Obesity confusion

Posted by on June 10, 2013 Comments Off on Obesity confusion

We are agreed that obesity is a problem, for individuals and for society.

We are agreed that dieting alone will not help. The latest popular diet approach is part of the background noise not part of the solution. Here is some noise from my Facebook feed as I was writing this posting.

Obesity diet noise

Exercise and dieting combined would work, but is probably beyond the ability of many if not most people facing obesity. Indeed, starting any exercise program may be a challenge to both will and health of someone morbidly obese.

We know that bariatric surgery can work; however, it is invasive, expensive, and there are debates among specialists about what works sufficiently.

Indeed, after Governor Chris Christie of New Jersey announced that he had had a gastric band implanted, there was considerable debate about whether that was sufficient compared to gastric bypass surgery, particularly given the failure rate of the laparascopic gastric band or “lap band.”

There is open debate about whether obesity prevention measures are cost-effective.

As if the problem were not challenging enough, a study has shown that physicians fail to demonstrate to obese patients the empathy necessary to effect change.

Al Lewis argues that many of our workplace wellness programs are ill-conceived and ineffective.

The seriousness of the problem is underscored by a Metlife study showing that obesity contributes $1,723 per person per year to the Medicare budget, or 8.5 percent of the total.

We are not left with a solid place to make a stand against obesity. My plan is to walk a bit more and eat a bit less as I contemplate next steps. What are your thoughts?

Fast food and slow death

Posted by on June 3, 2013 Comments Off on Fast food and slow death

My father returned from a business trip with great enthusiasm for a new food product he had experienced. A company had found the best meat available and mass produced hamburgers, with the mustard, ketchup, and pickle already on the bun. Dad had eaten his first McDonald’s hamburger, more than a half century ago.

He died at age 45 of a massive heart attack, a product not only of McDonald’s and other fast food, but of a sedentary lifestyle, poor heredity, and a 1950’s diet, in which it wasn’t a meal without meat.

He and others who lived through the Second World War had experienced the deprivation of rationing following not long after the Great Depression. Having enough to eat, enough protein to eat, and then seeing opulent food as a sign of material success were all very real to that generation.

The success of feminism led to changes in America’s eating habits. Instead of one partner packing the lunch pail and preparing dinner, both were in the work force, too hurried and harried to spend as much time on meals. Quick meals, whether processed from the grocery store or from a fast food chain, became the norm. In the not too distant future we will learn what the impact has been on gut bacteria that process nutrients and play a role in regulating our weight.

In October 2011 researchers from the University of Michigan, Warsaw School of Social Science and Humanities, and the University of Texas published a study showing significant correlation between national rates of obesity and the density of Subway restaurants in 28 developed nations. Their study ‘Globesization’:
ecological evidence on the relationship between fast food outlets and obesity among 26 advanced
economies found high rates of obesity in countries such as the United States and Canada with high density of Subway restaurants compared to low rates of obesity in countries such as Japan and Norway with low rates.

We can safely assume that it is not Subway alone, but a propensity to support fast food restaurants that is related to obesity. In the study graphic below, the clustering of values along a rising trend line from lower right to upper left, demonstrates the correlation between obesity on the vertical and subways on the horizontal:

Subway_Obesity

Source: Roberto De Vogli , Anne Kouvonen & David Gimeno (2011): ‘Globesization’: ecological evidence on the relationship between fast food outlets and obesity among 26 advanced economies, Critical Public Health, 21:4, 395-402

My father’s generation died sooner, from fatty diets, cigarettes, and a sedentary lifestyle. If anything, computers have made our lifestyles more sedentary, but we know the dangers of cigarettes and saturated fats. We have statin drugs to stave off early death. Now we live longer, die slower, and endure chronic illnesses, such as cardiovascular disease and diabetes.

One of the singular distinctions between children and adults is the ability of adults to postpone pleasure and even endure discomfort in pursuit of a greater good. That may mean planning healthier meals, lighter meals, walking more and driving less. It means, in short, all the things we know we should do but sometimes do not. A long life need not be accompanied by a slow death–if we are willing to act on the knowledge we already have.

