The truth is a lot more disturbing.

Slightly more than four out of five seniors who receive cardiopulmonary resuscitation in hospitals die before it's time to be discharged. That number hasn't changed substantially since 1992, even though CPR practices are constantly updated, according to a new study published today in the New England Journal of Medicine.

Put another way, about 18.5 percent of elderly men and women who get CPR in hospitals end up going home or to another medical facility.

Why?  Seniors in hospitals are sicker than ever, many with multiple chronic conditions.  When their hearts stop that's often a sign that an underlying illness is worsening and death approaching, says the lead author of the study, Dr. William Ehlenbach, senior fellow in pulmonary and critical care medicine at the University of Washington, Seattle.

CPR isn't anything like what's portrayed, he noted.   Doctors don't push down carefully on the patient's chest;  they slam down hard, trying to restore a heart beat and keep blood flowing. Often, families are shocked by the intensity and invasiveness of the intervention and ask whether it's painful.  "It's difficult to know," Ehlenbach says, candidly, adding that it's relatively common for families to decide after witnessing CPR that they don't want an elderly loved one to go through that again.

The most surprising finding in the study was a 37 percent increase in the proportion of hospitalized seniors receiving CPR in the period studied, from 1992 to 2005, Ehlenbach says. Altogether, the authors reviewed records for 433,985 hospital patients age 65 and up who underwent CPR during that period.

"Our care may be getting more aggressive rather than less aggressive, and that's a concerning finding," he explains.   It may be that patients and their families aren't sufficiently informed about the limitations of CPR, he speculates, or it may that medical practices are shifting.  More research is needed to tease out what's going on, he proposes.

For Ehlenbach, the new study reinforces the need for more education about CPR in the hospital setting and the prospects for patients.  Other research has shown that when patients are asked about CPR and presented with hypothetical survival rates, they're less likely to choose the intervention when the likelihood of survival is lower.

It's worth noting that CPR is performed in hospitals for anyone with cardiac arrest who doesn't have a "do not resuscitate" order.  If patients and their families haven't discussed the issue, doctors will do what they can to restart a person's heart, regardless of the odds of success.

Once this condition was thought to be rare.  But new research shows it's more common than previously thought and rising sharply.

Dr. Joseph Murray, a professor of medicine and immunology at the Mayo Clinic in Rochester, Minn., documents the upward trend in research published today in the journal Gastroenterology.

For the study, the physician examined blood samples gathered from people at Wyoming's Warren Air Force Base between 1948 and 1954 and compared them with samples taken recently from residents of Olmsted County, Minn.  He then matched the two databases by an individual's age.

Murray's analysis showed that young people today are 4.5 more likely to have celiac disease than they were in the 1950s.  "Celiac disease has become much more common in the last 50 years and we don't know why," Murray said. The illness now affects about one in a hundred people.

Auto-immune disease in general are increasing, and some scientists hypothesize that's because hygiene has improved considerably, exposing people to fewer germs and leading their immune systems to become less robust.

Also, the nature of wheat itself (the varieties grown) has changed in the past half century, as have methods for processing grains, Murray noted.  "Something has changed in our environment to make [celiac disease] much more common," he said.

Often, this illness, which has a broad array of vague symptoms, goes undiagnosed.  Symptoms include diarrhea (especially stinky, gray colored stools), anemia, fatigue, excess gas, bloating, skin rashes, mouth sores, Vitamin D deficiency, tingling in the hands or feet, and unexplained infertility, Murray said.

His study found that people with celiac disease that went undiagnosed were four times more likely to die than those without the condition over 45 years of follow-up.

The results convince Murray that testing for celiac disease should become more widespread.  People who should be tested include those with a family history of gluten intolerance, people with Type 1 diabetes or a family history of Type 1 diabetes, patients with irritable bowel syndrome (which is often mistaken for celiac disase), women and men with early onset osteoporosis, and people with anemia, he said.

A simple blood test is over 90 percent accurate, but it needs to be followed up with an endoscopy to draw a sample from the small intestine.  With celiac disease, fingerlike projections in the small intestine become damaged and less able to absorb nutrients.

