Something Not Unlike Research

Inequality? Oh we'd love to help, but...

post by Bill Gardner

Arnold Kling and Nick Schulz argue that the growth in US inequality derives from two factors:

• Technology that allows a few very able persons to achieve extraordinary things (think Sergey Brin), and
• Defective families and assortative mating based on ability that result in large groups of people at the bottom who lack the talent to produce much of value.

These are important causes of inequality. Kling and Schulz would do something about these things if they could, they really would, but 

there may be less that government can do than one might hope. Research from Heckman suggests that education is a relatively feeble remedy for the effects of family background (although Heckman believes that early intervention, in preschool or even before, shows promise). In order to make a dramatic impact on inequality, government would have to do something about the fundamental causes: technology and marriage patterns. However, putting a brake on technological progress seems hardly feasible or desirable. And forcing people to select mates at random rather than on the basis of similar backgrounds and tastes seems similarly unlikely. As much as inequality may be a problem, no real solution is in sight.

OMG, if the only alternatives are freezing technological progress or making people marry random partners (on second thought, this is the best explanation for my first marriage, and the kids turned out great anyway), then I guess there really is nothing to be done.

Or maybe we could try the following:

• We could give every mother good prenatal care, and institute programs to reduce premature delivery. 
• We could provide every child with universal, high-quality preschool education. Please, read Heckman for yourself. He isn't saying that early interventions "show promise." He's saying that "Early interventions promote schooling, reduce crime, foster workplace productivity, and reduce teenage pregnancy." 
• We could reform our criminal justice system. The US has 751 persons in prison per 100,000 population. Canada has 117. England's rate is 151; Germany's is 88; and Japan's is 63. Mexico has 204. The global median is 125. Are Americans really six times as violent and criminal as the rest of the world? The burden of US incarceration falls on the poor and above all on people of color. It destroys families. But it could be fixed.

America could do these things and it would still have considerable inequality. But these are solutions that would help and, contrary to Kling and Schulz, they are in plain sight.

'Health Shock': How childhood chronic illness affects children's schooling and adult employment

Pediatrics is sometimes treated as the least important branch of medicine. This kind of makes sense, because children are mostly healthy. Focusing just on health outcomes, however, is terribly short-sighted. As Jason Fletcher and Michael Richards show, chronic diseases that begin in childhood have powerful effects not only on children's adult health, but also on their non-medical development and achievements. 

Fletcher and Richards looked at the association between the 'health shock' of  getting diabetes in childhood and achievements in schooling and work for more than 15,000 children. They found

effects in several measures of educational attainment, including a high school dropout rate that was six percentage points higher than among young adults without the disease. We also found lower employment and wages: A person with diabetes can conservatively expect to lose more than $160,000 over his or her working life, compared to a peer without the disease. 

This is an observational study, so whether diabetes causes these effects is a matter of inference and interpretation. Fletcher and Richards used a data set that included detailed information on the children's family backgrounds, the health of parents, and other diseases that children had; and their estimates include statistical controls for such factors. We cannot necessarily infer that an intervention that prevented diabetes in a child would increase the years of schooling they would achieve, or how much they would earn as adults. But based on these data, it would be worth a shot.

23.5 hours a day

post by Bill Gardner

It's New Year's Eve, so my thoughts about prevention are about my health, not population health. I am old enough that chronic illness is a fact, not a risk. So my goal is to improve the management of the ones I have, and make sure that I do not pick up anything new. Here is a terrific argument for an important behavior change: getting at least half an hour of exercise a day.  Please, take 10 minutes and watch this great talk by Dr. Mike Evans.

Sometimes, getting unstuck just requires reframing the problem.

"Can you limit your sitting and sleeping to 23 & 1/2 hours a day?" 

Yes. I can.

Don Berwick and the lives not saved

Please read Harold Pollack's post on what Donald Berwick's resignation as head of CMS (the Center for Medicare and Medicaid Services) says about the lack of professionalism in US government. For a conservative view on the current 'comical' lack of professionalisim, see Tevi Troy. 

