Kim’s public health blog

A study reported in the Dartmouth Atlas of Health Care 2008 decsribes The remarkable variation in the way academic medical centers manage chronic illness is testimony to the weakness in the scientific basis of medicine. The neglect of the evaluative sciences— those sciences whose mission is to evaluate medical theory, understand patient preferences, and establish the cost-effectiveness of clinical practice—has left the nation unprepared to deal with unwarranted variation. The consequences for public policy should be obvious. Further the authors of the sudy say “the nation needs a crash program to transform the management of chronic illness to a rational system where what happens to patients is based primarily on illness severity, medical evidence, and the patient’s wishes, and where resource allocation and Medicare spending can be guided more and more by knowledge of what is needed to produce cost-effective, high-quality care”.
However the country cannot focus just on the cae of chronic disease without also changing the entire system to a focus on affordable, accessible, coordinated primary care. This will require different teaching goals in academic centers which must turn away from a focus on basic research and move toward a focus on patient care and effective efficient outcomes of care.

One more ‘fad’ heard on the weekend radio talk shows sells scams to the public in the name of health. Infomercials and Web sites urge us to eliminate the buildup of toxins that supposedly results from imprudent habits or exposure to hazardous substances.
If you’re healthy, concentrate on giving your body what it needs to maintain its self-cleaning system—a healthful diet, adequate fluids, exercise, sleep, and all recommended medical check-ups, instead of relying on so-called detox procedures, says the Harvard Women’s Health Watch.

Foodborne diseases cause an estimated 76 million illnesses in the U.S. each year with about half associated with restaurant meals. More than 70 billion meals per year are purchased in restaurants in the U.S., accounting for 47% of total food expenditure.
Eating out can be dangerous to your health. There are insufficient resources in most communities for frequent inspections by the local healtrh department. The public has to support them by watching what happens in the restaurant. Are the server’s nails short? Is their clothing clean? Is the restaurant clean? Is the hot food served hot? Are the servers ensuring that one plate does not touch the food on another? Is the serving-ware clean?
Does you state have a food service web site which you can visit to check on inspection outcomes before you visit? For an example look at the Virginia Department of Health’s food service web site.

The following from Science Daily is an example of the valuable information available from this site, I recommend a daily visit:
Researchers have found that a new obesity prevention program reduced the risk for onset of eating disorders by 61 percent and obesity by 55 percent in young women. These effects continued for as long as 3 years after the program ended. These results are noteworthy because, to date, the idea that we can reduce risk for future onset of eating disorders and obesity has been an unrealized goal: over 80 prevention programs have been evaluated, but no previous program had been found to significantly reduce risk for onset of these serious health problems.
One of the important issues is that few programs touted for schools have had much effect. What we do not know yet is what happens after three years. If all we do is delay obesity a few years it will make little difference over a life span now approaching 80 years. Preventing chronic disease requires lifelong behavioral changes.

The American College of Medical Genetics has developed a 2008 Policy Statement on DTC Genetic Testing. The college is concerned with sudden influx of genetic tests offered to the to the public without requiring professional support and recommendation
The college discusses five principles in its public statement which should be read by everyone before planning to use any genetic test, however well intentioned:
A knowledgeable professional should be involved in the process of ordering and interpreting a genetic test.
The consumer should be fully informed regarding what the test can and cannot say about his or her health.
The scientific evidence on which a test is based should be clearly stated.
The clinical testing laboratory must be accredited by CLIA, the State and/or other applicable accrediting agencies.
Privacy concerns must be addressed.

There will not be enough geriatricians when the 78 million baby boomers begin to turn 65 in 2011, according to a new Institute of Medicine report. By 2030, there will be an estimated 8,000 geriatricians, but the nation will need 36,000, according to the Assn. of Directors of Geriatric Academic Programs. IOM report recommends an increase in geriatric competency throughout the health care work force to offset a shortage in geriatric specialists. It also called for the adoption of interdisciplinary care models and a fundamental change in how health care is reimbursed. As noted in this blog previously, the primary care workforce is desperately underfinanced. The current reimbursment system militates against physicians choosing to work in primary care settings (of which geriatrics is part) after graduation. The current practice of training primary care physicians in hospitals where they are trained by specialists is also dysfunctional.

In an interesting turn about, the Chicago Tribune has reversed its policy of fining employees who smoke on their own time. The original intent was to pressure employees into better health and reduce insurance premiums for all its employees. The president of the company has decided to try efforts ot entice employees to change behaviors with rewards rather than punishment.  Changing adult behavior is very difficult. Peer pressure may work better than executive pressure. Should you be concerned about the health of your fellow workers if their behavior causes your insurance bill to increase?  Few people today accept reponsibility for anything. We have become too lax with rewards and punishments. They need to be balanced. Is rewarding someone for changing behavior appropriate when those with desired behaviors get no reward?

The New England Journal of Medicine today published two ‘Perspective’ articles on the responsibilities of the FDA and the total lack of responsibility of both the legislative and executive branches of government to support the FDA. Then the politicians turn around and criticize the FDA for their own failings.  The FDA is given oversight responsibility by Congress to evaluate all drugs and medical devices.  No-one in Congress has put a price tag on these legislated mandates.  It is easier to criticise the FDA when they cannot carry out their assigned role. The Congressional Budget office recommends $multimillion increases to the FDA budget.  It is clear that the politicians have no idea about the complexity of scientific accountability, or the time it takes ot hire, train and disperse staff.  Even if they provide the funding required there is little evidence that the Executive Branch would pass the appropriation to the FDA.,  The FDA Commissioner is put in an untenable position and cannot criticize either the President or Congress.  All of us who vote should remove every congressman who has failed to support the FDA and who criticizes the agency without providing the necessary resources. Yet, there are some who think Congress can fix our failed health system!!

Today the National Academies of Science released a report on links between Ozone Exposure and Premature Motality. The crux of the information is in Chapter 5, which explains the biological plausibility and the problems with analyses of previous studies comparing cities and even countries, over time. Ozone can be seriously considered as an adverse contributor to chronic heart and lung disease, but while it is possible to describe associations there are so many confounding variables and demographic differences between the various study groups, and changes in variables such as obesity and lack of exercise over time make it is very difficult to separate out the effect of ozone from all the other contributors to early mortality. Much more definitive research is needed. There is no test that identifies the contribution of ozone to death from chronic heart and lung diseases.

Just because the media annouce a new drug, don’t assume you should rush out to your doctor and ask for it. A careful patient should only ask about a new drug if the present one, or a less expensivce one, is not doinig the job. Most new drigs do nothing except expand income for drug companies. Very few new drugs make any significant difference to the outcome of most chronic diseases. This is the case with Vytorin and Zetia.