Saturday, January 17, 2009

Free to be warehoused - Colby Cash, National Post

A major study of the way several health care systems deal with the chronically ill was printed in the medical journal Health Affairs in November. Aside from a brief notice in a recent Medical Post, it went almost entirely unreported in Canada -- yet Canadians helped pay for it; our country data were collected by the Health Council of Canada and by provincial agencies in Ontario and Quebec. In eight developed countries, similar large samples of "sicker adults" were quizzed on various aspects of their continuing care. The paper caught my attention partly because my genetic history of hypertension finally caught up with me in November and landed me in the hospital; depressingly, I now qualify as a "sicker adult." (Send chicken broth c/o this newspaper.) Other chronic conditions included in the samples included heart and lung disease, arthritis, diabetes, cancer and depression.

These repeat health care customers are naturally well-equipped to report on access, care co-ordination and medical error. Although Canadians were in the middle of the league table when it came to overall satisfaction with their health care, we fared shockingly badly in some respects -- in precisely the ones you might expect, actually, which perhaps explains why the study results were not covered more widely. Respondents were asked how long it took them to get in to see a doctor the last time they were sick. In Germany and the Netherlands, more than 50% were able to get treatment the same day. Canada's numbers were the worst of all: just 37% reported receiving care the same day or the next, and 34% had to wait six days or longer for primary care.

Chronically ill Canadians were also much more likely than those in other countries to visit the emergency room if they fell ill at night or on a weekend. (Apparently, in some places, they actually have other options.) Overall, 23% of the sicker Canadian adults had visited the ER in the past two years with conditions that would have been treatable by means of a regular doctor's appointment. The same figure was 19% in the U. S., 17% in Australia and under 10% in France, Germany, Holland, New Zealand and the U. K. Needless to say, Canadians also experienced the longest wait times for specialist care by an equally discouraging margin.

The numbers aren't all bad. Canadian doctors, for example, seem pretty well-trained at communicating with patients and preparing treatment plans for them. We are no better or worse than average in making sure that medical information follows the patient around, and that family physicians and specialists seeing the same patients are in touch. We are world leaders, with the U. K., in providing medical advice by telephone.

But overall the picture that emerges is that of a country which, as the authors state in their concluding discussion, "continues to face capacity restraints in both primary care and access to specialists." As usual, comparisons with the screwed-up American health care system are beside the point; down south you at least do get the quality of care you can afford. But we seem to be paying more than other peers for health care that is, on the whole, more tightly rationed.

It's usual here for a libertarian like myself to roll out the skein of familiar arguments about personal freedoms for doctors and patients. But if we're studied against the backdrop of non-American systems, it may actually be our high degree of patient choice and physician freedom that makes our system suboptimal. We tolerate what is, increasingly, warehouse-style care for the middle class in exchange for the freedom to choose our own physician and switch easily -- assuming we can find a physician at all. And we face capacity restraints partly because we have deliberately limited ability to order doctors to move to the countryside or work nights and weekends.

(British Columbia, for example, is facing a squabble over a directive from its college of physicians and surgeons that walk-in clinics who see a patient three times for the same complaint must take over full, formal responsibility for that patient's primary care. Doctors who chose walk-in careers as an alternative to becoming full-time family physicians -- because B. C. allowed them to -- are complaining, with some justice, that they've been subjected to a bait-and-switch.)

These fundamental libertarian considerations are important morally, and worth paying for. It's when we combine them with an ideology of equal (or equally compromised) access that we run into practical trouble. But on the other hand, we are relatively content with the expensive status quo, and one would have serious trouble, more than most laymen recognize, proving that health care rationing creates much harm. I sometimes wonder if the political class recognizes this, and prefers that we actively forget our memories of a more humane, efficient style of health care that once existed here -- a style that would reduce wait times and ostentatious ER abuse, but might not make much difference to outcomes.

Ailing system

A teenage boy dies of a heart virus after being misdiagnosed with liver disease. Another young man's severe head injury goes virtually untreated by nurses and doctors for days before he finally succumbs to the wounds. A war veteran is ignored in an emergency department examining room as he suffers a debilitating cardiac arrest.

All three died in the wake of apparent medical error and, until recently, their stories would likely have ended there or in some closed hospital boardroom, the incidents kept quiet by health professionals reluctant to openly admit mistakes. But these patients' loved ones are part of an unusual new group determined to see the health-care system exposed for these kinds of missteps that leave many people worse off, not better, after seeking medical help.

