Category Archives: policy

healthy habits, nutrition, policy, politics

Marion does fish politics

 

Fish politics: The FDA’s updated policy on eating fish while pregnant

JUN172014

Fish politics: The FDA’s updated policy on eating fish while pregnant

Eating fish presents difficult dilemmas (I evaluate them in five chapters of What to Eat).

This one is about asking pregnant women to weigh the benefits of fish-eating against the hazards of their toxic chemical contaminants to the developing fetus.

The Dietary Guidelines tell pregnant women to eat 2-to-3 servings of low-mercury fish per week (actually, it’s methylmercury that is of concern, but the FDA calls it mercury and I will too).

But to do that, pregnant women have to:

  • Know which fish are low in mercury
  • Recognize these fish at the supermarket, even if they are mislabeled (which they sometimes are).

Only a few fish, all large predators, are high in mercury.  The FDA advisory says these are:

  • Shark
  • Swordfish
  • King Mackerel
  • Tilefish

What?  This list leaves off the fifth large predator: Albacore (white) tuna.  This tuna has about half the mercury as the other four, but still much more than other kinds of fish.

The figure below comes from the Institute of Medicine’s fish report.  It shows that fish highest in omega-3 fatty acids, the ones that are supposed to promote neurological development in the fetus and cognitive development in infants, are also highest in mercury.

fish

White tuna is the line toward the bottom.  The ones in the blue boxes are all much lower in omega-3s and in mercury except for farmed Atlantic salmon (high in omega-3s, very low in mercury).

What’s going on here?

  • Tuna producers know you can’t tell the difference between white and other kinds of tuna and don’t want you to stop eating tuna during pregnancy.
  • The data on the importance of eating fish to children’s cognitive development are questionable (in my opinion).  The studies are short term and it’s difficult to know whether the small gains in early cognitive development that have been reported make any difference a few months later.
  • The FDA must be under intense pressure to promote fish consumption.

I think it is absurd to require pregnant women to know which fish to avoid.  In supermarkets, fish can look pretty much alike and you cannot count on fish sellers to know the differences.

Other dilemmas:

  • Even smaller fish have PCBs, another toxin best avoided by pregnant women, if not everyone.
  • The world’s seafood supply is falling rapidly as a result of overfishing.
  • Half of the mercury in seafood derives from emissions from coal-burning power plants.  The best way to reduce mercury in fish is to clean up the emissions from those plants, but plant owners want to avoid the expense.

That’s fish politics, for you.

The FDA documents:

healthy habits, nutrition, policy

On how good broccoli is

 

http://www.theatlantic.com/health/archive/2014/06/the-only-reason-anyone-would-eat-broccoli/372899/

Broccoli Loves Us

New cancer-prevention research says that consuming broccoli sprouts makes people excrete benzene in their urine, mitigating effects of breathing polluted air.
Nick Saltmarch/Flickr

What are you doing with the benzene you inhale? Just absorbing it, stocking up on sleepiness, dizziness, anemia, possibly leukemia? Or are you taking control and expunging it in your urine?

This week in the journal Cancer Prevention Research, scientists from Johns Hopkins and China’s Qidong Liver Cancer Institute report that daily consumption of a half-cup of “broccoli-sprout beverage”—a tea made with broccoli sprouts—produced rapid, sustained, high-level excretion of benzene in research subjects’ urine. Their conclusion, building on prior research, is that broccoli helps the human body break down benzene and excrete its byproducts. As benzene is a known human carcinogen commonly found in polluted air in both urban and rural areas, voiding it is an unmitigated virtue.

The broccoli-sprout beverage also increased the levels of the lung irritant acrolein, another common air pollutant, in the subjects’ urine.

So every alt-juice shop that sells a $14 broccoli-sprout smoothie on its “cleansing” merits is technically not entirely lying.

The broccoli-sprout beverage is understood to be a vehicle for the compound sulforaphane, which has been shown to have cancer-preventive qualities in animal studies, apparently by activating a molecule called NRF2 that enhances cells’ abilities to adapt to environmental toxins. In another study earlier this year, sulforaphane-rich broccoli sprout preparations decreased people’s nasal allergic responses to diesel exhaust particles.

The researchers found that among participants who drank the broccoli-sprout beverage, excretion of benzene increased 61 percent—beginning the first day and continuing throughout the 12-week study. Excretion of acrolein increased by 23 percent.

Outdoor air pollution is associated with cardiorespiratory mortality, chronic obstructive pulmonary disease, lung cancer, and overall decreased lung function. According to the World Health Organization, air pollution kills around seven million people every year. It might seem absurd to suggest putting the onus on individual dietary choices, but that’s basically what’s happening here. Environmental researchers call it chemoprevention. A quarter of the world is breathing unsafe air, and while government officials are hard at work implementing regulatory policies to improve air quality and reduce reliance on fossil fuels, which they surely are, we get to eat more broccoli.

“This study points to a frugal, simple, and safe means that can be taken by individuals,” said lead researcher Thomas Kensler, a professor at Johns Hopkins Bloomberg School of Public Health, in a press statement, “to possibly reduce some of the long-term health risks associated with air pollution.”

