Later On

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Archive for the ‘Healthcare’ Category

Why choosing the right surgeon matters even more than you know

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Marshall Allen and Olga Pierce report in ProPublica:

IN FEBRUARY 2012, LaVerne Stiles went to Citrus Memorial Hospital near her home in central Florida for what should have been a routine surgery.

The bubbly retired secretary had been in a minor car accident weeks earlier. She didn’t worry much about her sore neck until a scan detected a broken bone.

The operation she needed, a spinal fusion, is done tens of thousands of times a year without incident. Stiles, 71, had a choice of three specially trained surgeons at Citrus Memorial, which was rated among the top 100 nationally for spinal procedures.

She had no way of knowing how much was riding on her decision. The doctor she chose, Constantine Toumbis, had one of the highest rates of complications in the country for spinal fusions. The other two doctors had rates among the lowest for postoperative problems like infections and internal bleeding.

It’s conventional wisdom that there are “good” and “bad” hospitals — and that selecting a good one can protect patients from the kinds of medical errors that injure or kill hundreds of thousands of Americans each year.

But a ProPublica analysis of Medicare data found that, when it comes to elective operations, it is much more important to pick the right surgeon.

Today, we are making public the complication rates of nearly 17,000 surgeons nationwide. Patients will be able to weigh surgeons’ past performance as they make what can be a life-and-death decision. Doctors themselves can see where they stand relative to their peers.

The numbers show that the stark differences that Stiles confronted at Citrus Memorial are commonplace across America. Yet many hospitals don’t track the complication rates of individual surgeons and use that data to force improvements. And neither does the government.

A small share of doctors, 11 percent, accounted for about 25 percent of the complications. Hundreds of surgeons across the country had rates double and triple the national average. Every day, surgeons with the highest complication rates in our analysis are performing operations in hospitals nationwide.

Subpar performers work even at academic medical centers considered among the nation’s best.

A surgeon with one of the nation’s highest complication rates for prostate removals in our analysis operates at Baltimore’s Johns Hopkins Hospital, a national powerhouse known for its research on patient safety. He alone had more complications than all 10 of his colleagues combined — though they performed nine times as many of the same procedures.

By contrast, some of the nation’s best results for knee replacements were turned in by a surgeon at a small-town clinic in Alabama who insists on personally handling even the most menial aspects of each patient’s surgery and follow-up care.

ProPublica compared the performance of surgeons by examining five years of Medicare records for eight common elective procedures, including knee and hip replacements, spinal fusions and prostate removals.

To be fair to surgeons, ProPublica’s analysis accounted for factors such as patients’ health and age. We focused only on elective cases because they typically involve healthier patients with the best odds of a smooth recovery.

As would be expected, . . .

Continue reading.

At the link, the app is available.

Written by LeisureGuy

14 July 2015 at 10:54 am

Posted in Healthcare, Medical

A simulator for Big Pharma explores trends produced by incentives

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Edwin Evans-Thirlwell reports at Motherboard:

Big Pharma is a management simulation game that, to quote its UK-based creator Tim Wicksteed, explores “the strange ethical dilemmas that occur when you bring together the goal of curing the sick with the burden of running a profitable business.”

Unlike many an artwork with a social or political message, however, it isn’t an exercise in pointing fingers. Rather, Big Pharma shows how dangerously easy and routine it can become to disregard the human fallout of a decision while operating in an abstract world of market trends and logistical planning.

The game’s world isn’t just abstract—it’s downright cosy. Now available in beta to pre-ordering players, with a Steam release to follow, Big Pharma recalls the cartoon look and handling of the Bullfrog-developed classic Theme Hospital. Most of it takes place on your production floor, a cheery expanse of checkerboard floating in a clinical grey void, where you buy and click together chunky, pleasingly animated machines that turn raw materials into products such as pills and creams.

