An essay in this month’s Health Affairs is compelling reading, at least for folks like me. In brief, the author describes the reasons why she, despite a positive family history, does not get an annual mammogram.

The following paragraphs encapsulate the argument nicely, I think:

“If 2,000 women are screened regularly for ten years, one will benefit from the screening, as she will avoid dying from breast cancer. At the same time, ten healthy women will…become cancer patients and will be treated unnecessarily. These women will have either a part of their breast or the whole breast removed, and they will often receive radiotherapy, and sometimes chemotherapy. Furthermore, about 200 healthy women will experience a false alarm. The psychological strain until one knows whether or not it was cancer, and even afterward, can be severe.”

And:

“Another important fact from my friends at the Nordic Cochrane Centre: It has not been shown that women who undergo regular screening live longer than those who don’t. This information is available elsewhere in different forms, but I like the clarity and concision of the Nordic Cochrane Centre pamphlet—as well as its list of solid scientific references.”

Both of these are from the Nordic Cochrane Center, an offshoot of the Cochrane Collaborative, probably the most respected outcomes and effectiveness research group there is. Cochrane Reviews are widely thought to be authoritative answers to the question “What is the best way to diagnose and treat/manage $DISEASE?” Note that because they’re the best evidence there is doesn’t mean it’s what’s *done*, but the evidence is available if you want to look for it. They have a recently done an analysis of breast cancer screening with mammography which I have yet to read, but which is essentially a redo of the work the USPSTF did a while back on mammography, when they scaled back their recommendations to great political uproar. They came to the same conclusion: mammography doesn’t work as well as we think it does. We aren’t good enough yet to know who should be screened and who should not, and screening may not do all the good we’ve ascribed to it.

And now the political problem. A *lot* of people have invested a *lot* of themselves, their scientific and professional careers, their volunteering lives, and their incomes, in the goal of increased and aggressive screening, early detection and treatment. Which, it turns out, may not work. But these folks have sunk a *lot* of themselves into those goals, including making those goals the focus of their work- from oncologists and surgeons who treat breast cancer patients (who basically treat people with breasts as if they all have cancer, either now or Real Soon Now), to cancer survivors who are going to be hard to convince that either they would have survived anyway, or they basically got lucky by having screening at *just* the right time, to the thousands of people who have devoted their volunteer efforts to increasing awareness and funding for breast cancer research and treatment. None of those people wants to hear they may have been wrong. That they may have spent their time fruitlessly, needlessly. Or that the work they have devoted themselves to (and make their living from) may be, not just a waste of time, but an active harm to many women who worry needlessly about having cancer, or worse, who are treated as if they have cancer when they do not.

So no one is hearing the Cochrane review, just as no one hears the one which says that surgery for back pain is wrong, or that reducing dust mites doesn’t control asthma, or that any of a number of other things we do to control or treat disease don’t work. And some politicians, quick to sense an opportunity to get in good with a large voting block (people with breasts, or who know someone with breasts), are happy to decry the review, or the USPSTF guidelines, as a ploy to reduce health benefits for vulnerable people (with breasts).

There is, really, a science of figuring out what works and what doesn’t. It’s called epidemiology, and its sister science, biostatistics. They both require really large data sets to chew on to give results anywhere near accurate, but when large data sets are available, they’re really good at pulling some wheat out of that there chaff. And it turns out that mammography may be chaff, and maybe we shouldn’t be shilling for it the way we have been.

Read the essay. It’s thoughtful, well written, and enlightening.

Writing for the Commonwealth Fund, a well respected health policy foundation, Karen Davis (one of the two important Karen’s in health policy, the other being Karen Ignani, the leader of America’s Health Insurance Plans or AHIP) noted that the number of uninsured people in the US continues to rise. This is a fairly clear result of the ongoing recession, as more people lose employer sponsored insurance, and more employers don’t offer employer sponsored insurance. Last year 7 million people lost the insurance they had through their employer. Seven million people added to the rolls of taxpayer funded health care, or left without any health care at all. Oh, sure, they can go to the Emergency Department, as former President George W. Bush famously remarked. But if they do, they’ll get a bill, and probably a bigger bill than their insurance company would have received for the same service. and definitely a bigger bill than they would have gotten for going to their own doctor-emergency departments charge a premium for being open 24/7/365, because it makes their overhead much higher.

