Dr. Buttery'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.

Posted by at 12:06 PM | Permalink | Comments (0)

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.

Posted by at 10:37 AM | Permalink | Comments (1)

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.

Posted by at 10:01 AM | Permalink | Comments (0)

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.

Posted by at 9:45 AM | Permalink | Comments (0)

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.

Posted by at 10:21 AM | Permalink | Comments (1)

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.

Posted by at 11:09 AM | Permalink | Comments (0)

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?

Posted by at 1:42 PM | Permalink | Comments (1)

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 reccomends $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!!

Posted by at 6:59 PM | Permalink | Comments (1)

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.

Posted by at 11:25 AM | Permalink | Comments (0)

The Wall Street Journal and others today have discussed the possible heart disease developed among children labeled as having ADHD. Most medicines have undesired side effects. The issue is deciding when the benefit outweighs the risk. While the stimulant drugs used to control ADHD are found valuable by parents, one msy wonder how much of the acting out is the result of poor discipline rather than disease. It is too simple to diagnose a 'condition' and prescribe a drug. Maybe this wake up call from the American Heart Association will help more parents consider behavioral therapy rather than drugs to help their children. We have not investigated if when the children become adults there performance may be less productive for having been on drugs all their lives.

Posted by at 10:56 AM | Permalink | Comments (1)

"For the first time since the Spanish influenza of 1918, life expectancy is falling for a significant number of American women," according to a study published in PLoS Medicine. Lead author Christopher J.L. Murray, M.D., a physician and epidemiologist at the University of Washington, and colleagues at the Harvard School of Public Health. Women seem to learn slowly from the adverse behavior of men. While the survey cannot pin direct cause and effect to these results, the public health community has seen the excess of obesity, smoking, minimal exercise, poor diet and the adverse effects of increasing urbanization upon the population. To change these outcomes it will be necessary to change the infrastructure of the social support system, instead of maintaining the current barriers between health, social service, mental health, primary care and nutrition programs.

Posted by at 10:33 AM | Permalink | Comments (0)

WhIle everyone talks about it, and this latest report from The Center for Health System Change adds to the data, few in Congress take notice. The media continues to publish stories about the need for more attention to prevention, yet as this paper shows less than 3% of the annual $2.2 Trillion health care dollars is spent on public health and disease prevention, particulalry to enhance the staff needed to carry out the services. Insurance companies only give lip service to the idea but do not reimburse primary care physicians for preventive interventions , except in those instances where intrusive technology is used. There needs to be a close liaison between public health agencies and primary care practitioners, who together will be a more effective force for prevention than either by themselves.

Posted by at 10:35 AM | Permalink | Comments (2)

A paper reviewing use of antioxidants, published by the Cochrane Library, found that supplemental antioxidants do not reduce mortality and that some -- including vitamin A, beta-carotene and vitamin E -- could increase mortality. The review combined evidence from more than 200,000 people. I wonder how many more studies of over the counter nutritional supplements showing lack of effect, or possible danger, will be needed before the FDA is given authority to regulate the claims made by the 'nutritional' industry. It would be useful if various watchdog groups provided information on how much those who promote these scams give to congressional campaigns.

Posted by at 9:54 AM | Permalink | Comments (3)

The Robert Wood Johnson Foundation has just released a landmark report and founded the Commission to Build a Healthier America. The report and commission spell out the reason for studying disparities in health status and state that much ill health has little to do with medical care and everything to do with the social support system provided within communities. The commission will study health disparities within the U.S and recommend actions to change support systems to improve everyone's health. Tables within the current report show how far the U.S. has is fallen behind the other developed countries in caring for its citizens during the last 40 years. Part of the problem is clearly the focus on technology and research while loosing sight of social needs.

Posted by at 5:14 PM | Permalink | Comments (2)

The News Media today publish two stories about the inability of Congress to come to grips with changes needed to the health care system. First, Senator Baucom fails to understand that Medicare is rapidly going broke but he is trying tu repeal cuts in the Medicare payment system. He should be concentrating on the cause for Medicare's forthcoming insolvency, the excess of preventable chronic disease in a growing aging population with a payment system that focuses on the wrong interventions. Secondly, Congress is concerned about a "Dr. Shortage". For the most part this is a myth. The 'shortage'' is in primary care. The third party payment programs short change primary care and focus om specialty care. Thus, young doctors $100,000 or more of debt choose a spocialty that will reduce their debt most rapidly, As usual politicians focus on perception rather than reality.

