Health Services Researcher

Health reform repeal

2011-02-01T12:34:00.001-08:00

Here's an article in the New Republic that discusses legal challenges to health reform. And here's a post from The Incidental Economist that explains why the mandate is very similar to other government programs that try to use economic incentives to get us to do stuff.

It seems to me like the Democrats have totally screwed themselves by not structuring the mandate like a tax deduction, but I think they thought they'd be in safe territory since the mandate thing was a Republican idea to start with.

The States’ Next Challenge — Securing Primary Care for Expanded Medicaid Populations

2011-01-26T19:35:00.000-08:00

New paper in NEJM from researchers at the Department of Health Policy, George Washington University, Washington, DC.

A nice analysis. I hope to do something along these lines - related to health reform, modeling the impact under different assumptions - for my dissertation.

Will health services research determine whether health reform succeeds? - Something Not Unlike Research

2011-01-26T17:16:00.000-08:00

Will health services research determine whether health reform succeeds?

Bill Gardner totals up the length of time necessary to do a pilot study of a health systems intervention (like a new care delivery model or physician payment program), get funding, do a larger-scale study, then publish the results: up to 10 years. Then there's a lag between the publication and the implementation by other healthcare systems. That can take another 10-15 years. Sounds similar to the lag described in the Institute of Medicine's Crossing the Quality Chasm report:

It now takes an average of 17 years for new knowledge generated by randomized controlled trails to be incorporated into practice, and even then application is highly uneven.

The lag between the introduction of a new technology or system and its widespread adoption is of great interest to me. Much of the research I've read is either coming at it from a diffusion of innovations perspective or an evidence-based medicine approach. This whole area is touchy for some doctors, and given that a third of US doctors are over 65 and older doctors tend to be slower to adopt new things, I think we need more levers to move clinicians to adopt better practices. And if that means putting them all on salary, I'd be okay with that.

Why home-based primary care is needed

2011-01-24T19:25:00.000-08:00

A doctor posed this question in the ethics column in the New York Times magazine yesterday:

My elderly aunt became ill and phoned me, a physician, to ask if she should call an ambulance. I surmised that she was severely dehydrated. From my hospital, I took a bag of saline, IV tubing, an IV lock and a needle. An unsuspecting nurse handed me the tape that secures the needle. I gave my aunt these fluids at home, and she soon felt better, as did I: my stealing $50 worth of medical supplies saved the taxpayers more than a thousand dollars for an E.R. visit. Did I do right? E.G., NEW YORK

The ethicist, Randy Cohen, replied in part:

I should offer a word in your defense from another doctor, Paul R. Marantz, director of the Center for Public Health Sciences at Albert Einstein College of Medicine, who acknowledged that what you did was stealing, but said in an e-mail that “purloining $50 (more likely $20) worth of medical supplies while saving hundreds (more likely thousands) seems a good choice compared with the more burdensome alternative of a visit to the E.R.” I agree that those who practice medicine in imperfect institutions might — must — sometimes choose imperfect actions, but believe that your supply-room raid still fell short.

Here's a great example of a case where home-based primary care practices can make a big impact. If a system were in place that allowed for sending a primary care nurse to the woman's home, the entire ethical problem could have been avoided.

Warnings About Statins Grow Louder

2011-01-24T16:20:00.000-08:00

Someone at Miller-McCune really doesn't like statins. Warnings About Statins Grow Louder: "New research suggests previous studies supporting widespread use of cholesterol-lowering drugs is flawed."

The research in question is a Cochrane systematic review. Here is a link to the study's abstract and "plain language summary". From the abstract:

Although reductions in all-cause mortality, composite endpoints and revascularisations were found with no excess of adverse events, there was evidence of selective reporting of outcomes, failure to report adverse events and inclusion of people with cardiovascular disease. Only limited evidence showed that primary prevention with statins may be cost effective and improve patient quality of life. Caution should be taken in prescribing statins for primary prevention among people at low cardiovascular risk.

I think what the authors are really saying is, don't prescribe pills willy-nilly unless the patient is actually at risk. Yes, prevention is worth a pound of cure and all that - but if the patient doesn't need the cure in the first place, then all you're doing is increasing the risk of side effects for no compelling reason.

Variation in Treatment Patterns

2010-12-18T15:46:00.000-08:00

Some interesting new research suggests that variation in treatment patterns may not be as closely related to how we pay for care as we once thought. Instead, it may be more related to how doctors are trained and local variations in provider culture.

The British National Health Service, in which most doctors are salaried, recently released the Atlas of Variation in Healthcare, a UK version of the Dartmouth Atlas of Health Care.