One of Harold's sentences stands out for me:

His methodical research and practice have saved many thousands of lives.

Harold is referring to what I think is the most important part of Berwick's career. He is a physician, and he will probably return to being a professor, but he was above all a reformer of the practice of medicine. Not a political reformer, but rather someone who ran campaigns that have saved lives by changing how medicine is practiced. These were not campaigns to redistribute medical care, or change how medicine is paid for. The goals were to change physician behaviors that killed patients, by persuading doctors to:

• Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction
• Prevent Adverse Drug Events
• Prevent Central Line Infections
• Prevent Surgical Site Infections
• Prevent Ventilator-Associated Pneumonia

These are practical, not ideological goals. Like Harold, I am persuaded that Berwick's efforts prevented tens of thousands of deaths stemming from substandard US medical care. This is the strongest possible credential for the administrator of Medicare and Medicaid.

What might Berwick have done with eight years to promote quality of care as head of CMS? Based on his record, he would have saved lives.

More Data, Obviously

In a recent post, I noted that it is a problem that the US Preventive Services Task Force frequently finds that it has insufficient evidence to grade the effectiveness of a preventive service. I argued that the best improve the decision making of the USPSTF was to get more evidence by doing more comparative effectiveness studies.

"Duh," sez the thought balloon above your head.

Or as Daniel Goldberg said more politely in the Comments,

this is simply a well-studied feature of the problematic that is evidence-based public health policy. Namely, that we frequently (usually?) lack evidence of reasonable, let alone high, quality that would be sufficient to guide us with a modicum of confidence on any particular public health policy question.

No one disagrees that the best answer to this problem is to obtain better evidence of sufficient quality, but that does not address the real-time problem that the data simply may not exist at the time a decision needs to be made.

In the next post, I will discuss Daniel's absolutely real "problem that the data simply may not exist at the time a decision needs to be made."

But first, is it true that "[n]o one disagrees that the best answer to this problem is to obtain better evidence"? My strong impression is that most if not all Republican legislators and pundits would resist legislation to increase federal funding for comparative effectiveness research on preventive services. We have to speak up for more data.

 

The Prevention and Public Health Fund: Where is the money going?

post by Bill Gardner

Evidence-based strategies for preventing chronic diseases are essential for improving the health of current and future generations. So it is distressing to read Sarah Kliff's reporting on the political jeopardy of the Prevention and Health Fund:

Republicans have regularly attacked the $16 billion investment [over 10 years] in programs meant to reduce chronic diseases and improve Americans’ health. Wyoming Sen. Mike Enzi has quipped that the program was a “slush fund” for jungle gyms... “There’s certainly concern among the public health advocates,” says Jeff Levi, who chairs the new National Advisory Group on Prevention, Health Promotion and Integrative and Public Health “The concern is will it fall into a catch all category of things that can be cut, and that’s a challenge.” ...The White House proposed slashing its budget for the first time in its last deficit reduction proposal. House Republicans, meanwhile, would like to zero out the program’s funding in their budget...“The question is: are we funding the status quo, are we funding the stagnant quo, or are we getting an effort...that’s transformative?,” Maryland Sen. Barbara Mikulski vented at a Senate hearing on the fund last week.

Sadly, I think there is something to Sen. Mikulski's concerns. I looked at what the Fund is doing in the state of Ohio. The graph shows how much money will be spent on three types of activities in Ohio over 10 years (the vertical axis is in $1000s). The categories are:

1. Community and Clinical Prevention: Prevention activities that have been shown to be effective in reducing health care costs and promoting health and wellness. Specific activities include: a) Assisting communities with the integration of primary care services into community-based mental & behavioral health settings, b) HIV Prevention, and c) Tobacco Cessation. 
2. Public Health Infrastructure: To strengthen state and local capacity to prepare health departments to meet 21st century public health challenges and support the training of existing and next generation public health professionals. The money supports information technology, laboratories, public health training, and something called 'capacity building'.
3. Primary Care Training: Spending to expand the primary care workforce. These are training programs for (in order of increasing spending): State health care workers, physician assistants, advanced nurse practitioners, and primary care physicians.

