Thursday, May 24, 2012

America's Elderly Pay $240,000 In Medical Costs (Study) - Business Insider

"Medical costs continue to loom large over retirement, a report from Fidelity Investments says.

A 65-year-old couple retiring this year without any employer-based health coverage would need an estimated $240,000 to cover medical costs through retirement, according to Fidelity's latest estimate. That's a 4 percent increase from last year's figure. (The number has increased by 50 percent since 2002, when Fidelity first calculated the cost at $160,000.)

The estimate assumes the couple is covered by traditional Medicare, the federal health plan for the elderly. The estimate is based on life expectancies of 17 years for men, and 20 years for women." 

My mother is 90 and has Alzheimers and a variety of other ailments. Her expenses would be on the high side of the typical retiree.

I manage her life and care, and I bear much of the out of pocket expenses so I have a pretty good idea of the costs. Not counting long term care costs, her out of pocket medical expenses including Medicare and Medigap premiums and prescription drugs are about $7,500, and she takes multiple medications.  If my father were still alive, I can imagine that their combined expenses would be around $15,000 per year. So the $240,000 estimate seems reasonable.

That's enough to be ruinous for many Americans. This country is insane. We spend 19% of GDP on the medical business while no other civilized nation spends more than 10-11% and they all get better statistical outcomes. Doctors and medical labs and clinics are paid twice as much here as anywhere else in the world. Carpetbagging providers pull up stakes in their homelands to come to the US and profiteer because the pickings are so juicy. Meanwhile 4o million Americans don't have access to affordable medical services. People die or face financial ruin because of this insane system. American business is less competitive in the world market because of it.  This must stop. The playing field must be leveled in all respects.

Other nations have crushed the private medical cartel that owns the US political system and have taken the delivery of health care away from the criminals that run that system.  That's the only solution that works.  Obamacare is no solution. We must end the private, for profit medical business and put medical services under government control. Nothing less will work.

The bribery of our elected officials by the medical industry cartel must end. It will end sooner or later, because this system is so corrupt and rotten, it will eventually collapse.

That day cannot come soon enough for senior citizens and for all who are deprived of the opportunity to get medical care at a fair and reasonable cost.

A Life Worth Ending - Michael Wolff - New York Magazine

The era of medical miracles has created a new phase of aging, as far from living as it is from dying. A son's plea to let his mother go.

On the way to visit my mother one recent rainy afternoon, I stopped in, after quite some constant prodding, to see my insurance salesman. He was pressing his efforts to sell me a long-term-care policy with a pitch about how much I'd save if I bought it now, before the rates were set to precipitously rise. For $5,000 per year, I'd receive, when I needed it, a daily sum to cover my future nursing costs. With an annual inflation adjustment of 5 percent, I could get in my dotage (or the people caring for me would get) as much as $900 a day. My mother carries such a policy, and it pays, in 2012 dollars, $180 a day—a fair idea of where heath-care costs are going.

I am, as my insurance man pointed out, a "sweet spot" candidate. Not only do I have the cash (though not enough to self-finance my decline) but a realistic view: Like so many people in our fifties—in my experience almost everybody—I have a parent in an advanced stage of terminal breakdown.

It's what my peers talk about: our parents' horror show. From the outside—at the office, restaurants, cocktail parties—we all seem perfectly secure and substantial. But in a room somewhere, hidden from view, we occupy this other, unimaginable life.

I didn't need to be schooled in the realities of long-term care: The costs for my mother, who is 86 and who, for the past eighteen months, has not been able to walk, talk, or to address her most minimal needs and, to boot, is absent a short-term memory, come in at about $17,000 a month. And while her LTC insurance hardly covers all of that, I'm certainly grateful she had the foresight to carry such a policy. (Although John Hancock, the carrier, has never paid on time, and all payments involve hours of being on hold with its invariably unhelpful help-line operators—and please fax them, don't e-mail.) My three children deserve as much.

And yet, on the verge of writing the check (that is, the first LTC check), I backed up.

We make certain assumptions about the necessity of care. It's an individual and, depending on where you stand in the great health-care debate, a national responsibility. It is what's demanded of us, this extraordinary effort. For my mother, my siblings and I do what we are supposed to do. My children, I don't doubt, will do the same.

And yet, I will tell you, what I feel most intensely when I sit by my mother's bed is a crushing sense of guilt for keeping her alive. Who can accept such suffering—who can so conscientiously facilitate it?

"Why do we want to cure cancer? Why do we want everybody to stop smoking? For this?" wailed a friend of mine with two long-ailing and yet tenacious in-laws.

In 1990, there were slightly more than 3 million Americans over the age of 85. Now there are almost 6 million. By 2050 there will be 19 million—approaching 5 percent of the population. There are various ways to look at this. If you are responsible for governmental budgets, it's a knotty policy issue. If you are in marketing, it suggests new opportunities (and not just Depends). If you are my age, it seems amazingly optimistic. Age is one of the great modern adventures, a technological marvel—we're given several more youthful-ish decades if we take care of ourselves. Almost nobody, at least openly, sees this for its ultimate, dismaying, unintended consequence: By promoting longevity and technologically inhibiting death, we have created a new biological status held by an ever-growing part of the nation, a no-exit state that persists longer and longer, one that is nearly as remote from life as death, but which, unlike death, requires vast service, indentured servitude really, and resources.

This is not anomalous; this is the norm.

The traditional exits, of a sudden heart attack, of dying in one's sleep, of unreasonably dropping dead in the street, of even a terminal illness, are now exotic ways of going. The longer you live the longer it will take to die. The better you have lived the worse you may die. The healthier you are—through careful diet, diligent exercise, and attentive medical scrutiny—the harder it is to die. Part of the advance in life expectancy is that we have technologically inhibited the ultimate event. We have fought natural causes to almost a draw. If you eliminate smokers, drinkers, other substance abusers, the obese, and the fatally ill, you are left with a rapidly growing demographic segment peculiarly resistant to death's appointment—though far, far, far from healthy.

Sometimes we comb my mother's hair in silly dos, or photograph her in funny hats—a gallows but helpful humor: Contrary to the comedian's maxim, comedy is easy, dying hard. Better plan on two years minimum, my insurance agent says, of this stub period of life—and possibly much more.