Variations in the way doctors treat patients are "independent of the way health care's organized and financed," Dr. Jack Wennberg, the godfather of Dartmouth's variation research, said in an interview here Thursday, noting that his work uncovered similar patterns in Britain and Norway in the 1970s. What matters when it comes to medical tests and surgeries, he says, is whether there's clear evidence that treatments work.

(h/t: Kaiser Health News via the Incidental Economist)

Fun with data

2010-11-23T17:02:00.000-08:00

I've recently discovered that Google has embedded a fun Flash data visualization tool in Google Docs. I've tested it out using data on the amount of buprenorphine (a drug used to treat opioid addiction) distributed from 2005-2009, by state. Grams of buprenorphine are shown both overall and adjusted for the number of opioid users in each state. The other variable is the supply of physicians who are licensed to prescribe buprenorphine adjusted for the number of opioid users in each state. Check it out.

Happiness and focus

2010-11-22T20:01:00.000-08:00

I've been taking part in the Track Your Happiness project for the past few weeks, and as of today I finished the 50th sample and have access to my happiness report.

Overall, I am slightly happier at work than at home, cooking and doing homework make me happy, and I'm happiest when doing something I want to do that I don't have to do.

I found this chart especially interesting (happiness on a scale of 0 to 100 is on the vertical axis, and focus is on the horizontal axis).

Focus

Drug costs

2010-03-25T19:47:00.000-07:00

I'm working on a project involving a health economic evaluation of a clinical trial. The trial collected data on drugs prescribed for each patient over the course of, let's say, a year. My job is to assign a cost for each row in a very large Excel spreadsheet (each of which represents one prescription). The data I have are sometimes incomplete, but in general, I have: Drug Dose (a number), Drug Unit (eg, milligrams), Drug Frequency (free text), Drug Route (oral, topical, intramuscular, etc.), and Drug Name (free text).

The process involves a cumbersome program called Red Book for Windows, which allows me to look up the drugs by name or by National Drug Code (NDC) -- unfortunately, I don't have the NDC, so I have to look them up by name. The first problem is that many of the drug names don't match. Let's take, for example, ciprofloxacin, a generic antibiotic often referred to as cipro. Cipro is sold in dozens of forms (pills, eyedrops, eardrops, etc.) in dozens of strengths by dozens of manufacturers. It's listed in Red Book in lots of different ways, including: CIPRO, CIPROFLOXACIN, ciprofloxacin, ciprofloxacin/ciprofloxacin hydrochloride, ciprofloxacin HCL, CIPROFLOXACIN HYDROCHLORIDE, ciprofloxacin hydrochloride, ciprofloxacin hydrochloride/dexamethasone, ciprofloxacin hydrochloride/hydrocortisone, CIPROFLOXACIN IN DEXTROSE, CIPRO HC, CIPRO IV, and CIPRO XR.

The cost of a 500mg tablet may be listed under any of these, and I have to locate the lowest cost available (because we're using a conservative approach to costing - rather than use an average, we use the lowest cost in order to underestimate the potential burden or cost of the illness). Then I can apply that cost to all the instances where it shows up in my spreadsheet. Then I have to go find the lowest cost for 200mg delivered intravenously, and so on.

So this fun project has been eating up lots of my time lately. It's not exactly brain surgery, but it can't be automated and can't be outsourced - and it has to be done very carefully. It would go a lot faster if the Red Book program were easier to query, but, in my opinion, it's not a user-friendly application at all!

Health reform: preventive care for all

2010-03-23T18:44:00.000-07:00

I honestly didn't pay that much attention to the measures in the health reform bill. I was supportive, in theory, while being cynical about its chance of passing (especially since January) and about how much good it might actually do. But now that it's passed, I've been taking a closer look. Guess what? There are some really, really great things in the bill.

As a public health person at heart, I am especially thrilled about the measures in the bill that will encourage prevention of disease with first-dollar coverage of important screening procedures. Here are just a few of the recommended services which insurers (private and public) will have to offer and provide with no deductibles, co-payment, or co-insurance within the next 6 months:

mammography and genetic risk assessment for breast and ovarian cancer;
cervical cancer screening (Pap smears);
colorectal cancer screening;
screening adults for depression;
intensive behavioral dietary counseling for adult patients with known risk factors for cardiovascular and diet-related chronic disease;
oral fluoride supplementation to preschool children older than 6 months of age;
screening for high blood pressure in adults aged 18 and older;
screening and behavioral counseling interventions to reduce alcohol misuse by adults, including pregnant women, in primary care settings.

