Starting With Curious

I signed up for the 2015 “Healthy Rewards” (the Children’s Hospital of Wisconsin workplace wellness program) within about five minutes of getting the email that it was available.  Aside from the fact that I’m a bit on the competitive side, I figure the only thing better than having good health care when you’re sick is staying well in the first place.  For employers, a healthy workforce should have all kinds of benefits,  including lowering their health care costs, which helps explain why Children’s, along with over half of all US businesses, offers a wellness program (with larger companies more likely to have them).  In fact, workplace wellness is a $6 billion a year industry.  Must be a smart investment, right?

That’s not entirely clear.  A recent NY Times article, citing several reports and systematic reviews, called into question the health and financial benefits of these programs.  At the risk of oversimplifying, here’s a summary of the salient points from those articles:

1)  Studies of the impact on employee health are generally poorly designed and have mixed results.  Better designed studies (i.e., randomized trials) are less likely to show benefits, but still half of these have demonstrated that wellness programs lead to improvements in some aspects of health including exercise, weight management, and smoking cessation.

2)  Programs that are focused on disease management (e.g., targeting employees with chronic conditions and incentivizing them to better management and preventive care) have a generally better impact than those focused on more general lifestyle management or screening.

3)  The overall benefit of these programs is probably muted by the fact that on average fewer than half of eligible employees participate, with some evidence that those most likely to benefit are the ones who are opting out.

4)  Overall wellness programs seem to save employers money, but part of that is from shifting costs to employees (e.g., higher premiums for those who do not meet screening criteria).  Most studies showed a positive return on investment, but the quality of these studies was low.

5)  Key facilitators of success include making wellness activities convenient and easily accessible for employees, and making wellness an organizational priority among senior leaders.

So yes, the jury is still out; it’s not a slam dunk that these programs are all they are cracked up to be.  But if half the randomized trials indicate a positive benefit, I’d say the glass isn’t half empty, it’s half full – of clean, non-bottled tap water, of which we ought to drink 64 ounces a day.  In the meantime, go ahead and sign up.

Picking a top 10 list is like deciding which of your children is your favorite.  So, at the risk of omitting some very important and meaningful people, events, programs, or accomplishments, here’s my list (in no particular order) of the top 10 happenings at Children’s Hospital of Wisconsin in 2014.

1. CHW was verified by the American Nursing Credentialing Council as a Magnet hospital for the third straight time, a distinction placing us in the top 1% of hospitals. This is a recognition of many aspects of quality, but especially the level of nursing care.
2. For the first time, CHW was ranked in all ten specialties evaluated by US News and World Report, including a number 5 ranking for our Herma Heart Center. Others include diabetes/endocrine, gastroenterology, neonatology, nephrology, neuroscience, oncology, orthopedics, pulmonology, and urology.
3. Our neonatal ICU was featured in a cover story in Time magazine.
4. A multidisciplinary team from the Fetal Concerns Center completed the first ever in utero repair of a myelomeningocele (aka spina bifida) in Wisconsin, making us one of the few centers in the country performing this sophisticated procedure.
5. There was a groundbreaking for the Sojourner Family Justice Center, a collaborative effort with numerous community partners and the state of Wisconsin. Hailed as a national model, this innovative center will bring together shelter, community, and legal services for women and their children who are victims of domestic violence and child abuse into a single location, improving access for those in need.
6. The first phase of our new NICU opened, providing private rooms and incorporating a variety of new technologies to improve quality of care and family-centeredness.
7. The latest step in our commitment to provide care closer to home was the opening of our Delafield clinic in December, with primary and specialty care services.
8. In July we overhauled our clinic fee structure, which greatly reduced costs to families for outpatient care.
9. A variety of steps to improve access for families. This includes an expansion of our access center which coordinates visits for patients traveling from outside the area for care; the initiation of the Wisconsin International Patient Program, with a focus on patients from the Middle East needing some of our highly specialized services not available elsewhere; the expansion of the Ronald McDonald House, an important partner that provides accommodations for families from out of town; and the reopening of  Watertown Plank Road (a blessing for everyone!).
10. Many of our staff relocated to space at the Summit building in West Allis, consolidating those staff into a single (and quite lovely) location.

I am a racist.  There, I said it.

I don’t mean an Archie Bunker-type bigot who hurls invective and spews hate.  But view the world through the concept of race, the idea that characteristics are bundled together, and that knowing the color of someone’s skin can be informative about what is inside.  That is the essence of racism: the idea that race is determinative, that people of different color differ in other important ways.  (Some prefer to refer to this as racialism, but let’s just call a racist a racist.)

Now, I didn’t say I believe it; actually, I do not.  But being honest with myself, I’d have to admit that when I encounter someone I don’t know, I reflexively begin to make assumptions about them based on their appearance.  I do not consciously accept the concept of race, but my instincts are otherwise.  When I see a patient in the emergency department who is black, I make assumptions about the fact that they probably live in the city of Milwaukee, and they are likely to be insured by Medicaid.  I virtually always catch myself, and I work furiously not to allow that initial assumption to enter into my thinking and actions.  But no matter how good I am at suppressing it, I can’t deny it came up.