Treatment consists of a gluten free diet, and symptom relief can begin in as little as a week.  Usually, the condition is reversable with a proper diet within six months to a year, Murray said.

To see a copy of the atlas, click here and register.  (There is no charge for doing so.)

You won't get precise HIV and AIDS prevalence rates for each county;  instead, you'll discover whether prevalence rates -- the number of cases per 100,000 people -- are high, medium or low.  (There are seven gradations for prevalence rates represented by seven colors, from deep red for "extremely high" to kelly green for "extremely low.")

When you click on the Illinois map for HIV (non-AIDS) cases, you'll see that most of the state is green or yellow -- on the low side in terms of HIV penetration.  (HIV is the virus that can cause AIDS.)

Cook County is orange, signifying a large number of HIV cases.  And other Illinois areas that you might not expect are orange as well:  Brown, Fayette, Johnson, Livingston, Logan, and Montgomery counties.

A map makes it easy to visualize where public health problems are surfacing and where resources may need to be directed.

As for AIDS, the new atlas shows surprising results in Illinois.  Cook County isn't the area with the highest prevalence of people with AIDS;  Brown, Johnson and Livingston counties have that distinction.  In fact, the three counties are among 72 in the nation that have the highest concentration of residents with AIDS.  (Keep in mind these are non-urban counties with a relatively small population to begin with.)

I wonder what services for people with AIDS look like in those counties.  That's the subject for another post, but if you have thoughts to share, please do so here.

Companies may support reform in public, but behind the scenes they'll do everything they can to derail policies they don't like, claims Potter, who was for many years a consummate industry insider.

The industry didn't keep promises made the last time health reform was on the table in early-1990s and this time shouldn't be trusted to voluntary adopt policies in consumers' best interest, Potter says.

Now that he's left Cigna he's discussing insurance practices and what he considers the industry's worrisome strategy vis a vis health reform.

Potter talked recently to Trudy Lieberman, director of the health and medicine reporting program at the City University of New York journalism school.  I include a section of their provocative interview -- a one-sided perspective, to be sure, but one worth hearing -- published in the Columbia Journalism Review, below.

TL: How do companies manipulate the medical loss ratio?  [The portion of the premium dollar that is paid out for medical claims.)

WP: They look at expensive claims of workers in small businesses who are insured by the company, and the claims of people in the individual market. If an employer-customer has an employee or two who has a chronic illness or needs expensive care, the claims for the employee will likely trigger a review. Common industry practice is to increase premiums so high that when such accounts come up for renewal, the employer has no choice but to reduce benefits, shop for another carrier, or stop offering benefits entirely. More and more have opted for the last alternative.

TL: What tactics do they use in the individual market?

WP: They rescind policies when a review indicates that an individual has filed a lot of expensive claims. They will look for conditions that were not disclosed on the application. Often the policy likely will be canceled and the individual left without coverage. Sometimes people aren’t aware that they have a pre-existing condition. It might be listed in the doctor’s notes but not discussed with the patient.

TL: One way to end this practice might be to regulate it out of existence. Can we count on the industry to submit to more stringent regulation?

WP: The industry says it will accept more regulation, but the evidence is that it flaunts regulation on the books now. Insurers are often cited for violations of many state regulations, and they usually agree to settle with insurance commissioners or the attorney general and pay a fine. Fines are the cost of doing business, and even if the fine is several million dollars, it is inconsequential compared to profits insurers make.

TL: What can we expect from insurers as this reform discussion continues?

WP: Until there is actual legislative language, we will see the industry continue to be in favor of reform and portray themselves as coming to the table with solutions. They will try to persuade reporters that the industry has changed this time. They are saying the same things now that they said before. A lot of young reporters weren’t around then, and don’t know what they said in ’93-’94.

TL: What can we expect from insurers after the bill language appears?