Confronting the epidemic of "adverse events" has become a hot topic in the health-care system lately. A study released just last week exposed the poor hand-washing habits of doctors at a Montreal hospital, another report showed that death rates at many of the country's worst-performing hospitals have not improved in the last year, and figures released by Winnipeg health officials suggested that 32 hospital patients died in 2008 for reasons other than their underlying medical condition. Yet the issue is often couched in clinically abstract terms. Patients for Patient Safety Canada, on the other hand, is trying to humanize that analytical discourse, publicizing some of the thousands of heart-breaking tales behind the statistics of medical error.

Group members have addressed physicians and nurses at conferences, worked with the very hospitals that failed their family members and even written articles for medical journals.

"We were a pretty healthy family. We hadn't asked much of the system, and when we did, it failed us," says Theresa Malloy-Miller, mother of the teen killed by a heart virus. "We were just in zombie land. One day you have a healthy son, and one day you don't have a son at all.... It just didn't make sense to us."

Many members of the patients' organization -- part of an international network of such groups -- faced brick walls at first as they tried to get to the bottom of what went wrong, but have managed to wring apologies, disciplinary action and changes aimed at avoiding more tragedy. "I don't want to go around as a vindictive person," said Donna Davis, a nurse and mother of the brain-injured Saskatchewan teenager. "You've got to channel it into something constructive."

A few months ago, she spoke at the country's major patient-safety congress. The group has advice for patients and their families, as well, urging them to monitor the care they receive, and alert doctors and nurses if it seems something is going wrong.

It goes wrong fairly often. An eye-opening study published in 2004 estimated that 9,000 to 23,000 Canadian patients die yearly as a result of preventable adverse events, out of 2½ million annual hospital admissions.

Last week, the Winnipeg Regional Health Authority became the first hospital organization in Canada to release figures on the number of its patients who died due to medical care, not their underlying illness, and admitted that at least some of the deaths were likely preventable. The revelation followed the demise of a man who had waited 34 hours for help in the Winnipeg Health Sciences' Centre emergency department.

Led by the five-year-old Canadian Patient Safety Institute, projects have been launched across the country in recent years to try to make going to the hospital less risky, though there is little data yet on what progress has been made. The patients' stories make clear why it is considered such a pressing issue.

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Friday, January 16, 2009

Winnipeg tries apologetic approach to deal with medical mistakes

After her abdominal operation last summer, the patient's hip started to ache. The symptom of a painful joint was hardly a surprise - she was a senior citizen - but the cause of it, picked up on an X-ray, was: a pair of four-inch forceps floating in her abdominal cavity.

What happened next is equally astonishing: The surgeon who performed the gynecological procedure in a Winnipeg operating room apologized. Hospital staff followed up with their own apology, telling the patient if she required any help, it was available.

It's all part of a new approach by Winnipeg officials, hailed as the first of its type in Canada: apologizing to patients when a mistake is made and offering compensation where appropriate.

"People are slowly getting used to the idea that there are lots of preventable injuries and preventable deaths," said Rob Robson, chief patient safety officer for the Winnipeg Regional Health Authority. "And we need to get off our butts and do something about it."

Mistakes in medicine have long been seen as something best buried with the patient. In the past, the tendency to defend and deny has been favoured by malpractice lawyers and insurers, who feared full disclosure would unleash a torrent of lawsuits.

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Thursday, January 15, 2009

Anti-Love Drug May Be Ticket to Bliss -

In the new issue of Nature, the neuroscientist Larry Young offers a grand unified theory of love. After analyzing the brain chemistry of mammalian pair bonding — and, not incidentally, explaining humans' peculiar erotic fascination with breasts — Dr. Young predicts that it won't be long before an unscrupulous suitor could sneak a pharmaceutical love potion into your drink.

That's the bad news. The not-so-bad news is that you may enjoy this potion if you took it knowingly with the right person. But the really good news, as I see it, is that we might reverse-engineer an anti-love potion, a vaccine preventing you from making an infatuated ass of yourself. Although this love vaccine isn't mentioned in Dr. Young's essay, when I raised the prospect he agreed it could also be in the offing.

Could any discovery be more welcome? This is what humans have sought ever since Odysseus ordered his crew to tie him to the mast while sailing past the Sirens. Long before scientists identified neuroreceptors, long before Britney Spears' quickie Vegas wedding or any of Larry King's seven marriages, it was clear that love was a dangerous disease.

