When faked surgeries work as well as the real ones

The current issue of Health Affairs has an excellent case study of the aftermath of two rigorous 2009 studies in the New England Journal of Medicine that showed that vertebroplasty – an invasive back procedure that injects bone cement into the spine to treat fractures – offered no more pain relief than “surgeries” that were faked.

Two years later, Medicare and insurance companies continue to pay for the procedures. Science is ignored, and patients apparently are being ill served. This does not bode well for health reform’s efforts to increase comparative effectiveness research to determine the best way to treat medical conditions. There is a political constituency arrayed behind every procedure – the physician, the facility where it is performed and the medical device maker who produces medical supplies. A meek effort to stop paying for vertebroplasty by a Medicare carrier in the western U.S. was squashed by medical-lobbying forces.

In 2002, 180 patients with osteoarthritis were randomly assigned to undergo either arthroscopic knee surgery or fake surgery, although neither group was aware of the parameters. The results indicated that knee surgery provided no more pain relief or added mobility than the fake surgery. Predictably, the results were attacked by those who do knee surgeries. A second set of researchers did a similar study in 2008. The results were the same. Regardless, more than 500,000 patients spent $3 billion on arthroscopic surgery for arthritic knees in 2009.

An estimated 30 percent of medical spending is considered to be of no benefit. If the U.S. payers do not react to solid evidence such as this, we have no hope of dealing with medical costs that are overtaking government and household budgets.


Fast-food imperialism

You knew this was true. You just needed proof.

Researchers compared the number of fast-food restaurants per-capita to the obesity rate in 26 wealthy nations. They used Subway as a proxy, given that it had the most outlets worldwide in 2010.

The U.S. and Canada led the way with 7.52 and 7.43 outlets per 100,000 people respectively. About 32 percent of Americans and about 23 percent of Canadians are obese. Conversely, Japan and Norway had .13 and .19 outlets per 100,000 and obesity rates of about 3 and 6 percent respectively.

Researchers emphasized it was a correlation, not a causation.

The New York Times published an excellent piece in 2008 about how fast-food joints, pizza places and ice cream parlors have overtaken the birthplace of the Mediterranean diet in Greece.  Two-thirds of the children and three-quarters of the adults there are overweight or obese.

Greece, Italy, Spain and Morocco asked Unesco to designate the diet as an “intangible piece of cultural heritage,” which speaks to its historical importance and that it now appears to be a thing of the past in that region.

It is no coincidence that worldwide fast-food expansion coincided with the world’s expanding obesity rate. Activists used to complain about U.S. “cultural imperialism,” primarily referring to the ubiquity of U.S. movies and television shows. This kind of imperialism has caused far more damage.

More smoking parents are taking it outside

Household smoking bans

Household smoking bans are taking hold. Smoking is now forbidden in half the U.S. households that contain children and adult smokers. That rate was a paltry 14 percent in the early 1990s.

For younger children, mounting research has identified second-hand smoke as the most certain, and avoidable, asthma trigger. The longer children are exposed to second-hand smoke, the more likely they are to develop the condition. Remarkably, parents are no more likely to quit smoking or smoke outdoors after their child has been diagnosed with asthma. However, the bloodstreams of nearly nine out of 10 apartment-dwelling children contain cotinine – which  is a biomarker for cigarette-smoking exposure – regardless of whether their parents smoke because of seepage through walls and shared ventilation.

Parents have a direct impact on whether their children smoke. Parents are most effective when they specifically seek to persuade children not to smoke, do not smoke themselves and impose a smoking ban at home.

For many smoking parents, it was an inconvenience to go outdoors to smoke. Mercifully, it now is becoming a duty.

Public health is withering away

States and cities continue to hollow out the public health workforce. Officials at the Association of State and Territorial Health say an analysis of 55 health agencies shows a loss of 16,380 jobs since 2008. The health agencies also had nearly a quarter of a million furlough days in the last two years – the equivalent of 1,000 full-time jobs.

Public health gets no respect despite its considerable historical impact.

Of the 30-year increase in U.S. average life expectancy in the last century, only five years can be credited to advances in medical care. The 25 other years are credited to public health, yet less than 1 percent of Americans can define the mission of public health.

Public-health measures virtually eliminated the scourge of infectious disease through efforts to provide clean and fluoridated drinking water, better sanitation, widespread immunization, motor-vehicle and occupational safety, family planning, smoke-free public places and chronic-disease management.

Public health differs from medical care in two distinctive ways. First, public health is aimed at prevention rather than the curative aspects of health. Second, it deals with collective, population-level health, while medical care generally is individual.