WP: It’s what we won’t see—what goes on behind the scenes—that will be most important. The industry conducts what I call duplicitous PR campaigns—one of which I refer to as the charm offensive. They talk about how much they are committed to reform. But, behind the scenes, they are financing efforts to kill elements they are opposed to, or they kill reform entirely. They will work through what they refer to as “third-party advocates”—people and groups that are ideologically aligned with them—and use their PR firms and lobbyists to do that work. These surrogates will reach out to radio and TV talk show hosts and conservative editorial writers. Insurers will also activate their grassroots organizations—their employees, businesses, and political allies—and if their ability to make money in the Medicare program is threatened, they will reach out to senior citizens enrolled in their plans. Activities range from sending industry-written letters and e-mails to lawmakers and the media to flying people to Washington to lobby on their behalf. These are called fly-ins.

TL: Who are the industry’s grass tops, and how do they work?

WP: Grass tops are corporate executives and business leaders who develop relationships with elected officials. Insurance company executives routinely go to Washington to meet with members of the House and Senate. Companies’ lobbyists regularly meet with their staffs and bring plenty of “leave-behinds,” such as carefully crafted position papers and talking points.

TL: How much weight does that carry?

WP: Quite a bit. Even if an executive meets with a Democrat not perceived as an ally, just a meeting and an offer to be supportive is worthwhile. It improves or forms a relationship that might not otherwise take place. Executives want to be perceived as reasonable and cooperative—as people who have their constituents in mind. The executives don’t go to Congress to talk about medical loss ratios and profits.

TL: What else will we see?

WP: We will see front groups formed to attack any legislation or parts of legislation the industry doesn’t like. They’ve done this in past campaigns. They will use front groups to rip legislation to shreds. It’s inevitable that will happen again. It already is. You can be assured that the industry is behind the increasingly vocal opposition to the public plan that would compete with private insurers.

TL: Can you give an example?

WP: The Health Benefits Coalition was formed in the ’90s to fight anti-managed care legislation, including the patients’ bill of rights. It was funded primarily by big insurance companies, but it was portrayed as a broad-based business organization. The industry recruited the NFIB (National Federation of Independent Business) to be the primary spokesperson. Insurers and the NFIB have had a long history of being allies.

TL: Can you explain how the industry organized to fight Sicko a couple of years ago?

WP: Through one of its PR firms, it orchestrated a huge behind-the-scenes campaign that involved giving industry allies, including columnists and editorial page editors, very selective and often misleading information about the shortcomings of other countries’ health systems that were depicted as socialistic or government controlled. It created a front group to churn out press releases and statements criticizing the movie, and warning about long waits for care in Canada and the U.K. That’s what went on behind the scenes. What the PR firm advised insurance executives to say to the press was quite different. You might recall hearing executives and industry spokespeople dismissing Michael Moore as an “entertainer” and quickly adding that the movie served a useful role in focusing attention on the need for meaningful health care reform.

TL: What practices will the industry fight to the death to keep?

WP: They will fight to keep flexibility to design benefits as they see fit; in other words, low-cost policies that don’t cover very much. They will insist on flexibility to continue designing more products that shift the financial burden to consumers. That will enable them to market leaner benefit plans, and it will let them market “voluntary” plans to certain employers that have high employee turnover. These plans don’t require financial participation by employers. Insurers want to have the flexibility to continue designing plans that cover less and move further and further away from the concept of insurance to personal responsibility. Insurers want people to have “more skin in the game,” and they want to have less.

TL: What else will they fight strongly for?

WP: They will fight to keep the ability to base rates on age. That will be a way to keep charging the most to people who are likely to be the sickest. That will enable them to offer cheaper policies to younger and healthier people, and that is the market where the competition will be.

TL: If there is an individual mandate, how will the industry benefit?

WP: They have the potential for millions of more health plan enrollees. The ability to have flexible benefit design and base rates on age will allow them to design plans to maximize their profitability.

TL: Why is the industry so powerful?

WP: Over the many years, their PACs and individual executives have contributed to many political campaigns. They’ve hired former members of Congress as lobbyists, such as my former colleague Bill Hoagland, who was a top aide for Senate majority leader Bill Frist and now heads CIGNA’s government relations operation. All the companies have independent lobbying firms working for them. Some are close to Democrats and some are close to Republicans.

TL: How else has the industry strengthened its grip?