Are we making progress or falling behind?

Posted by on May 27, 2013 Comments Off on Are we making progress or falling behind?

In health care we don’t need to look far for bad news. In the past week, I have read:

  1. The prevalence of diabetes has increases 75 percent from the early nineties to the late naughts. A more extensive discussion (may require free Medscape subscription registration) is at New Statistics Shed Light on ‘Worrisome’ Diabetes Epidemic
  2. Leapfrog Hospital Safety Scores ‘Depressing’
  3. Study finds jump in ER-related admissions

And certainly we could include partisan bickering in Washington among politicians more focused on the next election than any meaningful policy debate or measures.

However, the simple fact is that none of this matters. We have no choice. If we do not adequately address our health care needs, then we will no survive as individuals or as a society.

If that premise, the premise of this blog, is correct, then we must assure access to healthcare for everyone. We must get the public health epidemics of obesity, diabetes, and gun violence, among others, under control.

On this Memorial Day, as we reflect on how many Americans have given up their lives at a young age to protect the American experiment, let us consider our debt to them: we owe it to them to insure that our society does not fail and that individuals not on battlefields do not give up their lives at a young age because they ate too much or someone bought a gun out of fear.

We are Americans: we do not accept failure in ourselves. The rest is trivial distraction.

How researchers confuse the public

Posted by on May 20, 2013 Comments Off on How researchers confuse the public

A nursing professor once told me how a graduate student came to her all excited. There was a population cohort dying from an epidemic of cardiac disease that had been ignored in the literature: women above age 85.

Now, while we can chuckle together about the naivete of the observation, consider it for a moment from the graduate student’s perspective:

1. Clearly the phenomenon was real as a high percentage of women over age 85 may well be dying of cardiac disease.
2. The red flag of gender bias stood out–it was women who were being victimized by this scourge.
3. A literature search turned up no one acknowledging the problem.

What was missing was the larger context: the twin facts that no one lives forever, and everyone eventually dies of something.

Sometimes more experienced researchers fail to provide the needed context. The following study came to my attention this week. Truth be known, I have not read the entire study, just the abstract and the accounts of those who have, so I will admit up front that this discussion may be unfair to the researchers.

The Canadian study is The long arm of parental addictions: The association with adult children’s depression in a population-based study.

It came to my attention in Trouble Coping with Parental Addiction

I am going to quote the abstract in full:

Parental addictions have been associated with adult children’s depression in several clinical and population-based studies. However, these studies have not examined if gender differences exist nor have they controlled for a range of potential explanatory factors. Using a regionally representative sample of 6268 adults from the 2005 Canadian Community Health Survey (response rate=83%), we investigated the association between parental addictions and adulthood depression controlling for four clusters of variables: adverse childhood experiences, adult health behaviors, adult socioeconomic status and other stressors. After controlling for all factors, adults exposed to parental addiction had 69% higher odds of depression compared to their peers with non-addicted parents (OR=1.69; 95% CI, 1.25–2.28). The relationship between parental addictions and depression did not vary by gender. These findings underscore the intergenerational consequences of drug and alcohol addiction and reinforce the need to develop interventions that support healthy childhood development.

The authors suggest that previous studies have not directly looked at gender differences of children of addicted parents. If so, then that is a clear contribution to the literature. But, the abstract and the descriptive article that I cited above go further: there is the clear implication that beyond a correlation or “relationship,” depression is the consequence of parental addiction.

Let’s consider two scenarios:

First, parents engage in substance abuse. The substance abuse causes them to act out, to neglect their children’s physical and emotional needs. The children grow up insecure and prone to depression. That is the clear implication of the abstract.

Second, a small but measurable percentage of the population inherit a tendency to mental illnesses (bi-polar, uni-polar depression, anxiety disorder, etc.) They self-medicate with both legal and illegal substances. They have children, whom they raise while self-medicating. A high percentage of their children inherit the tendency to mental illness, including uni-polar depression, and depressive cycles of bi-polar, showing a higher tendency toward those illnesses in the general population.

