Friday, December 25, 2009

Can Touching Your Toes Test Your Arteries? - Well Blog -

For years, cardiologists were aware that heart attacks are more common during the winter months than in any other season. Most assumed that the cause was cold weather. But then researchers in California examined death certificates in Los Angeles County, an area not known for its inclement winters, and found that, even there, fatal heart attacks spiked during the winter months. More specifically, they started rising around Thanksgiving, climbed inexorably through Christmas and peaked on New Year's Day. A subsequent study of death certificates nationwide, published in Circulation in 2004, confirmed the association between the two holidays and heart-attack deaths. It was accompanied by a cheery editorial headlined "The 'Merry Christmas Coronary' and 'Happy New Year Heart Attack' Phenomenon."
Why the number of heart-attack deaths should surge so significantly during the holidays still is not clear, although cardiologists have some well-founded guesses. "We suspect there is often an inappropriate delay in seeking medical attention" at this time of year, says Dr. Robert A. Kloner, a professor of medicine at the University of Southern California, a cardiologist at Good Samaritan Hospital and the lead author of both the 2004 study of deaths in Los Angeles County and the accompanying editorial. "People ignore the pain in their chest," perhaps because they don't wish to disrupt the festivities or they misinterpret the ache as overindulgence, Dr. Kloner says. By the time they get to an emergency room, it's too late to save them. Stress and tension likely play a role, too. "Spending time with family members can be trying," he says. "And there are often concerns about financial issues, buying presents and so on." Even a wood-burning fireplace, a romantic symbol of wintry, holiday evenings, could be a contributing factor, because particulate matter in the air has been connected to an increase in the risk of heart attacks, Dr. Kloner says.
A provocative new study published this year in the journal Heart and Circulatory Physiology suggests, however, that there may be a novel way to test at least one element of your heart's health right in your own living room, right in the middle of the holidays. Sit on the floor with your legs stretched straight out in front of you, toes pointing up. Reach forward from the hips. Are you flexible enough to touch your toes? If so, then your cardiac arteries probably are also flexible.
In the study's experiment, scientists from the University of North Texas and several Japanese universities recruited 526 healthy adults between the ages of 20 and 83 and had them perform the basic sit-and-reach test described above, although their extensions were measured precisely with digital devices. Taking into account age and gender, researchers then sorted the subjects into either the high-flexibility group or the poor-flexibility group.
Next, using blood-pressure cuffs at each person's ankles and arms, researchers estimated how flexible their arteries were. Cardiac artery flexibility is one of the less familiar elements of heart health. Supple arterial walls allow the blood to move freely through the body. Stiff arteries require the heart to work much harder to force blood through the unyielding vessels and over time could, according to Kenta Yamamoto, a researcher at North Texas and lead author of the study, contribute to a greater risk for heart attack and stroke.
What the researchers found was a clear correlation between inflexible bodies and inflexible arteries in subjects older than 40. Adults with poor results on the sit-and-reach test also tended to have relatively high readings of arterial stiffness. In short, the study concluded that "a less flexible body indicates arterial stiffening, especially in middle-aged and older adults." No such correlation was found in those under 40, even when gender and fitness were considered as factors.
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Wednesday, December 23, 2009

A table that's clear, concise, worth reading and not boring | Michael Tomasky |

TNR's Jon Cohn and MIT's Jonathan Gruber, both oft-cited in this blog, have collaborated on a chart laying out typical costs for families up to about $85,000 per annum without reform (Senate version) and with it. The table can be found here
The numbers aren't just good, they're pretty great. Take a family of four at $48,000, double the poverty line. Currently, this family faces roughly a $12,000 premium and another $12,000 limit on out-of-pocket expenses, for a total possible annual cost of $24,000 -- half their income. Under reform, the premium is $3,629, and total out-of-pocket max is $6,300, for a total possible liability of $9,929 -- 21% of income. That's still a lot, but it's a helluva lot less than half.
The political problem -- the "backlash" problem everyone speaks of -- is that $9,929 is, well, a lot more than zero, which is what a lot of people (who choose to eschew insurance) pay now. But of course people will hit that $9,000-plus only if they have extraordinary health issues (in which case another benefit of reform kicks in -- they can't be thrown off their plans or see their rates jacked up extortionately). 
So assume instead that the typical family that does not now buy insurance won't spend the full $9,929, but something closer to the $3,600 premium level -- a few trips to the doctor, a couple of prescriptions, one consultation with a specialist. Say it brings them to right around $4,800. That's 10% of their income. 
It's a lot. But if this family didn't buy insurance and had to rush a kid to an emergency room, they'd be staring at maybe a $2,000 bill right away. And they wouldn't even bother with the trips to the doctor and the specialist, meaning that they would really only pay more later.
The backlash question, it seems to me, comes down to this. Will this family decide that $300 a month is a rape of their liberty? Or will they decide yeah, $300 a month in premiums hurts, but it sure feels nice to be able to take a kid to a doctor when she's sick instead of just avoiding the problem, and to pay a usually affordable co-payment. And get the kid antibiotics when needed for $5 or $10. 
The coverage has to be good, and the GOP will find every little example where things didn't work and will peddle them to the media and so forth. But big-picture, I dunno: I really think most people would take the above trade-off. And of course they'd really take if one of them had diabetes or MS or something worse.