There is an argument to be made for each of these categories of spending. But I'm concerned about the priority of infrastructure and training programs relative to actual community interventions. The latter appear to be getting less than $100,000 / year. The details will matter here. Are the Infrastructure and Primary Care Training funds being spent in ways that will generate a sustained increase in evidence-based preventive care by primary care practitioners? If so, the money could be well spent. If not, we will just have more doctors doing more of the same. I hope that the Senators push the Prevention Fund managers hard on this point.

 

 

 

Politics, Cancer Screening, and Evidence-Based Medicine

post by Bill Gardner

Here is what Newt Gingrich said about prostate cancer screening last night.

...the most recent U.S. government intervention on whether or not to have prostate testing is basically going to kill people.  So if you ask me, do I want some Washington bureaucrat to create a class action decision which affects every American's last two years of life, not ever.  I think it is a disaster.  I think, candidly, Governor Palin got attacked unfairly for describing what would -- would, in fact, be death panels.  

And -- and -- what [former Director of the National Cancer Institute] von Eschenbach will tell you if you call him is:  The decision to suggest that we not test men for -- with PSA will mean that a number of people who do not have the -- who are susceptible to a very rapid prostate cancer will die unnecessarily. 

What is he talking about?

There was a great article in The New York Times Magazine on the difficult decision about whether men should be screened for prostate cancer using the prostate-specific-antigen test (and there is more here). This is a relatively inexpensive, minimally-invasive test that can spot a potentially deadly prostate cancer years earlier than the alternative of manual examination of the prostate. Unfortunately, in my view, the test doesn't work:

six randomized clinical trials that considered whether being screened for prostate cancer reduced overall and cancer-specific mortality in men. Mia Djulbegovic and her colleagues analyzed data on over 350,000 men who participated in experiments where they either were or were not screened. Their stark conclusions:

In this systematic review and meta-analysis of prostate cancer screening we failed to find a significant impact of prostate cancer screening on overall mortality or death from prostate cancer.

The US Preventive Services Task Force (USPSTF) also reviewed the evidence. They concluded,

In summary, PSA-based screening is associated with detection of more prostate cancers; small to no reduction in prostate cancer–specific mortality after about 10 years; and harms related to false-positive test results, subsequent evaluation, and therapy, including overdiagnosis and overtreatment.

This is the "government intervention" that Gingrich is referring to. Except that it is not an intervention, and the Task Force does not make decisions about anyone's treatment. What they do is summarize the evidence. The "decision to suggest that we not test men" claimed by Gingrich is not, so far as I can see, in the text. I think that not getting the test is the rational inference from the evidence, but read the evidence and draw your own conclusions. However, whatever the USPSTF wrote, men have the same right to make their own decision about the test that they had before the USPSTF issued the report.

Prevention -can- reduce the growth in health care cost

post by Bill Gardner

Austin Frakt read a recent article by Charles Roehrig and David Rousseau and wrote

Bottom line: prevention can’t play a major role in curbing the rate of growth in health care spending. The rationale for prevention is for health and other economic and social benefits (greater ability to work, enjoy leisure, etc.). [italics added]

The basic idea is that

Spending on Health Care = (Number of Cases) x Spending/Case.

If so, growth in Spending must result from either the increase in Cases, or the increase in Spending/Case. Roehhrig and Rousseau's found that between 1996 and 2006, only about 25% of recent growth in health care costs can be explained by the increased prevalence of diseases. The rest of it resulted from increases in the Spending/Case. Moreover, even if the Number of Cases had stayed constant during this period, the increase in Spending/Case was so aggressive that Spending would nevertheless have grown faster than GDP.