Each ingredient must be discovered by hiring explorers to scour the unseen world beyond your factory, then imported for a fee. All of them have a number of possible effects, good and bad. To unlock or cancel out these traits, you need to feed the ingredient through various devices that alter its concentration, or combine it with another substance, before ferrying the results to the export hopper. In theory, of course, you’ll want to ship the most effective cures you can while ironing out negative symptoms such as constipation. But in practice, this may not make sense economically.

Each component in a production line takes a small chunk out of your earnings each and every time it’s used, so the more elaborate the purification and enhancement process you set in motion, the smaller your net profit. A cheap ‘n’ dodgy migraine remedy that causes hypertension and diarrhea may prove more lucrative, overall, than an expensive miracle cure that obliges you to fill up your real estate with ionisers and condensors.

More sinisterly yet, Big Pharma also generates an evolving worldwide market simulation that takes into account the global distribution of diseases versus the distribution of income. Thus, in addition to letting the player cut corners with each drug, it allows you to callously ignore regions where the need for treatment is greatest but wallets are light.

“A cure for hair loss is a relatively small market but is highly valuable to the rich Westerners who demand it,” Wicksteed told me by email. “Whereas an antimalarial drug is in very high demand but can’t sustain such a high price, because most of the demand is coming from people living in poorer countries.”

There’s the projected infection rate of each disease to consider, too. “You can deliberately hold off producing your tuberculosis remedy until it infects half of Africa, in order to maximise your profits.”

Wicksteed became interested in such ethical breaches after reading Dr Ben Goldacre’s acclaimed 2012 book Bad Pharma, which examines how companies such as GlaxoSmithKline have distorted or buried data about the usefulness and drawbacks of their products. On balance, he feels that such failings are evidence of “systematic” problems rather than confined to a particular set of corporations.

“People are incentivised to make decisions for the good of the company or themselves to the detriment of patients,” Wicksteed commented. “This is very human. It’s something we’ve all encountered at work under the pressure to hit a deadline or get a certain result. The problem with this in the pharmaceutical industry is that it can lead to human suffering, or worse, death. It’s because of this that I try to avoid overtly demonising the industry in the game, and prefer to simply place the player in a position of power and ask ‘what would you do?’”

Not very encouragingly, Wicksteed has found that Big Pharma players “are very profit driven, and don’t give a second’s thought to sacrificing quality to make a few extra dollars per sale.” This may, however, reflect a lack of in-game accountability systems to counter the siren wail of your company’s bottom line—compromised or feeble remedies sell for less, but there’s no blowblack from injured members of the public, and no threat of a legal challenge. . .

Continue reading. Fascinating article, which supports my own view that for-profit hospitals should be illegal.

Here’s a promo video of the game. Turn off sound to avoid irritating and irrelevant music:

Written by LeisureGuy

14 July 2015 at 10:45 am

Transparency Program Obscures Pharma Payments to Nurses, Physician Assistants

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Businesses cannot be trusted, it repeatedly turns out. Charles Ornstein reports in ProPublica:

A nurse practitioner in Connecticut pleaded guilty in June to taking $83,000 in kickbacks from a drug company in exchange for prescribing its high-priced drug to treat cancer pain. In some cases, she delivered promotional talks attended only by herself and a company sales representative.

But when the federal government released data Tuesday on payments by drug and device companies to doctors and teaching hospitals, the payments to nurse practitioner Heather Alfonso, 42, were nowhere to be found.

That’s because the federal Physician Payment Sunshine Act doesn’t require companies to publicly report payments to nurse practitioners or physician assistants, even though they are allowed to write prescriptions in most states.

Nurse practitioners and physician assistants are playing an ever-larger role in the health care system. While registered and licensed practice nurses are not authorized to write prescriptions, those with additional training and advanced degrees often can.

A ProPublica analysis of prescribing patterns in Medicare’s prescription drug program, known as Part D, shows that these two groups of providers wrote about 10 percent of the nearly 1.4 billion prescriptions in the program in 2013. They wrote 15 percent of all prescriptions nationwide (not only Medicare) in the first five months of the year, according to IMS Health, a health information company.

