Half the population over 40 on Pine Ridge has diabetes, and tuberculosis runs at eight times the national rate. As many as two-thirds of adults may be alcoholics, one-quarter of children are born with fetal alcohol spectrum disorders, and the life expectancy is somewhere around the high 40s — shorter than the average for sub-Saharan Africa. Less than 10 percent of children graduate from high school.
Editorial by Nicholas D. Kristof in the NYT.
Jason Shafrin writes:
In response to concerns about tele-medicine’s effect on patient safety, many states have begun prohibiting physicians from prescribing drugs without conducting a prior physical examination. In fact, more than 30 states have instituted this type of rule since 1998.
A paper by Cotet and Benjamin investigates this regulation which they call the physical examination requirement (PER).
The findings:
The adoption of PER is associated with a 1% rise in disease-related mortality rates the equivalent of 8.5 deaths per 100,000 people, presumably because it raised the implicit cost of, and thus reduced access to, medical care. In addition, the adoption of the PER is associated with a 6.7% reduction in injury-related mortalities, the equivalent of 2.5 deaths per 100,000 people. Thus, the reduction in injury mortality is smaller than the elevation of disease-related mortality, yielding a rise in overall mortality.
Ryan has a good plan. I don’t think it goes fast enough. But the fact is he’s got a plan. The president won’t put out a plan. The Senate Democrats won’t put out a plan. It’s kind of like boxing with a shadow. You can’t ever hit it. But it doesn’t matter if you’re Democrat or Republican. The pain will get worse every year we don’t fix these things. And there will come a time when it won’t matter if you’re a Republican or Democrat. And I don’t have much faith right now that we’re up to the task of coming to agreement to fix this.
Tom Coburn interview with Ezra Klein on his new book, The Debt Bomb. Good throughout.
For those of you interested in the recent work on the diversity of different cancer cell genotypes inside single tumors, there’s a review out that covers the field well. The authors also go into some of the major unanswered questions: does having a tumor cell population with a lot of genetic diversity correlate with a poor prognosis for treatment? Can small populations of potentially troublesome cells be identified ahead treatments that might give them too free a field to work in? Can the huge genetic diversity be reduced to a more manageable set of practical phenotypes, to make therapeutic recommendations? This will keep everyone busy for a long time to come.
I’ve read a couple of medical papers recently that show how tricky it is to draw conclusions on what patients would be best helped by a specific therapy. Many of you will have seen the paper in The Lancet on the use of statins in low-risk patients. This isn’t something you’d necessarily think would do much good – it all depends on what the benefits are, at the margin, of lowering LDL. But the results appear surprisingly strong:
In individuals with 5-year risk of major vascular events lower than 10%, each 1 mmol/L reduction in LDL cholesterol produced an absolute reduction in major vascular events of about 11 per 1000 over 5 years. This benefit greatly exceeds any known hazards of statin therapy. Under present guidelines, such individuals would not typically be regarded as suitable for LDL-lowering statin therapy. The present report suggests, therefore, that these guidelines might need to be reconsidered.
A note to the conspiratorially minded, should any such come across this: it’s worth noticing that this “maybe everyone should take statins” result comes after the major ones have gone off patent. Pfizer, Merck et al. would have greatly enjoyed this recommendation had it occurred ten years ago, but it didn’t (and probably couldn’t have, since we didn’t have as much data as we do now).
Now to another (often related) disease, type II diabetes. It’s been found that bariatric surgery improves glycemic control in the very obese patients who are candidates for the procedure. And that makes sense – obesity is absolutely a risk factor for type II in the first place. But as more and more of these surgeries are being done, something odd is becoming apparent:
Clinicians note that bariatric operations can dramatically resolve type 2 diabetes, often before and out of proportion to postoperative weight loss. Now two randomized controlled trials formally show superior results from surgical compared with medical diabetes care, including among only mildly obese patients. The concept of ‘metabolic surgery’ to treat diabetes has taken a big step forward.
Why this happens is a very good question indeed. Patients seem to benefit greatly within the first two weeks after gastric bypass surgery, well before any significant weight loss has occurred. My first guess is that it’s something to do with secretion of hormones from the gut itself, and you’d also have to think that nutrient sensing gets profoundly altered. It’s not going to be easy to turn this into an approved therapy, though. Running randomized clinical trials for dramatic surgical procedures (versus noninvasive care) is difficult, as you’d imagine:
Despite these compelling clinical observations, RCTs of surgery versus nonsurgery are sorely needed. Ample precedents exist wherein RCTs reversed longstanding paradigms derived from nonrandomized clinical trials. Some of the best evidence in bariatric surgery, from the Swedish Obese Subjects study (a long-term observation of various operations versus conventional care), is prone to allocation bias because participants were not randomized. Subjects who actively chose surgery may be more motivated overall and generally take better care of themselves. The NIH is unlikely to reconsider its guidelines without pertinent RCTs, and insurance companies are unlikely to pay for operations that are not NIH-sanctioned.
Both of these results point out the completely nonlinear nature of living systems. It can work for good, as in these cases, or for bad. Alzheimer’s, the subject of yesterday’s post, is a perfect example of the latter: one protein, out of perhaps a few million, has one of its hundreds of amino acids changed in one small way on its side chain. And it’s a death sentence. Good to know that things can work in the other way once in a while.
Agent commissions have declined dramatically since the medical loss ratio (MLR) provision of the health care reform law went into effect, forcing many agents to reduce their services to clients, consider charging fees for services they had been providing at no additional charge and in some cases, laying off employees and leaving the health insurance market.
That’s according to a survey by the National Association of Insurance and Financial Advisors (NAIFA) of 861 of its members who sell health insurance. Seventy percent of respondents who sell health insurance have seen a decrease in commissions.
Almost a third are ready to leave the market. The survey reports that 30% say that if commissions remain depressed they will stop selling and servicing individual health policies and 22% say they will stop selling all health insurance.
How’s it going in your area?
Full article by Elizabeth Festa in LifeHealthPro.
Getting a medical degree is not easy: It requires 10 years of medical education and 16,000 hours of clinical experience to get certified to provide treatment. Even so, most of us think we can make equally as good diagnoses as our doctors—as long as we have a little help from Google.
A Wolters Kluwer poll out this morning finds that not only are most consumers turning to the Internet to answer medical questions, but that they also put strong faith in their own diagnosis. Among college educated Americans, 63 percent say they have “never” misdiagnosed themselves. Add in those who have say they’ve “rarely” made a wrong call and the number jumps up to 84 percent.
More by Sarah Kliff at Ezra Klein’s blog.