How to Take American Health Care From Worst to First - NYTimes.com

IN the past decade, baseball has experienced a data-driven information revolution. Numbers-crunchers now routinely use statistics to put better teams on the field for less money. Our overpriced, underperforming health care system needs a similar revolution.

Data-driven baseball has produced surprising results. Michael Lewis writes in "Moneyball" that the Oakland A's have won games and division titles at one-sixth the cost of the most profligate teams. This season, the New York Yankees, Detroit Tigers and New York Mets — the three teams with the highest payrolls, a combined $486 million — are watching the playoffs on television, while the Tampa Bay Rays, a franchise that uses a data-driven approach and has the second-lowest payroll in baseball at $44 million, are in the World Series (a sad reality for one of us).

Remarkably, a doctor today can get more data on the starting third baseman on his fantasy baseball team than on the effectiveness of life-and-death medical procedures. Studies have shown that most health care is not based on clinical studies of what works best and what does not — be it a test, treatment, drug or technology. Instead, most care is based on informed opinion, personal observation or tradition.

It is no surprise then that the United States spends more than twice as much per capita on health care compared to almost every other country in the world — and with worse health quality than most industrialized nations. Health premiums for a family of four have nearly doubled since 2001. Starbucks pays more for health care than it does for coffee. Nearly 100,000 Americans are killed every year by preventable medical errors. We can do better if doctors have better access to concise, evidence-based medical information.

Look at what's happened in baseball. For decades, executives, managers and scouts built their teams and managed games based on their personal experiences and a handful of dubious statistics. This romantic approach has been replaced with a statistics-based creed called sabermetrics.

These are not the stats we studied as children on the backs of baseball cards. Sabermetrics relies on obscure statistics like WHIP (walks and hits per inning pitched), VORP (value over replacement player) or runs created — a number derived from the formula [(hits + walks) x total bases]/(at bats + walks). Franchises have used this data to answer some of the key questions in baseball: When is an attempted steal worth the risk? Whom should we draft, and in what order? Should we re-sign an aging star player and run the risk of paying for past performance rather than future results?

Similarly, a health care system that is driven by robust comparative clinical evidence will save lives and money. One success story is Cochrane Collaboration, a nonprofit group that evaluates medical research. Cochrane performs systematic, evidence-based reviews of medical literature. In 1992, a Cochrane review found that many women at risk of premature delivery were not getting corticosteroids, which improve the lung function of premature babies.

Based on this evidence, the use of corticosteroids tripled. The result? A nearly 10 percentage point drop in the deaths of low-birth-weight babies and millions of dollars in savings by avoiding the costs of treating complications.

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http://www.nytimes.com/2008/10/24/opinion/24beane.html?em=&pagewanted=print

Survey: Half of US doctors use placebo treatments

About half of American doctors in a new survey say they regularly give patients placebo treatments - usually drugs or vitamins that won't really help their condition. And many of these doctors are not honest with their patients about what they are doing, the survey found.

That contradicts advice from the American Medical Association, which recommends doctors use treatments with the full knowledge of their patients.

"It's a disturbing finding," said Franklin G. Miller, director of the research ethics program at the U.S. National Institutes Health and one of the study authors. "There is an element of deception here which is contrary to the principle of informed consent."

The study was being published online in Friday's issue of BMJ, formerly the British Medical Journal.

Placebos as defined in the survey went beyond the typical sugar pill commonly used in medical studies. A placebo was any treatment that wouldn't necessarily help the patient.

Scientists have long known of the "placebo effect," in which patients given a fake or ineffective treatment often improve anyway, simply because they expected to get better.

"Doctors may be under a lot of pressure to help their patients, but this is not an acceptable shortcut," said Irving Kirsch, a professor of psychology at the University of Hull in Britain who has studied the use of placebos.

Researchers at the NIH sent surveys to a random sample of 1,200 internists and rheumatologists - doctors who treat arthritis and other joint problems. They received 679 responses. Of those doctors, 62 percent believed that using a placebo treatment was ethically acceptable.

Half the doctors reported using placebos several times a month, nearly 70 percent of those described the treatment to their patients as "a potentially beneficial medicine not typically used for your condition." Only 5 percent of doctors explicitly called it a placebo treatment.

Most doctors used actual medicines as a placebo treatment: 41 percent used painkillers, 38 percent used vitamins, 13 percent used antibiotics, 13 percent used sedatives, 3 percent used saline injections, and 2 percent used sugar pills.

In the survey, doctors were asked if they would recommend a sugar pill for patients with chronic pain if it had been shown to be more effective than no treatment. Nearly 60 percent said they would.