Public health more broadly promotes healthier lifestyles and addresses environmental factors to prevent widespread illness on a community level. Medicine focuses on diagnosis and treatment of specific diseases with drugs, surgery and medical technology.

Because public health addresses large populations, it has more potential to lessen health disparities cost-effectively. Research has repeatedly shown that effective public-health programs and disease-prevention initiatives can reduce cancer, heart disease and diabetes, as well as continue to suppress infectious diseases.

Despite widespread support for disease prevention, less than 5 percent of U.S. health-care spending goes toward public health. Public-health activities primarily are carried out by state and local governments. Departments vie for scarce resources from government entities that by law usually must balance their budgets. As a result, public health is destined to be underfunded, especially in a difficult economy.

By contrast, the economics of medicine are immune from these constraints, as evidenced by the fact that health-care costs rise at a significantly higher rate annually than the overall Consumer Price Index.

 Trust for America’s Health (TFAH), a nonpartisan advocacy group, estimates that an annual $10-per-person investment in proven disease-prevention programs based in communities could save more than $16 billion annually in medical costs within five years – a return on investment of more than 5 to 1.

Local public-health funding varies dramatically. The top 20 percent of communities in public-health funding spend more than 13 times the amount of the lowest 20 percent. More spending translates into better health surveillance and research, and lower mortality rates.  A 2011 Health Affairs journal study found that death rates fell between 1 and 7 percent for each 10 percent increase in local public health spending.

More than half of local health department budgets are funded by federal and state governments. Federal funding in recent years has remained relatively flat, while state and local support has waned because of the recession. The average state budget’s projected deficit was 24 percent in 2010, and 29 states projected deficits for 2011.

The $35 billion spent on U.S. public health each year is about $20 billion short of optimum funding for critical programs, according to a 2008 analysis by TFAH and the New York Academy of Medicine.

Readmissions: Why always blame the hospital?

Hospitals release patients as early as possible to minimize care expenses. Health plans and the government determine in advance how much they will pay the hospital based on the patient’s condition. There is one price for the entire hospital stay, rather than a charge for every service and supply used. Medicare has a list of about 750 diagnostically related groups of similar medical episodes.

This is a cost-containment strategy. The incentive is to release the patient on or before the reimbursement period runs out. Unfortunately, too many come back for additional care within a month. This may be a penny-wise, pound-foolish situation. Initial costs were minimized but overall costs likely increased. Hospitals are able to bill the government or health plans for another hospitalization.

Hip replacement illustrates the point. In the early 1990s, according to a study in the Journal of the American Medical Association, patients spent more than nine days, on average, for surgery and recuperation in the hospital. By 2008, that period was less than four days. The percentage of patients sent directly home decreased from about two-thirds to less than half. The proportion sent instead to rehabilitation facilities doubled. Furthermore, there was a 44 percent increase in the number of patients returning to the hospital within 30 days for further care.

Dr. Peter Cram, the study’s lead author, said, “You’re really just squeezing a balloon here. If we reduce the length of stay in the hospital, we can save money … But when we squeeze the balloon on one end to reduce length of stay, other costs pop up on the other end. This is why it’s so hard to reduce or contain health-care costs.”

A key provision of the health-reform law attempts to reduce 30-day hospital readmission rates by penalizing the worst offenders. As of October 2012, Centers for Medicare and Medicaid Services can decrease payments by 1 percent to hospitals with excessive rates for patients with heart failure, acute myocardial infarction or pneumonia.

One in 5 Medicare beneficiaries was readmitted to the hospital within 30 days, and 1 in 3 within 90 days in 2003-2004. The cost of these unplanned readmissions was more than $17 billion in 2004. Blacks are 43 percent more likely to have unplanned readmissions. The risk is up to 33 percent more likely for those on high-risk medications.

The Joint Commission, which accredits hospitals, studied miscommunication from one caregiver to the next in 10 hospitals. These so-called transitions of care often are the culprit in readmissions. The commission found that handoffs were defective 37 percent of the time. There are 4,000 handoffs a day at a typical hospital, which means nearly 1,500 are mishandled. Those fumbled handoffs are associated with 80 percent of serious medical errors.

However, a recent study found that Medicare regions that have the highest readmission rates also have the highest hospital admission rates. In other words, doctors in some areas are quicker to stick – and re-stick – patients into the hospital than those elsewhere.

There are simply too many confounding factors to blame hospitals for readmission rates.

The feds flunk the American diet

Americans are still flunking when it comes to eating a healthy diet, according to a federal government grade card.