I find the second scenario more compelling. Indeed, attributing the problems of children to their parents because children follow their parents temporally is to my mind a classic case of the post hoc, ergo propter hoc logical fallacy in which one concludes that events following another event were caused by the previous event due to their proximity.

Runny noses do not cause colds, nor does “catching a chill,” whatever that means. Scientific studies are confusing enough to the general public, particularly through the filter of news media that do not look past the headline. We need researchers to be more cautious and guarded in their conclusions.

When we read that President Harry Truman wanted some “one-handed economists,” we can be sure that the economists were doing their job in informing him. We need the same of healthcare researchers.

Are we doing ourselves in faster than we think?

Posted by on May 6, 2013 Comments Off on Are we doing ourselves in faster than we think?

We know that our health is adversely affected by obesity, a sedentary lifestyle and fat consumption, not to mention tobacco and lack of access to healthcare. These factors are holding down what should otherwise be continued gains in life expectancy. They also adversely affect those who survive: the strains of obesity on the skeletal structure, emphysema from tobacco consumption, chronic heart disease, cancer that takes over lives, etc.

Recent studies indicate that not only are we experiencing indirect and long-term impacts on our lives and health, but the rate of suicide is increasing, surpassing deaths by motor vehicles in 2009. What adverse lifestyles are not doing to us in the long-term, we are doing directly to ourselves in the now.

The recent CDC study Suicide Among Adults Aged 35–64 Years — United States, 1999–2010 showed that the largest increase in the suicide rate was among whites between ages 45 and 64, in contrast to the common concern about teen and geriatric suicide.

In general, the suicide rate is related to stressors and the availability of means. The following chart, with data from the National Vital Statistics system, is from that CDC study:

Suicide by Sex and Means 1999-2010

Noteworthy are the increased use of firearms, which account for about half of all suicides among men, and suffocation (euphemism for hanging). The study lists the rates of suicide by state as well as the rate of increase from 1999 to 2010. I wondered about the ownership of firearms in those states.

I found that the study, “Association of suicide rates, gun ownership, conservatism and individual suicide risk,” was published online in the journal Social Psychiatry & Psychiatric Epidemiology in February.

The title a bit provocative, but if the availability of firearms reflects the political views of a population, and if the availability of firearms is related to the suicide rate, then it is possible to find statistical correlations among the three, without implying that a particular political view is suicidal or causes suicide any more than suicide causes a political view.

The study by researchers at the University of California, Riverside presented the following map of suicide rates by state:

Suicide_2000_2006

The map seems to show higher rates in states where one might expect more gun ownership, but, being a data person, I did a little experiment of my own.

I ran a couple of regressions, down and dirty, not up to publishable, academic standards. I used MS Excel, probably acceptable for this purpose but not a tool I would use for a publishable regression analysis.

My data sets were gun ownership from the Behavioral Risk Factor Surveillance System for 2001 and Median Income from the US Census Bureau for 2006. First, regressing gun ownership by state on income found that income was a significant factor, inversely related to gun ownership, and explaining 35 percent of the unexplained variation. This is not surprising as rural states are generally poorer and are more likely to have traditions of gun ownership for protection as well as for hunting.

It also meant that the cross correlation of income and firearms ownership might cloud the findings when I looked at the suicide rate from the latest CDC report and its separate relationships to the two factors. Those figures were for only 39 states, so that is how I handled it. My informal findings were that gun ownership rates were strongly correlated with the suicide rate, p=.00025 with R squared =.308, accounting for 30.8% of the unexplained variation. Income was inversely related to suicide and was much weaker, with p=.045 and R squared = .104.

Now, you might say, “Oh, suicide is related to economic factors. With recent economic challenges, of course suicide is rising.” You would be correct. Researchers from Rutgers have provided a graph of the relationship between suicide and unemployment.

Suicide and Unemployment
Source: Social Fact: The Great Depressions?