Regular broccoli also contains sulforaphane, though in considerably lower quantities than the sprouts studied here, which the researchers found to be “the maximum tolerated dose.”

“The more bitter your broccoli, perhaps the better,” Kensler told The Wall Street Journal, adding that one would have to consume roughly 1.5 cups of broccoli every day to get the same amount consumed in this study—even more if it’s boiled, which is just no way to prepare broccoli.

Chemoprevention could empower people who live in areas with high levels of air pollution, and this study will provide leverage for broccoli-pushing parents everywhere. “Eat your broccoli, child, or the air will get you. Chemicals that the corporations put in the air will give you cancer. Finish it. The air is coming for you. Finish your broccoli. Eat your broccoli. Don’t you. No. Don’t you talk to me about policy reform. The only person you can count on in this world is yourself. Swallow. Eat it.”

complex adaptive systems, data saving lives, health market quality, healthcare, healthy habits, policy, politics, rapid learning health systems

Cth Fund Country Comparisons

 

http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror

PPT: Exhibit_ES1_CthFund

Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally

Executive Summary

The United States health care system is the most expensive in the world, but this report and prior editions consistently show the U.S. underperforms relative to other countries on most dimensions of performance. Among the 11 nations studied in this report—Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States—the U.S. ranks last, as it did in the 2010, 2007, 2006, and 2004 editions of Mirror, Mirror. Most troubling, the U.S. fails to achieve better health outcomes than the other countries, and as shown in the earlier editions, the U.S. is last or near last on dimensions of access, efficiency, and equity. In this edition of Mirror, Mirror, the United Kingdom ranks first, followed closely by Switzerland (Exhibit ES-1).

Expanding from the seven countries included in 2010, the 2014 edition includes data from 11 countries. It incorporates patients’ and physicians’ survey results on care experiences and ratings on various dimensions of care. It includes information from the most recent three Commonwealth Fund international surveys of patients and primary care physicians about medical practices and views of their countries’ health systems (2011–2013). It also includes information on health care outcomes featured in The Commonwealth Fund’s most recent (2011) national health system scorecard, and from the World Health Organization (WHO) and the Organization for Economic Cooperation and Development (OECD).

Overall health care rankingClick to download Powerpoint chart.

The most notable way the U.S. differs from other industrialized countries is the absence of universal health insurance coverage.5 Other nations ensure the accessibility of care through universal health systems and through better ties between patients and the physician practices that serve as their medical homes. The Affordable Care Act is increasing the number of Americans with coverage and improving access to care, though the data in this report are from years prior to the full implementation of the law. Thus, it is not surprising that the U.S. underperforms on measures of access and equity between populations with above- average and below-average incomes.

The U.S. also ranks behind most countries on many measures of health outcomes, quality, and efficiency. U.S. physicians face particular difficulties receiving timely information, coordinating care, and dealing with administrative hassles. Other countries have led in the adoption of modern health information systems, but U.S. physicians and hospitals are catching up as they respond to significant financial incentives to adopt and make meaningful use of health information technology systems. Additional provisions in the Affordable Care Act will further encourage the efficient organization and delivery of health care, as well as investment in important preventive and population health measures.

For all countries, responses indicate room for improvement. Yet, the other 10 countries spend considerably less on health care per person and as a percent of gross domestic product than does the United States. These findings indicate that, from the perspectives of both physicians and patients, the U.S. health care system could do much better in achieving value for the nation’s substantial investment in health.

Major Findings

  • Quality: The indicators of quality were grouped into four categories: effective care, safe care, coordinated care, and patient-centered care. Compared with the other 10 countries, the U.S. fares best on provision and receipt of preventive and patient-centered care. While there has been some improvement in recent years, lower scores on safe and coordinated care pull the overall U.S. quality score down. Continued adoption of health information technology should enhance the ability of U.S. physicians to identify, monitor, and coordinate care for their patients, particularly those with chronic conditions.
  • Access: Not surprisingly—given the absence of universal coverage—people in the U.S. go without needed health care because of cost more often than people do in the other countries. Americans were the most likely to say they had access problems related to cost. Patients in the U.S. have rapid access to specialized health care services; however, they are less likely to report rapid access to primary care than people in leading countries in the study. In other countries, like Canada, patients have little to no financial burden, but experience wait times for such specialized services. There is a frequent misperception that trade-offs between universal coverage and timely access to specialized services are inevitable; however, the Netherlands, U.K., and Germany provide universal coverage with low out-of-pocket costs while maintaining quick access to specialty services.
  • Efficiency: On indicators of efficiency, the U.S. ranks last among the 11 countries, with the U.K. and Sweden ranking first and second, respectively. The U.S. has poor performance on measures of national health expenditures and administrative costs as well as on measures of administrative hassles, avoidable emergency room use, and duplicative medical testing. Sicker survey respondents in the U.K. and France are less likely to visit the emergency room for a condition that could have been treated by a regular doctor, had one been available.
  • Equity: The U.S. ranks a clear last on measures of equity. Americans with below-average incomes were much more likely than their counterparts in other countries to report not visiting a physician when sick; not getting a recommended test, treatment, or follow-up care; or not filling a prescription or skipping doses when needed because of costs. On each of these indicators, one-third or more lower-income adults in the U.S. said they went without needed care because of costs in the past year.
  • Healthy lives: The U.S. ranks last overall with poor scores on all three indicators of healthy lives—mortality amenable to medical care, infant mortality, and healthy life expectancy at age 60. The U.S. and U.K. had much higher death rates in 2007 from conditions amenable to medical care than some of the other countries, e.g., rates 25 percent to 50 percent higher than Australia and Sweden. Overall, France, Sweden, and Switzerland rank highest on healthy lives.