Mike Wallace, that indefatigable network newsman, died last month in a burst of stories about his accomplishments and character. I focused, though, on a lesser element in the Times' obituary, that traditional wave-away line: "He had been ill for several years."

"What does that mean?" I tweeted the young reporter whose byline was on the obit. Someone else responded that it meant Wallace was old. Duh! But then I was pointed to a Washington Post story mentioning dementia. The Times shortly provided an update: Wallace had had bypass surgery four years ago and had been at a facility in Connecticut ever since.

This is not just a drawn-out, stoic, and heroic long good-bye. This is human carnage. Seventy percent of those older than 80 have a chronic disability, according to one study; 53 percent in this group have at least one severe disability; and 36 percent have moderate to severe cognitive impairments; you definitely don't want to know what's considered to be a moderate impairment.

From a young and healthy perspective, we tend to look at dementia as merely ­Alzheimer's—a cancerlike bullet, an unfortunate genetic fate, which, with luck, we'll avoid. In fact, Alzheimer's is just one form—not, as it happens, my mother's—of the ­ever-more-encompassing conditions of cognitive collapse that are the partners and the price of longevity.

There are now more than 5 million demented Americans. By 2050, upward of 15 million of us will have lost our minds.

Speaking of price: This year, the costs of dementia care will be $200 billion. By 2050, $1 trillion.

Make no mistake, the purpose of long-term-care insurance is to help finance some of the greatest misery and suffering human beings have yet devised.

Hospitals and Insurers Join to Cut Health Care Costs -

Giselle Fernandez is only 17 but she has had more than 50 operations since she was born with a rare genetic condition. She regularly sees a host of pediatric specialists, including an ophthalmologist, an endocrinologist and a neurologist at UCLA Health System. Her care has cost hundreds of thousands of dollars so far, and she will need special treatment for the rest of her life.

While UCLA Health System has long prided itself on being at the forefront of treating patients like Giselle, it is now trying to lower sharply the cost of providing that care. By enrolling young patients with complex and expensive diseases in a program called a medical home, the system tries to ensure that doctors spend more time with patients and work more closely with parents to coordinate care. The program has cut emergency room visits by slightly more than half.

The effort is part of a much broader ambition by UCLA Health System to reduce its costs by 30 percent, or hundreds of millions of dollars, over the next five years, according to Dr. David T. Feinberg, the system's president.

"We have definitely found religion," Dr. Feinberg said.

After years of self-acknowledged profligacy, hospitals, doctors and health insurers say there is a strong effort under way to bring medical costs under control. Their goal is to slash the rate of growth in the nation's $2.7 trillion health care bill by roughly half to keep it more in line with overall inflation.

Private insurers, employers and government officials are providing urgency to these efforts, and the federal health care law passed two years ago helped accelerate them.

Even if the Supreme Court decides next month to declare the entire law unconstitutional, many experts in the field say the momentum is likely to continue.

"Regardless of what happens to the law, the market will force the system to become more efficient," said Paul H. Keckley, the executive director of the Deloitte Center for Health Solutions, a research arm of the consultant Deloitte.

The drive to lower costs is resulting in numerous efforts. UCLA Health System is scrutinizing its use of imaging procedures on patients in the cardiothoracic intensive care unit. Over the last year, the average number of X-rays per patient each day was reduced to two, from 10.

The Cleveland Clinic, another medical powerhouse that has little difficulty attracting patients and demanding high prices, is trying group visits for diabetic patients so more people can be seen at a lower cost. The clinic has started reminding its surgeons about the $400 price of a unit of blood as a way of discouraging unnecessary transfusions, which along with other changes in patient care last year helped save $4 million. The clinic's medical residents also can no longer order as many expensive tests as they want. "What we're talking about is driving the value equation," said Dr. Delos M. Cosgrove, the chief executive for the clinic.

These efforts include trying to keep the health system's own employees healthy by enlisting them in wellness programs or, as at UCLA, eliminating fried food in the cafeteria.

"Nobody has died because the Tater Tots are gone," said Dr. Feinberg.

Many of those involved say the impetus should come directly from hospitals and doctors.

"The medical community needs to transform care," said Dr. Thomas L. Simmer, the chief medical officer of Blue Cross Blue Shield of Michigan, the state's largest insurer.

By collaborating with Michigan hospitals to share best practices, Blue Cross estimated it achieved savings of $233 million over three years.

Despite the flurry of activity, many caution that these efforts may not succeed in saving money. Many previous programs failed in the end to reduce costs or improve care. And many people within the industry are still wedded to the status quo, said Dr. Michael W. Cropp, the chief executive of Independent Health, an insurer in Buffalo. Dr. Cropp has been vocal about the need to address rising costs.

 "The mind-set shift is beginning, albeit too slowly," he said.

Experts also warn that many of these initiatives will take time to work, especially since the more tests and procedures they do, the more money doctors and hospitals get. But there are also signs that insurers, which traditionally have focused on paying hospitals and doctors the least they can, are working much more closely with providers to improve care.

In Michigan, for example, Blue Cross financed an effort to have the state's major hospitals compare results in areas like bariatric or general surgery so that they could reduce infection rates and surgical complications. The insurer never sees data that identifies individual hospitals, and the hospitals meet regularly to discuss how they can learn from one another to improve care.

"There's basically a 'leave your guns at the door' attitude," said Dr. Darrell Campbell, the chief medical officer for the University of Michigan Health System.

The program's benefits extend far beyond Blue Cross's own customers, according to the insurer's calculations. Only a third of the savings was attributable to patients it insured. Unlike previous attempts by insurers to reward individual hospitals for quality and efficiency, the program tries to help all hospitals improve.

The earlier efforts, which focused on overly specific measures or reporting on individual hospitals, "tended to inspire providers to do the least necessary to achieve the incentive rather than the most to transform care," said Dr. David Share, a senior executive at Blue Cross.

In other cases, health insurers are collaborating with hospitals and doctors through new models like so-called accountable care organizations, which coordinate the care for a group of people. In early 2010, Blue Shield of California teamed with a San Francisco-based hospital system, now Dignity Health, and a large medical group, Hill Physicians, to provide coverage for 40,000 members of the California Public Employees' Retirement System in Sacramento. Blue Shield promised to keep premiums flat the first year and increase them as little as possible afterward.