For some drugs, including narcotic controlled substances, nurse practitioners and physician assistants are among the top prescribers. . .

Continue reading.

Written by LeisureGuy

6 July 2015 at 12:30 pm

Another significant achievement of Obamacare, praised by Republicans: Community health clinics

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Again we see the paradox of GOP condemnation of Obamacare: they love what it does, but they hate the name. (And, of course, they have NEVER proposed any alternative: it’s not their way to develop solutions; their only interest is in destruction.)

Lee Fang reports in The Intercept:

The conventional wisdom on Senator Bernie Sanders of Vermont is that he’s a charming if impractical dreamer, a pie-in-the-sky socialist who’s good at inspiring young people and aging hippies, but hopeless at the knife fighting that real-life politics requires.

Despite the inherent limitations of a self-described democratic socialist who eschews the norms of Beltway fundraising, the Democratic presidential candidate from Vermont has won legislative victory after victory on an issue that has been dear to him since his days as Burlington’s mayor.

That issue is the simultaneously benign and revolutionary expansion of federally qualified community health clinics.

Over the years, Sanders has tucked away funding for health centers in appropriation bills signed by George W. Bush, into Barack Obama’s stimulus program, and through the earmarking process. But his biggest achievement came in 2010 through the Affordable Care Act. In a series of high-stakes legislative maneuvers, Sanders struck a deal to include $11 billion for health clinics in the law.

The result has made an indelible mark on American health care, extending the number of people served by clinics from 18 million before the ACA to an expected 28 million next year.

As one would expect, the program was largely met with plaudits from patients and public health experts, but it has also won praise from even the biggest Obamacare critics on Capitol Hill. In letters I obtained through multiple record requests, dozens of Republican lawmakers, including members of the House and Senate leadership, have privately praised the ACA clinic funding, calling health centers a vital provider in both rural and urban communities.

To Sanders, the clinics have served as an alternative to his preferred single-payer system. Community health centers accept anyone regardless of health, insurance status or ability to pay. They are founded and managed by a board composed of patients and local residents, so each center is customized to fit the needs of a community. No two health centers are alike.

In rural North Carolina, ACA-backed health centers now provide dental and nutrition services, while in San Francisco, the clinics provide translation services and outreach for immigrant families. In other areas, they provide mental health counseling, low-cost prescription drugs, and serve as the primary care doctors for entire counties. They have also served as a platform for innovation, introducing electronic medical record systems and paving the way with new methods for tracking those most susceptible for heart disease and diabetes.

Author John Dittmer, in The Good Doctors, traces the history of the modern health center to the civil rights activists who ventured into the South during the early 1960s. The activists were seen as outside agitators, and local doctors refused to treat them. As a solution, volunteer bands of physicians were organized by a group called the Medical Committee for Human Rights.

Beyond treating the civil rights workers, the MCHR physicians were struck by the stark disparity in health services, encountering many African-Americans who had never seen a doctor before in their lives. The activist physicians returned to the South after the “Freedom Rides” to found a small clinic in Mound Bayou, Mississippi, in the heart of the Mississippi Delta, and by doing so, began a movement to launch health clinics across the country in underserved areas. Winning support from President Lyndon Johnson’s Office of Economic Opportunity, the clinics became part of Johnson’s “War on Poverty.”

Over the years, health centers have gained support on a bipartisan basis. Health centers secured critical funding from the efforts of the late Sen. Ted Kennedy, D-Mass., and both George W. Bush and John McCain campaigned on pledges to expand them. . .

Continue reading. There’s quite a bit more to the article.