Posted by at 9:45 AM | Permalink | Comments (0)

The news media are having their usual feeding frenzy about the latest report on foodborne disease outbreaks outlined this week by the CDC. Washing fresh fruits and vegetables can reduce the risk of food poisoning, but only irradiation kills almost all disease-causing bacteria according to a study presented at the American Chemical Society's annual meeting in New Orleans. The researchewrs noted "washing with plain water did not reduce bacteria levels in spinach or lettuce. Chemical treatment did not significantly reduce E. coli in spinach leaves, and was less than 90 percent effective when it came to removing E. coli from lettuce." But, irradiation "reduced the level of E. coli by 99.99 percent in lettuce, and by 99.9 percent in spinach." The researchers also noted that "salmonella died more easily when exposed to radiation, while E. coli was a little bit more resistant."
If we can just get the public away from the 'Jane Fonda" syndrome about radiation being bad, we might make more progress in food safety. Suing food producers will not improve food safety.

Posted by at 10:53 AM | Permalink | Comments (0)

The Wall Street Journal today highlights a report from PricewaterhouseCoopers putting the value of the waste sloshing around in the health care system at a whopping $1.2 trillion a year, or 50% of the total spending.. However the "waste" may be more in the eyes of the auditors than real. For example waste includes such items as missed appointments, medicines not taken, Dr's recommendations not followed, diseases associated with adverse behaviors. It also believes there is much administrative waste in the way medical services are delivered. There are many deficiencies in the system , much of it due to illogical legislation and federal laws, or services delivered that are usually unecessary but are used to prevent lawsuits. The headlines in The Journal make good copy. Probably 50% of the "waste" could be averted, Even $600 billion dollars a year are well worth saving. This will not happen without a major overhaul of our broken system.

Posted by at 10:29 AM | Permalink | Comments (0)

Since Mumps vaccine was introduced there has been a significant drop in new cases, as seen in this graph.

However in 2006 a resurgence of mumps ocurred in the upper central USA. There was only moderate uptake of a second dose of mumps vaccine putting adolescents and young adults at risk. This shows a similar pattern to the Measles outbreak in South Texas twenty years ago which lead to recommendation of a second dose of vaccine in middle school. The difference was that 98%+ of the Texas students had received their vaccine dose as recommended. This was not the case with the mumps vaccine. Part of the problem is anxiety anong parents about supposed ill effects from vaccines, grossly overestimated but pushed by the media for its value as a scary story. Future studies will help to evaluate the national vaccine policy, including whether the administration of a second dose of MMR vaccine at a later age or the administration of a third dose would provide higher or more durable immunity.
N Engl J Med 2008;358:1580-9.

Posted by at 11:02 AM | Permalink | Comments (0)

Senator Kennedy has it absolutely right in commenting on policy changes to rein in the health care system. He is quoted in 'The Hill' as saying " reducing the cost and improving the quality of healthcare in the United States cannot be accomplished without changing the way patients with chronic diseases are treated and the way medical providers are paid. He is joined by Dr. Carmona, former Surgeon General who says “We are obviously not doing enough to reward real value in healthcare,” pointing out that treatments for the chronically ill with conditions such as diabetes and high blood pressure consume a grossly disproportionate share of the nation’s spending on healthcare. Seventy-five cents of every dollar you’re spending on healthcare is on chronic disease, much of which is preventable.” With healthcare costs continuing to mount, rates of chronic illnesses like diabetes rising and the Baby Boom generation advancing in age, the situation will deteriorate without change, he cautioned. “The bank is breaking now and it’s only going to get worse.”

Posted by at 10:50 AM | Permalink | Comments (0)

While many people of all ages take dietary supplements, the prevalence increases as people age, amd could well be labelled substance abuse. A wonderful piece in today’s NYT by Jane Brody is essential reading. Ms. Brody discusses abuse of legally sold dietary supplements — vitamins, minerals, herbals and homeopathic remedies — all of which can be sold over the counter without prior approval for safety and effectiveness. A new federal law requires supplement manufacturers to report serious adverse effects to the Food and Drug Administration, but it depends on consumers to call in reactions. This form of passive reporting is unlikely to describe the depth, distribution and dangers of this form of supplement abuse. The ‘complementary medicine’ advocates make the problem worse while Congress shows no will to intervene. This form of abuse may be just as bad as addiction to narcotics, but is silent because of research priorities which focus on highly visible and often relatively rare medical problems, than on a common and dangerous habit. We might well ponder how many of these supplemetary producers are underwritten by drug companies.

