Something Not Unlike Research

We are joining the Inequalities blog

Paul Kelleher and I have decided to join Brendan Saloner, Ben Baumburg, and many other brilliant bloggers at Inequalities: Research and Reflection from both sides of the Atlantic. There may be an occasional post here at Something Not Unlike Research, but we expect to be principally blogging at Inequalities. From Inequalities statement of purpose:

This blog was set up by a bunch of young researchers – sociologists, political scientists, geographers, demographers, social policy scholars, economists – from universities on both sides of the Atlantic who wanted to create…

… a space to critically discuss research on inequality, both our own research and the most interesting research we come across; and

… a community of people who want to try and tackle the injustices they see in the world by shedding light on things that would otherwise be invisible.

We thank all readers and commenters for their attention, and we hope that you will read (subscribe to the RSS feed of) Inequalities (http://inequalitiesblog.wordpress.com/). 

Medication and the hidden structure of experience

I woke up this morning in the hospital, feeling a lot better. It was a reminder about how our given world -- the world of experience -- is not the world. The fundamental fact about the world, it seems, is that we actually dream it.

I had been admitted yesterday to change my anti-arrhythmia medication. Over the last year I've steadily lost ground in my ability to control my heart rhythm, to the point where I have been in atrial fibrilation about 20% of the time, despite a pacemaker and diltiazem. Fibrilation is a sustained high (e.g., 180 beats / minute) and erratic heart rate. I don't suffer, exactly, but it is debilitating. There wasn't a crisis that led to the admission. It just took some time to acknowledge that the old therapy was no longer working. 

So now, following the advice of Dr. Charles Love, my awesome electrophysiologist, we are pulling out a higher caliber weapon and switching to propafenone. Bigger drugs have bigger risks and you have to start propafenone in the hospital to make sure you can tolerate it.

And so far, so good. My heart is STABLE. This is revelatory:

Then felt I like some watcher of the skies
 When a new planet swims into his ken;
 Or like stout Cortez when with eagle eyes
 He star'd at the Pacific — and all his men
 Look'd at each other with a wild surmise —
 Silent, upon a peak in Darien.

What I hadn't understood was how much of my attention had been focused on my cardiophysiology. Even when I was thinking about other things, part of me worried about whether a mild flutter was about to become a hammering effort regain a steady beat. Or whether just standing up from a chair would lead to a sudden loss of blood pressure and syncope. Those concerns are gone. I'm able to be here in a way that I wasn't yesterday. All the metaphors about character and the heart are true: When you can't count on your heart, it's difficult to be steadfastly present.

The person I was yesterday had forgotten what it was like to have a steady heart. I am now back in the world; and I hadn't recognized the degree to which I was gone. The former state seems like a dream state although at the time it seemed wholly real. Our experience is constructed, and we only see the moving parts when something like a change in heart points it out to us. When you encounter another person, be gentle. He is in a dream and so are you.

UPDATE: Thanks to Dan, Austin, Paul, & Brad for their kind wishes. As it happens, I had a stress test right after the post and went right back into atrial fibrilation. So much for the hopes that profanenone (aka rythmol) would be sufficient. Looking at a ablation procedure on Monday.

Seven-fold increase in antipsychotic prescriptions to children and youths

How do you handle a really difficult child or youth? A child prone to uncontrollable rages, a child who is violent against his or her peers in a frighteningly unpredictable way. What do you do if the child is being raised by parents with limited control over their impulses, with a truncated sense of responsibility for the child, and who discipline the child with a wild savagery? Parents who may not even be present much of the time? How do protect such a child from harm?

Here are some things we should do. If the child is from a disordered home -- this is not always the case -- we should see what can be done to help the parents sort out their employment problems, their housing, their substance abuse, and their disordered characters. We should get them some training in effective parenting. We should look carefully to be sure that the child is not suffering physically, for example, from the chronic pain of abscessed teeth. We should get the child with a therapist who can train him or her in effective strategies to manage negative affect and interpersonal conflict. If necessary, we should place the child in therapeutic residential care.

These things rarely happen, because these services are expensive. Increasingly, what we do instead is sedate these children with powerful antipsychotic drugs. Antipsychotics are expensive as drugs go, but they cost less than mental health care professionals or residential therapy centres. And they make the problem go away. Sort of.