That is not, however, the public health issue, as there will always be stressors causing suicide. We need to find a way to block access to guns in the same way that we block access to bridges for suicidal people. Of course, there are a lot more guns than bridges. In the United States we ban automatic weapons from private ownership, so the issue is not whether the right to bear arms can be restricted: the entire debate is how extensive those restrictions should or should not be. The data on suicide suggests that greater restrictions on access would have a positive public health impact.

How Do We Implement What Works?

Posted by on April 29, 2013 Comments Off on How Do We Implement What Works?

Medicare is abandoning the one experimental program that works. So claims Ezra Klein of the Washington Post in “If this was a pill, you’d do anything to get it.”

Klein describes a program by Healthy Quality Partners (HQP) where nurses make home visits to geriatric patients with chronic illnesses. It has been subsidized by Medicare as an experiment, in which some randomly chosen patients receive the intervention while some do not. The results have been better outcomes at lower cost to Medicare per the article as well as a study published last July.

Let’s assume that the claims are true: better outcomes and lower costs. How do we take an experiment, and by definition experiments have a beginning and an end, and generalize it into practice?

There are numerous possibilities:

First, we could do what the article implies: provide more government funds to Healthy Quality Partners, instructing them to expand the experiment operationally beyond the 1,736 members in Pennsylvania. I am assuming that maintaining indefinitely a small-scale experiment that works makes no sense–onward and upward.

Second, we could change the reimbursement scheme at Medicare to provide reimbursement for such services so that anyone in the country could create a similar program with the financial incentive of knowing that Medicare would reimburse the services.

Here is how that second possibility has developed:

The Clinical Procedure Terminology (CPT) codes were created and are owned by the American Medical Association. Recently Medicare adopted additional CPTs for coding reimbursement for coordination of care services.

Care Coordination CPTs

A statement by the American Nurses Association (ANA) is enthusiastic about the addition of the codes. Note: the ANA participates on the AMA CPT and RVU Update Committee.

ANA Care Coordination

Eileen Shannon Carlson RN, JD of the ANA points out that it is rare for CPTs to be adopted that only apply to nurses, as do two of chronic care coordination additions.

To be fair, the new codes only reimburse care coordination after a hospitalization and for a short period of time, why the HQP initiative addressed the needs of the elderly with chronic conditions. Nonetheless, I can imagine the next step being a protocol to target care coordination for the elderly independent of a hospitalization. Contrary to much in the popular press, government programs are very aware of spending dollars and getting value in return, so they limit risk by taking baby steps in developing programs.

Ezra Klein may well be correct, or he might be underestimating the challenge of turning a large ship, particularly when the upfront costs of such a turn may be prohibitive. What do you think?

Does the US face a shortage of primary care physicians? Part IV

Posted by on April 22, 2013 Comments Off on Does the US face a shortage of primary care physicians? Part IV

We showed it exists. We show that one proposed solution probably won’t help without extensive micro-managing: conditioning receipt of new residencies on service in under-served areas, e.g. service in the National Health Service Corps.

What else can be done?

First, we can make alterations in the practice of primary care by physicians in the United States.

Peter Ubel makes this argument, suggesting that primary care physicians adopt the model of anesthesiologists supervising nurse anesthetists. He argues that the advantages of having more non-physicians offering care under the supervision of a physician are:

  1. More non-physicians doing routine primary care frees physicians from routine.
  2. Such a practice could see more patients per hour, improving physician compensation in primary care
  3. The model would improve primary care, as it is not physicians but primary care that is in shortage.

A recent article in Health Affairs adds the element of telemedicine to changes in primary care, long distance diagnosis and supervision of non-physicians through the use of technology.

Second, we can move more of primary care to non-physicians.

The second proposal takes the first one step further: allow nurse practitioners and physician assistants to practice independently of physicians. Peter Ubel is a physician, so his proposal in part reflects his background.

Consider this: we allow paramedics operating in a moving vehicle to make life-saving decisions but do not permit nurse practitioners to prescribe or refuse to prescribe an antibiotic with a supervising physician.