Smaller studies done elsewhere, including Britain, Denmark and Sweden, have found similar results.

Jon Tilburt, the lead author of the U.S. study, who is with NIH's bioethics department, said he believes the doctors surveyed were representative of internists and rheumatologists across the U.S. No statistical work was done to establish whether the survey results would apply to other medical specialists, such as pediatricians or surgeons.

The research was paid for by NIH's bioethics department and the National Center for Complementary and Alternative Medicine.

The authors said most doctors probably reasoned that doing something was better than doing nothing.

In some cases, placebos were given to patients with conditions such as chronic fatigue syndrome. Doctors also gave antibiotics to patients with viral bronchitis, knowing full well that a virus is impervious to antibiotics, which fight bacteria. Experts believe overuse of antibiotics promotes the development of drug-resistant strains of bacteria.

Some doctors believe placebos are a good treatment in certain situations, as long as patients are told what they are being given. Dr. Walter Brown, a professor of psychiatry at Brown and Tufts universities, said people with insomnia, depression or high blood pressure often respond well to placebo treatments.

"You could tell those patients that this is something that doesn't have any medicine in it but has been shown to work in people with your condition," he suggested.

However, experts don't know if the placebo effect would be undermined if patients were explicitly told they were getting a dummy pill.

Brown said that while he hasn't prescribed sugar pills, he has given people with anxiety problems pills that had extremely low doses of medication. "The dose was so low that whatever effect the patients were getting was probably a placebo effect," he said.

Kirsch, the psychologist, said it might be possible to get the psychological impact without using a fake pill. "If doctors just spent more time with their patients so they felt more reassured, that might help," he said.

Some patients who had just seen their doctors at a clinic in London said the truth was paramount.

"I would feel very cheated if I was given a placebo," said Ruth Schachter, an 86-year-old Londoner with skin cancer. "I like to have my eyes wide open, even if it's bad news," she said. "If I'm given something without being warned what it is, I certainly would not trust the doctor again."

http://apnews.myway.com/article/20081023/D940G7Q01.html

Los Angeles Times: The battle of the medical bills

In late 2007, Centinela Hospital in Inglewood was losing nearly $1 million a month and had piled up $15 million in debt. Among the causes of the crisis: $25 million in overdue bills.

Collecting that money would have given Centinela a measure of relief. But the bills went unpaid, and the century-old medical center was sold. The new owners slashed services, closed half the operating rooms and laid off a third of the employees.

Who owed Centinela that elusive $25 million? According to hospital officials, it was health insurance companies."

Insurers have found a very creative way of denying, delaying or slowing payments in a way that is having a real impact on patient care and some of our survival," said Von Crockett, Centinela's chief executive. "Every single doctor and hospital is writing off money they are legally owed but don't collect. It's an insane situation."

Doctors and hospital executives say collecting payments from insurers has become an expensive headache that is driving up the nation's healthcare costs.

Billing disputes and protracted payment delays are one consequence of a massive consolidation among health insurers that has created de facto monopolies in much of the country, the Los Angeles Times found.

Two decades ago, the top 10 insurers covered about 27% of all insured Americans. Today, four companies -- WellPoint Inc., UnitedHealth Group, Aetna Inc. and Cigna Corp. -- cover more than 85 million people, almost half of all those with private insurance.

A 2007 survey by the American Medical Assn. found that in two-thirds of metropolitan areas, one health insurer controlled at least 50% of the market. In the Los Angeles area, two companies dominate -- Kaiser Permanente and WellPoint's Anthem Blue Cross.

As a result, doctors and hospitals have little negotiating power and few options when an insurer rejects a bill. Some physicians are dropping out of insurance networks or turning away new patients. Others have moved to cash-only practices. Some smaller hospitals and solo-practice physicians say they are being driven out of business entirely.

The insurance industry lays much of the blame for billing problems on doctors and hospitals. Insurers question or reject claims "when we don't get full information or when we get duplicate bills," said Karen Ignagni, president of America's Health Insurance Plans, the industry's lobbying arm in Washington. "Efficiency is a two-way street."

In some cases, she said, insurers are simply trying to ensure that doctors treat patients consistently and in accordance with the highest medical standards -- that they're not wasting premium dollars by overusing costly treatments or ordering unnecessary tests."

Utilization review is coming back," she said, referring to heightened scrutiny of doctors and hospitals. "You can't run a health plan today without using some of these tools and techniques" to control costs.But Ignagni acknowledged that billing processes were inordinately complex. She said insurers were aware of providers' complaints and were trying to streamline billing systems."