Written by LeisureGuy

6 July 2015 at 11:37 am

Those who are against teen pregnancies and oppose abortion should welcome the news from Colorado

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Unfortunately, many will not, despite Colorado’s success in reducing teen pregnancies (by 40%) and reducing the number of abortions (by 42%). What’s wrong? The problem is that the success is due to birth control, which means that women (and men, let it be noted) are continuing to have sex. Some people do not think women and men should have sex, regardless of what actually happens. (I.e., they do.)

Sabrina Tavernise reports in the NY Times:

Over the past six years, Colorado has conducted one of the largest ever real-life experiments with long-acting birth control. If teenagers and poor women were offered free intrauterine devices and implants that prevent pregnancy for years, state officials asked, would those women choose them?

They did in a big way, and the results were startling. The birthrate for teenagers across the state plunged by 40 percent from 2009 to 2013, while their rate of abortions fell by 42 percent, according to the Colorado Department of Public Health and Environment. There was a similar decline in births for another group particularly vulnerable to unplanned pregnancies: unmarried women under 25 who have not finished high school.

“Our demographer came into my office with a chart and said, ‘Greta, look at this, we’ve never seen this before,’ ” said Greta Klingler, the family planning supervisor for the public health department. “The numbers were plummeting.”

The changes were particularly pronounced in the poorest areas of the state, places like Walsenburg, a small city in Southern Colorado where jobs are scarce and unplanned births come often to the young. Hope Martinez, a 20-year-old nursing home receptionist here, recently had a small metal rod implanted under the skin of her upper arm to prevent pregnancy for three years. She has big plans — to marry, to move West, and to become a dental hygienist.

“I don’t want any babies for a while,” she said.

More young women are making that choice. In 2009, half of all first births to women in the poorest areas of the state happened before they turned 21. By 2014, half of first births did not occur until they had turned 24, a difference that advocates say gives young women time to finish their educations and to gain a foothold in an increasingly competitive job market.

“If we want to reduce poverty, one of the simplest, fastest and cheapest things we could do would be to make sure that as few people as possible become parents before they actually want to,” said Isabel Sawhill, an economist at the Brookings Institution. She argues in her 2014 book, “Generation Unbound: Drifting Into Sex and Parenthood Without Marriage,” that single parenthood is a principal driver of inequality and long-acting birth control a powerful tool to prevent it.

Teenage births have been declining nationally, but experts say the timing and magnitude of the reductions in Colorado are a strong indication that the state’s program was a major driver. About one-fifth of women ages 18 to 44 in Colorado now use a long-acting method, a substantial increase driven largely by teenagers and poor women.

Continue reading.

Written by LeisureGuy

5 July 2015 at 2:09 pm

The VA’s Broken Promise To Thousands Of Vets Exposed To Mustard Gas

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The VA too often fails in its mission, and very little seems to be done to fix that. If we had a functioning Congress, they could exercise their oversight, but Congress is almost totally dysfunctional at this point. Caitlin Dickerson reports on NPR (and there’s an audio report at the link):

In secret chemical weapons experiments conducted during World War II, the U.S. military exposed thousands of American troops to mustard gas.

When those experiments were formally declassified in the 1990s, the Department of Veterans Affairs made two promises: to locate about 4,000 men who were used in the most extreme tests, and to compensate those who had permanent injuries.

But the VA didn’t uphold those promises, an NPR investigation has found.NPR interviewed more than 40 living test subjects and family members, and they describe an unending cycle of appeals and denials as they struggled to get government benefits for mustard gas exposure. Some gave up out of frustration.

In more than 20 years, the VA attempted to reach just 610 of the men, with a single letter sent in the mail. Brad Flohr, a VA senior adviser for benefits, says the agency couldn’t find the rest, because military records of the experiments were incomplete.

“There was no identifying information,” he says. “No Social Security numbers, no addresses, no … way of identifying them. Although, we tried.”

Yet in just two months, an NPR research librarian located more than 1,200 of them, using the VA’s own list of test subjects and public records.

The mustard gas experiments were conducted at a time when American intelligence showed that enemy gas attacks were imminent. The tests evaluated protective equipment like gas masks and suits. They also compared the relative sensitivity of soldiers,including tests designed to look for racial difference.