Summary and Implications

The U.S. ranks last of 11 nations overall. Findings in this report confirm many of those in the earlier four editions of Mirror, Mirror, with the U.S. still ranking last on indicators of efficiency, equity, and outcomes. The U.K. continues to demonstrate strong performance and ranked first overall, though lagging notably on health outcomes. Switzerland, which was included for the first time in this edition, ranked second overall. In the subcategories, the U.S. ranks higher on preventive care, and is strong on waiting times for specialist care, but weak on access to needed services and ability to obtain prompt attention from primary care physicians. Any attempt to assess the relative performance of countries has inherent limitations. These rankings summarize evidence on measures of high performance based on national mortality data and the perceptions and experiences of patients and physicians. They do not capture important dimensions of effectiveness or efficiency that might be obtained from medical records or administrative data. Patients’ and physicians’ assessments might be affected by their experiences and expectations, which could differ by country and culture.

Disparities in access to services signal the need to expand insurance to cover the uninsured and to ensure that all Americans have an accessible medical home. Under the Affordable Care Act, low- to moderate-income families are now eligible for financial assistance in obtaining coverage. Meanwhile, the U.S. has significantly accelerated the adoption of health information technology following the enactment of the American Recovery and Reinvestment Act, and is beginning to close the gap with other countries that have led on adoption of health information technology. Significant incentives now encourage U.S. providers to utilize integrated medical records and information systems that are accessible to providers and patients. Those efforts will likely help clinicians deliver more effective and efficient care.

Many U.S. hospitals and health systems are dedicated to improving the process of care to achieve better safety and quality, but the U.S. can also learn from innovations in other countries—including public reporting of quality data, payment systems that reward high-quality care, and a team approach to management of chronic conditions. Based on these patient and physician reports, and with the enactment of health reform, the United States should be able to make significant strides in improving the delivery, coordination, and equity of the health care system in coming years.

us health care ranks last

complex adaptive systems, data saving lives, health market quality, healthcare, policy, politics, rapid learning health systems

Selecting health insurance based on value of care covered…

A solid idea.

Allowing consumers to pick how “fruity” they want their cover to be. This takes self-serving autonomy from the clinicians and places it back with the patients, who no longer have to cross-subsidise silly, exorbitant care.

 

http://www.nytimes.com/2014/06/10/upshot/how-to-pay-for-only-the-health-care-you-want.html

How to Pay for Only the Health Care You Want

Magoz

By Austin Frakt andAmitabh Chandra

One reason health insurance is expensive is that most plans cover just about every medical technology — not just the ones that work, or the ones that are worth the price. This not only drives up costs, but also forces many Americans into purchasing coverage for therapies they may not value. But there’s no reason things couldn’t be different, and better for consumers.

Consider the latest technology for treating prostate cancer: the proton beam. It’s delivered with a football field-size machine costing well over $100 million. Per treatment, this therapy costs at least twice as much as alternative approaches, but is no more effective. Many health plans cover it and other therapies of low or uncertain value because they pay for anything that physicians deem medically necessary even when evidence suggests otherwise. And, without even knowing it, Americans pay for it in higher premiums.

It doesn’t have to be this way. If plans could compete on the basis of the therapies they cover, consumers could decide what they wish to pay for. This sounds complicated, but it need not be.

Health plans could define themselves at least in part by the value of technologies they cover, an idea proposed by Professor Russell Korobkin of the U.C.L.A. School of Law. For example, a bronze plan could cover hospitalizations and visits to doctors for emergencies and accidents; genetic diseases; and prescription drugs that keep people out of hospitals. A silver plan could cover what bronze plans do but also include treatments a large majority of physicians find useful. A gold plan could be more inclusive still, adding coverage, for instance, for every cancer therapy shown to improve patient outcomes (no matter the cost) as long as it was delivered at a leading cancer center. Finally, a platinum plan could cover experimental and unproven cancer therapies, including, for example, that proton beam.

This way, nothing would be concealed or withheld from consumers. Someone who wanted proton-beam cancer treatment coverage could have it by selecting a platinum policy and paying its higher premiums. Someone who did not want to pay higher premiums for lower-value care, in turn, could choose a bronze or silver plan. This gives a different, but more useful, meaning to the terms “gold,” “silver” and “bronze” than they have in the new insurance exchanges today.