No question that administrative simplicity has to be job one," she said.

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http://www.latimes.com/business/la-fi-insure23-2008oct23,0,4561223,print.story

Television as the cause of rising autism rates?

In Search of the Cause of Autism
How about television?
By Gregg Easterbrook
Posted Tuesday, Sept. 5, 2006, at 3:57 PM ET

Autism in the United States has been increasing for two and a half decades, from one child in 10,000 to one in 500 or perhaps even one in 166 today. Maybe advancing parental age is a factor; this Israeli study, published Monday, shows that men over 40 are more likely to father autistic children than men under 30. And it's clear that part of the rise can be attributed to better identification by doctors, improved parental candor, and, especially, an expanded definition of the psychiatric diagnosis for the ailment. But because the autism surge began around the year 1980, researchers and parents of afflicted children continue to ask what kind of exposure could have begun at that time that might account for the surge.

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http://www.slate.com/id/2149002/

TV Really Might Cause Autism
A Slate exclusive: findings from a new Cornell study.
By Gregg Easterbrook
Posted Monday, Oct. 16, 2006, at 6:52 AM ET

Last month, I speculated in Slate that the mounting incidence of childhood autism may be related to increased television viewing among the very young. The autism rise began around 1980, about the same time cable television and VCRs became common, allowing children to watch television aimed at them any time. Since the brain is organizing during the first years of life and since human beings evolved responding to three-dimensional stimuli, I wondered if exposing toddlers to lots of colorful two-dimensional stimulation could be harmful to brain development. This was sheer speculation, since I knew of no researchers pursuing the question.

Today, Cornell University researchers are reporting what appears to be a statistically significant relationship between autism rates and television watching by children under the age of 3. The researchers studied autism incidence in California, Oregon, Pennsylvania, and Washington state. They found that as cable television became common in California and Pennsylvania beginning around 1980, childhood autism rose more in the counties that had cable than in the counties that did not. They further found that in all the Western states, the more time toddlers spent in front of the television, the more likely they were to exhibit symptoms of autism disorders.

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http://www.slate.com/id/2151538

TV causes autism? I doubt it.
By Steven D. Levitt
October 17, 2006

An article in Slate yesterday argued that TV watching causes autism. The Slate article is based on research done by Cornell economists Michael Waldman, Sean Nicholson, and Nodir Adilov. You can download the academic working paper here.
The paper gives some theories why TV and autism might be linked, but the more interesting part of the paper is the data analysis. The researchers are trying to find a “natural experiment” that shifts around TV watching, but otherwise has no impact on whether a child is diagnosed as autistic. Rainfall is one of the things they use. In places where it rains a lot, kids watch more TV. Maybe rainfall doesn’t affect autism in any other way. This is a creative approach, although it suffers from the weakness (which they acknowledge in the paper), that rainfall changes other things, like how much time you spend indoors doing other things besides watching TV. They also use the arrival of cable TV in an area. This approach is potentially stronger, although it would be better if they used availability of cable TV, rather than the number of people who actually subscribe.

These are intriguing approaches, but personally I did not find the empirical evidence in the paper very compelling.

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http://freakonomics.blogs.nytimes.com/2006/10/17/tv-causes-autism-i-doubt-it/

Does watching TV cause autism?
William M. Briggs, Statistician

I have no idea, but two gentlemen from the Johnson School of Management at Cornell and one from the Economics department at Purdue seem to think so. They have written a paper, which has found interest at Slate, which they boast as an “exclusive.”

Waldman’s (and others) paper, which is a couple of years old, is a prime example of how to get carried away with an idea, so it is worthwhile to review it. It’s best to download the paper so you can follow along (the paper is freely available).

The genesis of the idea was noticing that autism rates at birth in the state of California started to increase in the early 1970s, picking up pace until 2000, when their data stops (see their Figure 1). It is true to say that something caused this increase. But what?

There is no way to know, but we can posit causes and then test them. The best way to do that is by direct measurement: Propose a cause, design an experiment or collect data in which the cause was controlled and the effect happened. That is difficult to do in the case of autism, of course, since you won’t know a child is inflicted for some time after his birth. But, of course, it would not be ethical to let a cause stay in place if you suspected it would lead to autism. It is also not clear when the cause, or causes, whatever they might be, have to manifest themselves. That is, the same cause might be in place for two children, but miss its timing, so to speak, in the first case and get it right in the second. A plausible biological mechanism for the cause that fits in with other known medical science must also be in place. In short, this kind of investigation is not impossible, but it is difficult and must proceed by, if I can use the pun, baby steps.