“But wait”, you ask. “Wasn’t this part of the problem health care reform was supposed to solve?” Well, yes, it was. But the important provisions of that law, with a few exceptions, don’t take effect until 2014. Some of the provisions do take effect sooner-importantly, the provision which requires insurers to cover “minor children” up to age 26 takes effect today (September 23, 2010), as well as the elimination of lifetime coverage limits. But the major parts-the health insurance exchanges, the premium subsidies for middle-income families with children, the expanded Medicaid eligibility, and COBRA assistance for the unemployed-are still three years away. That may be too long for some folks who don’t have insurance now, but still need health care.

Here in Massachusetts we have an advantage-we’ve set those things up already, and when time comes to implement them, all we’ll really need to do is make sure they meet the Federal standards. Since Congress used the Massachusetts law as something of a template for the Affordable Care Act, most likely our exchanges will exceed the requirements quite a bit. We ought to be proud of that.

The Great Brook Valley Neighborhood Health Center in Worcester changed names this Thursday, becoming the Edward M. Kennedy Community Health Center, a tribute to Ted Kennedy’s role in bringing Community Health Centers into being. Seems like a good time to review the history and role of a neighborhood health center.

Technically, a Federally Qualified Health Center is a community based organization which provides comprehensive primary and preventive care to a community, regardless of their ability to pay. They are generally governed by a locally based board of directors, and one of the unique features of the governance structure is that 51% (or more) of the board members must represent the population of the community (and generally receive their care there). Health care reform funding is expected to modernize existing centers, and significantly expand the network of centers nationwide.

Since health centers are a much cheaper way of providing health care, this can help save money for the health system overall, especially the parts of the system paid for by tax money. At the same time, people served at these health centers will generally be healthier, because the same research shows that the reason people who receive care at health centers have lower costs is because “providing quality primary care services can reduce the need for other ambulatory and hospital-based medical care, thereby lowering overall medical costs”.

Unfortunately, neighborhood or community health centers still carry the stigma of being places where poor people get their care-not a place you’d like to go if you had the chance to get out. People have a love/hate relationship with them-sort of like coming from a bad neighborhood that you still love, because it’s home. The stigma is in some sense justified-most of the people (70%) who get their care at neighborhood health centers are living in poverty by the federal definition. This is another way of saying, though, that they do one of the toughest jobs in health better than any other model of care delivery, for less money.

The facts suggest that we’d be served a lot better, most of us, if we got our primary care through a place which used the community health center model. Health care is almost never just about medicine, because so many other things impact your health. If your house is being foreclosed, it affects your health. If you’re having trouble handling your teenager, that affects your health. If your neighborhood is in the middle of an epidemic of flu, or norovirus, that affects your health. If your drinking is out of control, that affects your health. None of these problems are directly the responsibility of your doctor, but wouldn’t it be nice if, when you went to see her about them, she had the resources to work on the whole problem or set of problems, rather than just bandaiding over your symptoms?

That is what neighborhood health centers are designed to do; treat the whole person, in their family unit, in their community. And whatever you think of Ted Kennedy, I think that’s evidence of solid service to the nation.

Many of you will remember the “death panel” controversy during the health care reform debates last year. For those who don’t, a proposal to create a better payment mechanism for discussions between physicians and patients about end-of-life choices was derided by opponents of reform as funding for “death panels” which would make sure that elderly people chose the option of “dying early” to save on health care costs. Now it appears that early palliative care not only helps you be more comfortable and more in control of your health during serious illness, it can help you live longer as well.

A recently completed study from the Massachusetts General Hospital, researchers studying end of life care in a group of lung cancer patients found that the group assigned to early palliative care had higher quality of life and less depression than patients who received “standard care” (without early palliative care). Alone, this wouldn’t be a surprise; the surprise came when they found that the patients who received early palliative care lived longer, as well.