Using data from the National Ambulatory Medical Care Survey, Mark Olfson and his colleagues report the trends in the prescriptions of antipsychotics in youths and adults (where youth means 20 years old or younger). Looking from the period from 1993-1998 to 2005-2009, there has been an almost seven-fold increase in the proportion of medical visits for children that involve an antipsychotic prescription (see, the graph, prescriptions of antipsychotics for adults have doubled over the same period.) This is not because antipsychotics are being used more extensively in the treatment of psychosis: that hasn't changed. What is happening is that antipsychotics are being used more frequently with children with no psychotic disorder (a greater than seven-fold increase).

Antipsychotics do not teach interpersonal skills. They do not, to my knowledge, increase the child's ability to modulate emotions when they are not sedated. Antipsychotics are powerful tranquilizers; so they make certain problems go away. When used to quell a violent patient on a ward, they are referred to, without irony, as "chemical restraints."

Antipsychotics have extensive side effects: they impair movement, they promote rapid weight gain, and they lead to metabolic disorder and diabetes. The use of these drugs is too new for us to be certain of the long term effects on the development of children's brains and bodies, but the initial evidence suggests that the damage may be extensive. When psychiatrists use these drugs, they rarely test for these side effects.

Antipsychotics are typically prescribed without any particular plan for how or when they will be discontinued. Similarly, it seems that we have come to this strategy for managing difficult children without any plan for discontinuing it. Will we continue to sedate them through adulthood? Is there some point where the rapid growth in the use of antipsychotics even slows down? Do we intend to keep an increasingly proportion of the population chemically restrained for their whole lives? 

Why are antipsychotic prescriptions to children increasing? In part because they have been pushed by pharmaceutical manufacturers, often using deception. But largely because we are unwilling to pay the cost of providing good care.

 

On Chris Hayes's reformation

post by Bill Gardner

I have just finished Chris Hayes's Twilight of the Elites. It's great. The only possible disappointment is the title: Be aware that it is not a paranormal romance about aristocrat vampires. Here is a summary of the argument, from an excellent review by Aaron Swartz at Crooked Timber:

Hayes pins the blame on an unlikely suspect: meritocracy. We thought we would just simply pick out the best and raise them to the top, but once they got there they inevitably used their privilege to entrench themselves and their kids (inequality is, Hayes says, “autocatalytic”). Opening up the elite to more efficient competition didn’t make things more fair, it just legitimated a more intense scramble. The result was an arms race among the elite, pushing all of them to embrace the most unscrupulous forms of cheating and fraud to secure their coveted positions... This creates a unitary elite, detached from the bulk of society, yet at the same time even more insecure. You can never reach the pinnacle of the elite in this new world; even if you have the most successful TV show, are you also making blockbuster movies? bestselling books? winning Nobel Prizes? When your peers are the elite at large, you can never clearly best them.

The result is that our elites are trapped in a bubble, where the usual pointers toward accuracy (unanimity, proximity, good faith) only lead them astray. And their distance from the way the rest of the country really lives makes it impossible for them to do their jobs justly—they just don’t get the necessary feedback.

Whether elites were somehow better before meritocracy doesn't matter: This book gets at what is wrong with the elites that we have now.

So what do we do about it? Hayes argues for increased equality of outcomes, for example through redistributive taxation. I'm for it.

It is important, however, to make sure that Hayes's proposed reformation is read in the way that I think he intends it. He writes that

The first step is persuading the public -- including the elites themselves -- that the ideology of meritocratic achievement stands in the way of social progress. The first commandment of the post-1970s meritocracy can be summed up as follows:

"Thou shall proclaim equality of opportunity to all, regardless of race, gender, or sexual orientation but worry not about equality of outcomes."

That is,

1. Continue to fight for equality of opportunity.
2. Resume fighting for greater equality of outcomes. There was nothing about the meritocratic ideal that required us to ignore gross inequality of outcomes.

Point 1 is perhaps under-emphasized by Hayes, but it remains extraordinarily important, for the following reasons:

• The US has nothing like a "level playing field." Inequality is baked in at birth, and not just because the poor may somehow have worse genes. Making professional schools open to both genders and all races is just the beginning. 
• As Hayes notes, inequality of opportunity and inequality of outcomes are causally interdependent, and you cannot make things equal for children without making things more equal for their parents.
• Part of making outcomes more equal is achieving greater equality in the human capital held by Americans. Tax redistribution alone would be inefficient and politically unacceptable.