A second concern is that as people become sick, they will prefer plans that cover more treatments, including experimental ones. As sick people disproportionately choose more generous plans, their expenses and premiums will have to rise. This phenomenon, known as adverse selection, is familiar in most health insurance markets, including those for employer-sponsored plans, private plans that participate in Medicare and in the Affordable Care Act’s new marketplaces. One common way to address it is to permit individuals to switch plans only once per year, during an open enrollment period. This locks people into their choice for some time, so they can’t suddenly upgrade their plan after getting sick. If a once-per-year enrollment period proves insufficient in this case, a longer period could be imposed.

Structuring health plans according to value would give Americans the ability to buy whatever health care technologies they choose — including, if they want it, unproven and expensive care — without forcing others to pay for that choice. This would help address the key, though under-recognized, problem in American health care today: not that Americans spend a lot on health care, but that they spend a lot without always getting good value for the money.

Austin Frakt is a health economist with several governmental and academic affiliations. He blogs at The Incidental Economist, and you can follow him on Twitter at @afrakt.

Amitabh Chandra is a professor of public policy at Harvard’s John F Kennedy School of Government. His government affiliations and financial disclosures are listed on hisHarvard website. Follow him on Twitter at @amitabhchandra2.

The Upshot provides news, analysis and graphics about politics, policy and everyday life. Follow us on Facebook and Twitter.

healthy habits, nutrition, policy, politics

Dairy and Government

Government funds dairy promotions which are then siphoned off by junk food manufacturers including dairy in their junk products… everything is awesome!!!!

Exec Summary: SimonWhitewashedDairyReportExecSum

Michele Simon’s latest report: “Whitewashed” (she means dairy foods)

Michele Simon’s latest report: “Whitewashed” (she means dairy foods)

I always am interested in Michele Simon’s provocative reports.  Her latest,Whitewashed, is no exception.  It’s about how the government promotes dairy foods, no matter what kind or where they appear.

New Picture

Read her blog post here.

Download the full report here.

Read the executive summary here.

Here’s are some of the surprising (to me) findings detailed in the report:

  • About half of all milk is consumed either as flavored milk, with cereal, or in a drink;
  • Nearly half of the milk supply goes to make about 9 billion pounds of cheese and 1.5 billion gallons of frozen desserts–two-thirds of which is ice cream;
  • 11 percent of all sugar goes into the production of dairy products.

Where the government enters the picture is through the “checkoff programs” for promoting milk and dairy.  These are USDA-Sponsored programs, paid for by dairy farmers through checkoff fees, but run by the USDA.

U.S. Department of Agriculture employees attend checkoff meetings, monitor activities, and are responsible for evaluation of the programs. The U.S. Supreme Court has upheld the legality of the checkoff programs as “government speech”, finding: “the message … is controlled by the Federal Government.”

The report has some interesting findings about the checkoff.  Although checkoff funds are supposed to be used for generic marketing, the dairy checkoff helped:

  • McDonald’s make sure that dairy foods play an important role in product development.
  • Taco Bell introduce its double steak quesadillas and cheese shreds.
  • Pizza Hut develop its 3-Cheese Stuffed Crust Pizza and “Summer of Cheese” ad campaign.
  • Dominos add more cheese to its pizzas as a result of a $35 million partnership.
  • Domino’s “Smart Slice” program introduce its pizza to more than 2,000 schools in 2011.
  • Promote “Chocolate Milk Has Muscle” and “Raise Your Hand for Chocolate Milk.”

I like dairy foods, but should the government be doing this?

complex adaptive systems, data saving lives, health market quality, healthcare, healthy habits, musings, policy, politics, rapid learning health systems

A chat with Terry

An excerpt of a conversation with Terry Hannan on the business and bureaucracy of health and clinical care…

 

Terry, thank you for sharing those terrific papers by John Wennberg and Brent James… inspiring and affirming thinking.

 

Regarding your request for me to expand on how “true” priorities of the system are expressed:

My overarching thesis for eHealth and its myriad follies is that the systems built often correctly reflect the “true” priorities of the system. The only glitch is that these priorities are often so radically divorced from those stated by the system’s leaders and in turn expected by clinicians and/or the public.[I would like you to expand this # as I am not sure I entirely grasp your focus here.]

 

Different stakeholders expect different returns from their investments. Roughly speaking (and apologies in advance for some of the generalisations that follow):

– politicians want to maximise votes in return for policy announcements

– bureaucrats want to maximise budget, status and power, and minimise risk in return to turning up to work

– public sector doctors want to maximise the health of their patients and status in return for turning up to work and working hard

– private sector doctors want to maximise income and status and minimise legal exposures in return for doing as much work as possible

– private hospitals want to maximise revenue in return for getting as many patients through their doors as possible

– nurses unions want to maximise members in return for negotiating improved work conditions

– not-for-profit (mutual) private health insurers want to maximise their perks by keeping doctors and private hospitals happy

– for-profit private health insurers want to maximise their profit margins by minimising doctor and hospital payments and maximising membership

– health researchers want to maximise their research capacity in return for increased publications

 

(Patients don’t even make my list of stakeholders, because they are not truly involved at present. An interesting remedy for this is citizen juries, a discussion for another time – did you ever engage with Prof Gavin Mooney before his untimely death?)

 

This suggests that each of these tribes wants a different “currency” in exchange for the “value” they deliver to the health system. They all use “patient interest” as the public justification for their claims on the system, but most of them are not actually remunerated in a currency that relates to the patient’s interest.