WP: Consolidation in the industry into seven dominant carriers makes it more powerful. It has strengthened its grip through mergers and acquisitions. A consequence of this is that, as a few insurers have grown to dominate local markets, doctors and hospitals have organized themselves into powerful conglomerates. As a result, insurers don’t have the bargaining clout they once had with providers and have lost the ability they once claimed to have to control medical costs.

TL: Why is the industry scared of a public plan that would look and act like Medicare?

WP: A public plan could offer the same benefits as a private plan at less costs because it would not have the high administrative costs—which include sales, marketing, and underwriting expenses—associated with most private plans. It would not be under constant pressure from Wall Street to reward shareholders by constantly keeping an eye on the medical loss ratio and earnings per share, another key measure of profitability.

TL: Are the members of Congress who are most vocally against a public plan aligned with the industry?

WP: Yes. One of the things they can exploit is to talk about how a government-run plan would wreck the free market system in health care. Many members of Congress believe the free market can still work with health care.

TL: Can it?

WP: There’s no evidence that it has worked since the Clinton plan failed.

TL: Will we see a reprise of Harry and Louise? [An industry-sponsored ad campaign against the Clinton health reform plan.]

WP: No. The industry knows its image is at an all-time low. So the industry can’t be as obvious in attacking a plan as it was in 1994. They will work through front groups and allies to attack it through ads and commercials.

Increasingly, that's the mantra of experts in Alzheimer's disease, a condition that robs people of their memories and ability to think.

The Alzheimer's Association is highlighting the message in a new media campaign that began last month on television and is continuing with print ads in local markets.

How does this work? And why deliver a diagnosis of Alzheimer's, an incurable condition that many older people fear, sooner rather than later?

If a family member is becoming confused and forgetful much more often, experts recommend a brief test that can suggest potential dementia. (For 10 possible warning signs of dementia, go the Alzheimer's Association Web site, www.alz.org.)

The most common is the Mini Mental State Exam, which asks takers to name several objects, identify the year, date and season, and count backward, among other tasks.

Limitations of the exam include its length and relatively poor ability to identify people with mild cognitive impairment, explained William Thies, chief medical office for the Alzheimer's Association. Mild cognitive impairment is often a precursor to dementia.

A new test by researchers in Britain, called Test Your Memory, may become an alternative. In a recent article in the British Medical Journal, researchers reported the five-minute, self-administered exam detected 93 percent of patients with Alzheimer's.

These brief cognitive tests are "a first step," said Dr. Raj Shah, an Alzheimer's expert at Rush University Medical Center in Chicago. Further evaluation involves ruling out other conditions that can compromise memory, such as stroke or depression, and taking a thorough history with the person and a family member.

Often, more extensive cognitive testing will also be ordered. "It's unrealistic to expect a very brief test to discriminate between normal aging and mild cognitive impairment," said Dr. Ronald Petersen, head of the Mayo Clinic's Alzheimer's Disease Research Center.

What's the value of a diagnosis?

People with mild cognitive impairment or early-stage Alzheimer's can make lifestyle changes -- exercise more, eat diets rich in vegetables and fish, engage in cognitively stimulating activities -- that may improve their quality of life, Shah said.

Also, people who receive diagnoses early can participate in decisions about their treatment and connect with community resources. For instance, those newly diagnosed could put their financial affairs in order or get counseling for depression.

It's important to note that the Food and Drug Administration hasn't approved any medications for use in people with mild cognitive impairment. Researchers have tested drugs commonly used to treat Alzheimer's in these patients, but results are inconclusive, Petersen noted.

With Alzheimer's disease, the medications produce a slight benefit -- a relief of some symptoms for 6 to 12 months for about half of people who take them. No medication has been shown to alter the disease's progression.

For all the emphasis on early detection, many people may not want to know they're at risk for Alzheimer's disease. Indeed, almost two-thirds of people with dementia haven't received a diagnosis, the Alzheimer's Association reports. Currently, 5.3 million Americans are living with Alzheimer's disease.

Of course, the White House vigorously supports the need for a health care system overhaul.  But many experts are worried about our ability to pay for plans under consideration.