The Health Eating Index gauges consumption of several nutritional categories such as whole fruits, brightly colored vegetables, meat and added sugar. The aggregate national score was about 60 out of 100.

Americans are eating more from all of the major food groups – even fruits and vegetables – at the same time that the obesity rate has doubled since 1970. However, many are not meeting dietary recommendations. To do so, they would have to cut back significantly on added fats, refined grains and added sweeteners while increasing consumption of fruits, vegetables, whole grains and low-fat dairy products.

The typical Western diet – fried foods, salty snacks and generous portions of fat-laden meat – accounts for nearly a third of the heart-disease risk worldwide, according to a study of dietary patterns in 52 nations.

What constitutes an ideal diet continues to be elusive. Diets rich in lean meat, poultry and beans keep weight off best, according to a November 2010 New England Journal of Medicine study.

An analysis of 21 studies involving 350,000 people found “no significant evidence” that long-maligned saturated fat increases heart risk. But refined carbohydrates – white bread, white pasta and processed baked goods – do.

Another study compared the effectiveness of low-fat vs. low-carbohydrate diets. The verdict: Either works. Both groups lost about 7 percent of their body weight. A 2009 study was even more detailed, creating four groups with diets of varying amounts of fats and carbohydrates. For example, one diet consisted of 40 percent fat and 35 percent carbohydrates. Another had 20 percent fat and 65 percent carbohydrates. The same result: They also lost equal amounts of weight.

The safest way of eating for nutrition and weight control is what is known as the Mediterranean diet. It is more of a dietary pattern than a specific list of foods. Its key elements: fruits and vegetables, whole grains, nuts, olive oil and beans; moderate amounts of red wine, low-fat dairy, poultry and fish, and not much meat or added unhealthy fats. Experts say the diet contains thousands of vitamins, minerals and micronutrients that guard against heart disease and cancer, protect mental health and lengthen life. The diet even has the ability to change the genes that influence heart disease.

Washington State shows leadership on tobacco control

Washington State has shown legislative courage on tobacco control gets results. Smoking declines have exceeded the national average, thanks to a comprehensive state program that included a statewide public smoking ban and tax increases. The estimated return on investment was more than $5 for every $1 spent.

Four proven strategies, if pursued aggressively, could nearly wipe out cigarette smoking. The only barrier is political will. The policies with documented success: increasing tobacco taxes, expansion of public smoking bans, anti-smoking advertising campaigns, and banning methods of cigarette marketing.

State excise taxes on a pack of cigarettes range from 17 cents in Missouri to $4.35 in New York. By comparison, Norway taxes cigarettes by more than $11. Tobacco has long been a significant contributor to U.S. government coffers. Alexander Hamilton first proposed tobacco excise taxes in 1794, and they were eventually implemented in the 1860s. By 1880, the taxes accounted for nearly one-third of federal tax receipts.

Steep tax increases would hit two groups especially hard: low-income households and people with chronic mental illness or substance-abuse disorders. Both groups have a disproportionate share of heavy smokers, despite the fact that it has become a very expensive habit. For example, more than 40 percent of U.S. smokers also have alcohol, drug or mental disorders. More than 60 percent of alcohol abusers are smokers. People with these disorders consume 44 percent of the cigarettes sold in the U.S. However, a 10 percent increase in cigarette prices would cut their smoking by an estimated 18 percent.

Cigarette tax increases would be a double victory for cash-strapped states. An analysis by a coalition of several anti-tobacco organizations concluded that a $1 tax increase per pack would:

  • Increase state revenues by more than $9 billion annually.
  • Prompt 1.2 million adult smokers to quit.
  • Prevent more than 2.3 million adolescents from acquiring the habit.
  • Forestall more than 1 million premature deaths; and
  • Save nearly $53 billion in health-care costs.

Two-thirds of voters would support the $1 increase, according to a national poll released in conjunction with the report.

However, cigarette manufacturers would fight back. They use coupons and discounts to neutralize tax increases. In 2009, tobacco companies spent nearly three-quarters of their marketing and promotion budgets on retail-price reduction.

Smoking bans continue their relentless advance nationwide. Nearly two-thirds of Americans are subject to comprehensive smoke-free laws. At one time, it was common that states would not allow local governments to enact anti-smoking laws that were more stringent – known as state pre-emption laws. The number of states that pre-empt local action against smoking melted from 19 in 2005 to 12 in 2010.

The bans have measured effects on public health. Fatal heart attacks decreased 7 percent in Massachusetts after the state outlawed smoking in workplaces. Studies in other states and nations that  have imposed bans reaffirm that effect.