The policy implications of this finding are profound and seem to run counter to common sense. People have the idea that they can either fight disease as aggressively as possible, to live as long as possible or opt for care whose very name – palliative – seems to say that you’ve given up, and you’re just going to paper over the disease. The research from MGH is telling us that this is a false choice. Early palliative care-care which pays attention to relieving the symptoms of the disease-as well as fighting the disease through the usual means, you can live longer and feel better.

Far from demanding that we “die early”, advocates for palliative care want us to live as long as possible, but to help us keep our dignity and our humanity while we fight, and to make us ready for whatever our next step may be. Death is still inevitable; it doesn’t have to be miserable as well. We have it in our power to ease the transition, as well as delay it, and there doesn’t have to be a choice between the two. Promoting better and earlier use of palliative care is good healthcare policy choice, as well as a good use of our healthcare dollar.

The health reform law (now mostly called the Patient Protection and Affordable Care Act, or just the Affordable Care Act (ACA) requires many insurers to maintain a “medical loss ratio” of at least 85%. The medical loss ratio is the percentage of premiums which the insurer must pay out as health care. So if the premium for health insurance is $100 per month, the insurer must, on average, spend $85/month on payments for health care used by everyone insured by the company.

Naturally, health insurers are interested in maximizing the kinds of things they get to call “spending on health care”. For instance, is utilization review “spending on health care”? Generally, I would argue it is not; it is generally of little benefit to the individual person insured, but of significant benefit to the insurance company. (Utilization review is the process an insurance company uses to assess whether you still need to be in the hospital, or if you really need that MRI, or if you could manage with a less costly medication). Is there a benefit to these programs? Well, yes and no; the individual doesn’t benefit that much. The group of beneficiaries as a whole benefits some, since every dollar saved by UR is a dollar which can potentially be spent on other health care. But UR is much hated by patients and doctors, not because it is done (it’s done some useful things for length of stays, which were arguably way too long when UR started in the 80’s), but because it’s so haphazard. Everyone has their own rules, the rules are often arbitrary, or arbitrarily enforced, and the appeals process is arduous and uncertain.

The National Association of Insurance Commissioners (the group of state insurance commissioners; this is a government organization, like the association of governors, etc,) has recently come out with a guidance document which has a relatively narrow definition of “health care spending”. And unsurprisingly, the insurance companies, led by Karen Ignani (the remarkably effective president of America’s Health Insurance Plans, or AHIP), are incensed that their favorite spending categories, (investments and fraud prevention) are not counted as “health expenditures”. Naturally, they couch this in language calculated to frighten patients into calling their congresscritters: “the current proposal could have the unintended consequence of turning-back-the-clock on efforts to improve patient safety, enhance the quality of care, and fight fraud” according to Ms. Ignani.

Uh-huh. Investments did so much to improve patient safety. And fighting fraud is a cost of doing business, not a direct cost of health care. Now Ms. Ignani is a smart woman; she knows the buttons to push. But I wish they insurance companies would, just once, recognize that the exemption from anti-trust law they enjoy is at least in part a statement of the public’s faith that they will act in the public’s interest. You know, from time to time. So far their record is spotty to a kind reading. (To a fair reading it’s exploitative, in my opinion, but I’ll stick with spotty for now).

A story in today’s Modern Healthcare (a magazine I just discovered through the good offices of Emily Friedman, who was one of my favorite teachers at BUSPH) (Also, registration required) reports that a significant minority of nurses have little confidence in the institutions where they work, and a remarkable 72% majority feel that the institution where they work understaffs for the work done.

As someone who is not a nurse, but works with a lot of them very regularly, I agree with this assessment on both counts. While it is not unusual for employees to feel they are overworked, nurses are asked to provide direct care to increasing numbers of increasingly ill patients, which requires not only making people comfortable and handing out their meds, but making accurate snap judgements on how they’re doing, whether they’re getting better or worse, how to intervene if things aren’t going well, and generally expected to be the patient’s first line of defense against the system (which we all know patient’s need defending against, ref. IOM report on medical error). Institutions don’t want there to be many nurses (because a good nurse is expensive), and so try to remove a lot of the “direct care” from nursing hands, leaving them with the more technical aspects of care. This ignores a huge part of what a nurse does, though; nurses spend a lot of time with patients in the course of changing the sheets, bathing and toileting, assisting with ambulation, and all of the “direct care” which can be done by others but ought to be done by nurses. Because it’s that time with the patient where the nurse learns the patient’s baseline, and can then judge departures from that baseline, and either intervene themselves, or call other providers to intervene if the problem is outside their scope of practice.