Illinois-specific data released by the White House is far from comprehensive.  It includes the following information: 

*  Since 2000, the cost of premiums for a family's insurance has skyrocketed 89 percent in Illinois.  The average price of family coverage in the state is now $13,630.

*  13 percent of state residents report not visiting a doctor due to high costs.

*  14 percent of state residents are uninsured.

*   Providing care to the uninsured adds $1,200 yearly to the cost of an Illinois  family's premiums for health insurance.

*   Only 41 of small businesses in Illinois offer their workers health care benefits -- down 7 percent since 2000.   Altogether, 64 percent of Illinoisans get health care through the workplace, down from 67 percent in 2000.

*   Insurance companies in Illinois are free to deny coverage to individuals based on pre-existing conditions or exclude pre-existing from insurance plans that are offered.  Insurers can also raise rates for people who are sick.

*  Preventive care in the state is deficient.  Almost one in four Illinois women (22 percent) over the age of 50 haven't had a mammogram in the past two years.   Four out of every 10 men over age 50 have never been screened for colorectal cancer.  One in every five children in Illinois is obese.

Separately, the federal Agency for Healthcare Research and Quality also released today its second annual update on the quality of health care in Illinois.  For a copy of that report, click here.

It's disturbing that the quality of care has fallen in several domains, according to the agency's data.  Noteworthy are declines in the quality of care at nursing homes and for people with chronic health conditions.

Improvements occured in quality for patients with heart disease and diabetes, as well as maternal and child health.  Unfortunately, care remained notably weak  in Illinois for patients with cancer and respiratory conditions. 

This should be the central question that policymakers ask and the primary issue they address in public discourse.  Everything flows from it.

Yet the current debate about overhauling health care isn't usually discussed in these terms.  Instead it's about policies that most people don't understand.

Take the debate over whether a public plan should be available to people under 65 as an alternative to private insurance.   Does anyone really believe that this is a burning issue for consumers?

I don't think so.  What people really want, I think, is a sense of security -- a sense that there is an insurance option available if they lose a job or become sick or disabled and unable to work.

For this kind of security, people appear willing to pay extra taxes, the New York Times reported on Sunday. 

This willingness to make tradeoffs isn't attached to the notion of a public plan.  It's attached to the idea that "I'll be able to get medical care when I need it."

What else do people want when it comes to health care? I suspect they want doctors who deliver top-notch care, spend time talking with them about what's wrong, and coordinating with other providers.

People value the ability to choose their doctors.  And they want these doctors to be able to tailor treatment plans that make the most sense for them.

Pay-for-performance or bundled payments --  policy options getting attention in Washington -- don't mean a thing to consumers.  They don't address a more basic challenge:  making it possible for everyone to find a doctor they can trust to manage their care.

Every day I hear from people who say they wish the health care system was simpler and easier to navigate.  I bet consumers would vote to reduce the mind-numbing complexity of the current system, if asked.

The scariest thing in the world is to have a serious medical condition, like cancer, and not be able to afford the drugs that have been prescribed or the surgeries that have been recommended.

Or to have a sick child and no money to pay for the bus that could take you to the nearest community health center.

Or to have a chronic illness, like congestive heart failure, and no wherewithal to pay for help that can cook your food, bathe you, help you go to the toilet, or help you get into bed at night.

Of course, people want to be able to afford these services. 

Yes, many people want a lot more -- every medical trick in the book, the latest technology, a medicine cabinet full of medications.   Most Americans still believe more is better when it comes to medical care.  They're wrong, of course, as we've learned most recently in the New Yorker courtesy of Dr. Atul Gawande.  Often, more medical care is simply unnecessary, expensive and produces worse outcomes.

Changing this expectation -- that more is better -- is an enormous challenge.

What does this add up to?  

Health reform makes sense only if it addresses what people want from the health care system.  If it makes medical coverage more secure and easier for doctors to attend to patients, simplifies the system and lower costs, then there's a strong case to be made for change. If reform proposals undermine the security of insurance coverage, raise costs, sustain complexity and make it more difficult for doctors to offer care, they're counterproductive.

Politicians have yet to consistently articulate the case for specific plans being floated in the nation's capitol in these terms.