Bars and restaurants frequently oppose smoke-free laws, fearing that cigarette-smoking customers will go elsewhere. However, research consistently has shown that the bans do not harm sales and, in many cases, actually increase business.

An Oklahoma study found that the average particulate level in bars and restaurant smoking rooms was beyond the “hazardous” level established by the U.S. Environmental Protection Agency (EPA) for outdoor air. Tobacco smoke levels were tested based on very fine particulate matter. The EPA considers air containing 250 micrograms per cubic meter or more to be hazardous outdoor air pollution, labeling it as emergency conditions. Restaurant rooms contained an average of 380 micrograms. Bars averaged 655.

Secondhand smoke annually kills 600,000 people worldwide. More than 1 in 4 of those deaths is a child under 5 years old. Smokers are at additional risk of their own secondhand smoke. For someone who smokes 14 cigarettes a day, his or her own secondhand smoke yields the risk of having smoked 2.6 more cigarettes.

The residue from secondhand smoke – called thirdhand smoke – can leave cancer-causing toxins on furniture, carpets, walls and drapes. The chemical, called tobacco-specific nitrosamines, can mix with dust or stick to the fingers of children or infants.

It is not surprising that nearly all children – 98 percent – who live with a smoker have measurable tobacco toxins in their bodies.

Anti-smoking campaigns are effective, but the recession and more pressing financial needs have  decimated state tobacco-control programs. States spent $517 million on anti-tobacco programs in 2011, which is 28 percent less than in 2008 and just 14 percent of the $3.7 billion recommended by the Centers for Disease Control. Tobacco companies spend about $25 on marketing for every $1 the states spend to fight tobacco use.

Countries that have completely outlawed tobacco advertising have been effective in reducing tobacco use. Nations with limited policies, such as the United States, have not had much impact.

The killer too few have heard of

November was COPD (chronic obstructive pulmonary disease) Awareness Month, devoted to the lethal killer too few people have heard of.  It has become the third-leading cause of death after heart disease and cancer.

COPD generally is a combination of emphysema and chronic bronchitis. The condition can destroy the lung’s airways, making their walls thick, inflamed and inelastic. The airways also become clogged with excess mucus. The progressive, incurable disease makes breathing difficult. Cigarette smoking causes 80-90 percent of COPD. Breathing second-hand smoke, air pollution, and chemical fumes or dust from the environment or workplace can also contribute to COPD.

One of the reasons COPD may not get the attention accorded other chronic diseases is the unspoken belief that COPD is self-inflicted and undeserving of charitable funding for research and treatment.

The COPD rate has remained steady for the past decade. COPD has killed more men than women by a ratio of 6-1. However, the burden is beginning to shift from men to women. Women began smoking in greater numbers in the 1970s and 1980s, and COPD symptoms generally begin to emerge decades later. About 20 percent of U.S. adults continue to smoke, and about 25 percent of those eventually will develop COPD.

According to the World Health Organization, COPD will be the third-leading cause of death worldwide by 2030. An international study found that 1 out of 4 people aged 35 or older are likely to develop COPD in their lifetimes, a risk comparable to that of diabetes and asthma.

An estimated 12 million Americans have been diagnosed with COPD, and a comparable number likely have it but are unaware of it. Common symptoms are shortness of breath, chronic cough and difficulty in performing daily tasks such as housework or climbing stairs. Fewer than 3 out of 4 U.S. adults are aware of COPD. The federal government launched a campaign in 2007 to raise awareness among patients and health-care providers.

COPD is associated with several other chronic conditions, such as cardiovascular disease, osteoporosis and diabetes. Anxiety and depression are also common in COPD patients, in part because the disease often isolates them socially. One study concluded that 80 percent of COPD patients had depression, anxiety or both.

The most common causes of death in patients with COPD are cardiovascular disease and lung cancer. Lung cancer is more than four times more common in COPD patients.

Each case of COPD costs patients and the health-care system about $6,000 annually.

Early detection of COPD can change its course and progress. A simple test can be used to measure pulmonary function and make a diagnosis. The goals of COPD treatment are to relieve symptoms, slow the disease’s progress, improve stamina and prevent hospitalization and emergency-department visits. Treatments include medication, pulmonary or lung rehabilitation, oxygen treatment and surgery.

Doctors, parents and overweight children

Less than 1 out of 4 parents of overweight children recall ever being told by a physician that their child was overweight. It could be because the doctor has given up. Ample research shows that parents rarely acknowledge their overweight children are … well, overweight.

Child obesity has emerged as the No. 1 health problem for children.