Simply by working together, the three were able to reduce the number of times patients had to be readmitted to the hospital by 15 percent. Previously, the insurer, the hospital and the medical group had each assigned a case manager to the same patient, but patients were still failing to schedule follow-up visits with their doctors and were not getting clear instructions about their care when they left the hospital.

"None of the case managers from the three organizations were talking to each other," said Paul Markovich, an executive vice president of Blue Shield.

In the end, the hospital was deemed responsible for follow-up care, even though it had the least incentive to prevent a patient from returning, he said.

Before the program, "there's no way we could even contemplate doing that," Mr. Markovich said.

The hospital system says it is committed to more affordable care, which is why it agreed to work with Blue Shield in the first place.

"We do think there is a problem with cost," said Michael D. Blaszyk, the chief financial officer for Dignity Health.

"Our goal was not to ramp up our profits," he said. "Our goal was not to lose money on this."

Patients also benefit. Sandra Fernandez, Giselle's mother, said she appreciates that the doctors at Mattel Children's Hospital UCLA are now well versed in her daughter's condition so that she does not have to go through the complicated history repeatedly. Giselle's condition involves developmental delays, and she has also been treated for hypothyroidism and seizures, and the program ensures that she is connected to all the right specialists.

"For me as a mother, it was easier to communicate," said Ms. Fernandez, who speaks Spanish, through an interpreter.

Wednesday, May 23, 2012

Phys Ed: Cancer Survivors Who Exercise Live Longer -

Can going for a walk improve cancer survivors' long-term prognosis? It may, according to new research showing that exercise can lower survivors' risk of premature death, not only from cancer but from any cause. The findings are likely to resonate widely at a time when about 14 million Americans, and many more worldwide, have survived cancer.

In one report, a major new review published this month in The Journal of the National Cancer Institute, scientists at the agency gathered available studies examining exercise and cancer survivorship, dating to 1950. Most had been published in the past five years.

"This is an area of growing scientific interest," says Dr. Rachel Ballard-Barbash, the associate director for applied research at the National Cancer Institute and lead author of the study. "Exercise is an accessible, low-cost intervention. But before we can suggest that cancer survivors become physically active, we need to understand what effects exercise has" on the bodies and life spans of those who've been given a cancer diagnosis.

To date, messages about the effects of exercise on cancer patients have been mixed. Some physicians have worried that exercise might exacerbate the fatigue that is common after cancer treatment. Others have raised concerns that the physical stress of exercise could even create conditions within the body that might contribute to tumor recurrence.

A 2010 roundtable convened by the American College of Sports Medicine concluded that exercise appeared to be safe for most cancer survivors, but anyone whose treatment had involved drugs harmful to the heart muscle or bone density should be closely monitored. But those recommendations didn't directly address the issue of whether or how exercise might affect tumor recurrence or to what degree exercise could affect a survivor's overall life span.

So those became the concerns that Dr. Ballard-Barbash and her colleagues set out to examine in more detail.

In the end, they found 45 studies that looked at physical activity among people who'd received a diagnosis of cancer. The types of tumors studied included prostate, ovarian, brain and colorectal. But a majority of the studies, "as in most cancer research," involved women who had survived breast cancer, Dr. Ballard-Barbash said. "There's a lot of research money in that field," so, in general, there is more available science.

Most of the studies also were observational, meaning that patients completed questionnaires about their activities, which can be unreliable since people may not accurately recall their true activity levels. Only a few were actual experiments, during which volunteers were assigned to exercise or to remain sedentary. And although none were designed expressly to determine what biochemical or genetic effects exercise might be having on cells within the body, several did look at various biomarkers that have been found to play a role in cancer recurrence and progression.

As it turned out, virtually all of the studies, whatever their methodology, showed that regular physical activity "decreased the risk of cancer-related mortality and of all-cause mortality," Dr. Ballard-Barbash said.

Exercise, in other words, made it less likely that a survivor would subsequently die from a recurrence of his or her cancer. When Dr. Ballard-Barbash and her colleagues teased out specific information about biomarkers related to cancer recurrence, they found that exercise tended reliably to improve insulin levels, reduce inflammation and increase populations of the very immune system cells that are thought to attack tumors.

Exercise also lessened the chances that a survivor of cancer would later succumb prematurely to other common diseases like heart disease or diabetes. "We live in an era when cancer has moved away from being generally fatal to being itself a chronic disease," Dr. Ballard-Barbash said. People can live many years after a cancer diagnosis. "If they are inactive," she continued, "they risk developing other chronic diseases."

Exercise made the cancer survivors in the studies she and her colleagues examined healthier and far more likely to enjoy a longer life span than if they were sedentary, although she cautioned that the patients who exercised may have been in better health or faced a less aggressive cancer to begin with.

Interestingly, exercise did not seem to increase fatigue among most survivors. More often, it lessened it.

Researchers found similar results in another new study published this month, this one involving colorectal cancer survivors in the Netherlands. Those who exercised reported much less exhaustion and, in general, greater health-related quality of life than those who did not. "Fatigue and the fear of tiredness may be a barrier to physical activity for some people" who've survived cancer, said Laurien M. Buffart, a professor at VU University Medical Center in Amsterdam, who led the study. "But more and more evidence suggests the reverse," that exercise energizes people who are undergoing or have completed cancer treatment.

And the exercise does not need to be intimidating or vigorous. "In our review, the most common activity was walking," Dr. Ballard-Barbash said, "which happens to be an activity that is within the scope of almost anyone."

She added that many more experiments are needed to determine the ideal dose and type of exercise to improve long-term survival after cancer treatment. Survivors also should consult a physician, of course, about the effects of treatment on the heart or about their readiness, in general, to exercise. But if you get the go-ahead, she said, "it appears that any activity," in any amount, "is beneficial for those who've had cancer."

Higher Education Linked to Better Health | Inside Higher Ed

People with higher degree attainment and their families have healthier lives, according to new data from the Centers for Disease Control and Prevention. Among the findings:
  • In 2007-2010 in households where the head of household had less than a high school education, 24 percent of boys and 22 percent of girls were obese. In households where the head had a bachelor's degree or higher, 11 percent for males aged 2-19 years and 7 percent for females were obese.

