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Archive for the ‘Public Health’ Category

Atul Gawande is at it again.  This article really needs to be read by everyone in Health Care or who is interested in the Health Care debate.  And particularly anyone who dose Health Care and Statistics.  Courtesy of The New Yorker

Brenner wasn’t all that interested in costs; he was more interested in helping people who received bad health care. But in his experience the people with the highest medical costs—the people cycling in and out of the hospital—were usually the people receiving the worst care. “Emergency-room visits and hospital admissions should be considered failures of the health-care system until proven otherwise,” he told me—failures of prevention and of timely, effective care.

If he could find the people whose use of medical care was highest, he figured, he could do something to help them. If he helped them, he would also be lowering their health-care costs. And, if the stats approach to crime was right, targeting those with the highest health-care costs would help lower the entire city’s health-care costs. His calculations revealed that just one per cent of the hundred thousand people who made use of Camden’s medical facilities accounted for thirty per cent of its costs. That’s only a thousand people—about half the size of a typical family physician’s panel of patients.

Things, of course, got complicated. It would have taken months to get the approvals needed to pull names out of the data and approach people, and he was impatient to get started. So, in the spring of 2007, he held a meeting with a few social workers and emergency-room doctors from hospitals around the city. He showed them the cost statistics and use patterns of the most expensive one per cent. “These are the people I want to help you with,” he said. He asked for assistance reaching them. “Introduce me to your worst-of-the-worst patients,” he said.

They did. Then he got permission to look up the patients’ data to confirm where they were on his cost map. “For all the stupid, expensive, predictive-modelling software that the big venders sell,” he says, “you just ask the doctors, ‘Who are your most difficult patients?,’ and they can identify them.”

via Lower Costs and Better Care for Neediest Patients : The New Yorker.

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This just seems strategically unwise.  I assume that the Republicans think they can take the PR hit because they believe that nobody is paying attention during the holidays.   Still, it certainly is fodder for the next set of elections.

WASHINGTON — Republican senators blocked Democratic legislation on Thursday that sought to provide medical care to rescue workers and residents of New York City who became ill as a result of breathing in toxic fumes, dust and smoke from ground zero.The 9/11 health bill, a version of which was approved by the House of Representatives in September, is among a handful of initiatives that Senate Democrats had been hoping to approve this year before the close of the 111th Congress. Supporters believe this is their last real opportunity to have the bill passed.The Senate action created huge uncertainty over the future of the bill. Its proponents were working on Thursday to have the legislation inserted into a large tax-cut bill that Republicans and Democrats are trying to pass before Congress ends it current session later this month.

via 9/11 Health Bill Blocked in Senate – NYTimes.com.

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One of the best articles I’ve read in a while:

Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coördination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.

via Annals of Medicine: The Cost Conundrum: Reporting & Essays: The New Yorker.

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Link to Story

Writing in the journal Academic Emergency Medicine, lead author Dr. Carlos A. Camargo of Massachusetts General Hospital estimates that it would take until 2019 to find enough fully-trained, board-certified emergency physicians to work in the 4,828 emergency departments that are open 24 hours a day. And that best-case projection assumes that no current doctors who meet those qualifications die or leave their jobs.

The Institute of Medicine said in 2006 that ERs should ideally be staffed by doctors who had spent their residency training in emergency medicine and had later passed tests to become certified in the specialty. But only about 55 percent of doctors working in ERs meet that standard, Camargo and his co-authors write.

Does any other field have such a low percentage of physicians that are not board certified in the field of practice?  I know some of this has to do with the recent certification process, but that is pushing nearly 20 years now, and grandfathering options were available for those who were practicing before that.  What makes this worse, these calculations were done under the rosiest of scenarios where the doctors do not burn out and leave the field… good luck with that.

I’m not sure there is an easy solution to this problem.  I don’t think anyone is (or shoud be) suggesting we lower the standard of being qualified as an emergency medicine specialist.  There are already over 1000 residents trained a year, and at some point you run out of quality facilities to train residents (getting the right amount of volume with broad, well-rounded training isn’t possible just anywhere).  Decreasing the meteoric rise in ER visits in the past decade will also help a whole lot.

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As China Roars, Pollution Reaches Deadly Extremes
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One of the hardest things to try to explain to people when discussing various kinds of institutional or governmental policy is the law of unintended consequences. It basically says the policy can have effects that are very different than what one expects. History is full of examples, yet people continue to believe that the idea/policy is smart enough to prevent thousands or millions of people from figuring out a way to mess it up while imaginatively trying to better their lives. It shouldn’t scare someone from trying to change things, but steps need to be taken to measure the change in order to ensure that what was intended to happen is indeed happening.

Glen Whitman, an associate professor of economics at California State University, Northridge, wrote a very nice article on this topic, linked here. It is worth a read, as it explains an idea which can be difficult to explain in a nice, accessible way.

The article is also saved after the break for archival purposes.

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Adam Bosworth, VP of Google recently has posted a few items on their blog regarding health care and the poor information transfer withiin the field.  I can only imagine that Health Informatics must seem truly backwards when one comes from a place like Google.

His first post is here:
http://googleblog.blogspot.com/2006/11/health-care-information-matters.html

And there is a second post, including a link to a transcript of a keynote address regarding this very issue.

http://googleblog.blogspot.com/2006/12/thoughts-on-health-care-continued.html

There are a number of obstacles to overcome, and the technical limitations are only a part of them. The bigger problem is that people working in the field are so fearful of litigation from a privacy breach, especially when it gets released to the “net.”  Some of this is because people are afraid of increased insurance rates, and many of these concerns are legitimate because information is just SO easy to duplicate a million times over once it is digitized.

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