The child obesity rate has been growing three times faster than that of adults. Over the last 30 years, the obesity rate has doubled for preschool children aged 2 to 5 and adolescents aged 12 to 19. It has more than tripled for children aged 6 to 11 years.

 About 45 percent of poor children are obese, which is about twice the rate for children in middle- and upper-class households. However, the epidemic affects boys and girls and affects all ages, races and ethnic groups.

Nearly 3 out of 4 obese children have at least one additional risk factor for cardiovascular disease, such as high blood pressure or high cholesterol. Increases in obesity have fueled a dramatic rise in type 2 diabetes. In some communities, youth account for nearly half of the new cases of type 2 diabetes.

Child obesity largely stems from too little exercise and eating too much of the wrong foods. Two-thirds of adults are obese or overweight and often serve as poor role models. About 2 out of 3 children aged 6 to 19 do not get the recommended 60 minutes of exercise, and about 1 out of 4 adolescents get none. Sugar-sweetened beverages comprise about 11 percent of children’s total calorie consumption. Each average daily serving increases a child’s obesity risk by 60 percent. Preschool children are consuming an average of 186 more calories a day than three decades ago, and more than a quarter of those come from snacks.

Genetics and home environment also plays roles. An obese preschool child with normal-weight parents has a 25 percent chance of being an obese adult. That risk rises to 60 percent if one of the parents is obese.

The direct costs of child obesity are more than $14 billion annually, including prescriptions and visits to emergency departments and physicians.  The average annual cost of treating childhood diabetes is $10,800, which is $2,000 more than the annual cost of treating a case of adult diabetes.

Obesity’s greatest financial burden is a lifetime of medical care for resulting chronic conditions. The rise in obesity accounted for more than one-quarter of the rise in health-care spending between 1987 and 2002. Adults who were obese or overweight as adolescents are much more likely to develop cardiovascular disease, colon cancer and arthritis, even if they lose weight later in life. One researcher calculated it would be cost effective to spend $2 billion a year to reduce obesity among 12-year-olds by 1 percent because of lifetime obesity treatment costs.

Dental care as a luxury good

Dental care apparently has become a luxury. Revenue at U.S. dental practices has dropped each of the last three years while the economy was in the tank, according to the Los Angeles Times.

Dental health is an underappreciated health issue. The mouth is often called the gateway to the body, and periodontal disease can signal more serious conditions, such as diabetes, heart disease and potential pregnancy complications.  Good oral health is also linked to well-being and quality of life. Teeth are critical to maintaining proper nutrition, physical attractiveness and have an impact on employment opportunities and income.

About 97 percent of Americans consider oral health important. However, dental care is an unmet need for many. Nearly 1 out of 3 U.S. adults has untreated dental decay, and more than 8 out of 10 have ever had decayed teeth. Fewer than 2 out of 3 adults visit a dentist annually, and those above the poverty line are twice as likely to do so. Employees lose more than 164 million hours of work annually because of dental disease or visits. The U.S. Surgeon General has characterized untreated oral disease “a silent epidemic.”

Major advances in the second half of the 20th century have had a major impact of U.S. oral health. Most baby boomers and younger adults can expect to keep their natural teeth and avoid major oral health problems throughout life. However, they also will be at more risk for decayed teeth.  On the other hand, more than 1 out of 4 elderly Americans are toothless.

Fluoride has been added to U.S. water supplies since 1945 to prevent tooth decay. Federal health officials have called fluoridation one of the 10 great public-health achievements of the 20th century and has resulted in an estimated 30-50 percent reduction in dental decay.

 Fluoridation exposure at birth affects tooth loss in their 40s and 50s, regardless of what the exposure was like in their 20s and 30s.  Fluoride improves tooth enamel, helps teeth damaged from the decay process, and breaks down bacteria on teeth.  A study of Medicaid dental patients in Louisiana showed that for every $1 invested in water fluoridation, the state saved $38 on dental costs.

However, the federal government lowered its recommended limit of fluoride in drinking water because spots on children’s teeth were indicating they were getting too much of the mineral. Fluoride is also in toothpaste, and experts suspect children are swallowing it.

A significant barrier to care is a widespread shortage of dentists, especially in rural areas. The U.S. dentist-to-population ratio declined during the 1990s, after peaking at 60 per 100,000 population. By 202, the ratio is expected to drop to less than 53 per 100,000, or about one dentist for about 1,900 people. By contrast, the physician-to-population ratio is about 286 per 100,000. The federal government in 2010 identified 4377 dental health professional shortage areas, and fewer than half of dentists were treating Medicaid or Children’s Health Insurance Program children in most states.