Category: Health

   Source of graph:  online version of the WSJ article cited below.

When it comes to managing its citizens’ health, the U.S. is a model of inefficiency.

Recently released figures from the U.S. Centers for Medicare and Medicaid Services show that in 2005, the U.S. health-care tab came to 16% of gross domestic product, more than any other country. France spends 10.5% of its GDP on health care, according to the Organization for Economic Cooperation and Development, while Japan spends 8%.

Americans don’t seem to be getting much for the money. In both France and Japan, the average life expectancy is higher than in the U.S., and the infant mortality rate is lower. This is true in most other OECD countries, so green tea and red wine don’t explain it all.

This is a drag on U.S. companies, raising their costs, pulling money out of consumer pockets and giving overseas firms a competitive edge.

For the full commentary, see: 

JUSTIN LAHART.  "AHEAD OF THE TAPE; Rethinking Health Care And the GDP." The Wall Street Journal (Thurs., January 25, 2007):  C1.

   Source of graphic:  online version of the NYT article cited below.

EXPERTS have long been puzzled by the existence of large regional disparities in medical care in the United States. Even for diseases for which the appropriate treatment is widely accepted, doctors across the country take vastly different approaches, often leading to enormous expense without making any appreciable improvement in their patients’ health.

Consider heart attacks. Prescribing beta blockers immediately after a heart attack is a well-established, cheap and efficient treatment. In Iowa, nearly 80 percent of victims in 2000 received the drugs within 24 hours of a heart attack. In Alabama or Georgia, by contrast, fewer than 6 out of 10 patients received the drugs.

“What makes the lag in beta-blocker adoption puzzling is that the clinical benefits have been understood for years,” wrote Jonathan S. Skinner and Douglas O. Staiger, economists at Dartmouth, in a recent study about these regional patterns.

Congress has decided that some treatment decisions may be best taken out of doctors’ hands. In one of their last acts this year before adjourning, lawmakers passed a bill entitling doctors to a bonus from Medicare if they report data on the quality of their care, using criteria like whether they prescribe aspirin or beta blockers to heart attack victims. In the future, this data would permit Medicare to reward doctors who followed government guidelines.

. . .

. . . , much spending on health care provides enormous benefits. A study published this year by Mr. Skinner, Mr. Staiger and Dr. Elliott S. Fisher of Dartmouth Medical School found that Medicare spending on hospital care for heart attack victims surged two-thirds from 1986 to 1996, after accounting for inflation. But the percentage of victims who were alive a year after their attacks also increased, though by just 10 percentage points, to roughly 68 percent.

The relationship — rising costs bringing increased benefits — has broken down recently. From 1996 to 2002, Medicare spending on treatments for heart attack victims increased about 14 percent, after inflation. But there was virtually no improvement in survival rates.

There is mounting evidence that the zeal to treat and spend may actually hurt patients. The study by Mr. Skinner, Mr. Staiger and Dr. Fisher found that hospitals in regions where spending grew fastest from 1986 to 2002 had some of the worst practices, in terms of providing tried-and-true therapies, and recorded the smallest gains in survival rates.

Treatment of heart disease underscores the deeply idiosyncratic nature of many choices made by America’s doctors and hospitals. Coupled with a fee-for-service system that encourages aggressive treatment, these choices stimulate health spending that provides little benefit to patients. “A lot of the innovation and spending growth are going into gray areas that are not helping people that much,” Mr. Skinner said.

For the full commentary, see: 

EDUARDO PORTER.  "ECONOMIC VIEW; The More You Pay, the Better the Care? Think Twice."  The New York Times  (Sun., December 17, 2006):  5.

(Note:  ellipses are added.)

Another lesson from an intriguing book by Steven Johnson, is that Edwin Chadwick’s good intentions were not enough to beat the cholera epidemic in London.  Johnson tells of Chadwick’s two catastrophic illusions:

The first was his belief that, since the mephitic odors of private cesspools posed such a clear and present danger to health, sewage ought instead to be discharged down public drains into the Thames, from which most Londoners took their drinking water. As the great builder Thomas Cubitt remarked: "The Thames is now made a great cesspool instead of each person having one of his own."

The consequences of this well-intentioned blunder were worse even than those of the decision of the Lord Mayor during the Great Plague of 1665-66 to exterminate all the city’s dogs and cats because of the false rumor that they were spreading the plague, thus allowing an exponential increase in the population of the rats who were the real transmitters.

Having contaminated a large part of the population he was trying to protect, Chadwick committed his second mistake, sternly setting his face against the simple explanation that would bring about a cure. To his dying day — which did not come until 1890 — Chadwick remained an unrepentant miasmatist, as proponents of the airborne explanation for cholera were known. So was Florence Nightingale. The Lancet, the leading medical journal, venomously denounced the waterborne theory and its dogged proponent, John Snow.

For the full review, see: 

FERDINAND MOUNT.  "BOOKS; Lost in a Time of Cholera; How a doctor’s search solved the mystery of an epidemic in Victorian London."  The Wall Street Journal   (Sat., October 21, 2006):  P8.