Ultimately, I'm not sure if most Americans really care whether medical coverage comes from the government or from private insurers.  I strongly suspect what they care about is whether health insurance is available, whether they have a choice of medical providers, whether doctors are free to pursue their best medical judgment, whether medical services and coverage are affordable, and whether they can make their way through the health care system with a minimum amount of hassle.

Seen through this prism, the terms of the great debate underway seem, unfortunately, off the mark. 

On average, one out of every 14 patients with clinically significant abnormal results -- for instance, a stool test that shows signs of blood -- don't get this information from their doctors, according to a new study today in the Archives of Internal Medicine. 

That's a dismal performance and one with dangerous consequences.  "Failure to report abnormal test results can lead to serious, even lethal consequences for the patient," said Dr. Lawrence Casalino, chief of the division of outcomes research at Weill Cornell Medical College in New York City. 

Fortunately, the problem can be fixed by changing medical office practices, the researchers found.  It's an example of how health care can be improved from the bottom up, without great expense or government intervention.

Instituting clear procedures for handling test results is key.  Doctors' offices without these procedures dropped the ball for as many as one in every four patients;  those with standard procedures did so very infrequently or not at all.

"In many cases, physicians and their staff told patients that 'no news is good news' -- meaning they should assume that their tests results are normal unless they are contacted," Casalino said. "This is a dangerous assumption."

The new study recommends that patients call for results after a certain period of time if they haven't heard from their doctor.  Every responsible physician should get a copy of lab result, sign it, and inform patients directly of the results or ask staff to do so, the authors say.  Also, staff should document that a patient has been informed of a test result each time this occurs.

"With good processes, we can ensure that patients with abnormal lab results get proper follow-up," said Dr. Alvin Mushlin, chair of the department of public health at Weill Cornell Medical College.

Researchers from Northwestern University Feinberg School of Medicine, the University of Chicago, and Rush University Medical Center participated in the research study.

Their new Internet site, www.LifelinetoModernMedicine.com, is an effort to get in the game and disseminate consumer-friendly information. (Public access is available starting Monday.)

Anesthesiologists administer pain eliminating, consciousness dimming medications to patients in more than 46 million surgeries each year.

Dr. Roger Moore, president of the American Society of Anesthesiolgy, admits his professional society's Web site -- being launched Monday -- isn't very sophisticated.  But he vows that the organization will update it regularly and improve it over time.  (Orders have already gone out to install a search engine.)

Most useful currently is the frequently asked questions section, an anesthesia checklist that the organization advises people to fill out and keep in their wallets, and descriptions of anesthesia options for childbirth and sleep apnea.

Then, they lied about the neglect and falsified medical records.

The Associated Press recently reported on the findings of a report by New York City's Department of Investigation, which discusses the cover-up.  The AP wrote:

"The report said that shortly after Green died, a senior nurse at the hospital, Aida Gonzalo, made three false entries in a medical record to make it appear as though she had been checking regularly on her patient."

"In actuality, the report said, Green had been ignored for hours -- a fact confirmed by security camera footage of her collapse and slow death."

"The Department of Investigation said the nurse subsequently admitted in an interview that she fabricated the entries because she was afraid of losing her job, but lied to authorities about the nature of those inaccuracies."

"Separately, a nursing aid made entries in a hospital log falsely indicating that he had observed Green alseep during the hour when she was actually lying face down on the floor dying, the DOI report said. The aide, Royal Easton, later admitted that he had not seen Green during the critical time period, according to the report."

Two doctors, Dr. Rashed Abedin and Dr. Dimitru Magardician, who appear on the security tape showing Green dying, invoked the Fifth Amendment when questioned by authorities, WPIX in New York reported.

Six staff members lost their jobs over the incident, the AP notes.  Now the question is whether some hospital staff might face criminal charges.

A year later, the indifference to the suffering of this poor woman still shocks.  We all know that people who work in health care can develop a hard skin.  But in this case, the extent of staff's callous disregard for a patient -- and concern for their own self interest -- remains unfathomable.

For my previous posts on Esmin Green, click here, here and here.