Tuesday, December 22, 2009

U.C.L.A. Medical Center at Heart of End-of-Life Debate -

LOS ANGELES — The Ronald Reagan U.C.L.A. Medical Center, one of the nation's most highly regarded academic hospitals, has earned a reputation as a place where doctors will go to virtually any length and expense to try to save a patient's life.

"If you come into this hospital, we're not going to let you die," said Dr. David T. Feinberg, the hospital system's chief executive.

Yet that ethos has made the medical center a prime target for critics in the Obama administration and elsewhere who talk about how much money the nation wastes on needless tests and futile procedures. They like to note that U.C.L.A. is perennially near the top of widely cited data, compiled by researchers at Dartmouth, ranking medical centers that spend the most on end-of-life care but seem to have no better results than hospitals spending much less.

Listening to the critics, Dr. J. Thomas Rosenthal, the chief medical officer of the U.C.L.A. Health System, says his hospital has started re-examining its high-intensity approach to medicine. But the more U.C.L.A.'s doctors study the issue, the more they recognize a difficult truth: It can be hard, sometimes impossible, to know which critically ill patients will benefit and which will not.

That distinction tends to get lost in the Dartmouth end-of-life analysis, which considers only the costs of treating patients who have died. Remarkably, it pays no attention to the ones who survive.

Take the case of Salah Putrus, who at age 71 had a long history of heart failure.

After repeated visits to his local hospital near Burbank, Calif., Mr. Putrus was referred to U.C.L.A. this year to be evaluated for a heart transplant.

Some other medical centers might have considered Mr. Putrus too old for the surgery. But U.C.L.A.'s attitude was "let's see what we can do for him," said his physician there, Dr. Tamara Horwich.

Indeed, Mr. Putrus recalled, Dr. Horwich and her colleagues "did every test." They changed his medicines to reduce the amount of water he was retaining. They even removed some teeth that could be a potential source of infection.

His condition improved so much that more than six months later, Mr. Putrus has remained out of the hospital and is no longer considered in active need of a transplant.

Because Dartmouth's analysis focuses solely on patients who have died, a case like Mr. Putrus's would not show up in its data. That is why critics say Dartmouth's approach takes an overly pessimistic view of medicine: if you consider only the patients who die, there is really no way to know whether it makes sense to spend more on one case than another.

According to Dartmouth, Medicare pays about $50,000 during a patient's last six months of care by U.C.L.A., where patients may be seen by dozens of different specialists and spend weeks in the hospital before they die.

By contrast, the figure is about $25,000 at the Mayo Clinic in Rochester, Minn., where doctors closely coordinate care, are slow to bring in specialists and aim to avoid expensive treatments that offer little or no benefit to a patient.

"One of them costs twice as much as the other, and I can tell you that we have no idea what we're getting in exchange for the extra $25,000 a year at U.C.L.A. Medical," Peter R. Orszag, the White House budget director and a disciple of the Dartmouth data, has noted. "We can no longer afford an overall health care system in which the thought is more is always better, because it's not."

By some estimates, the country could save $700 billion a year if hospitals like U.C.L.A. behaved more like Mayo. High medical bills for Medicare patients' final year of life account for about a quarter of the program's total spending.

Under the House health care legislation pending in Congress, the Institute of Medicine would conduct a study of the regional variations in Medicare spending to try to determine how to reward hospitals like Mayo for providing more cost-effective care. Hospitals identified as high-cost centers might even be penalized, perhaps receiving lower payments from the government. The Senate bill calls only for studies of Medicare spending variations, so it will be up to House-Senate negotiators to resolve the matter in the final legislation.

That prospect worries Dr. Rosenthal and his U.C.L.A. colleagues, who say that unless the distinction can be clearly drawn between excellence and excess in medical care, efforts to cut wasteful spending could be little more than blunt rationing.

"There's a real risk of doing harm here — real harm," he said.

Indeed, U.C.L.A. and five other big California medical centers recently published their own research results with a striking conclusion: for heart failure patients, the hospitals that spend the most seem to save the most lives.

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