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http://wmbriggs.com/blog/2008/07/

Autism Vox blog

http://www.autismvox.com/

Psychoanalytic Therapy Wins Backing - NYTimes.com

Intensive psychoanalytic therapy, the "talking cure" rooted in the ideas of Freud, has all but disappeared in the age of drug treatments and managed care.

But now researchers are reporting that the therapy can be effective against some chronic mental problems, including anxiety and borderline personality disorder.

In a review of 23 studies of such treatment involving 1,053 patients, the researchers concluded that the therapy, given as often as three times a week, in many cases for more than a year, relieved symptoms of those problems significantly more than did some shorter-term therapies.

The authors, writing in Wednesday's issue of The Journal of the American Medical Association, strongly urged scientists to undertake more testing of psychodynamic therapy, as it is known, before it is lost altogether as a historical curiosity.

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http://www.nytimes.com/2008/10/01/health/01psych.html?pagewanted=all

Gitmo: Psychologists and Torture | Newsweek International

Before he became a psychologist, Steven Reisner didn't know much about the long history between spies and shrinks. Soft-spoken and cerebral, he'd spent seven years as a theater actor and director, switching to psychology as a profession in 1989. But the ties go back decades, to the early years of the cold war when psychologists helped the CIA experiment on U.S. citizens with mind-altering drugs. The relationship has warmed and cooled over the years, heating up whenever defense or intelligence officials wanted better mind-control methods, ways to direct people's behavior or detect deception. Since 9/11 military and civilian psychologists at Guantánamo Bay and other sites have often watched through the glass when detainees have been interrogated, part of a secret program about which few details have ever emerged.

Reisner first read about the program in a newspaper article in 2004. The 54-year-old psychoanalyst is convinced that some of the techniques used in those interrogations amounted to torture, and he has made it his mission since then to get psychologists out of the business of helping the military as they break down prisoners. Reisner's crusade has been waged largely within the American Psychological Association—in the minutiae of association bylaws and on the pages of internal listservs. Last week, balloting began for a new APA president in what for many is a referendum on the relationship between psychologists and the military. Among five contenders, Reisner has staked his candidacy on the issue.

The APA is the only remaining medical association not to have shunned the contentious interrogations in the years since Guantánamo was opened in 2001. Two civilian psychologists helped introduce techniques like waterboarding into interrogations, drawn from the military's SERE (Survival, Evasion, Resistance and Escape) schools where troops are taught to withstand torture. Since 2002 psychologists have observed interrogations and suggested specific ways to exploit the weaknesses of detainees, including Mohammed Jawad, whose disturbing case is now being heard by a military tribunal in Guantánamo. The military claims the psychologists have only helped to make interrogations "safe, legal and effective."

Judging by recent internal votes, APA members have grown uncomfortable with the interrogation business. Reisner has received endorsements from a few big-name psychologists, including Stanford University's Philip Zimbardo. (The four other candidates in the race for president—two clinical psychologists, one professor and a researcher—have mostly campaigned on the bread-and-butter issues of the profession, such as gaining prescription-writing authority for psychologists.) If he wins, Reisner says he will use his authority to expose the precise role individual APA psychologists have played in the interrogations, not only at Guantánamo but at the CIA's "black" sites around the world. He says wrongdoers will be brought before an ethics board; like doctors and other caregivers, psychologists are bound by a do-no-harm principle. But for Reisner the main point is to air the details publicly, in a kind of truth-and-reconciliation process. "The discussions … need to have a public venue so that we can learn the lessons and not let it happen again," he says.

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http://www.newsweek.com/id/164497

Los Angeles Times: Health insurers reinvent themselves as money managers

WellPoint Inc., the nation's largest health insurance company, ran into a snag last year while pursuing an important new business initiative.

Federal banking regulators insisted on classifying WellPoint as a healthcare company. And that was interfering with its efforts to open a bank.

The Federal Reserve Board eventually agreed that the company's core insurance business could be considered financial services. But what about its mail-order pharmacy and its program for managing chronic diseases, which was overseen by WellPoint doctors and nurses? Wasn't that healthcare?

WellPoint finally convinced the Fed that those activities were merely "complementary" to its main business -- financial services. It pledged to limit them to less than 5% of total revenue.

That a medical insurer would agree to keep a lid on healthcare expenditures so it could get approval to open a bank illustrates a fundamental change in the industry: Insurers are moving away from their traditional role of pooling health risks and are reinventing themselves as money managers -- providers of financial vehicles through which consumers pay for their own healthcare.