Love was correctly identified as a potentially fatal chemical imbalance in the medieval tale of Tristan and Isolde, who accidentally consumed a love potion and turned into hopeless addicts. Even though they realized that her husband, the king, would punish adultery with death, they had to have their love fix.

They couldn't guess what was in the potion, but then, they didn't have the benefit of Dr. Young's research with prairie voles at the Yerkes National Primate Research Center at Emory University. These mouselike creatures are among the small minority of mammals — less than 5 percent — who share humans' propensity for monogamy. When a female prairie vole's brain is artificially infused with oxytocin, a hormone that produces some of the same neural rewards as nicotine and cocaine, she'll quickly become attached to the nearest male. A related hormone, vasopressin, creates urges for bonding and nesting when it is injected in male voles (or naturally activated by sex). After Dr. Young found that male voles with a genetically limited vasopressin response were less likely to find mates, Swedish researchers reported that men with a similar genetic tendency were less likely to get married. In his Nature essay, Dr. Young speculates that human love is set off by a "biochemical chain of events" that originally evolved in ancient brain circuits involving mother-child bonding, which is stimulated in mammals by the release of oxytocin during labor, delivery and nursing.

"Some of our sexuality has evolved to stimulate that same oxytocin system to create female-male bonds," Dr. Young said, noting that sexual foreplay and intercourse stimulate the same parts of a woman's body that are involved in giving birth and nursing. This hormonal hypothesis, which is by no means proven fact, would help explain a couple of differences between humans and less monogamous mammals: females' desire to have sex even when they are not fertile, and males' erotic fascination with breasts. More frequent sex and more attention to breasts, Dr. Young said, could help build long-term bonds through a "cocktail of ancient neuropeptides," like the oxytocin released during foreplay or orgasm.

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WSJ Health Blog : A Simple Surgical Checklist Saves Lives

Score another victory for the humble checklist. Adopting a surgical safety checklist reduced deaths and complications by more than a third in a study published online by the New England Journal of Medicine this week.

The 19-item list, developed by the World Health Organization, is pretty straightforward stuff. At various points in the procedure, team members confirm that they're doing the right thing on the right part of the right patient, that they're prepared for certain high-risk situations that might arise, and that key issues regarding post-op care are clear. (See the checklist by clicking on the PDF icon.)

But straightforward can be a good thing — especially if it encourages clear, systematic communication and behavior.

Researchers collected data on nearly 8,000 patients who were operated on in eight hospitals scattered around the world. As a basis for comparison, about half the patients underwent surgery before the checklist was adopted. The death rate fell from 1.5% to 0.8%, and the rate of inpatient complications fell from 11% to 7%.

The hospitals were located in both low-income countries such as India and Jordan, and high income countries, such as the U.S. and England. All of the hospitals saw declines in complications, and all except one saw a decline in deaths, though not all the shifts were statistically significant at the level of individual hospitals.

Atul Gawande, the maddeningly polymathic surgeon/writer/policy wonk who is corresponding author on the study, has published on checklists before. In 2007, he wrote a New Yorker article about the work of Peter Pronovost in using a simple checklist to prevent infections and save lives in the ICU.

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Criminal HIV cases do more harm than good, group warns - National Post

When a Toronto man was charged last week with sexual assault for knowingly exposing his girlfriend to HIV, it seemed like the logical action for police to take, and followed the pattern of an increasing number of such cases.

It was the second charge of its sort in two weeks in Ontario, and comes in the midst of a landmark murder trial of an HIV carrier who allegedly infected several women, two of whom later died of AIDS.

But HIV advocacy groups -- and now two respected AIDS scientists -- say such prosecutions are doing more harm than good, and are calling for authorities to stop criminalizing what they consider a public-health issue.

Dr. Mark Wainberg, a Montreal scientist who headed the International AIDS Society for two years, publicly joined the anti-criminalization movement with an editorial in the journal Retrovirology last month, and admits his stance might seem "counter-intuitive."

But, like others, he argued that publicity about the scores of criminal HIV cases that have cropped up across Canada is adding to the negative aura around the disease, discouraging people from coming forward to get tested, and thus furthering the virus's spread.

The criminal law should be used when someone deliberately tries to infect another person -- through a needle prick or similar malicious action -- but not in the context of consensual sex, he said.

"We don't want to stigmatize and, in a way, you are stigmatizing HIV-positive status," said Dr. Wainberg, who received the Order of Canada for his HIV-AIDS research. "We're not doing enough to encourage testing, and decriminalizing transmission would be a step in the right direction."