  • In 2007-2010, women 25 years of age and over with less than a bachelor's degree were more likely to be obese (39 percent - 43 percent) than those with a bachelor's degree or higher (25 percent).

  • In 2010, 31 percent of adults 25-64 years of age with a high school diploma or less education were smokers, compared with 24 percent of adults with some college and 9 percent of adults with a bachelor's degree or higher.

  • Between 1996-2006, the gap in life expectancy at age 25 between those with less than a high school education and those with a bachelor's degree or higher increased by 1.9 years for men and 2.8 years for women.  On average in 2006, 25-year-old men without a high school diploma had a life expectancy 9.3 years less than those with a bachelor's degree or higher.

What does it mean to say that something causes 16% of cancers? | Not Exactly Rocket Science | Discover Magazine

A few days ago, news reports claimed that 16 per cent of cancers around the world were caused by infections. This isn't an especially new or controversial statement, as there's clear evidence that some viruses, bacteria and parasites can cause cancer (think HPV, which we now have a vaccine against). It's not inaccurate either. The paper that triggered the reports did indeed conclude that "of the 12.7 million new cancer cases that occurred in 2008, the population attributable fraction (PAF) for infectious agents was 16·1%".

But for me, the reports aggravated an old itch. I used to work at a cancer charity. We'd get frequent requests for such numbers (e.g. how many cancers are caused by tobacco?). However, whenever such reports actually came out, we got a lot confused questions and comments. The problem is that many (most?) people have no idea what it actually means to say that X% of cancers are caused by something, where those numbers come from, or how they should be used.

Formally, these numbers – the population attributable fractions (PAFs) – represent the proportion of cases of a disease that could be avoided if something linked to the disease (a risk factor) was avoided. So, in this case, we're saying that if no one caught HPV or any other cancer-causing infection, then 16.1% of cancers would never happen. That's around 2 million cases attributable to these causes.

From answering enquiries and talking to people, I reckon that your average reader believes that we get these numbers because keen scientists examined lots of medical records, and did actual tallies. We used to get questions like "How do you know they didn't get cancer because of something else?" and "What, did they actually count the people who got cancer because of [insert risk factor here]?"

No, they didn't. Those numbers are not counts.

Those 2 million cases don't correspond to actual specific people. I can't tell you their names.

Instead, PAFs are the results of statistical models that mash together a lot of data from previous studies, along with many assumptions.

At a basic level, the models need a handful of ingredients. You need to know how common the risk factor is – so, for example, what proportion of cancer patients carry the relevant infections? You need to know how big the effect is – if someone is infected, their risk of cancer goes up by how many times? If you have these two figures, you can calculate a PAF as a percentage. If you also know the incidence of a cancer in a certain population during a certain year, you can convert that percentage into a number of cases.

There's always a certain degree of subjectivity. Consider the size of the effect – different studies will produce different estimates, and the value you choose to put into the model has a big influence on the numbers that come out. And people who do these analyses will typically draw their data from dozens if not hundreds of sources.

In the infection example, some sources are studies that compare cancer rates among people with or without the infections. Others measure proteins or antibodies in blood samples to see who is infected. Some are international registries of varying quality. The new infection paper alone combines data from over 50 papers and sources, and some of these are themselves analyses of many earlier papers. Bung these all into one statistical pot, simmer gently with assumptions and educated guesses, and voila – you have your numbers.

This is not to say that these methods aren't sound  (they are) or that these analyses aren't valuable (they can tell public health workers about the scale of different challenges). But it's important to understand what's actually been done, because it shows us why PAFs can be so easily misconstrued.

The numbers aren't about assigning blame.

For a start, PAFs don't necessarily add up. Many causes of cancer interact with one another. For example, being very fat and being very inactive can both increase the risk of cancer, but they are obviously linked. You can't calculate the PAFs for different causes of cancer, and bung them all into a nice pie chart, because the slices of the pie will overlap.

Cancers are also complex diseases. Individual tumours arise because of a number of different genetic mutations that build up over the years, potentially due to different causes. You can't take a single patient and assign them to a "radiation" or "infection" or "smoking" bucket. Those 16.1% of cancers that are linked to infections may also have other "causes". Cancer is more like poverty (caused by a number of events throughout one's life, some inherited and some not) rather than malaria (caused by a very specific infection delivered via mosquito).

You can't find trends by comparing PAFs across different studies. 

The latest paper tells us that 16.1% of cancers are attributable to infections. In 2006, a similar analysisconcluded that 17.8% of cancers are attributable to infections. And in 1997, yet another study put the figure at 15.6%. If you didn't know how the numbers were derived, you might think: Aha! A trend! The number of infection-related cancers was on the rise but then it went down again.

That's wrong. All these studies relied on slightly different methods and different sets of data. The fact that the numbers vary tells us nothing about whether the problem of infection-related cancers has got 'better' or 'worse'. (In this case, the estimates are actually pretty close, which is reassuring. I have seen ones that vary more wildly. Try looking for the number of cancers caused by alcohol or poor diets, if you want some examples).

Unfortunately, we have this tricky habit of seeing narratives even when there aren't any. Journalists do this all the time. A typical interview would go like this: "So, you're saying infections cause 16.1% of cancers, but a few years ago, you said they cause 17.8% of cancers." And then, the best-case scenario would be: "So, why did it go down?" And the worst-case one: "Scientists are always changing their minds. How can we trust you if you can't get a simple thing like this right?"

The numbers are hard to compare, and obscure crucial information.

Executives and policy-makers love PAFs, and they especially love comparing them across different risk factors. They are nice, solid numbers that make for strong bullet points and eye-grabbing Powerpoint slides. They have a nasty habit of becoming influential well beyond their actual scientific value. I have seen them used as the arbitrators of decisions, lined up on a single graphic that supposedly illustrates the magnitude of different problems. But of course, they do no such thing.

For a start, the PAF model relies on a strong assumption of causality. You're implying that the risk factor you're studying clearly causes the disease in question. That's warranted in some cases, including many of the infections discussed in the new paper. In others… well, not so much.