Like home and auto insurance, traditional health coverage is based on shared risks within broad populations of customers: a small proportion with big medical expenses and a large majority with few or none. Premiums paid by the latter help pay the costs incurred by the others and provide a margin of profit. In theory, this system serves everyone's interests, because people generally can't know in advance which group they'll fall into.

For several decades, health insurance has been retreating from this paradigm.

A sea change occurred in the 1970s, when large employers began self-insuring medical costs, in part because a new federal law exempted self-insured plans from state regulation.

Insurance companies began remaking themselves as administrators, providing employers with expert help in processing claims and negotiating rates with doctor groups and hospitals. Profit margins on these services are high because the companies can charge fees without assuming the cost of underwriting customers' medical needs.

A similar change is now rippling through the rest of the health insurance market, driven by federal tax breaks for individuals who pay for their own routine medical care.

"This is a turning point," said Jacob Hacker, a professor of political science at UC Berkeley who has written extensively on healthcare reform. "It's a fundamental shift away from the idea of broadly shared risk. It's going to lead to a complete transformation of the health insurer, which will be increasingly focused on providing management of money."

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http://www.latimes.com/business/la-fi-insure22-2008oct22,0,3119429,print.story

An eroding model for health insurance - Los Angeles Times

Working Americans once could rely on employer-based benefits. But more people are being forced into the individual market, where coverage is costly, bare-bones and precarious.

Jennifer and Greg Danylyshyn of Pasadena are conscientious parents. They keep proper car seats in their used BMW, organic vegetables in the family diet and the pediatrician's number by the phone.

They don't have access to the group medical insurance offered by many employers. She's a stay-at-home mom. He's a self-employed music supervisor in the TV and film industry. So they buy individual policies for each family member.

As careful consumers, they shopped for the best deals, weighed premium costs against benefits and always assumed they could keep their family covered.

Then last spring Blue Shield of California stunned them with a rejection notice. Baby Ava, their happy, healthy 7-pounder, was born with a minor hip joint misalignment. Her pediatrician said it was nothing serious and probably temporary.

Still, Blue Shield declared the infant uninsurable. The company foresaw extra doctor visits, "the need for monitoring and an X-ray." Ava's slight imperfection "exceeds . . . eligibility criteria for acceptance," Blue Shield said.

"I was enraged, baffled; I just could not understand," recalled Jennifer, 36.

The family's experience is symptomatic of the nation's healthcare crisis. Ineligible for group insurance, millions of Americans are paying more for individual policies that offer less coverage and expose them to seemingly arbitrary exclusions and denials.

The health insurance system has become increasingly expensive and inaccessible. It leaves patients responsible for bills they understood would be covered, squeezes doctors and hospitals, and tries to avoid even minuscule risks, such as providing coverage to a newborn with no serious illness.

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http://www.latimes.com/classified/jobs/career/la-fi-insure21-2008oct21,0,6162888,full.story

Compassion & Choices: The Fight for Choice at the End of Life

On Tuesday, Gov. Schwarzenegger signed the Terminal Patients' Right to Know End- of-Life Options Act, AB 2747 (Berg-Levine). The act is the first in the nation to provide terminally ill patients with a full disclosure of, and counseling about, all available end-of-life care options accepted in law and medicine.

When requested, information about hospice care, refusal or withdrawing of life-prolonging treatments, voluntary stopping eating and drinking (VSED), palliative care and palliative sedation will be discussed with the patient. The Act also requires that health care providers who do not wish to comply with a particular patient's choice must refer or transfer the patient to another provider.

"Dying patients needlessly suffer due to a lack of essential information. As a result, many spend their last days in agony. Too many patients make the most important decision of their lives – how they will live their final days – without being fully informed of their legal rights," said Barbara Coombs Lee, president of Compassion & Choices, sponsor of the measure. "The Right to Know End-of-Life Options Act would require physicians and health care providers to provide a full range of information about options when patients request it. The Act puts the information and power to choose in patients' hands."

Thirty years ago, California led the nation by giving people the right to express their wishes for health care in advance. It's time to take this next step to ensure that terminally-ill patients have all of the information that they need to make timely and informed decisions regarding their care. Information and counseling regarding end-of-life care options is essential for many terminally ill patients and their families. It can help the patient weigh all of their options and make an informed decision that best meets their needs. It gives the physician an opportunity to discuss the benefits and disadvantages of all available treatments, and it can facilitate earlier access to hospice care.