It’s like this: when I was learning physical diagnosis (how to examine people), one of my instructors pointed out the value of seeing as many “normal” things as possible. That way, when I saw something subtly abnormal, I would recognize it as abnormal and investigate, even if I didn’t know what exactly the abnormality was. Realizing that something “doesn’t look right” is a highly valued skill in medicine. Nurses are in a position to look at a patient and recognize, because they’ve spent a lot of time with the patient, that they “don’t look right”. They may not know exactly what is wrong (although usually they do, especially at the higher experience levels), but they know it’s something. The earlier that recognition takes place, the earlier something can be done, and a problem, error or complication avoided.

This is the problem which led the California Nurses Association to demand, and get, mandatory staffing levels in California hospitals. Hospitals moaned loudly, because nurse staffing has traditionally been a management prerogative, but since nursing management (like physician management) has been co-opted by general management (whose priority is profit, even in non-profit institutions), that prerogative has been abused in the service of improving the bottom line. Rather than pay for proper nursing, management would rather buy a new magnet (MRI machine), or outfit a catheterization lab for which they don’t have enough volume, in the hopes of increasing that volume, or do some other thing which increases their “business competitiveness” while decreasing their ability to perform the core function of a hospital, which is to care for the patient. CNA had little confidence that management would protect the core mission when confronted with the desire of physicians and managers (and, let us be honest, patients) for the latest and greatest technology. And my confidence is just as low.

So there’s a story in today’s Boston Globe, which reports that slightly more than half of overweight adults are healthy, as measured by their cholesterol levels and blood pressure (and a few other things, basically measuring ‘metabolic health’). And not a few (about one quarter) of people of ‘normal’ weight were unhealthy by those measures.

Well, that’ll set the fox in the henhouse, won’t it?

Let’s have a look at the original, shall we? It does say about what is reported (have a look), but is interesting for what else it says:

“The independent correlates of 0 or 1 cardiometabolic abnormalities among overweight and obese individuals were younger age, non-Hispanic black race/ethnicity, higher physical activity levels, and smaller waist circumference.”

So, young white people who exercise and have smaller waists than hips are healthier than you might expect based on their body mass index. What does this tell us? Mostly, it tells us that BMI is a blunt instrument with respect to measuring cardiovascular health. If you’re paying attention at all, this is not news, although it is nice to have it confirmed by a data set as large as NHANES (National Health and Nutrition Examination Survey-it’s a Really Big, Really Good data set). Basically, obesity is not as big a problem as fat distribution. To quote the paper: “There is not yet a standardized definition of body size phenotype”. Perhaps we should work on that, because where the fat is, and whether you are ‘physically active’, may mean more in terms of health than BMI alone. So, now wither obesity prevention? Because it’s going to be hard to base any kind of health intervention on BMI, which is what we’ve been doing for a while now.

This matters for a couple of reasons. If you’re going to design an intervention with respect to obesity (and believe, me, a lot of money is going to be spent on this in the upcoming few years), you need to point the money at the right problem. And BMI is looking like the wrong problem. So what is the right problem? We’re getting a grip on it, but we need a ‘standardized definition of body size phenotype’. We also need to get a grip on activity. How do activity and ‘body size phenotype’, whatever we decide that is, interact? Which is more important, or are they interacting terms?

And this matters right now. I interviewed today for a position at a local health care think tank, which has a sizable initiative on obesity intervention. What is the future of that initiative, in light of these findings? It’s not dead, but it might need significant reworking in light of this paper. The nice part is, if I get the job (it’s an internship, but hey, still a job as far as I’m concerned), I might get to do some of the rework.

Ain’t science grand?