Here's an example. I could do two sets of calculations using exactly the same methods and tell you how many cases of cancer were attributable to radon gas, or not eating enough fruit and vegetables. A casual passer-by might compare the two, look at which number was bigger, and draw conclusions about which risk factor was more important. But this would completely obscure the fact that there is very strong evidence that radon gas causes cancer, but only tenuous evidence that a lack of fruit and vegetables does. Comparing the two numbers makes absolutely no sense.

There are other subtle questions you might also need to ask if you were going to commit money to a campaign, or call for policy changes, or define your strategy. How easily could you actually alter exposure to a risk factor? Does the risk factor cause cancers that have no screening programmes, or that are particularly hard to treat? Is it becoming more of a problem? PAFs obscure all of these issues. That would be fine if they were used appropriately, with due caution and caveats. But from experience, they're not.

What PAFs are good for

They're basically a way of saying that a problem is this big (I hold my hands bout an inch apart), or that it's this big (they're a foot apart now) or THIS big (stretched out to the sides). They're our best guess based on the best available data. In the case of infections, the message is that they cause more cancers than people might expect.

Used carefully, I have no real problem with PAFs, but I think that they're blunt instruments, often wielded clumsily. We could do a much better job at communicating what they actually mean, and how they are derived. I'd be happier if we quoted ranges based on confidence intervals. I'd be even happier if we stopped presenting them to one decimal place – that imbues them with a rigour that I honestly don't think they deserve. And if, whenever we talked about PAFs, we liberally used the suffix "-ish"? Well, I'd be this happy.

Attending religious services linked to better health | National Post

People who attend religious services regularly are less likely than others in this country to develop diabetes or high blood pressure, a new study suggests, adding a Canadian dimension to the growing but contentious body of research linking faith and good health.
The authors, from McMaster University in Hamilton, Ont., theorize that Christian and other religious gatherings help stave off disease by offering a stress-reducing social-support network, frowning on risky behaviour like smoking and drinking and encouraging good diet and exercise.
They suggest that doctors take advantage of the findings by urging religious patients to tap into the health-promoting traditions of their faith.
In interviews that were part of a related study, parishioners and clergy said they always felt that going to church was therapeutic, said Ananya Banerjee, the epidemiologist who headed the research.
"They [priests] felt people were in a meditative state, it was a place where they felt at peace," she said. "It was a time they could actually reflect on their lives and absorb everything that was being said … about how to live life to the fullest according to God's will."
Based on data from the federal government's Canadian Community Health Survey, the McMaster research is the first of its kind in Canada to link heart-related health and religious observance, the authors say.
The study used results from the 2007 edition of the survey, which included for the first time an optional query about religious attendance. Ms. Banerjee and colleagues looked at the 5,400 people surveyed in Saskatchewan, one of two jurisdictions where the question was actually asked.
They found that those who went to church or attended other religious services more than once a week were almost 20% less likely to suffer from hypertension and had 40% less chance of being diabetic. Fewer of the frequent churchgoers reported coronary-heart disease, as well, but the difference was deemed not statistically significant.
Ms. Banerjee said she met initial skepticism when she proposed the study as part of her work for a doctorate, and rejection from high-impact Canadian medical journals when she tried to publish the results. It ended up appearing in the U.S.-based Journal of Religion and Health.
The medical science world in the United States, however, has for years been delving heavily into the link between faith and health, with several medical schools offering courses on spirituality for doctors-in-training, and more than 3,000 studies on the issue published.
Critics dismiss much of that research, though, arguing partly that something other than religion likely explains the positive results.
The Canadian paper seems "reasonably well" conducted but suffers from a shortcoming shared by many of the U.S. studies: the source data made it impossible to filter out the general health effects of "social support," said Richard Sloan, who critiqued the field in his 2006 book, Blind Faith: The Unholy Alliance of Religion and Medicine.
Any disease-fighting benefits of attending church, synagogue or mosque probably stem from the support and comfort those institutions offer, said the behavioural medicine professor at Columbia University. And many other types of social activities — from bowling leagues to theatre groups — deliver similar rewards, he said.
"I don't think there's any problem with physicians saying 'You ought to engage in activities with other people,' " said Prof. Sloan. "The problem is when you single out religion … You confront the possibility of religious coercion, of invading religious privacy."
Some studies, though, have teased out the general effects of social support, and found them to represent only about 15% of the positive health impact of religious attendance, countered Dr. Harold Koenig, a psychiatrist and head of Duke University's Center for Spirituality, Theology and Health.
"It's kind of like a super-charged social support," he said. "In a religious community, that social contract is going on, but it's not the only thing. It is the religious belief system that is driving people to care for one another and love one another."
Most of the Canadian study's respondents were Christians, but Ms. Banerjee, who is Hindu, said she suspects the results would apply to other faiths, too.
"When I go to temple, I feel a lot better," she said. "I'm ready to go on for the rest of the week, and face any challenges that come by."

Tuesday, May 22, 2012

New Data on Harms of Prostate Cancer Screening -

In a controversial finding that will affect at least 44 million American men, a government task force published its final recommendations against regular prostate cancer screening, concluding that the harms of the simple blood test far outweigh any potential benefit.

The recommendations, from the United States Preventive Services Task Force, offer the most detailed breakdown to date of the potential risks and benefits of the prostate specific antigen blood test, commonly known as the P.S.A. test. Most important, the task force found that, at best, one man in every 1,000 given the P.S.A. test may avoid death as a result of the screening, while another man for every 3,000 tested will die prematurely as a result of complications from prostate cancer treatment and dozens more will be seriously harmed.

Even so, the suggestion that men should give up annual prostate cancer screening has met with resistance, particularly from prostate cancer advocacy groups as well as some medical groups, including the American Urological Association.

Dr. Michael L. LeFevre, the co-vice chairman of the task force and professor of family and community medicine at the University of Missouri, said the recommendations, published online Monday in Annals of Internal Medicine, were based on the best scientific evidence available.

"Change is hard," Dr. LeFevre said. "It's hard for all of us, both within and outside the medical profession, to accept that not all cancers need to be detected or treated, and that there are harms associated with screening and not just benefits."