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http://www.compassionandchoices.org/righttoknow/

Why Hire a Geriatric Care Manager? - The New Old Age Blog - NYTimes.com

Why Hire a Geriatric Care Manager?
By Jane Gross

During one especially dicey period with my mother, then in an assisted living facility, my brother and I hired a geriatric care manager, first for a consultation and then for additional help at an hourly rate. It felt like such an extravagance, given that we weren’t rolling in money, but the care manager helped solve a series of complex problems that I doubt I’d have solved by myself, mostly involving brokering a compromise with the facility, whose management wouldn’t let me hire a private aide for my mom but could not provide what she needed.

Relations had soured to the point that all I could do was scream at them, which was making a bad situation worse, so having an advocate was a blessing. Also, the care manager, who visited regularly with my mother, often was privy to concerns she was keeping from me, and she was always there for me by telephone, which was a lifesaver.

Many of you have asked questions about geriatric care management and how it is performed. I posed some of them to Patricia Mulvey, a care manager who has worked in hospitals, nursing homes, home-care agencies, hospice and bereavement programs, and as an independent contractor. Currently she is the director of the private geriatric care management service at the Jewish Home Lifecare System, which runs several long-term care facilities in New York City and its suburbs. With some modest editing, here are her thoughts.

http://newoldage.blogs.nytimes.com/2008/10/06/why-hire-a-geriatric-care-manager/

When Medicare Falls Short - The New Old Age Blog - NYTimes.com

For Dr. Cheryl E. Woodson, geriatric medicine is a passion that doesn’t pay the bills.

“I love this. I just love this,” she said one recent afternoon in her office in Chicago Heights, Ill. Dr. Woodson had just diagnosed early-stage dementia in a 73-year-old patient, recommending a hip replacement while the woman is still cognitively capable of rehabilitation, and then had consoled the woman’s weeping daughter.

But Dr. Woodson can no longer afford to run her solo practice as she once did. She has stopped taking new patients over the age of 65, when Medicare kicks in, since reimbursement for their care is now “40 cents on the dollar,” she said, not enough to staff her office and pay the rent.

“If I take new Medicare patients, I can’t keep the door open,” Dr. Woodson said. With Medicare paying less now then it did in 2001, she added, “you can serve seniors or feed your children.” Not both.
Dr. Woodson’s dilemma is shared by many internists and family practitioners, endangered specialists in a health care system that pays for procedures and tests but not for the time-consuming management of chronic conditions. “We get paid to do things to people, not for people,” Dr. Woodson is fond of saying.

This is especially true for the elderly, who are generally not good candidates for we-can-fix-it medicine. Instead, as they lose mobility, cognition and thus independence, they require lengthy office visits, close monitoring and supportive services. These days, it is difficult to find a new doctor for anyone over the age of 65, because they are so expensive to treat.

Dr. Woodson’s solution to the cash crunch is to keep her existing elderly patients and to turn away new ones. At the same time, however, she has begun providing geriatric consultations, much like a cardiologist or orthopedist might. Each Wednesday afternoon, she does three such consultations, each at least an hour long, which produce what she calls a “level-of-care prescription” that the primary-care physician and family can implement on their own.

The goal of the assessment is to determine what’s wrong with the elderly patient, whether it can be fixed and how to manage things if it can’t be, which is often the case. Each appraisal details the patient’s overall health status and involves a review of current medications, level of independence, mobility, behavior and memory.

From that assessment comes a recommendation of what services are needed, who can deliver them and where that is best accomplished: at home, in a retirement facility or in a nursing home. That determination is not based soley on a patient’s condition, but also on how much hands-on care family members are willing and able to provide and how much hired help they can afford. Often the evaluation is followed by a family meeting, with Dr. Woodson as referee.

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http://newoldage.blogs.nytimes.com/2008/10/16/when-medicare-falls-short/

In Sour Economy, Some Scale Back on Medications - NYTimes.com

For the first time in at least a decade, the nation's consumers are trying to get by on fewer prescription drugs.

As people around the country respond to financial and economic hard times by juggling the cost of necessities like groceries and housing, drugs are sometimes having to wait.

"People are having to choose between gas, meals and medication," said Dr. James King, the chairman of the American Academy of Family Physicians, a national professional group. He also runs his own family practice in rural Selmer, Tenn.

"I've seen patients today who said they stopped taking their Lipitor, their cholesterol-lowering medicine, because they can't afford it," Dr. King said one recent morning.

"I have patients who have stopped taking their osteoporosis medication."

On Tuesday, the drug giant Pfizer, which makes Lipitor, the world's top-selling prescription medicine, said United States sales of that drug were down 13 percent in the third quarter of this year.