I’d be willing to bet a decent amount of money that everyone reading this is also a racist.  No doubt, you do your best, like me, to overcome it, and you probably don’t ever do or say anything that would be considered “racist” in the common use of that word.  But it’s probably inevitable.  In large part, it is a manifestation of the way our minds process information.  I have written previously about heuristics – mental shortcuts our brains use to reach conclusions more efficiently. These heuristics are based on our prior experiences and on statistical facts about groups.  When a child encounters a dog for the first time, she is unlikely to be fearful.  If her first experience results in being bitten, she will instinctively react with caution to dogs in the future.  Even those of us who have never been bitten are likely to be more leery around pit bulls, based on reports (which it turns out are probably wrong) that the breed accounts for the majority of bites.

We live in a society where, statistically, there is an association between, for example, race and poverty, or race and crime.  In that sense, the heuristic isn’t wrong.  It’s true that in our ED, black patients do largely live in the city of Milwaukee, and are disproportionately poor.  We run into trouble in at least two ways.  First is when we take a true fact about a group and apply it to an individual.  Even if it’s true that more blacks in this area are more likely to not finish school, it is an affront to the inherent worth and dignity of each person to make any assumptions about an individual black person’s educational level.   When we deal with a person, we cannot use mental shortcuts.  But to overcome them we must acknowledge them.

It’s also a short and slippery slope from seeing an association to seeing causation.  Many people are too willing to make the leap from “black people are more likely to live in poverty” (a true if unfortunate fact), to “black people are poor because they are black.”  Therein lies the kind of thinking that people commonly associate with the term racism.  And racism in this sense is still too prevalent in 2014.

Just six years ago, in the aftermath of President Obama’s election, we were hearing about how America had become “post-racial.”  Now, it seems that race relations are in the worst shape I can remember.  What went wrong?

If the first step toward a solution is admitting there is a problem, we have to accept that we are, nearly universally, racist.  It takes a lot of mental effort to override our heuristics.  Pretending racism is something that only overt bigots experience, it’s too easy to let down our guard.  It also closes off conversation.   The inherent racial thinking that we all have is pretty obvious to most members of racial minorities, but less so to those of us in the majority.  Denying it invalidates their experience and prevents us from building the kind of connections that might mitigate its effects.

I’d love to think we can actually get beyond the idea that skin color has anything to do with any other inherent characteristics – we don’t tend to draw the same conclusions based on hair or eye color, after all.  Not that there hasn’t been some progress.  Some medical journals, for example, will not accept analyses based on race unless there is a clear biological explanation (e.g., a study involving actual skin pigmentation).  Too often race is used as shorthand for socioeconomic status or educational status; such reporting simply reinforces the stereotypes and does nothing to contribute to our understanding.  But race seems such an entrenched part of the way of looking at the world, it’s hard to imagine a “post-racial society” anytime soon.

In the meantime, if rational thinking is to prevail over instinct, need to accept that regardless of our best intentions, we all view the world through the lens of race.  Go ahead, say it.

I found the same book on Amazon.com for prices ranging from ten cents to ten dollars.  All were new; the cheaper ones were publisher overstocks so they had a stamp on the inside front cover, but it was hard to argue that it was worth paying more than three times as much (after adding in the shipping) for something I would never notice in reading the book.  Even if I hadn’t been raised by an accountant, I would have picked the cheaper one (which I did).

So how can one justify the variability in costs for fairly standardized things in medicine, such as the more than ten-fold difference in prices for an echocardiogram, even within a metropolitan area?  Traditionally, providers of those services have relied on the fact that consumer choice was almost non-existent.  First, in the paternalistic world of medicine, patients frequently deferred to their doctor’s recommendation, asking few questions.  There was no incentive for shopping on price for those with insurance, and the costs were often too high for those without to even consider seeking care.  And even if one wanted to comparison shop, pricing information was at best difficult to obtain.

Recent studies provide a glimpse of the effect of consumerism – driven by the rise in high-deductible plans and other factors that have placed more financial risk on patients – on both prices and spending in healthcare.  A study in Health Affairs examined the effect of providing pricing information on MRIs without a connected financial penalty.  Members of health plans that provided price information on MRI options spent an average of $220 less than those who did not have access to the information.  Moreover, in those regions where the pricing transparency was implemented, the range in prices for MRIs among facilities in that region decreased by 30%, mainly due to lowering of prices by the most expensive providers.  No similar price change was seen in the control regions.  Another study in JAMA looked at variation in healthcare spending between people who did or did not use an on-line calculator to research out-of-pocket costs before seeking care.  Those who searched for information chose lower priced services for laboratory tests and imaging (but not for providers) than those who did not search for the information.  Interestingly, the difference was similar for those with and without cost sharing.  It was not clear that utilization was affected, only that given price information people seek lower prices.

