Tuesday, November 21, 2023

Running and Depression: Be careful about spreading the results of research until you understand it.

During the COVID pandemic, a great deal of scientific and medical literature was published on line without going through the normal peer-review process. The justification was that things were happening so fast that scientists and doctors needed quicker access to the information being discovered to be able to implement prevention and treatment strategies.  Many of these were published on sites like MedRxiv (https://www.medrxiv.org/content/about-medrxiv), with little or no peer review. Some of these articles were later shown to be flawed, either in terms of the science of the research methods or in the presentation of the conclusions to be drawn from that research. In a number of cases, these articles, which would likely not have been published in normal (peer-review) circumstances were “taken down”, “unpublished” if you will. This was criticized by many during the pandemic, such as Rapid publications risk the integrity of science in the era of COVID-19, by Bagdasarian, Cross and Fisher.

Except, of course, nothing can truly be “taken down” from the internet. If it is out there, it can be copied, saved, reposted. Certainly this has been shown to be true on social media, where embarrassing posts (e.g., sexual, racist, etc.) have continued with lives of their own even after the original was taken down. In the case of medical and scientific articles, the information is out there, and the study can be referred to and cited by others. And with the thousands and thousand of such articles published on line, only a small percent are ever taken down, even if the methods used in the research are flawed, and the conclusions presented are inaccurate. This was the source of a lot of misinformation during the pandemic, transmitted on social media because it was “in a scientific journal”.

Hopefully we are past that (fingers crossed!), but we are still not without other misleading research being reported. As with almost everything, on line or in print or conveyed by mouth, people are more likely to believe things that reinforce what they already believe (“confirmation bias”), and in general, regarding medical and scientific information, most people are willing to read just the “bottom line” (is “X” good for you? Is “Y” better than “Z” for “A”?), which is usually far too simplistic. This is not limited to laypeople, few of whom have the expertise to actually read and interpret a research study; many doctors (and sadly residents and medical students) read only the Abstract or at best the Conclusion, skipping or skimming over the only important parts of a research paper, the Methods and Results. Reading the Abstract may be adequate to decide whether to read the whole article (“if they actually found what they say they found, do I care?”) but should never be conflated with actually having read it, and thought about it.

And while peer review should ensure that the methods, probably, were legitimate and that therefore the results are accurate, it does not always flag potential problems, particularly with regard to overstating the significance of the results in the conclusion -- or a one-sentence abbreviated conclusion. A recent study (and I pick on it not because it is more egregious than most, but because it was brought to my attention by Medscape, reporting on its presentation at an international conference), is ” Antidepressants or running therapy: Comparing effects on mental and physical health in patients with depression and anxiety disorders”, published in the Journal of Affective Disorders, May 2023. The study, done by a group of researchers in the Netherlands, in fact showed, as Medscape reports, that while both anti-depressant medications and running helped depression, running was better for overall physical health. That is good news if you are a runner, I guess, or if you have been wondering if taking up running would be good for your depression. But if your take-away is something like “See? Natural things – like running – are better for you than drugs!”, there are some details you need to pay attention to. Like who was studied. In any study, it is critical to see if the population studied is similar to you (or your patient, if you are a health care clinician). In this case the average age of participants was about 38. So if you are in that age range, it could apply to you. If you’re 70, the age of the oldest participants, maybe taking up running might not be the best idea.

But a much more important flaw in this study is illustrated by saying “taking up running”: it has to do with the allocation of people to the different treatments, running or medication. In a good study, participants are randomized to one treatment or another. In this study, people chose the treatment they wanted to try, with only those left over allocated to one treatment or another. 83 people chose running with another 13 assigned to it; 36 people chose medication, with another 9 assigned to it. So of the 141 participants, 83, 59%, chose running. Although those already exercising more than once a week were excluded, it is still possible, if not likely, that many of that 59% were, at least in the past, runners, or people who wanted to run. This is what is called a potential confounder, something that is associated with the treatment and the result, and leads to results that are much less convincing than does random allocation.

So does this mean running is not as good or better than drugs for treatment of depression? No (although obviously it requires the physical capability of being able to run). This study provides evidence that in a group of 141 people, average age 38, 58% female, 59% of who chose to be in the running “arm” of the study, it worked as well. But those are important caveats that make the study weaker, and less likely to work for someone who doesn’t fit the profile.

Enough of this study. I chose it because it came to my attention, but also because it was published in a reputable, peer-reviewed journal, and it is not totally worthless – but to draw the conclusion that “running is as good as drugs for depression and better for your overall health” is true for anyone, for you, could be inaccurate.