Posted by at 9:49 AM | Permalink | Comments (6)

According to an article in the American Journal of Clinical Oncology so many women survive for many years after treatment for breast cancer, due to improved treatment protocols, that like a number of other previously fatal diseases breast cancer is now a chronic diseaes and should be treated with longevity and quality of life in mind rather than just delaying death.

Posted by at 8:34 AM | Permalink | Comments (1)

The tendency for do-gooders amd politicans to write laws "for our own good" is typical of the new law in New York which prohibits the use of 'trans-fats' in preparation of meals. Now from University of Alberta researcher Flora Wang found that a diet with enriched levels of trans vaccenic acid (VA) -- a natural animal fat found in dairy and beef products -- can reduce risk factors associated with heart disease, diabetes and obesity. When it comes to diet, whatever 'research' shows today, wait another month, and you will find other research that shows something different. The dangers of trying to change behavior by law is that when new research shows your original stand may need modifying you cannot just turn around and tweak the law. We should be careful about those states such as New York and California who think the anwsers to all ills is to pass a new law.

Posted by at 10:47 AM | Permalink | Comments (1)

The opening paragraph of the executive summary of the 2008 report from the Dartmouth Atlas of Health Care focuses on chronic disease and raises important issues:
"More than 90 million Americans live with at least one chronic illness, and seven out of ten Americans die from chronic disease. The quality of care for Americans with chronic disease is remarkably uneven.Most patients receive episodic care from multiple different physicians who rarely coordinate the care they deliver. And the growing costs of chronic disease care present a threat not only to patients and their families but also to the nation."
Considering that the care of chronic disease is rapidly raising the cost of medical treatment beyond the capability of the nation to sustain it, this publication should be read by everyone. It is clear our training and organizational methods of care need radical revision. We do not provide equitable, appropriate, effective, efficient, affordable care across the couintry. We need to move away from organ based specialty training to developing teams of professionals who can intervene on our behalf before we get to the stage in life described in this report. We need much more focus on primary care.

Posted by at 9:44 AM | Permalink | Comments (0)

Massachussetts as the first state to develop a universal medical access plan "has reached a crisis point" because the "crushing costs of the program endanger its long-term viability," Says Christopher Anderson in the Boston Globe, The lesson to learn from Massachussetts is that money cannot buy universal access without reforming the medical care system, All Massachussetts has done is provide relatively low cost insurance to enable access to an unchanged system, overwhelmed by chronic disease and lawsuits. We have to move from a system dominated by specialists and drug companies to a primary care, prevention oriented system. We have to stop tinkering around the edges.

Posted by at 11:10 AM | Permalink | Comments (0)

The news that scientists report, in three papers in two journals today, that they have found evidence of genes that promote addiction to tobacco and thus to lung cancer, adds to evidence that tobacco. alcohol and narcotic addictions all seem to have genetic bases. However, it will take years before this research translates into effective treatment and prevention. In the meantime it could bring better understanding to policies that try inhibit exposure to, and treatment for, addicton. There is little evidence that punishment changes addictive behaviors.. Current punishment of addicts is probably counterproductive and should change we learn more about the role genes play in addiction.

Posted by at 10:39 AM | Permalink | Comments (0)

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.

Posted by at 11:01 AM | Permalink | Comments (1)

Doctors are trained mainly on younger patients and have little training to cope with older ones. Now from a study at Imperial College, London we learn that lowering the blood pressure of elderly patients could cut their total mortality by a fifth and their rate of cardiovascular events by a third, according to a new study presented today at the American College of Cardiology in Chicago. In the largest ever clinical trial to look at the effects of lowering blood pressure solely in those aged 80 and over, Benefits of treatment include a 21 percent reduction in total mortality rate, a 39 percent reduction in stroke mortality rate, a 64 percent reduction in fatal and non-fatal heart failures and a 34 percent reduction in cardiovascular events. The benefits were apparent within the first year of follow-up.

Posted by at 9:49 AM | Permalink | Comments (1)

Indiana University Study Finds Majority of U.S. Physicians Favor National Health Insurance Support Has Grown 10 Percent Over Past 5 Years. The largest survey ever of American physicians' opinions on health-care financing has found that 59 percent of doctors support government legislation to establish national health insurance while only 32 percent oppose it. A similar survey conducted by the IU researchers in 2002 found 49 percent of physicians supporting national health insurance and 40 percent opposing it. The 2007 survey results demonstrate a significant change in the level of support for national health insurance. While some of the presidentiaol candidates support such a move the details are mssing, as are major policy recommednations to develop such a system.

Posted by at 10:15 AM | Permalink | Comments (3)