The reference to the book is:

Johnson, Steven. The Ghost Map: The Story of London’s Most Terrifying Epidemic – and How It Changed Science, Cities, and the Modern World. New York: Riverhead Books, 2006.  299 pages, $26.95

   Source of graph:  online version of NYT article cited below.

WASHINGTON, Jan. 8 — Spending on health care in the United States increased in 2005 at the slowest pace in six years, mostly because of much slower growth in spending on prescription drugs, the government reported Monday.

It was the third consecutive year of slower growth in the nation’s medical bills. Total health spending reached nearly $2 trillion in 2005, growing only a bit faster than the economy as a whole, officials said.

But with new medical technology becoming available every month and with a generation of baby boomers approaching old age, federal officials made no bold claims about having tamed health costs.

“It is unclear whether this phenomenon is temporary or indicative of a longer-term trend,” said Aaron C. Catlin, the principal author of the government’s annual report on health spending, published in the journal Health Affairs.

For the full story, see: 

ROBERT PEAR. "In ’05, Medical Bills Grew At Slowest Pace in 6 Years."  The New York Times  (Tues., January 9, 2007):  A13.

Most people have of a clear image of how atherosclerosis, popularly known as hardening of the arteries, causes a heart attack — fatty deposits called plaque build up in a coronary artery until the day the blood flow that sustains the heart is blocked.

If only they were right.  In reality, severe coronary artery blockages almost always cause chest pain known as angina and other symptoms as they form.  But among those who suffer heart attacks, half of the men and two-thirds of the women report never experiencing a warning symptom.  And autopsies of such victims frequently show blood clots jammed into arteries that have been only modestly narrowed.

Standard atherosclerosis therapies include bypass surgery to route blood around blockages, angioplasty and stenting to clear blockages from inside the artery, and drugs like statins that reduce cholesterol levels to slow the formation of plaque.  But they have not been enough to prevent 200,000 to 500,000 American deaths annually from what doctors refer to as coronary artery disease.

As a result, many researchers have turned their attention from atherosclerosis in general to the tendency of some patients to develop a form of plaque prone to inflammation and rupture, which can spill a stew of cells into the bloodstream that can incite rapid clotting.  Such plaques have been called ”vulnerable” plaque. 

For the full story, see:

BARNABY J. FEDER.  "In Quest to Improve Heart Therapies, Plaque Gets a Fresh Look."  The New York Times  (Mon., November 27, 2006):  C1 & C3.

   Source of graph:  online version of the NYT article cited below.

For years, patients and many doctors assumed that a colonoscopy was a colonoscopy.  Patients who had one seldom questioned how well it was done.  The expectation was that the doctor conducting the exam would find and cut out any polyps, which are the source of most colon cancer.

But a new study, published today in The New England Journal of Medicine, provides a graphic illustration of how wrong that assumption can be, gastroenterologists say.  The study, of 12 highly experienced board-certified gastroenterologists in private practice, found some were 10 times better than others at finding adenomas, the polyps that can turn into cancer.

One factor distinguishing the physicians who found many adenomas from those who found few was the amount of time spent examining the colon, according to the study, in which the gastroenterologists kept track of the time for each exam and how many polyps they found.

They discovered that those who slowed down and took their time found more polyps.

. . .

The Rockford study was preceded by other signs that colonoscopies are by no means foolproof.   But as problems have been pointed out, they have all too often been met with disbelief among doctors, Dr. Rex said.

The first indication that colonoscopies were not as effective as widely believed came with two studies, one in 1991 and a larger one, in 1997, in which patients had two colonoscopies on the same day.  Those studies showed that doctors were missing 15 to 27 percent of adenomas, including 6 percent of large adenomas.

Then, in the last few years, two studies of so-called virtual colonoscopies, which use a CT scan to view the colon, found that the rate of overlooked adenomas in traditional colonoscopies was even higher.  Patients in those studies had traditional and virtual colonoscopy on the same day.   Traditional colonoscopies missed 12 to 17 percent of the large adenomas detected in the virtual colonoscopies.  But many doctors dismissed those findings, saying — if they believed them at all — that they applied to other doctors, not to themselves, Dr. Rex said.

Dr. Schoen, for one, said he was a believer.  The conclusions of the adenoma detection studies were reinforced, he said, by studies finding that colonoscopies missed not just polyps but actual cancers.

That finding emerged from studies testing ideas about how to prevent polyps, like taking beta carotene or calcium pills or sticking to a low fat, high-fiber diet.

The patients in all the studies had at least one adenoma detected on colonoscopy but did not have cancer.  They developed cancer in the next few years, however, at the same rate as would be expected in the general population without screening.

. . .

The study by the group in Rockford suggests a way to improve colonoscopy:  by slowing down.  “If you rush things, you miss things,” Dr. Schoen said.

That happens in part because reimbursement rates for colonoscopies have fallen in recent years, and some doctors are doing the exams faster than ever, Dr. Schoen and others say.

“I have heard of people who do it in 30 seconds,” Dr. Schoen said.  “Whoosh, and it’s out.”

For the full story, see: 

GINA KOLATA.  "Study Questions Colonoscopy Effectiveness."  The New York Times  (Thurs., December 14, 2006):  A23.