 

Indeed, in true “rent seeking” fashion, most of these stakeholders would rather not have to justify their remuneration to anyone – see this recent HLM news article.

 

At present, the easiest way to see what the system actually values is by looking at what it invests in. One “tell” that belies the health system’s “true” priorities is what it goes to the effort to properly records in electronic form i.e. billing data. This therefore suggests that money is the priority, and so it is what is tracked carefully.

 

If “patient interest” was truly the priority of the system, then far more effort and expense would be put into tracking patient outcomes, and in time, paying for them. On this, I am encouraged by the early shoots starting to sprout in the US around the development of ACOs, though I’m sure there are a lot more warts on it when seen up close.

 

My favourite “tale” of how to get there relates to how I’m told traditional chinese medical practitioners used to be paid. Everyone in the village would pay the practitioner as long as they were well, but stopped paying them whenever they ever got sick. This tight pecuniary alignment between patient and practitioner interest excites me, and makes me think there is still hope for ACO-style reform here. Indeed, my current health policy horizon doesn’t even involve hospitals and doctors, but rather looks at prevention efforts as the focus, as separate system with separate funding and separate participants.

 

I suspect this is best discussed over a long lunch or dinner, which I look forward to when the opportunity next arises.

 

Best regards, Paul

 

 

 

 

 

 

 

From: Hannan, Terry J (DHHS) [mailto:Terry.Hannan@dhhs.tas.gov.au]
Sent: Tuesday, 17 June 2014 9:07 PM
To: Paul Nicolarakis
Subject: RE: contact

 

See my inserted notes.

 

From: Paul Nicolarakis [mailto:pnicolarakis@cmcrc.com]
Sent: Tuesday, 17 June 2014 5:45 PM
To: Hannan, Terry J (DHHS)
Subject: RE: contact

 

Thanks for your forbearance Terry.

 

I’m inspired by your resilience and enthusiasm for the area, and quite certain that this particular eHealth conversation is going to yield some interesting insights. I present these ideas (which tend towards the political more than technical or clinical) to you in confidence, with a view to sharpening up the thinking. In light of my political experience, I would not want to offend any past masters as they were operating within some diabolical constraints.

 

My overarching thesis for eHealth and its myriad follies is that the systems built often correctly reflect the “true” priorities of the system. The only glitch is that these priorities are often so radically divorced from those stated by the system’s leaders and in turn expected by clinicians and/or the public.

 

Applying this analysis, it makes sense that an EMR purpose built to support HIV treatment in Africa would work because the only people involved in its development are dedicated clinicians, developers and minimal funding from similarly aligned entities with the specific purpose of improving the quality of care.

 

It also makes sense that physician led, integrated health systems (e.g. Regenstrief, Intermountain) that understand the “triple aim” nexus between high quality care and reduced costs would employ these systems successfully.

 

But finally, it also follows that systems built for governments in modern western democratic economies will never work because they are being built to get their political leaders re-elected, and make their vendors lots of money, but not really serve the community. The failure of these systems is ultimately guaranteed when the transparency they risk introducing into a system starts to threaten vested interests such as private medical providers and their associated institutions.

 

As per your slide from Blum, the red tail wags the yellow and blue dog because this is actually what matters in modern health care.

 

Microsoft learned this the hard way with their health solutions group efforts that I was involved in for a few years. The analytics software (Amalga) was quite impressive, initially developed by a group of keen, inquisitive (“data curious”) emergency physicians. They used the solution to monitor all sorts of clinical quality metrics across the business Washington Hospital Center service. Microsoft executives saw it, were impressed and acquired it. They then tried for 4 years to sell it to the world, only to discover that the “world” was not as interested in “clinical quality” as they were in bottom line revenues. What emerged from this experiment was the realisation that Microsoft had found itself ambushed by the gross conceit of modern healthcare i.e. stating that it was all about patient care, when in actual fact it was all about cash. Hence the highly administrative focus of most EMRs?

 

What has been terrific is to see US policy makers respond to this realisation by establishing “business models” around meaningful use and clinical outcomes. This is what seriously excites me now, though I suspect Australia is a decade away from adopting anything like what’s going on in the US at the moment.

 

One of the mantras we have here at the CRC (born in part out of our academic finance roots) is: “Healthcare is not a system, it’s a series of highly dysfunctional markets”. Applying this prism to healthcare really does start to clarify things, especially on the private side. On the public side, the currencies are sometimes different, but no less predictable.

 

I’ll pause here for fear of triggering some sort of global terrorist alert and/or offending you? Needless to say, I look forward to seeing where this conversation goes!