Through August of this year, the number of all prescriptions dispensed in the United States was lower than in the first eight months of last year, according to a recent analysis of data from IMS Health, a research firm that tracks prescriptions.

Although other forces are also in play, like safety concerns over some previously popular drugs and the transition of some prescription medications to over-the-counter sales, many doctors and other experts say consumer belt-tightening is a big factor in the prescription downturn.

The trend, if it continues, could have potentially profound implications.

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http://www.nytimes.com/2008/10/22/business/22drug.html?ref=health

When All Else Fails, Blaming the Patient Often Comes Next - NYTimes.com

Doctors and psychotherapists generally don't like it when their patients don't get better. But the fact is that lots of patients elude our clinical skill and therapeutic cleverness. That's often when the trouble starts.

I met one such patient not long ago, a man in his early 30s, who had suffered from depression since his teenage years. In six years of psychotherapy, he had been given nearly every antidepressant under the sun, but his mood hadn't budged.

Weeping in my office one day, he explained that he was depressed because he was a failure and a whiner. "Even my therapist agreed with me," he said. "She said that maybe I don't want to get better."

I could well imagine his therapist's frustration. She had been working with him for nearly three years without significant progress, and she was now doing what many clinicians do when the chips are down: blame the patient for failing to improve.

"I think he has an unconscious desire to remain sick," she told me.

About a month later, I saw this patient respond remarkably well to a novel treatment. Free of depression at last, he was joyful and relieved — an odd reaction, you must admit, from someone who secretly wished to be ill.

Not just that, but he no longer felt like a failure and was much more upbeat about his future prospects.

I decided to challenge him. "How come you're feeling so much better despite the fact that nothing in your life has really changed in the past few weeks?"

"Well, I guess I just think like that when I'm down."

Exactly. His sense of worthlessness was a result of his depression, not a cause of it. It's easy to understand why the patient couldn't see this: depression itself distorts thinking and lowers self-esteem. But why did his therapist collude with the patient's depressive symptoms and tell him, in effect, that he didn't want to get better?

For an all too human reason, I think. Chronically ill, treatment-resistant patients can challenge the confidence of therapists themselves, who may be reluctant to question their treatment; it's easier — and less painful — to view the patient as intentionally or unconsciously resistant.

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http://www.nytimes.com/2008/10/21/health/21mind.html?em=&pagewanted=print

Many Holes in Disclosure of Nominees’ Health - NYTimes.com

Fifteen days before the election, serious gaps remain in the public's knowledge about the health of the presidential and vice-presidential nominees. The limited information provided by the candidates is a striking departure from recent campaigns, in which many candidates and their doctors were more forthcoming.

In past elections, the decisions of some candidates for the nation's top elected offices to withhold health information turned out to have a significant impact after the information came to light. This year, the health issue carries extraordinary significance because two of the four nominees have survived potentially fatal medical problems that could recur.

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http://www.nytimes.com/2008/10/20/us/politics/20health.html

Prescription opiates and kids: One pill can kill - msnbc.com

Nine-month-old Shayla Davidson was a sick little girl, and her mother had no idea why.

Pale, listless and barely breathing, the baby wouldn't wake up one day last month, even when 25-year-old Nicolle Jones rushed her to an emergency room near Cincinnati.

Medical crews were stumped, too, until they noted that Shayla's pupils were constricted, a tell-tale sign of opiate poisoning.

"They kept asking me, 'Did she get ahold of any medicine?'" Jones recalled. "I said, 'No.'"

In fact, Shayla had ingested medication, a single 60-milligram tablet of oxycontin, a powerful prescription painkiller.

But pediatric specialists at the Cincinnati Children's Hospital and Medical Center wouldn't know that until later, after they'd treated the child five times with a strong antidote and performed tests that linked Shayla's life-threatening condition to the common drug her grandfather takes for back pain.

"I about fell on the floor when they told me," said Jones, who lives with her parents in nearby Independence, Ky. "My dad keeps his medicines up high. We're thinking he dropped it."

Shayla's fine now, but she's also lucky, according to a recently released report from the nation's poison control centers. It shows a rising tide of prescription drug use is threatening unintended users: young children who accidentally ingest the powerful painkillers.

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http://www.msnbc.msn.com/id/27168078//deck/

Could Anesthesia Cause Developmental Disorders? | Newsweek Health

Medicine changed for the better one day in 1846 when a Boston man became the first human to undergo an operation without feeling any pain. The magic bullet? Anesthesia. Today, drugs that dull the agony of surgery are used routinely, even in very young children who receive the meds when they need bad cuts stitched up or tubes inserted into their ears to reduce infections. But the drugs are not risk-free. This week, Columbia University researchers presented a study at the annual meeting of the American Society of Anesthesiologists showing a possible link between exposure to anesthesia and behavioral and developmental disorders in young children. Scientists say the new research is in no way conclusive and parents should not be alarmed. Still, says the study's lead author, Dr. Lena Sun, this is "something we can't ignore."