The impression that one can take away from hearing from someone that “a scientific study showed that…” (and tell me you never hear that!) can be a little, a lot, or completely wrong unless you both read the whole study and have enough background to understand what it does not say as well as what it does. Beyond “was this a well-done study?” and “was it published by reputable scientists in a reputable journal?”, the questions of “to whom are the results most likely to apply?” is also important. You may think yourself healthy and in good shape for your age, but a study of, say, 25 year olds, may not apply to you if you’re 65. The most reliable characteristic is replication of the results by other well-designed studies.

Is there a social justice issue here? I do not know. Probably well-off people have better access to doctors and other professionals, but they also have more choice and are able to choose the ones that they know have the same beliefs (or biases) that they do; for example, exercise is good, drugs are bad, natural is good, etc. My personal (not statistically valid!) experience is that people who are likely to believe something because it shows what they want to be true and to discount studies that show what they don’t want  to be true, come from all socioeconomic, ethnic, and other groups.

But my advice is to take a deep breath, and not believe everything you hear, or read, is 100% true, and certainly not that it is more broadly applicable that whatever the research showed.

Even if you want to.

Wednesday, November 1, 2023

People are more important than profit. Period.

In his recent piece, ‘An Appropriate Anger’ on his Substack “The Reframe”, writer AR Moxon states that “All people have an intrinsic and indestructible worth that cannot be measured”.

He notes:  “That’s not true of everything, you know. If a car stops functioning properly, it’s no longer as valuable as it was when it was functioning properly…[but] It’s not that way with people who, as it so happens, are not things.”

I happen to agree with that, and honestly believe that most people do. But not everyone does. Moxon has some things to say about the businesses, and the people who hide behind the corporate logo, who clearly think that profit is more important than people and act on it. He particularly focuses on healthcare as he had a very scary event with a person close to him. But healthcare is a particularly good example of the core problem that he cites. Healthcare is a system which people want to believe, and often in the face of powerful evidence to the contrary do believe, exists to help them. In fact, it is actually an incredibly efficient and effective producer of profit for the industry, often at the expense of the health of the people it ostensibly exists to help.

What makes this worth continuing to comment upon is the ongoing, aggressive, and accelerating rate at which it is happening. No sooner can one say “well, this is bad, but at least we have X as an alternative” than X is taken away or modified into a profit-producing structure that decreases availability and quality of care for people while increasing their costs. And, as a result, harming their health. (Just in recent blogs I have written about ‘Why are we paying wealthy corporations billions to limit our healthcare?, July 23, 2023; ‘Older adults cannot afford healthcare even if they are insured: Time for a new system!’, Aug 22, 2023; ‘The problems with our US 'Healthcare' system are well documented. We need to start with the solution!’, Sept 3, 2023;  Primary Care, Private Equity, and Profit: How to ensure poor quality care for the American people’, Sept 28, 2023).  The perpetrators of these evils – and they are evils -- are corporations including insurance companies, health care providers, and pharmaceutical companies, often now overlapping in a vertical integration, as for example with UnitedHealth’s ownership of the physician group Optum that now provides more income and profit than its insurance business! But the perpetrators are also the people that run those corporations and make their decisions.

Groups that study the healthcare system, such as the Commonwealth Fund and the Kaiser Family Foundation, continue to issue increasingly distressing, indeed terrifying, reports about the state of US healthcare, the access people have to it (or not), and the impact that this has upon their health. The Commonwealth Fund in particular has published a series of pieces that, although written in a calm manner, create great alarm in me because of their content. ‘High U.S. Health Care Spending: Where Is It All Going?’, Oct 4, 2023, notes that ‘The United States spends twice as much per person on health as peer nations’ and concludes that

More than half of excess U.S. health spending was associated with factors likely reflected in higher prices, including more spending on: administrative costs of insurance (~15% of the excess), administrative costs borne by providers (~15%), prescription drugs (~10%), wages for physicians (~10%) and registered nurses (~5%), and medical machinery and equipment (less than 5%). Reductions in administrative burdens and drug costs could substantially reduce the difference between U.S. and peer nation health spending.

[Note that wages for physicians and nurses is on 15% of this total!]

The ‘Findings from the Commonwealth Fund 2023 Health Care Affordability Survey’ are reflected in its title, ‘How Health Care Costs and Medical Debt Are Making Americans Sicker and Poorer’. Those findings demonstrate that they are, and it is getting worse, and although the greatest impact is in those already marginalized (particularly Black Americans and those already poor), it is affecting more than half of the US population, those insured and uninsured:

Large shares of insured working-age adults surveyed said it was very or somewhat difficult to afford their health care: 43 percent of those with employer coverage, 57 percent with marketplace or individual-market plans, 45 percent with Medicaid, and 51 and percent with Medicare.