 

Best regards, Paul

 

 

 

From: Hannan, Terry J (DHHS) [mailto:Terry.Hannan@dhhs.tas.gov.au]
Sent: Tuesday, 17 June 2014 2:15 PM
To: Paul Nicolarakis
Subject: Re: contact

 

Take your time you just spark my enthusiasm. The fact that you are interested is such joy. Terry

Sent from my iPhone Terry Hannan
On 17 Jun 2014, at 1:40 pm, “Paul Nicolarakis” <pnicolarakis@cmcrc.com> wrote:

Please bear with me Terry… I’ve got lots on at work… will respond soon… Paul

 

From: Hannan, Terry J (DHHS) [mailto:Terry.Hannan@dhhs.tas.gov.au]
Sent: Monday, 16 June 2014 2:12 PM
To: Paul Nicolarakis
Subject: RE: contact

 

Paul, thank you for the taking the time to write to me and if you think about it this is the first time in our long association where we have done a bit of eHealth “together”.

Based on your enthusiasm in the text I will now send you some materials which should further extend our discussions.

 

Firstly I have attached nan short slide set that I had prepared for the Sydney meeting-just in case.

The next slide is explained in the text flowing it.

<image001.png>

 

This slide is taken from B. Blum’s Clinical Information Systems and you can see the small RED Administrativebox in the top left which is where most HIS funding and management comes from and they try to meet the needs of the most important cost generator Clinical Decision Making.

This is confirmed by the work in cost reduction in CDSS as shown in the slide set attached by Tierney in Regenstrief.

Also in the references below.

1.         Slack WV. Cybermedicine, How Computing Empowers Doctors and Patients for Better Health Care. 2nd ed. San Francisco: Jossey-Bass; 2001 2001.

2.         Tierney WM, Fitzgerald JF, Miller ME, James MK, McDonald CJ. Predicting inpatient costs with admitting clinical data. Med Care. 1995;33(1):1-14. Epub 1995/01/01.

3.         Tierney WM, Overhage JM, Takesue BY, Harris LE, Murray MD, Vargo DL, et al. Computerizing guidelines to improve care and patient outcomes: the example of heart failure. J Am Med Inform Assoc. 1995;2(5):316-22. Epub 1995/09/01.

 

In addition these results from institutions such as Regenstrief, Intermountain Health (HELP System), Brigham’ and Women’s Hospital and Beth Israel Deaconess Hospitals confirm these findings and show that the current funding models by governments are incorrect.

 

I am attaching two summary papers from the Kenyan project.

I hope I have not burdened you.

 

Terry

Dr Terry J. Hannan MBBS;FRACP;FACHI;FACMI
Consultant Physician
Clinical Associate Professor  School of Human Health Sciences, University of Tasmania Department of Medicine, Launceston General Hospital
Charles Street Launceston 7250

Moderator: http://www.ghdonline.org/

Ph. 61 3 6348 7578
Mob. 0417 144 881
Fax 61 3 6348 7577
Email terry.hannan@dhhs.tas.gov.au

Skype: thehannans

 

From: Paul Nicolarakis [mailto:pnicolarakis@cmcrc.com]
Sent: Monday, 16 June 2014 1:33 PM
To: Hannan, Terry J (DHHS)
Subject: RE: contact

Paper (PDF): Are docs the weakness in the ehealth building

Dear Terry,

Thank you for sharing the paper and referring me to ghdonline.org – I’ve just signed up.

The paper touches on many issues close to my heart, but two that I am particularly interested in is the exploration of “healthcare as business” vs “the business of clinical care”.

I won’t commit my dismal views to this email for fear of offending due to lack of context, but would welcome an opportunity to a vigorous discussion with you when we next have an opportunity? To the discourse I would like to add “healthcare as a bureaucracy” and “the bureaucracy of clinical care” as I believe this frame paired with “business” frame are particularly explanatory of most things that happen (or in the case of e-health, don’t happen) in the sector. Needless to say, the clinical and information systems you helped to establish in Africa represent something of an ideal in my mind for an end-goal of a “lite”, modern, effective health system following the “less is more” maxim.

Looking forward to continuing the conversation.

Best regards, Paul

I’ve now seen the Australian health system laid bare while working for the Minister, and many other health systems up close while working internationally at Microsoft. I’ve concluded that with rare exceptions, health care represents “just another unremarkable business” or “just another unremarkable

bureaucracy” depending on the type of funding system that is used.

complex adaptive systems, cool, healthy habits, nutrition, policy

Prolonged fasting (2-4days) regenerates immune system…

The study has major implications for healthier aging, in which immune system decline contributes to increased susceptibility to disease as we age. By outlining how prolonged fasting cycles — periods of no food for two to four days at a time over the course of six months — kill older and damaged immune cells and generate new ones, the research also has implications for chemotherapy tolerance and for those with a wide range of immune system deficiencies, including autoimmunity disorders.

 

Fasting triggers stem cell regeneration of damaged, old immune system

Date:
June 5, 2014
Source:
University of Southern California
Summary:
In the first evidence of a natural intervention triggering stem cell-based regeneration of an organ or system, a study shows that cycles of prolonged fasting not only protect against immune system damage — a major side effect of chemotherapy — but also induce immune system regeneration, shifting stem cells from a dormant state to a state of self-renewal.
During fasting the number of hematopoietic stem cells increases but the number of the normally much more abundant white blood cells decreases. In young or healthy mice undergoing multiple fasting/re-feeding cycles, the population of stem cells increases in size although the number of white blood cells remain normal. In mice treated with chemotherapy or in old mice, the cycles of fasting reverse the immunosuppression and immunosenescence, respectively.
Credit: Cell Stem Cell, Cheng et al.