Dr. Wainberg conceded that there is little empirical evidence yet that criminal cases are, in fact, keeping potentially infected people underground.

But a study about to get underway in Ontario will examine how the criminal cases are affecting people who already know they are HIV-positive, said Barry Adam, a University of Windsor sociologist and research director of the Ontario HIV Treatment Network, who is leading the survey.

Not everyone in the field, though, views the criminal cases with distaste. Dr. Robert Remis, head of Ontario Epidemiologic Monitoring Unit, said other avenues, such as counselling and public health laws should be used first on people who exhibit irresponsible sexual behaviour. But using the criminal law is "just the right thing to do" in some circumstances, he said.

"To knowingly and sort of willfully expose someone else to a what can be a fatal disease I think is unacceptable," said Dr. Remis.

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Killer Economy? -

Recent weeks have seen a spate of suicides by some of the most financially powerful people in the world. German billionaire industrialist Adolf Merckle lay down in front of a train after huge investment losses threatened his family's business empire. Chicago real-estate mogul Steven Good shot and killed himself in the driver's seat of his Jaguar after the property-auction business turned sour. René -Thierry Magon de La Villehuchet lost $1.4 billion to Bernie Madoff, went to work, took sleeping pills and slit his wrist.

The deaths bring up two questions: Is this the start of a disturbing recession-induced trend? And will it spread to rank-and-file Americans? The answers to both questions are a matter of debate. New York Magazine this week questioned whether a suicide epidemic was really taking place on Wall Street. In the blogosphere, Greenspan's Body Count—named after the former Federal Reserve chief whom many people see as partly to blame for the current economic crisis—offers a macabre tally of people who killed themselves or close family members allegedly due to economic pressures (the current tally is up to 72).

Psychologists acknowledge that gloomy financial forecasts could well result in an increase in the number of suicides over the next year. "The suicide rate has already gone up, and my suspicion is that it will not go down," says Paula Clayton, director of the American Foundation for Suicide Prevention. "There are data to substantiate a relationship between unemployment and suicide."

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Los Angeles Times: Hospitals feel ill effects of recession

Hospitals across California and the country are reeling from the effects of the economic downturn and the troubled financial markets.

Patients are putting off medical care because of job losses, job insecurity and high out-of-pocket expenses. As a result, the number of paying patients and profitable elective procedures is down. At the same time, the number of uninsured patients whom hospitals treat is rising.

Like just about everybody else, hospitals are losing money on their investments. To operate, they need to regularly borrow money. Yet now, when they need working capital the most, the credit markets are all but frozen.

And in California, low Medi-Cal reimbursements for poor patients and the state budget crisis are making matters worse.

The latest complications follow a dozen years during which more than 70 hospitals closed in California, and there is concern that some may not pull through this downturn.

"We've got a number of hospitals that are absolutely on the brink," said Jan Emerson, spokeswoman for the California Hospital Assn.

Financial analysts and insiders expect the turmoil to accelerate a shakeout.

"The weaker hospitals will continue to get weaker in a bad economy, and the stronger hospitals will find a way to survive and build market share," said Chris Van Gorder, chief executive of Scripps Health, a nonprofit chain of five hospitals in San Diego County.

Most alarming to hospital administrators, healthcare advocates and patients are the financial, economic and government crises all hitting at once.

Hospitals are facing a "triple whammy," said Anthony Wright, executive director of Health Access California, a patient advocacy organization. "You have the healthcare safety net seeing more uninsured people in the system at the same time employers are scaling back coverage. At the same time, the state is seeking to further cut healthcare programs."

Just about every hospital is affected in one way or another.

At Cedars-Sinai Medical Center in Los Angeles, financial counselors are dealing with a surge in patients with high-deductible health insurance who are unable to pay their share of the bill.

In Oceanside, Tri-City Medical Center is struggling to plug a reported $400,000-a-month hole blown in its budget by the sudden escalation of the cost of its debt.

And in Northern California, NorthBay Healthcare closed a $15-million projected shortfall by shuttering a pediatric hospital unit and an outpatient pediatric rehabilitation program with a waiting list of 100 children.

"It was a tearful closing, but we only saw more cuts coming down the line," said Steve Huddleston, director of public affairs for NorthBay of Fairfield, Calif. "We didn't see any light at the end of the tunnel."

Two-thirds of hospitals nationwide report experiencing a decline since July in elective procedures, which tend to be profit centers, according to a recent survey by the American Hospital Assn. Overall admissions also are down at more than a third of hospitals, reversing a long upward trend.,0,6690620,print.story