Commonwealth also had a series of reports, appearing every year or two, called “Mirror, Mirror on the Wall” which compared US health care costs and outcomes to other comparable (wealthy) countries. The US always did worst (see ‘US Health Rankings remain low and #Trumpcare will make them worse!’, June 18, 2017, which includes scary data tables comparing US health system performance to others). The most recent report, from 2022, has a different title that is even scarier: U.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes. It includes as “highlights” (or lowlights)

·        Health care spending, both per person and as a share of GDP, continues to be far higher in the United States than in other high-income countries. Yet the U.S. is the only country that doesn’t have universal health coverage.

·        The U.S. has the lowest life expectancy at birth, the highest death rates for avoidable or treatable conditions, the highest maternal and infant mortality, and among the highest suicide rates.

Comment: These are not good things.

 It is also easy to lose health insurance. It can happen intentionally when insurance companies seek to offload high-cost individuals (ie., the sick people). This procedure (“lemon dropping”) is common in Medicare-substitute programs like Medicare Advantage and push them into regular Medicare. It is the complement to efforts to enroll only healthy seniors (“cherry picking”). The ideal insurance client, from the point of view of maximizing profit (is there another point of view?) is one who pays premiums and never uses care. Of course, if you are not yet on Medicare, you can be dropped and – that’s that. You are uninsured.

But you can also lose insurance coverage by mistake or oversight; in her Oct 25, 2023 essay ‘It Shouldn’t Be This Easy to Lose Your Health Insurance’ in the New York Times, physician Danielle Ofri describes how she lost coverage because the notification for “open enrollment” from her own HR department was collected by her spam filter, and she was put into the “basic” plan – without coverage for her family. Why does she have to re-enroll every year? And why do Medicaid patients?

The stated reason for this bureaucratic merry-go-round is that eligibility must be ascertained every year so as not to allot services to someone who doesn’t qualify. But the process of determining eligibility is highly flawed. Only some disenrolled Medicaid patients, for example, are truly ineligible; according to KFF, a health policy research organization, a majority of people (more than 90 percent in some states) were disenrolled for procedural reasons, such as missed deadlines, paperwork issues and outdated contact information. Many of these people are eligible for insurance but lose coverage because of the byzantine logistics.

Yes. Dr. Ofri was able to reinstate her coverage but not everyone can; she is not only highly educated but a physician: “For me, it took endless phone calls to fix the problem and a miserable week in which I was convinced that I’d failed my family. For millions of Americans, the system is simply unnavigable.” Especially for those Medicaid patients.

Dr. Ofri concludes with the key point:

Of course, none of this would be necessary if the only requirement for getting insurance was — as it is in many countries — being born. 

Think about that. Everybody is insured – and coverage is the same – for every person in the country. There is no enrollment or disenrollment, no coverage lapse, no inability to afford it. Everyone is covered. And it costs less – all of those countries spend less, overall and per capita, than does the US. It is administratively simpler, less costly, more effective, and results in better health status for the population. It has been adopted by every other well-to-do (and many much less well-to-do) country in the world. The US is an outlier, not in a good way, in being the only nation that doesn’t.

But American insurance companies and health care providers make huge amounts of money, money that is intended (often by the government) to be spent on providing health care but instead ends up on the positive side of a corporate balance sheet. That can be seen as a good thing, if you are a corporate executive, a completely heartless and unempathetic bastard, and, of course, you are certain that the negative impact will never affect you. We need to change that, i.e., make it affect them.

Moxon goes on at great length documenting how the “profit motive”, which can have positive effects on a society, has been so perverting by being the ONLY thing that is considered to matter (“the profit motive doesn’t care about enriching the lives of people, and it never will, any more than a garden trowel cares about the state of your garden”) that it leads to mass suffering, in health care and  “with justice, and with education, and public safety, and housing, and transport, and recreation, and water, and the arts, and elder care, and on and on and on.”

What is amazing is that so many of us have drunk enough of the Kool-Aid to believe that, while  these are not good things, we think it is inevitable and the way that things have to be. Of course, there are also those who in fact believe, either because they are ideologues or are getting rich from the corporations they control or both, or are politicians being paid from the lobbying arms of those corporations, that profit is in fact more important than people. They should voluntarily (or not) sign up on the list of people who will not get care because that would decrease profit. They are welcome to live out their principles. Until they can’t because they aren’t getting health care.

As long as the rest of us do not continue to have to sacrifice our health to their profit.

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