Hayes praises the Brazilian Bolsa Familia program, but frames it as an example of successful redistributive taxation. It is that, but the more important thing was that it directed the redistributed resources to the improvement of the health and education of poor young children.

 

Paul A. Samuelson on "You Didn't Build That"

post by Paul Kelleher

Economist Paul A. Samuelson (Economics, p. 484):

Many ingenious ways have been suggested for measuring this consumer's surplus, but they are of no particular significance. The important thing is to see how lucky the citizens of modern efficient communities really are. The privilege of being able to buy a vast array of goods at low prices cannot be overestimated.

This is a humbling thought. If ever a person becomes arrogantly proud of his economic productivity and his level of real earnings, let him pause and reflect. If he were transported with all his skills and energies intact to a primitive desert island, how much would his money earnings buy? Indeed, without capital machinery, without rich resources, without other labor, and above all without the technical knowledge which each generation inherits from society's past, how much could he produce? It is only too clear that all of us are reaping the benefits of an economic world we never made.

This basic fact is well stated in the following quotation:

The organizer of industry who thinks that he has "made" himself and his business has found a whole social system ready to his hand in skilled workers, machinery, a market, peace and order---a vast apparatus and a pervasive atmosphere, the joint creation of millions of men and scores of generations. Take away the whole social factor and we have not Robinson Crusoe, with this salvage from the wreck and his acquired knowledge, but the naked savage living on roots, berries, and vermin.[1]

[1] L. T. Hobhouse, "The Elements of Social Justice," pp. 162-163, Henry Holt and Company, Incorporated, New York, 1922.

Concentrated Medical Spending, Accountable Care Organizations, & Outcomes Measurement

post by Bill Gardner

Health care spending is highly concentrated in a small portion of the population (see the graph of the cumulative distribution of US health care spending, from the National Institute for Health Care Management). This concentration has consequences for policies to reduce national health care spending.

Notice that half the population -- the group on the left in the graph -- accounts for < 3% of the total spending. Aaron Carroll argues that

When we talk about incentivizing people to forego care, we’re talking mostly about healthy people. When we talk about consumer directed health care, we’re talking mostly about healthy people... The problem is that healthy people consume so little care to begin with. If we could incentivize the healthier half of people to forego all their personal health care spending, we’d spend $36 billion less out of a total $1.259 trillion in personal health care spending. That would be a drop in the bucket. 

OK, so we can't find significant health care savings in the healthy population. We do not want to deny care to the sick. So how are we going to bend the health care cost curve? 

First, we need to shrink the percentage of the population that has expensive chronic illnesses. Almost all of us will eventually acquire one or more chronic illnesses, but delaying these illnesses even a few years would reduce the overall cost of care. My bet is that the breakthrough here will be finding ways to shift our diets away from simple carbohydrates. This would, over time, significantly reduce rates of diabetes and hypertension, which are key cost drivers among the chronically-ill population. But even if we can make this work, these are savings that we collect only in the medium to far future.

So we have to find near-term ways to make caring for the sick less expensive. One approach is deliver care through Accountable Care Organizations (ACO = "a provider-led organization whose mission is to manage the full continuum of care and be accountable for the overall costs and quality of care for a defined population;" Rittenhouse, Shortell, & Fisher). In brief: Set the incentives so that health care providers make money by devising less expensive ways to deliver better care. Although some health care regulation is necessary, this is fundamentally a market solution, in which ACOs compete for contracts and prosper through successful innovation.

However, the ACO idea only works if we can objectively measure the quality and outcomes of care. We need those measurements to enforce contracts with the ACOs to take good care of their populations. If we can't measure the quality of what the ACOs deliver, then the ACOs' incentives are just to reduce costs. We will be back to Managed Care and routine denial of care, which is much easier than delivering good, efficient care. We need objective, transparent, and public measures of the quality and outcomes of care regardless of whether you support payer-driven or individual-consumer-driven health market reforms (or both!).

Developing and validating technologies for measuring the quality and outcomes of care are among the principal goals of the Agency for Health Research and Quality (AHRQ) and the Patient-Centered Outcomes Research Institute (PCORI). And this is why the effort to eliminate AHRQ and PCORI is so stupid. Valid measurement technologies for the quality and outcomes of care are essential to market-based health care solutions. Measuring the quality and outcomes of care is like certifying the accuracy of gas pumps at service stations: It makes the market work for purchasers.