Paramedics and emergency medical technicians have a scope of practice that they know. There is no reason for nurse practitioners and physician assistants not to have a similar scope of practice clearly defined for when they are operating independently of a physician–such a scope might be slightly different than when a physician is involved.

The scope of practice of health care professionals is at the state level. In Texas bills are under consideration to make it easier for nurse practitioners to locate supervising physicians. In Connecticut bills have proposed permitting nurse practitioners to operate independently.

Third, we can make it easier for foreign physicians to practice primary care in this country.

A study at the University of Virginia is skeptical of the additional residency requirements for foreign-trained physicians.

All physicians must pass the three sections of the US Medical Licensing exam. It is a good test: there are no statistical differences in patient outcomes or complaints to medical boards between foreign and domestic-trained physicians. The proposal is to permit those passing the exam to compete for residencies on an equal footing, regardless of the location of their medical school.

If the problem is as dire as the AAMC and US Senators have suggested, then we should use all of these approaches to be sure the problem is addressed. At the worst we will have too many primary care providers, improving our health and lowering costs through an abundance of supply.

Does the US face a shortage of primary care physicians? Part III

Posted by on April 15, 2013 Comments Off on Does the US face a shortage of primary care physicians? Part III

We have seen that there is a physician shortage, but it is confined to primary care–the number of specialists relative to the population has expanded.

In addition, there is a geographical factor that is beyond the scope of this blog: are the physicians, primary care and others, distributed to provide coverage of those in need, or are they concentrated geographically so that they are adequate in numbers but inadequate in dispersion? Huang and Finegold believe 44 million Americans will be living in places where the demand for physicians exceeds supply by more than 5 percent, 7 million where the deficit will exceed 10 percent.

The American Association of Medical Colleges (AAMC) advocates lifting the cap on Medicare-financed medical residencies imposed by the Balanced Budget Act of 1997. Senator Charles Schumer (D-NY) has introduced the Resident Physician Shortage Act to increase the number of residencies by 15,000 over the next several years. He is particularly concerned about the absence of physicians in the more rural–and colder–upstate New York. His argument is that the shortage is driven by retirements. Aside: New York appears to have more medical schools (12) than any other state (7 next highest).

However, if the problem is really primary care, will simply increasing residencies address the problem? The following chart from the Washington Post is cause for optimism or pessimism, depending upon how you look at it. The number of residents choosing family practice residencies has declined precipitously since 1998, followed by an upturn, which may be brief or long-lived.

Family Practice Residencies

Consequently, the AAMC, as does Schumer, stresses that retirement will affect specialties as well as primary care.

AAMC Specialty Shortage

The question of adequate numbers of medical residencies is actually a separate, though indirectly related, question than the adequacy of the physician supply. According to Peter Ubel, who supplies the following graph from Karen Sliff of the Washington Post. The source of the data is the AAMC, which is why it is so difficult to get at the truth of an issue in Washington: the providers of information have an interest in actions taken on that information.

Resident Positions

So, let us grant that it is probably reasonable, although not necessarily essential, to increase the number of financed medical residencies; however, it is fair that those residents take responsibility for part of the cost to us of providing them, and that such obligation be forgiven if they are willing to serve rural populations for 5 years? My support for increasing residencies is conditional on them going where the need is, not where specialists find the big bucks.

Next time, we will finish this series by looking at other approaches of providing care to a growing population.

Does the US face a shortage of primary care physicians? Part II

Posted by on April 8, 2013 Comments Off on Does the US face a shortage of primary care physicians? Part II

In the first act I left a gun on the wall. I questioned whether there was a physician shortage in the US.

The rule of drama is that a gun on the wall in the first act has to be used later in the play. Let’s look at the US physician shortage.

We want to determine: is there really a shortage? what is the nature of the shortage? if there is a shortage, do the measures proposed address that shortage?

The AAMC claims that the shortage has resulted from the cap on Medicare-funded residencies implemented under the Balanced Budget Act of 1997.

