness, examining the value and cost-effectiveness of various prevention strategies. In “Preventing chronic disease: an important investment but don’t count on cost savings,”[1] Louise Russell uses the techniques of cost-effectiveness analysis (CEA) to look at a number of prevention and screening strategies and looks at the cost per QALY (quality-adjusted life year) compared to treating the disease. What becomes clear is that the more that the prevention strategy is targeted to a high-risk group, the more cost-effective it is, that is, the less the cost per additional QALY.

For low-risk men ages 45-54 with LDL cholesterol between 160 and 189 mg/dl, the additional cost of statins [moderate cholesterol-lowering agents] in 1997 was $270,000 per healthy year, or about $400,000 today. For smokers ages 45-54 with LDL above 190 mg/dl, high blood pressure, and poor HDL [good] cholesterol, cost per healthy year is much less: $57,000 in 1997, or $85,000 today. For men with established heart disease, statins are highly cost-effective: under $10,000 per healthy year in 1997, or $15,000 today.”

The primary reason for the difference, of course, is the large number of people who need to be treated to prevent one person from dying; the higher risk the population considered, the lower that ratio. The other variable, obviously, is the frequency of screening. Doing a test every year costs twice as much as doing it every two years; unless the condition occurs and progresses so quickly that twice as much disease is uncovered and prevented (or treated successfully) the CEA will be worse. A good example is Pap smear tests for cervical cancer, arguably the best (most effective in preventing morbidity and mortality) screening test we have. “…screening every 3 to 5 years is cost-effective compared with no screening, but costs rise rapidly with more frequent screening. Compared to screening every 2 years, annual screening cost $1 million per healthy year in 1995, or more than $3 million today.” There are certainly women who are at higher risk of cervical cancer, and should be screened annually, but this illustrates that, even in the case of the best screening test, going from the benefit to some to screening for all is not always – or even usually – a good thing.

There are other issues besides cost when people who have a low likelihood of a disease are screened. They may be “false positives” – have a positive test but not have the disease – and undergo more tests that could be unpleasant, expensive, risky, or all three – before they find out they are really disease free. This is a difficult concept, even for medical students, but the reason is that if a disease is very uncommon – as most are – then even a good test may find more false than true positives.[2]

In the same issue, Ron Goetzl talks about different conceptions of prevention. These vary greatly, with the public (and legislators) often meaning very different things than academics or health professionals; moreover, health professionals are often afflicted with biases toward prevention of diseases in their “area”; a specialist will see a much higher percent of people with a very advanced or serious form of a disease than a generalist (because they have often been referred) and thus may have a perceptual overestimate of the commonness (prevalence) of that disease. Goetzl describes a variety of types of prevention: screening (discussed above), immunizations, and various public policies that may limit risk: “…raising taxes on cigarettes, limiting employees’ exposure to toxic substances, mandating seat-belt use, screening for cancer, restricting alcohol scales to minors, building bicycle paths, and eliminating sales of sugary beverages in schools”.[3] He notes that while these policy interventions, and immunizations, may be prevention, screenings are actually identification of disease in its early stages when treatment can prevent progression. He then talks about health promotion, a kind of primary prevention that rarely or ever requires medical intervention, “…managing one’s weight, being physically active, eating a healthy diet, not smoking, drinking moderate amounts of alcohol[4], getting enough rest, surrounding oneself with family and friends, driving safely, managing stress, and, in general, living what most would agree is a healthy lifestyle.” Well, anytime one says “most would agree” one has abandoned the world of evidence for belief systems, but you get the point. Pretty much all these things are cost-effective and work very well. Goetzl also addresses secondary prevention – treatment of early disease to prevent worse disease, such as treating high cholesterol, high blood pressure, or stopping smoking. He notes that “Although these interventions rarely save money, certain ones offer high value in terms of adding QALYs at a relatively low cost”.

If cost-effectiveness analysis can help us to understand what the cost per benefit (usually $ per QALY) is, it is also important to understand that I may be willing to spend a lot more on ME per QALY than on you, or particularly someone I don’t know;. Thus the importance of having standards, not individuals choosing enormously expensive screening interventions for themselves (which can often, as noted above, backfire by finding “disease” that is not present, not treatable or less risky than the diagnostic and treatment interventions.

Goetzl’s most important point is to counter the argument that prevention is not worthwhile because …”people have to die of something – all prevention does is postpone the time of eventual death and introduce new and more costly diseases that are the consequences of aging. As Woolf points out, the aim of prevention is not to replace one disease with another, but to compress the time one is sick or disabled before one’s ultimate demise.”

Much disease can be prevented, much suffering can be averted. Some of the preventions are behavioral changes such diet and exercise and not smoking, and real progress has been made in this arena. Others require social policies – seatbelt laws, safer cars, even safer guns. Yet others use social policies to facilitate individual behavior change – eliminating sweets from schools, making public places smoke free, prominently displaying calorie counts on fast food items. And, yes, some are medical: immunizations and some screening tests and some treatments for early disease. But people cannot expect that everything can be prevented by medicine, or found early, or successfully treated even when treatment is offered – and even when it is “successful” (that is, diseases sometimes get better or do not progress regardless of treatment, but the benefit is attributed to the treatment if it has been instituted (prostate cancer, for example).

Just because something makes sense doesn’t make it true; it is a research question, not an answer. If something doesn’t make sense, you probably won’t study it, but if it does you need to do the research to find out if it is true. People – their biology and their behavior – is too complex for something to be true just because it makes sense in one dimension. And certainly not because you just “want” it to be.

[1] Russell, LB, “Preventing chronic disease: an important investment but don’t count on cost savings”, Health Affairs, Jan/Feb 2009;28(1):42-45.
[2] Consider a disease which is very common; say 1 in 1000 people have it. And let’s say the test for it correctly identifies 9 of 10 people who have it and misses 1 (this is known as 90% sensitivity), and is negative in 9 of 10 people who DON’T have it (90% specificity). If we test the 1000 people, the one person who has it will probably have a positive test (true positive). But 10% of the 999 who don’t have it – 99.9 people – will have a false-positive test. So there are 99.9 false positives for every true positive; a person with a positive test is 100 times as likely to NOT have the disease as to have it (1% positive predictive value). However, if we take a population where the risk is 10 times as great, 1 in 100, then of the 1000 people there will be 9 (90% of 10) true positives and 90 (90% of 900) false positives, so the positive predictive value is up to 10% (1 in 10 positives is a true positive).
[3] Goetzl, RZ, “Do prevention or treatment services save money? The wrong debate”, Health Affairs, Jan/Feb 2009;28(1):37-41
[4] “ drinking moderate amounts of alcohol…” – his phrase, not mine. To suggest “not smoking” but “drinking moderate amounts of alcohol” is the most healthful demonstrates a clear bias and is not evidence based. From a health perspective, “not drinking alcohol” is the best choice.

Total Pageviews