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Archive for August, 2006

An article in the New York Times presents a microcosm to a phenomenon that occurs throughout medicine.  In Public Health school we call this “small area variation,” and it drives insurers completely nuts.

When it comes to treating blocked arteries, there are no definitive studies showing which approach most benefits patients in the long term. And some local insurers agree that the Elyria hospital provides high-quality care.

But there is little doubt that hundreds of Elyria patients each year are getting angioplasties that they would not be getting if they lived elsewhere in Ohio — or in any other part of the country for that matter — at a cost of millions of dollars a year to Medicare, the federal insurance program for the elderly. Elsewhere in the state, some of the sickest of these patients might have received bypass surgery, while many others might have simply been treated with drugs. Or, for those whose conditions were not diagnosed or were not deemed serious enough, there might have been no treatment at all. .

Experts know that changing the financial incentives can change the way medicine is practiced.

A major problem, as cited above, is that often times medical technology and approaches change so fast that it is very difficult to have definitive studies.  At the same time, many doctors are not comfortable with the fiscally conservative approach which demands that the cheapest method be used unless a more expensive option is proven to be more effective.  The truth is that many other industry have practices that don’t demand clear undisputed evidence, and medical practice will often not advance without it.

Still, small-area variation clearly is evidence that a problem exists.  Both groups of doctors can’t be right, and extreme variation like this only make it obvious the degree to which we simply don’t know.

complete story below

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An excellent post from a fantastic blog, Get Rich Slowly:

Beggars are a moral quandary for me. I want to help. In an ideal world, I’d help them all. Or I’d at least help those who are legitimately in trouble. But how can I tell which beggars are truly needy, and which are just going to use the money for booze or pot? Does it matter? And who am I to judge?

It might seem silly to write about this — it’s such a trivial part of personal finance (if a part of it at all) — but I think it presents important moral implications. I know many people are opposed to giving money to beggars ever, and I cannot blame them. I’m always reminded of one of my favorite Bible passages, the parable of the Sheep and the Goats (Matthew 25:31-46), which reads in part:

For I hungered, and ye gave me no meat: I was thirsty, and ye gave me no drink: I was a stranger, and ye took me not in: naked, and ye clothed me not: sick, and in prison, and ye visited me not. Then shall they also answer him, saying, Lord, when saw we thee hungered, or athirst, or a stranger, or naked, or sick, or in prison, and did not minister unto thee? Then shall he answer them, saying, Verily I say unto you, Inasmuch as ye did it not to one of the least of these, ye did it not to me.

The comments I posted in that blog:

The Sheep and Goats parable is troubling. It is easily to justify not giving by making judgments like “they probably use it for drugs,” but I don’t think that is what God intended. The Bible doesn’t tell us to try to figure out the scammers, it just asks us to give what we can. There is an ultimate judge, and I try to trust that the scammers will get what they deserve, and those who are not scammer will find some measure of comfort.

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A number of people asked me how to beat stress on a recent entry, well I always like to find answers that don’t require much more than common sense.  Medications have their role when indicated as well. 🙂

Singing can certainly relieve stress, but I do wonder what it does to the banker’s co-workers….

From Reuters below:

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Slate’s explainer podcasts are among my favorites, and occasionally including those with medically related questions. This one is on heatstroke. The link to the mp3 can be found here.

The parts directly related to what doctors worry about is here:

Once your core gets above about 104 degrees, you’re in serious danger. High internal temperatures lead to increased pressure in your skull and decreased blood flow to your brain. (Doctors diagnose “heatstroke” when the heat starts to affect your central nervous system.) Damaged tissue may also enter your bloodstream and lead to kidney failure. Very high internal temperatures—like 120 degrees—can destroy the cells in your body through direct heat damage.

The other parts are good too. Listen or Read!

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Posted on a fascinating blog Damn Interesting! today, is a article regarding the uncanny ability of some dogs to predict seizures in those who have epilepsy.  As a dog lover, I find the following particularly touching:

One of the most surprising facets of finding that dogs could predict a seizure was that it seemed that without any training the dog would signal that the seizure was coming by barking, whining, pacing, or the usual dog-things; there is at least one instance of a dog bringing his owner pillows, and another where a dog would grab his owner’s pants and pull him to lay on the ground. Dogs trained to help a person in the aftermath of a seizure show these predicting traits more often than dogs without training.

It takes the concept of “Man’s Best Friend” to another level.  I might be recommending that my epilepsy patients get a dog. 🙂

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The New York Times is reporting today about how Medicare changes that were planned are being reversed.  I guess it’s a fancy way of saying that nothing has changed.

The “scale back” (lack of change) was argued as being a good thing.  In particular, the new payment system would have made heavy cuts into the payments for cardiac coronary artery drug-eluting stents, defibrillators, and other “newest technology.”  The New York Times cites a number of analysts:

“The final rule significantly moderates proposed cuts for cardiac procedures,’’ Citigroup said in a note to investors. Lehman Brothers described the final rule as “a win for cardiac and orthopedic device companies, specialty hospitals and general acute care hospitals.’’ The Prudential Equity Group said the final rule, which takes effect on Oct. 1, was “favorable for device manufacturers’’ like Boston Scientific, Medtronic and St. Jude Medical.

The part that concerns me, however, is what follows:

“Under the final rule, hospitals will receive much smaller increases than originally proposed for treating some conditions, like pneumonia and chronic obstructive pulmonary disease.”

The issue I have is with the assumption that the newest technology represent the best of medicine.  As a self-proclaimed gadget geek, this might surprise you, but it is not entirely clear that the latest findings are the best and most accurate.  In particular regarding devices, very few of these have good long term studies showing safety and efficacy.  In fact, by their very nature, because they are new technologies, nobody truly knows what is going to happen 20 years down the road.

Medical devices, unlike other technologies, don’t automatically improve.  Windows XP (no matter how bad) is better than Windows 95, is better than Windows 3.1, but it’s not clear if the new hip device is worth 50% more than the old hip device.  This goes hand-in-hand with the fact that a major reason for rising health care costs in this country for the past 20 years is due to medical technology such as these.

I’m not down on medical devices in general.  The innovation of these companies is commendable.  I just worry that the “new technology” is taking precedence over tried and true technology such as antibiotics.  I worry that innovation is being steered away from less profitable fields like pulmonology and into fields flush with money such as cardiology and orthopedics.  In my hospital, I can already see that the patients who have “high-paying” problems generally get preference, and these payment structures only exaggerate the multiple-tier system.

I suppose these payment systems are examined by people smarter and better informed than me.  I am happy that the health care field is getting money, I just wonder if it is going to the right place, and whether we are creating the proper incentives for innovators within our field.
The complete article, as usual, is below:

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Heat Index reached 102 degrees today, so stay hydrated!

For you crazies who are still trying to work out, check out some tips here from Lifehacker. How to Exercise in the Heat.

For example, don’t go drinking alcohol until you pass out somewhere that is unprotected from the sun during the day.

You might end up in Elmhurst Hospital ER with a temperature of 108.

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