Last fall, the task force shocked the men's health community when it issued a draft recommendation against routine use of the P.S.A. test. The recommendations apply only to the routine screening of healthy men and do not affect men who seek medical advice about cancer symptoms. Currently, many men in their 40s, 50s and older receive annual P.S.A. screenings in hopes of detecting prostate cancer before symptoms appear. A high P.S.A. score, or a rising score over time, typically leads to a potentially painful biopsy in which a dozen or so tissue samples are taken to determine if cancer has begun to grow in a man's prostate.

But for years, the scientific community has been concerned that widespread use of the test was harming far more men than it was helping. Prostate cancer is incredibly common, particularly in older men, and most of the time cancers found through screening tests are so slow-growing that they are unlikely to ever cause harm. The problem is that even with staging and grading of tissue samples, there is no way to know for sure which cancers detected through screening are likely to kill a man and which could be left untreated and unnoticed for decades.

Prostate biopsies can cause pain, infection and emotional distress, while a cancer diagnosis typically leads to surgery or radiation treatment that can render a man impotent or incontinent, or both. In rare cases, a man can die from complications of treatment. Although "watchful waiting" is an option for men with prostate cancer, the vast majority of patients who learn they have prostate cancer choose more aggressive treatment.

As a result, the task force weighed in, analyzing several large studies that tried to determine whether the potential benefits of prostate cancer screening outweighed the harms. Since the draft recommendations were issued last fall, additional data from the largest American and European P.S.A. screening trials have been published, giving the task force additional evidence on which to make its final recommendations.

The task force found that up to 43 men per 1,000 tested will face serious harms. Thirty to 40 men will develop incontinence or erectile dysfunction, or both, as a result of treatment. Two more men will have a serious cardiovascular event, like a heart attack, due to treatment, and one man will develop a life-threatening blood clot in his legs or lungs.

Even so, the American Urological Association issued a statement saying the group was "outraged" by the task force decision to finalize the recommendations. The group said the findings did not adequately reflect the benefits of P.S.A. testing and that it was "inappropriate and irresponsible" to issue a blanket statement against the testing.

Annals of Internal Medicine also published an accompanying article, in which the authors described themselves as "an ad hoc group including nationally recognized experts in the surgical and radiological treatment of prostate cancer, oncologists, preventive medicine specialists, and primary care physicians" who disagreed with the recommendations.

The group takes issue with the data that the task force used to formulate its decision, saying that it "overlooked or misinterpreted the impact of significant methodological flaws" in the research. Among other concerns, the group claimed that the task force failed to consider the needs of high-risk groups, and also claimed insurance companies were likely to refuse to reimburse for P.S.A. testing as a result of the task force guidelines.

"We suggest that physicians review the evidence for themselves, follow the continuing dialogue closely, and individualize prostate cancer screening decisions based on their patient preferences," the group wrote.

Dr. LeFevre said that some men might look at the data on risks and benefits and decide that they still want to be tested, and nothing in the recommendations would prevent that. He also noted that federal legislation passed in the 1990s requires Medicare to cover the cost of P.S.A. testing, and that law will remain in effect unless Congress overturns it. Many insurance companies follow the lead of Medicare when it comes to reimbursement for health coverage.

For more information about the recommendations, go to the task force's topic page on P.S.A. testing.

Canadians want feds to assume "leadership role" and fix health care: report

OTTAWA — Canadians believe the health care system is "overburdened" and they want the federal government to assume a broader "leadership role" to fix the problem, a new report commissioned by the Harper government has found.

Moreover, while many Canadians still believe medicare is "compassionate" and is among the best of the world's health care systems, it is not working effectively and is showing signs of decline that make it "unreliable" and "wasteful".

The public opinion research report finds Canadians are frustrated — despite many promises by political leaders — about the lack of action on improving medical wait times, a shortage of doctors and nurses, and cutbacks in medically available services.

The analysis delivered to Health Canada comes as Prime Minister Stephen Harper's Conservative government is under pressure to change its hands-off approach to medicare and adopt a more aggressive stance in ensuring that provinces are held accountable for the billions of dollars they receive annually in federal health-care transfer payments.

In December, the government surprised premiers by revealing it is cutting back the future growth rate of funds it gives them for medicare, and Harper said it was up to the provinces to control spending and find innovative solutions to improve health care.

Since then, political critics, a Senate committee, and the Canadian Medical Association have all called on the government to play a more central role in ensuring provinces adopt much-needed medicare reforms. But there has been no clear signal for Harper's cabinet that it is prepared to exercise any clout by jumping into the health-care fray.

Meanwhile, it is being told through a $127,916 report — entitled "Canadians' Attitudes toward the Health Care System" — there is a public appetite for such action.

The March 2 final report, prepared by The Strategic Counsel, is based on a major national public opinion survey, and a dozen focus groups held in six cities across Canada last November.

"Most participants support a broader role for the federal government in health care, focusing on standardizing access and quality of care across the country, but also providing a range of other services," the report revealed in its summary of the focus group findings.

Indeed, the report notes the "perception" about the federal government's current role in health is "somewhat limited, or vaguely understood."

However, there was a "widely expressed consensus" that the government "could, and should, take on a much greater leadership role" without establishing new bureaucracies or adding to administrative costs.

Among the areas cited for federal leadership:

- Conduct "audits" of the provincial health care systems and work to reduce "waste and inefficiencies".

- Act as a "bulk purchaser" of prescription drugs, hospital supplies and equipment to lower the costs.

- Negotiate drug prices and reduce patent protection to create a market for cheaper generic drugs.

- Promote community or home-based care.

- Accelerate national certification for foreign-trained physicians.

- Promote the use of other health-care professionals — nurses, nurse practitioners and pharmacists — in place of doctors.

- Use the tax system to promote healthier lifestyles, by taxing "junk foods" and subsidizing gym memberships.

- Regulate food companies to eliminate additives known to be harmful or contribute to obesity.

The report also touched on the federal government's controversial plan for paying a reduced share of medicare's bills.

In December, federal Finance Minister Jim Flaherty unilaterally unveiled a non-negotiable funding plan that runs to 2024.

Federal health-care transfers will continue to increase by six per cent until 2016-17. After that, increases will only be tied to economic growth including inflation — currently roughly four per cent — and never fall below three per cent.