The test subjects who are still alive are now in their 80s and 90s. Each year more of their stories die with them.

“We weren’t told what it was,” says Charlie Cavell, who was 19 when he volunteered for the program in exchange for two weeks’ vacation. “Until we actually got into the process of being in that room and realized, wait a minute, we can’t get out of here.” . . .

Continue reading.

There’s lots more: it’s a lengthy report.

Written by LeisureGuy

28 June 2015 at 11:22 am

Scalia v. Scalia

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Justice Scalia seems to have trouble remembering his own opinions. Linda Greenhouse reports in the NY Times:

Sometimes the Supreme Court moves in mysterious ways. The health care decision was not one of those times.

A case that six months ago seemed to offer the court’s conservatives a low-risk opportunity to accomplish what they almost did in 2012 — kill the Affordable Care Act — became suffused with danger, for the millions of newly insured Americans, of course, but also for the Supreme Court itself. Ideology came face to face with reality, and reality prevailed.

The 6-to-3 vote to reject the latest challenge means that one or perhaps two of the justices who grabbed this case back in November had to have jumped ship. Here’s why: It takes at least four votes to add a case to the court’s docket. Given that the decision to hear this case, King v. Burwell, was entirely gratuitous — the Obama administration had won in the lower court, and an adverse decision in a different appeals court had been vacated — we can assume the votes came from the four justices who nearly managed to strangle the law three years ago in National Federation of Independent Business v. Sebelius.

These four were Justices Anthony M. Kennedy, Antonin Scalia, Clarence Thomas and Samuel A. Alito Jr. Maybe Chief Justice John G. Roberts Jr., excoriated in right-wing circles for having saved the statute with a late vote switch last time, also agreed to hear the new case. Or maybe his four erstwhile allies were trying to put the heat on him. It’s a delicious question without, at least for now, an answer.

When I think of this case on its trajectory toward the court, the image that comes to mind is of the great white shark in “Jaws,” swimming silently under the water, its lethal teeth bearing down on the statutory language freshly discovered by the administration’s enemies: “Exchange established by the State.”

Do “words no longer have meaning,” as Justice Scalia put it in his angry dissenting opinion? What, after all, could be clearer? The state, not the federal government. The two are not the same. They are different! So poor and middle-class people in the 34 (mostly red) states that refused to set up their own insurance exchanges, defaulting that task to the federal government, are just out of luck. They aren’t eligible for tax subsidies to help them buy insurance, subsidies that are critical to making the law work. End of story, end of case, end of the Affordable Care Act (or Scotuscare, as Justice Scalia said the law should be re-named).

The chief justice’s masterful opinion showed that line of argument for the simplistic and agenda-driven construct that it was. Parsing the 1,000-plus-page statute in a succinct 21-page opinion, he deftly wove in quotations from recent Supreme Court opinions.

Who said that we “must do our best, bearing in mind the fundamental canon of statutory construction that the words of a statute must be read in their context and with a view to their place in the overall statutory scheme”? Why, it was Justice Scalia (actually quoting an earlier opinion by Justice Sandra Day O’Connor) in a decision just a year ago.

And who said that “a provision that may seem ambiguous in isolation is often clarified by the remainder of the statutory scheme” because “only one of the permissible meanings produces a substantive effect that is compatible with the rest of the law”? Why, Justice Scalia again.

“In this instance,” Chief Justice Roberts wrote, “the context and structure of the Act compel us to depart from what would otherwise be the most natural reading of the pertinent statutory phrase.” He concluded: “A fair reading of legislation demands a fair understanding of the legislative plan.” Among the chief justice’s silent partners in the six-justice majority opinion was Justice Kennedy, by most accounts the driving force behind the near miss three years ago. . .

Continue reading.

Written by LeisureGuy

25 June 2015 at 9:54 pm


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