Using a database of Medicaid patients in New York, the Columbia scientists compared a group of 625 children under the age of 3 who had received general anesthesia for hernia repair to a group of 5,000 kids who never had the surgery. They found that kids who had hernia surgery and received anesthesia were twice as likely to be diagnosed with a developmental or behavior disorder within two years. Because the study relied on past history and billing codes, "there are definitely limitations," says Sun. One example: researchers don't know any details about the kinds of disorders the children actually had. The study is "provocative," says Sun, "but very preliminary." An estimated 4 million children receive anesthesia every year, Sun says, not just for surgery but for diagnostic procedures like MRI and CAT scans.

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http://www.newsweek.com/id/165041

Arthritis Research & Therapy | The Scientific Basis of Rheumatology

To mark its 10th anniversary, Arthritis Research & Therapy is publishing a comprehensive four-part collection of review articles, entitled "The Scientific Basis of Rheumatology: A Decade of Progress". 

This special collection of reviews will provide an in depth overview of the current status of basic and clinical research in rheumatology, and will focus particularly on developments in the past decade, during which there has been an explosion of new information in this field. 

Half of the reviews will focus on biologic processes underlying rheumatic diseases and the other half will analyze developments in specific rheumatic diseases. Featuring 40 reviews by renowned experts, this collection will provide both researchers and clinicians with a comprehensive understanding of current knowledge on the scientific basis of rheumatology and should become an essential reference in the field.

http://arthritis-research.com/sbr/

Some Cut Back on Prescription Drugs in Sour Economy - NYTimes.com

For the first time in at least a decade, the nation's consumers are trying to get by on fewer prescription drugs.

As people around the country respond to financial and economic hard times by juggling the cost of necessities like groceries and housing, drugs are sometimes having to wait.

"People are having to choose between gas, meals and medication," said Dr. James King, the chairman of the American Academy of Family Physicians, a national professional group. He also runs his own family practice in rural Selmer, Tenn.

"I've seen patients today who said they stopped taking their Lipitor, their cholesterol-lowering medicine, because they can't afford it," Dr. King said one recent morning.

"I have patients who have stopped taking their osteoporosis medication."

On Tuesday, the drug giant Pfizer, which makes Lipitor, the world's top-selling prescription medicine, said United States sales of that drug were down 13 percent in the third quarter of this year.

Through August of this year, the number of all prescriptions dispensed in the United States was lower than in the first eight months of last year, according to a recent analysis of data from IMS Health, a research firm that tracks prescriptions.

Although other forces are also in play, like safety concerns over some previously popular drugs and the transition of some prescription medications to over-the-counter sales, many doctors and other experts say consumer belt-tightening is a big factor in the prescription downturn.

The trend, if it continues, could have potentially profound implications.

If enough people try to save money by forgoing drugs, controllable conditions could escalate into major medical problems. That could eventually raise the nation's total health care bill and lower the nation's standard of living.

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http://www.nytimes.com/2008/10/22/business/22drug.html?_r=1&oref=slogin&ref=todayspaper&pagewanted=all

Lisa's story - A fibromyalgia patient's suicide

Creating Roadmaps for Surgeons - Using the Mac for Better Surgical Navigation

A woman in her forties lies anesthetized on an operating table. The surgical team prepares her torso for surgery, and switches on an overhead projector. A three-dimensional image of the patient's internal organs appears on the surface of her abdomen and is aligned with her body. The image changes as Dr. Maki Sugimoto, using a wireless remote to control a Mac Pro workstation, navigates through the 3D volume to bring up the surgical target –early stage gastric cancer. Guided by the display, the team makes precise incisions to insert ports for laparoscopic surgery.

The same 3D images of the patient's anatomy appear on a 23-inch Apple Cinema Display beside the surgical table. Sugimoto uses the remote to move and rotate images for a better view of the cancerous tissue. He inserts the laparoscope into a port and navigates to the surgery site, guided by the monitor of the scope and the reference images on the Apple Cinema Display.

In many operating rooms, this cancer would have been treated with aggressive open surgery. But in this case 3D visualization has enabled efficient, minimally invasive surgery and a better outcome for the patient.

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http://www.apple.com/science/profiles/maki/?sr=hotnews