The focus groups revealed people are not keen with this approach.

"Participants held the view, for the most part, that funding should be linked to needs rather than economic growth," the report said, adding most people want an approach with more "stability and predictability."

"Many were worried that the variable nature of tying spending to economic growth would necessarily mean a lower level of care in periods of downturn."

Also, the research found outside of Quebec, people were "firmly of the view that there should be some accountability linked to the transfer of health care dollars from the federal government to the provinces."

"Few believe that putting more money into the system will solve the problems," says the report. "Note, however, that this does not mean there was support for reducing health care budgets."

Instead, people said they think money can be saved by eliminating waste in the system, cutting back on administrative costs, and preventing "system overuse and abuse."

The report said a near-unanimous consensus emerged at the focus groups that health care is a "significant issue that requires a significant response" from both the federal and provincial governments.

"For some, the sense that a greater degree of privatized care and business-like approaches appears to be creeping into the public health care system were singled out as specific causes for concern."

Another concern was that Canada is not prepared for an "impending crisis in aging".

"Many expressed fear that Canada is facing a permanent fiscal shortfall due to an aging population (and shrinking tax base) and that this incongruity can only have a negative impact on the levels of patient care Canadians can expect in the future."

Sunday, May 20, 2012

Psychiatry Giant Sorry for Backing Gay ‘Cure’ - NYT

The simple fact was that he had done something wrong, and at the end of a long and revolutionary career it didn't matter how often he'd been right, how powerful he once was, or what it would mean for his legacy.

Dr. Robert L. Spitzer, considered by some to be the father of modern psychiatry, lay awake at 4 o'clock on a recent morning knowing he had to do the one thing that comes least naturally to him.

He pushed himself up and staggered into the dark. His desk seemed impossibly far away; Dr. Spitzer, who turns 80 next week, suffers from Parkinson's disease and has trouble walking, sitting, even holding his head upright.

The word he sometimes uses to describe these limitations — pathetic — is the same one that for decades he wielded like an ax to strike down dumb ideas, empty theorizing and junk studies.

Now here he was at his computer, ready to recant a study he had done himself, a poorly conceived 2003 investigation that supported the use of so-called reparative therapy to "cure" homosexuality for people strongly motivated to change.

What to say? The issue of gay marriage was rocking national politics yet again. The California State Legislature was debating a bill to ban the therapy outright as being dangerous. A magazine writer who had been through the therapy as a teenager recently visited his house, to explain how miserably disorienting the experience was.

And he would later learn that a World Health Organization report, released on Thursday, calls the therapy "a serious threat to the health and well-being — even the lives — of affected people."

Dr. Spitzer's fingers jerked over the keys, unreliably, as if choking on the words. And then it was done: a short letter to be published this month, in the same journal where the original study appeared.

"I believe," it concludes, "I owe the gay community an apology."

Disturber of the Peace

The idea to study reparative therapy at all was pure Spitzer, say those who know him, an effort to stick a finger in the eye of an orthodoxy that he himself had helped establish.

In the late 1990s as today, the psychiatric establishment considered the therapy to be a nonstarter. Few therapists thought of homosexuality as a disorder.

It was not always so. Up into the 1970s, the field's diagnostic manual classified homosexuality as an illness, calling it a "sociopathic personality disturbance." Many therapists offered treatment, including Freudian analysts who dominated the field at the time.

Advocates for gay people objected furiously, and in 1970, one year after the landmark Stonewall protests to stop police raids at a New York bar, a team of gay rights protesters heckled a meeting of behavioral therapists in New York to discuss the topic. The meeting broke up, but not before a young Columbia University professor sat down with the protesters to hear their case.

"I've always been drawn to controversy, and what I was hearing made sense," said Dr. Spitzer, in an interview at his Princeton home last week. "And I began to think, well, if it is a mental disorder, then what makes it one?"

He compared homosexuality with other conditions defined as disorders, like depression and alcohol dependence, and saw immediately that the latter caused marked distress or impairment, while homosexuality often did not.

He also saw an opportunity to do something about it. Dr. Spitzer was then a junior member of on an American Psychiatric Association committee helping to rewrite the field's diagnostic manual, and he promptly organized a symposium to discuss the place of homosexuality.

That kicked off a series of bitter debates, pitting Dr. Spitzer against a pair of influential senior psychiatrists who would not budge. In the end, the psychiatric association in 1973 sided with Dr. Spitzer, deciding to drop homosexuality from its manual and replace it with his alternative, "sexual orientation disturbance," to identify people whose sexual orientation, gay or straight, caused them distress.

The arcane language notwithstanding, homosexuality was no longer a "disorder." Dr. Spitzer achieved a civil rights breakthrough in record time.

"I wouldn't say that Robert Spitzer became a household name among the broader gay movement, but the declassification of homosexuality was widely celebrated as a victory," said Ronald Bayer of the Center for the History and Ethics of Public Health at Columbia. " 'Sick No More' was a headline in some gay newspapers."

Partly as a result, Dr. Spitzer took charge of the task of updating the diagnostic manual. Together with a colleague, Dr. Janet Williams, now his wife, he set to work. To an extent that is still not widely appreciated, his thinking about this one issue — homosexuality — drove a broader reconsideration of what mental illness is, of where to draw the line between normal and not.

The new manual, a 567-page doorstop released in 1980, became an unlikely best seller, here and abroad. It instantly set the standard for future psychiatry manuals, and elevated its principal architect, then nearing 50, to the pinnacle of his field.

He was the keeper of the book, part headmaster, part ambassador, and part ornery cleric, growling over the phone at scientists, journalists, or policy makers he thought were out of order. He took to the role as if born to it, colleagues say, helping to bring order to a historically chaotic corner of science.

But power was its own kind of confinement. Dr. Spitzer could still disturb the peace, all right, but no longer from the flanks, as a rebel. Now he was the establishment. And in the late 1990s, friends say, he remained restless as ever, eager to challenge common assumptions.

That's when he ran into another group of protesters, at the psychiatric association's annual meeting in 1999: self-described ex-gays. Like the homosexual protesters in 1973, they too were outraged that psychiatry was denying their experience — and any therapy that might help.