However, I disagree that this shows that "prevention can’t play a major role in curbing the rate of growth in health care spending." I completely agree that our increase in Spending/Case has been the main cause of growth, and I completely agree that we must find more efficient ways to deliver care. But even if increasing Spending/Case is the way Spending grew, it doesn't follow that that reducing it is the only way it could grow or shrink. If we found the means to prevent some of the major chronic illnesses, and thereby reduced the Number of Cases, that would help reduce the growth in Spending.

Roehhrig and Rousseau show that this has happened for a group of diseases for which we have effective prevention strategies:

Our findings do document, however, that changes in clinical prevalence have had an impact on spending growth for certain conditions. One of the greatest public health achievements in the past fifty years is the reduction in cigarette smoking, and this is almost certainly reflected in our finding that spending growth was less than the rate of GDP growth for respiratory conditions, in spite of the rapid growth in treated prevalence and spending for asthma. [italics added]

Spending also fell for cerebrovascular diseases (which include strokes). Again, reduction in smoking contributed to this fall. So the results also suggest that you can reduce health carespending if you can implement effective prevention strategies. Reducing smoking was a home run for prevention; we are behind in the game now, and we need another big hit.

Living young and reckless

post by Bill Gardner

Reading Aaron Carroll on the consumption of sugared drinks by young males, I had a thought about why the young are reckless with their health -- adolescence is the peak time for initiation of health risk behaviors. There is a lot of work on problems of time discounting and other problems of self-control, which are more severe for adolescents. What occurred to me, though, was a sense in which it is rational to be reckless with your health when you are young.

I have in mind a simple model in which a person holds two stocks of resources that they can expend to obtain well-being: money and health. The person converts these resources into well-being by engaging in activities. Suppose there are two such activities: drinking Coke and eating at world class vegetarian restaurants. Drinking Coke costs very little, but if you consume a lot of it you are spending down your stock of health. Eating at Greens costs a lot of money but little if any health. The young, of course, have seeming limitless health, but little cash. (It is often said that the young think they are immortal, is this what that stupid phrase means?) Consuming Coke is, therefore, much cheaper than gourmet vegetarian food, when we consider cost as including both cash and health. As you age, most of us get more income, while our health dwindles, and high-end vegetarianism becomes increasingly attractive. So it is rational to specialize in health-destroying behaviors when you are young. 

This is obvious, and likely has been written about many times before. The point is just to underscore the challenge of promoting healthy behavior in kids.

eHealth technology enhances active self care, but is not a substitute for it

post by Bill Gardner

Here is a cool new eHealth technology: a bone cast with wireless telemetry of muscular activity. It is

threaded with electromyographic (EMG) sensors that track muscle activity around a fracture site. Created by Pedro Nakazato Andrade, a recent graduate of the Copenhagen Institute of Interaction Design, the cast can relay data wirelessly to physicians and physical therapists. It shows how much mobility a patient has in an affected area and how physical therapy and daily activity are affecting the area, allowing clinicians to adjust treatment accordingly.

The key thing this device does is measure "how physical therapy and daily activity are affecting the area." It is not, itself, a device with therapeutic activity. More to the point, it does nothing if you are not doing your physical therapy -- which is most of us. eHealth will fundamentally change health care only in the context of interventions that successfully engage patients in self-care. 

I've overstated the point somewhat. My motivation to adhere to my physical therapy regimin will likely increase if that I know (or at least believe) that that regimin will work. So if the smart cast makes therapy more effective, I'll be more likely to do it.

The problem is that eHealth technology is often presented as if it were a pill: you put it on and you get better. Rather, you put it on, and your self-care becomes more effective. And getting patients to effectively and consistently care for themselves is the hardest problem in chronic care. 

Jimmy Connors was once asked, what are the most effective exercises to improve your tennis?Connors: "The ones that you will actually do."