I wanted to find a time series on the number of physicians from 1997 to the present. It may be that the AAMC and AMA have such a series but it would be time-consuming, even if possible, to get hold of those figures.

Consequently I went to the Bureau of Labor Statistics (BLS) for physician employment and to the US Census Bureau for population figures. Also, the BLS changed the way it classified and calculated numbers of health care practitioners. The BLS has confirmed to me that the physician totals for 1999-2003 do not exist, although some sub-totals do.

First, I compared the number of physicians to the US population. I simply divided the number of physicians by the population and multiplied by 1000 to get physicians per 1000 population, yielding this graph:

Physicians Per 1000 2004_2012

Now that does not look like a physician shortage–indeed, it looks like we may have a physician surplus with the growth in the number of physicians outstripping population growth.

So, I looked a bit further. I grouped pediatricians, general internists, and family practice physicians, calling them “Primary Care.” Then, I produced this graph, indexing them to 2004 being 100 so we could see the relative growth.

Physicians Indexed 2004_2012

It is clear that while the total number of physicians has grown faster than the population, the number of primary care physicians has trailed.

Since we have the sub-categories going back to 1999, just after the Balanced Budget Amendment of 1997 was passed, here is the indexed comparison:

PCP to US Population 1999_2012

While the number of Primary Care Physicians kept pace with the population from 2004 through 2007, it has generally fallen short of population growth.

The challenge then is: how do we allocate resources to increase the number of physicians in primary care without those funds being diverted to creation of even more specialists?

Does the US face a shortage of primary care physicians? Part I

Posted by on April 1, 2013 Comments Off on Does the US face a shortage of primary care physicians? Part I

Several recent studies and news stories suggest that the US faces a physician shortage, particularly in primary care. Access to health care requires not only insurance but adequate numbers of health care providers such as physicians and nurses, among others. Theoretically, we could imagine everyone in the country with adequate insurance but an insufficient number of practitioners to meet their needs.

Pauline W. Chen M.D., for example, asks Where Have All the Primary Care Doctors Gone?

The obvious solution is to graduate more doctors, but three years ago the Wall Street Journal stated that Medical Schools Can’t Keep Up with the expanding number of insureds. A graphic based on data from the Kaiser Family Foundation shows the geographic nature of the problem.

Doctor Shortage_Kaiser_from WSJ

What the map does not tell us is what the optimal number of physicians per 1000 in the population is, nor does it tell us whether that number varies with the degree of urbanization.   For example, does a geographically dispersed population require more physicians per thousand because the expanse is too great for coverage by one person?

The American Association of Medical Colleges (AAMC) provides the figures quoted in almost all of the stories.

From their website:

AAMC Doc Shortage

But, the AAMC does not suggest that increasing the number of medical students will solve the problem. They point out that medical schools planned a 30 percent increase in medical students by 2016 and were on target to meet that goal.

The problem, according to the lobbying group for medical schools, is the number of residencies, which have not kept pace because of the cap on Medicare-funded residencies in the 1997 Balanced Budget Act. They are calling for removal of the cap by the funding of an additional 4,000 residencies annually.

Not at all coincidentally, the AAMC praises introduction of a bill to create 3,000-4,000 new residencies:

20130315_AAMC_pressrelease

If that would solve the physician shortage that has been alleged, then we could all applaud. However, even if we accept that there is a shortage, that it is related to residencies, and that this proposal increases the necessary residencies, there is another possibility.

What if US medical students will not choose primary care residencies over specialties no matter how many there are. Jacob Goldstein noted in a 2009 WSJ blog that residents in internal medicine often go on to do residencies in more lucrative sub-specialties while

In family medicine, another key supplier of primary-care docs, there isn’t even enough interest among qualified young docs to fill existing residency slots. Hundreds of slots went unfilled this year, and graduates of foreign med schools filled many of the available positions.

Goldstein’s point was validated by a study published in the December 2012 JAMA. The accompanying editorial notes that only 21.5 percent of third-year residents plan to practice in primary care. (to be continued)