In the first evidence of a natural intervention triggering stem cell-based regeneration of an organ or system, a study in the June 5 issue of the Cell Press journal Cell Stem Cell shows that cycles of prolonged fasting not only protect against immune system damage — a major side effect of chemotherapy — but also induce immune system regeneration, shifting stem cells from a dormant state to a state of self-renewal.

In both mice and a Phase 1 human clinical trial, long periods of not eating significantly lowered white blood cell counts. In mice, fasting cycles then “flipped a regenerative switch”: changing the signaling pathways for hematopoietic stem cells, which are responsible for the generation of blood and immune systems, the research showed.

The study has major implications for healthier aging, in which immune system decline contributes to increased susceptibility to disease as we age. By outlining how prolonged fasting cycles — periods of no food for two to four days at a time over the course of six months — kill older and damaged immune cells and generate new ones, the research also has implications for chemotherapy tolerance and for those with a wide range of immune system deficiencies, including autoimmunity disorders.

“We could not predict that prolonged fasting would have such a remarkable effect in promoting stem cell-based regeneration of the hematopoietic system,” said corresponding author Valter Longo, the Edna M. Jones Professor of Gerontology and the Biological Sciences at the USC Davis School of Gerontology, and director of the USC Longevity Institute.

“When you starve, the system tries to save energy, and one of the things it can do to save energy is to recycle a lot of the immune cells that are not needed, especially those that may be damaged,” Longo said. “What we started noticing in both our human work and animal work is that the white blood cell count goes down with prolonged fasting. Then when you re-feed, the blood cells come back. So we started thinking, well, where does it come from?”

Prolonged fasting forces the body to use stores of glucose, fat and ketones, but also breaks down a significant portion of white blood cells. Longo likens the effect to lightening a plane of excess cargo.

During each cycle of fasting, this depletion of white blood cells induces changes that trigger stem cell-based regeneration of new immune system cells. In particular, prolonged fasting reduced the enzyme PKA, an effect previously discovered by the Longo team to extend longevity in simple organisms and which has been linked in other research to the regulation of stem cell self-renewal and pluripotency — that is, the potential for one cell to develop into many different cell types. Prolonged fasting also lowered levels of IGF-1, a growth-factor hormone that Longo and others have linked to aging, tumor progression and cancer risk.

“PKA is the key gene that needs to shut down in order for these stem cells to switch into regenerative mode. It gives the ‘okay’ for stem cells to go ahead and begin proliferating and rebuild the entire system,” explained Longo, noting the potential of clinical applications that mimic the effects of prolonged fasting to rejuvenate the immune system. “And the good news is that the body got rid of the parts of the system that might be damaged or old, the inefficient parts, during the fasting. Now, if you start with a system heavily damaged by chemotherapy or aging, fasting cycles can generate, literally, a new immune system.”

Prolonged fasting also protected against toxicity in a pilot clinical trial in which a small group of patients fasted for a 72-hour period prior to chemotherapy, extending Longo’s influential past research: “While chemotherapy saves lives, it causes significant collateral damage to the immune system. The results of this study suggest that fasting may mitigate some of the harmful effects of chemotherapy,” said co-author Tanya Dorff, assistant professor of clinical medicine at the USC Norris Comprehensive Cancer Center and Hospital. “More clinical studies are needed, and any such dietary intervention should be undertaken only under the guidance of a physician.”

“We are investigating the possibility that these effects are applicable to many different systems and organs, not just the immune system,” said Longo, whose lab is in the process of conducting further research on controlled dietary interventions and stem cell regeneration in both animal and clinical studies.

Story Source:

The above story is based on materials provided by University of Southern California. The original article was written by Suzanne Wu. Note: Materials may be edited for content and length.

Journal Reference:

  1. Chia-Wei Cheng, Gregor B. Adams, Laura Perin, Min Wei, Xiaoying Zhou, Ben S. Lam, Stefano Da Sacco, Mario Mirisola, David I. Quinn, Tanya B. Dorff, John J. Kopchick, Valter D. Longo. Prolonged Fasting Reduces IGF-1/PKA to Promote Hematopoietic-Stem-Cell-Based Regeneration and Reverse Immunosuppression. Cell Stem Cell, 2014; 14 (6): 810 DOI:10.1016/j.stem.2014.04.014

Cite This Page:

University of Southern California. “Fasting triggers stem cell regeneration of damaged, old immune system.” ScienceDaily. ScienceDaily, 5 June 2014. <www.sciencedaily.com/releases/2014/06/140605141507.htm>.
health market quality, healthcare, policy, politics, rapid learning health systems

Menadue: Auction off provider numbers

Now there’s an interesting thought:

Another option to overcome shortages of doctors in rural Australia would be to auction provider numbers by postcode but that would probably be too radical for many professional people who don’t like open markets.

John Menadue. Have we too many doctors?

John Menadue. Have we too many doctors?