For the whole list, see this AHRQ page.
And for more, see this Health Reform Talk post.

Comparative effectiveness

2010-03-11T14:19:00.000-08:00

Comparative effectiveness research (CER) is the latest buzzword in my field, in large part because Obama has promoted it as an important component of healthcare reform and included $1 billion of funding for it in the stimulus bill. This Reuters article discusses a new study by Hochman and McCormick finding that only 32% of drug studies published in top medical journals compare the effectiveness of existing treatments. Most of the time, studies compare the new drug to placebo because that's what the FDA requires. In other countries, such as the UK, health technology assessments are required that compare the new drug to the standard of care.

The study is published in this week's issue of JAMA - here's a link to the abstract.

Couple of thoughts:

They only looked at articles in the six top-ranked general medicine and internal medicine journals. If I were going to try to publish a comparative effectiveness study, I would think it probably wouldn't get in to a top-ranked general journal (JAMA, NEJM, etc.), so I'd probably target it to a specialty journal.
Pharma company-sponsored research often seems to be less favorably reviewed than academia-sponsored research, plus companies are often in a hurry and don't want to go through the excruciatingly long review processes at the top journals.
They point out the lack of cost-effectiveness (CE) studies. Again, if I were going to try to publish a CE study, JAMA and NEJM would be my last choice for a target journal unless I thought I had a real blockbuster... they just don't publish many CE studies.

In short, I think this study is majorly confounded by the conventions of the medical publishing world.

Lit review methods at the abstract stage

2009-11-06T10:53:00.000-08:00

With the volume of medical literature that's published, even a relatively narrow search may get thousands of hits in PubMed. A lot of people have published on the topic of rating full text articles - see this, for example - but when you're doing a large-scale lit review, it's often necessary to do some paring down at the abstract stage.

What I usually do is work through my pile of abstracts (easiest for me to do this on hard copy) and make clear notes on each one about whether or not it fits my search criteria. This is usually not that hard.

For example, say I'm doing a lit review of cost-effectiveness of treatments for multiple sclerosis. Up front, I have a list of reasons for excluding articles altogether:

Not an economic analysis
Review/opinion article with no meta-analysis
Fewer than 30 subjects per study arm
Trial not conducted in a relevant country (often I'm looking specifically for US studies)
Study concerns a treatment that is no longer in use in the US
etc.

Once I have narrowed it down to just the abstracts for articles that might contain something relevant, I usually pull the full texts of all of them. Even if a particular article itself isn't useful, I still need to go through each bibliography to identify articles that I may have missed in my searches of lit databases.

Mistakes Were Made

2009-10-15T16:19:00.000-07:00

Database analyses are the hardest part of our work, in my opinion. I've mostly managed analyses of large government databases so far - like Medicare claims data and data from the Hospital Cost and Utilization Project (HCUP). The difficulty is really that it's hard to know when you get the wrong answer. If you get something that looks right, you have to pretty much trust it once you've checked all the SAS code and any formulas used to get results into Excel or wherever the results are being displayed.

It's different from clinical trial data analysis because in a clinical trial, you always have a source document to go back to. The source data in a large government database are often so numerous that it's really hard to go back and verify that the analysis is correct. I guess it's similar to modeling in some respects, but models can often be recreated in another language to verify the results. Databases could conceivably be analyzed in multiple programs (like SAS and STATA, for example), but that would probably add 10-25% to the timeline and budget. In my small company, at least, we don't have the luxury.

At least the error I caught today was detected before we had already published the results!

Evaluating a Job Offer

2009-10-14T19:00:00.000-07:00

I've been at my current job for 3 years now, and while I'm generally satisfied, I have occasionally looked around for other opportunities. Earlier this year, I received a very generous offer from a competitor. Of course, as everyone knows, job satisfaction is about more than money. Here's my little system I use to help me in the decision making process. It mainly consists of a cost/benefit matrix. Here's how part of my matrix looked:

Pros of staying at current job	Cons of staying at current job
Comfortable/known quantity Nice office Decent commute (bike-able) Get closure on long-standing projects More time in one place on my resume ...	Less money Less support for school/conferences/professional development Same title for the foreseeable future Stagnation? ...
Pros of going to competitor	Cons of going to competitor
More money Better support for conferences/prof dev/classes Better title now and more opportunity for advancement later New challenges and more opportunity for learning ...	Longer commute/not bike-able Longer hours Fewer publication opportunities ...

As you can see, this matrix is different for every situation, but it helps to brainstorm and list everything, no matter how minor. This system allows me to really think through the decisional balance process!