Reparative Therapy

Reparative therapy, sometimes called "sexual reorientation" or "conversion" therapy, is rooted in Freud's idea that people are born bisexual and can move along a continuum from one end to the other. Some therapists never let go of the theory, and one of Dr. Spitzer's main rivals in the 1973 debate, Dr. Charles W. Socarides, founded an organization called the National Association for Research and Therapy of Homosexuality, or Narth, in Southern California, to promote it.

By 1998, Narth had formed alliances with socially conservative advocacy groups and together they began an aggressive campaign, taking out full-page ads in major newspaper trumpeting success stories.

"People with a shared worldview basically came together and created their own set of experts to offer alternative policy views," said Dr. Jack Drescher, a psychiatrist in New York and co-editor of "Ex-Gay Research: Analyzing the Spitzer Study and Its Relation to Science, Religion, Politics, and Culture."

To Dr. Spitzer, the scientific question was at least worth asking: What was the effect of the therapy, if any? Previous studies had been biased and inconclusive. "People at the time did say to me, 'Bob, you're messing with your career, don't do it,' " Dr. Spitzer said. "But I just didn't feel vulnerable."

He recruited 200 men and women, from the centers that were performing the therapy, including Exodus International, based in Florida, and Narth. He interviewed each in depth over the phone, asking about their sexual urges, feelings and behaviors before and after having the therapy, rating the answers on a scale.

He then compared the scores on this questionnaire, before and after therapy. "The majority of participants gave reports of change from a predominantly or exclusively homosexual orientation before therapy to a predominantly or exclusively heterosexual orientation in the past year," his paper concluded.

The study — presented at a psychiatry meeting in 2001, before publication — immediately created a sensation, and ex-gay groups seized on it as solid evidence for their case. This was Dr. Spitzer, after all, the man who single-handedly removed homosexuality from the manual of mental disorders. No one could accuse him of bias.

But gay leaders accused him of betrayal, and they had their reasons.

The study had serious problems. It was based on what people remembered feeling years before — an often fuzzy record. It included some ex-gay advocates, who were politically active. And it did not test any particular therapy; only half of the participants engaged with a therapist at all, while the others worked with pastoral counselors, or in independent Bible study.

Several colleagues tried to stop the study in its tracks, and urged him not to publish it, Dr. Spitzer said.

Yet, heavily invested after all the work, he turned to a friend and former collaborator, Dr. Kenneth J. Zucker, psychologist in chief at the Center for Addiction and Mental Health in Toronto and editor of the Archives of Sexual Behavior, another influential journal.

"I knew Bob and the quality of his work, and I agreed to publish it," Dr. Zucker said in an interview last week. The paper did not go through the usual peer-review process, in which unnamed experts critique a manuscript before publication. "But I told him I would do it only if I also published commentaries" of response from other scientists to accompany the study, Dr. Zucker said.

Those commentaries, with a few exceptions, were merciless. One cited the Nuremberg Code of ethics to denounce the study as not only flawed but morally wrong. "We fear the repercussions of this study, including an increase in suffering, prejudice, and discrimination," concluded a group of 15 researchers at the New York State Psychiatric Institute, where Dr. Spitzer was affiliated.

Dr. Spitzer in no way implied in the study that being gay was a choice, or that it was possible for anyone who wanted to change to do so in therapy. But that didn't stop socially conservative groups from citing the paper in support of just those points, according to Wayne Besen, executive director of Truth Wins Out, a nonprofit group that fights antigay bias.

On one occasion, a politician in Finland held up the study in Parliament to argue against civil unions, according to Dr. Drescher.

"It needs to be said that when this study was misused for political purposes to say that gays should be cured — as it was, many times — Bob responded immediately, to correct misperceptions," said Dr. Drescher, who is gay.

But Dr. Spitzer could not control how his study was interpreted by everyone, and he could not erase the biggest scientific flaw of them all, roundly attacked in many of the commentaries: Simply asking people whether they have changed is no evidence at all of real change. People lie, to themselves and others. They continually change their stories, to suit their needs and moods.

By almost any measure, in short, the study failed the test of scientific rigor that Dr. Spitzer himself was so instrumental in enforcing for so many years.

"As I read these commentaries, I knew this was a problem, a big problem, and one I couldn't answer," Dr. Spitzer said. "How do you know someone has really changed?"

Letting Go

It took 11 years for him to admit it publicly.

At first he clung to the idea that the study was exploratory, an attempt to prompt scientists to think twice about dismissing the therapy outright. Then he took refuge in the position that the study was focused less on the effectiveness of the therapy and more on how people engaging in it described changes in sexual orientation.

"Not a very interesting question," he said. "But for a long time I thought maybe I wouldn't have to face the bigger problem, about measuring change."

After retiring in 2003, he remained active on many fronts, but the reparative study remained a staple of the culture wars and a personal regret that wouldn't leave him be. The Parkinson's symptoms have worsened in the past year, exhausting him mentally as well as physically, making it still harder to fight back pangs of remorse.

And one day in March, Dr. Spitzer entertained a visitor. Gabriel Arana, a journalist at the magazine The American Prospect, interviewed Dr. Spitzer about the reparative therapy study. This was not just any interview; Mr. Arana went through reparative therapy himself as a teenager, and his therapist had recruited the young man for Dr. Spitzer's study (Mr. Arana did not participate).

"I asked him about all his critics, and he just came out and said, 'I think they're largely correct,' " said Mr. Arana, who wrote about his own experience last month. Mr. Arana said that reparative therapy ultimately delayed his self-acceptance as a gay man and induced thoughts of suicide. "But at the time I was recruited for the Spitzer study, I was referred as a success story. I would have said I was making progress."

That did it. The study that seemed at the time a mere footnote to a large life was growing into a chapter. And it needed a proper ending — a strong correction, directly from its author, not a journalist or colleague.

A draft of the letter has already leaked online and has been reported.

"You know, it's the only regret I have; the only professional one," Dr. Spitzer said of the study, near the end of a long interview. "And I think, in the history of psychiatry, I don't know that I've ever seen a scientist write a letter saying that the data were all there but were totally misinterpreted. Who admitted that and who apologized to his readers."

He looked away and back again, his big eyes blurring with emotion. "That's something, don't you think?"