Posted on June 4, 2014 by John Menadue

There are no international comparisons that I can find that show that we have a shortage of doctors in Australia. In fact, we may be moving into a situation of having a surplus of doctors.  In its “Health at a glance” the OECD found that we are above the average in our supply of doctors. The OECD provided details of “practising doctors per 1000 of population in 2011” for over 40 major countries. The OECD average was 3.2 practising doctors per1000 of population. Australia was slightly above the average with3.3 practising doctor’s per1000 of population. For the Netherlands it was 3.0, for the UK 2.8, for NZ 2.6 and Canada 2.4. The top four countries with over 4 practising doctors per 1000 were Greece, Russia, Austria and Italy. The OECD is quite explicit about trends in Australia It says “in several countries (e.g. Australia, Canada, Denmark, the Netherlands and the UK) the number of medical graduates has risen strongly since 2000 reflecting past decisions to expand training capacity…In Australia the number of medical graduates has increased two and a half times between 1990 and 2010 with most of the growth occurring since 2000”

In 2004 when Tony Abbott was Minister for Health he decided against advice that we had a shortage of doctors. As a result the number of domestic students graduating from medical schools in Australia increased dramatically from 1,287 in 2004 to 2,507 in 2011. It has been described as a “tsunami” of medical graduates. The OECD found that in 2011 with 12.1 medical graduates per 10,000 of population we were well above the OECD average of 10.6. We know that this increase in numbers is making it very difficult to find training places for the increased number of medical graduates.

We also know that with bulk billing and with patient dependence on the advice of their doctor about future appointments, tests and referrals, doctors have an ability to generate work for themselves and other professionals. Doctors can and do drive the demand for their services through fee for service.  That has serious cost implications.
Apart from the total numbers the other important issue is the distribution of doctors across Australia.  All the data shows serious shortages of doctors and other health professionals in rural and remote Australia. These shortages are occurring despite the fact that we now have about 3,000 International Medical Graduates (IMGs) who are tied to areas of need. These IMGs have performed a useful role in rural areas although there has been some concern over language and sometimes professional skills. However it seems logical and legally defensible (“civil conscription”) that if we can determine where IMGs can work, why can’t we do the same for Australian medical graduates and insist that new provider numbers only be issued according to need in Australia. We don’t need more provider numbers and doctors in Belleview Hill and Toorak, but we do need them in rural and remote Australia.  Through governments, taxpayers subsidise medical education and about 80% of the remuneration of doctors comes from government. There is a legitimate interest in new doctors working in areas of need, at least in the early stages of their career. Hopefully they will find professional and personal satisfaction in country areas and decide to stay.

Another option to overcome shortages of doctors in rural Australia would be to auction provider numbers by postcode but that would probably be too radical for many professional people who don’t like open markets.

In short we are moving to a surplus in the total number of practising doctors but serious shortages still exist in rural and remote Australia which could be addressed, at least in part by limiting new provider numbers to areas of need.

Why can we send teachers to areas of need but not doctors?

health market quality, healthcare, policy, politics

Better prostate ca. markers in seminal fluid than PSA

The urologists will not be happy, ‘fuckers:

The men tested were already considered to be candidates for prostate cancer according to their prostate-specific-antigen (PSA) test results. Biopsy later confirmed that 32 of the men had cancer and 28 did not.

http://www.medicalobserver.com.au/news/seminal-fluid-markers-more-accurate-than-psa

Seminal fluid markers more accurate than PSA

Emily Dunn   all articles by this author

BIOMARKERS in seminal fluid have been found to be a more accurate indicator of prostate cancer than standard PSA testing, according to results from an Australian study.

Researchers from the Freemasons Foundation Centre for Men’s Health at the University of Adelaide tested semen samples from 60 men for a range of ribonucleic acid (RNA) molecules or microRNAs that are known to be increased in prostate tumours.

The men tested were already considered to be candidates for prostate cancer according to their prostate-specific-antigen (PSA) test results. Biopsy later confirmed that 32 of the men had cancer and 28 did not.

University of Adelaide research fellow and lead author of the study, Dr Luke Selth said that the results of the study indicated that, in the men tested, each of the micro-RNAs alone was a better predictor of a cancer diagnosis via biopsy than the PSA test. In addition, several of the micro-RNAs, when added to the PSA test results, were a better predictor of the presence of cancer than the PSA test alone.

Dr Selth said the results were promising both in terms of detecting the presence of cancer and identifying aggressive subtypes which could help to reduce both over-diagnosis and over-treatment of suspected prostate cancer.

“The presence of these microRNAs enabled us to more accurately discriminate between patients who had cancer and those who didn’t, compared with a standard PSA test,” Dr Selth said.

“We also found that the one specific microRNA, miR-200b, could distinguish between men with low grade and higher grade tumours. This is important because, as a potential prognostic tool, it will help to indicate the urgency and type of treatment required.”

The results add to previous research which indicated that microRNAs in blood can predict men who are likely to relapse after surgery for prostate cancer. The team have now applied for funding for a larger study into the role of microRNA biomarkers in predicting prostate cancer.

“We are not at the stage where we can say there is a new test for prostate cancer just around the corner,” Dr Selth said. “While these results are encouraging and exciting, we need to validate them in a much larger cohort.”

Endocr Relat Cancer 2014; online 23 May