These and other studies show that, despite what we providers might like to think, price does matter to patients, and even without punitive levels of cost-sharing, people will seek lower prices when they have the information.  But of course, price is not the only thing, or even the most important.  Quality matters.   In recent years we’ve referred to this as “the value proposition.”  But this concept has been around for a long time; the older and wonkier term is “cost-effectiveness.”  Which is why it is disappointing and puzzling that making data on cost-effectiveness available has been seriously hindered.  The ranting about “death panels” was a reaction to the idea that giving elderly patients information about cost-effectiveness of end-of-life options was at best “rationing,” and at worst one step away from the world depicted in the movie “Soylent Green.”  The Patient Centered Outcomes Research Institute (PCORI), established as part of the Affordable Care Act, was intended to be able to provide the sort of data to inform consumer choices in medical care.  Yet the law explicitly prohibits PCORI from funding or conducting cost-effectiveness research!  This is crazy.

Medical consumerism is here.  It is affecting the way patients choose, and it is affecting prices.  If people are to make good choices, we need more transparency, and more good data on cost-effectiveness.  If Amazon can do it, so can we.

Disparities in the criminal justice system have replaced health disparities in the headlines recently.  Is this because health disparities have improved?  Some recent articles confirm my suspicion that the answer is mostly no.

Two New England Journal of Medicine articles and one editorial examine this question.  In one article, researchers examined racial differences in performance on 17 process-of-care quality measures – for example, did patients with heart attacks or pneumonia receive appropriate medications.  In 2005, quality of care was substantially worse for black and Latino patients compared with non-Latino whites.  In 2010, the performance gap had improved substantially.  That seems like good news.  However, in another article in the same issue, racial differences in actual health outcomes (such as control of high blood pressure or diabetes) among Medicare recipients persisted from 2006 to 2011 nationally, though there were improvements in some regions.

How to reconcile these two reports?  Of course the populations and methods are somewhat different.  But a larger point is that reducing disparities in health care does not necessarily translate to reducing disparities in health.  Health care is one of many determinants of a person’s health, and only accounts for about 10% of health status.  The remaining 90% is due to genetics, behavior, and environment.  Improving health takes a lot more than improving health care.

Even in regard to disparities in care, the evidence is not necessarily encouraging.  The findings of an article in Pediatrics were fairly provocative.  Using national data, authors found that adherence to prescribing guidelines for otitis media was actually better for black children than non-black children, which seems like good news.  However, the difference was due to less prescribing of broader-spectrum, more expensive (and not recommended) antibiotics for black children.  These national data confirm early, localized findings from other studies.  While it would be nice to attribute this to more diligence by providers when treating blacks, a more realistic explanation is less parental pressure for expensive antibiotics – or more likely less anticipation by the provider of such pressure – for blacks compared with whites.  The authors of an accompanying editorial describe this as an example of “structural racism.”

Eliminating health disparities is going to take more than changing prescribing.  It will require addressing those behavioral and environmental factors that are the primary determinants of our health.  It means Ferguson, MO needs to have more in common with the nearby but much more affluent suburb of Ladue.

There are many ironies of the term “health care” as currently used, especially in the US.  Not the least is that actually keeping people healthy is financially punished.  But an irony that is not as often discussed is the enormous adverse environmental impact that hospitals and other medical facilities typically have.  For example, hospitals produce nearly 12,000 tons of waste per day, an average of 26 pounds per bed.  They are also major consumers of water and energy.  Hospitals are among the most energy-intensive facilities; they account for 8% of all of the nation’s energy use.  The resulting waste and emissions of carbon and other pollutants adversely affect the health of a community, in the name of providing health care.

Some systems are working to change that.  In October, Gundersen Lutheran Health System in La Crosse, WI, became the first health system in the US to be energy independent, generating more energy than it consumed.  In 2008, Dr. Jeff Thompson, Gundersen CEO (and a pediatrician!) set a goal of energy neutrality as way to reduce cost and lower the negative impact of the facility on the health of the community.   They achieved this through a combination of conservation (a 40% reduction in energy use, saving roughly $2 million a year to the system despite a 25% increase in the size of the facility over the same time) and development of renewable, non-polluting energy sources like geothermal, wind, and biomass, through both local projects and regional partnerships.

We want the kids in Wisconsin to be the healthiest in the country.  This won’t happen without, among other things, a healthy environment.  Gundersen Lutheran is doing its part to ensure that.  What more could we do?

We just had the great fortune to spend 2 weeks vacationing in Argentina.  It represented a couple of first for us: first time in that country, and first time taking an entire two week vacation.  We thought it was pretty luxurious, and actually it was.  So we were struck by the number of travelers we met, from a range of other countries, who were in the midst of a 4, or 8, or 12 week trip.  Indeed, the only people we encountered who were on a shorter vacation than us was a couple from Philadelphia.  What were we doing wrong?

Some of the people were retired (although they indicated that they had done similarly long vacations when they were younger), but many were working age.  How do they pull this off, we wondered?  There seem to be a few factors:

1. Paid leave. Most industrialized countries provide much more generous paid leave, either by mandate or due to union leverage, than the US.  One of our guides, when asked whether Argentine workers get much vacation time, seemed shocked at the question.  “Of course, it’s in our constitution!  I mean, we may be Argentina, but it’s not like we’re in Africa or someplace like that.”
2. Culture. Americans work longer hours than most other industrialized countries (including all of Europe and Japan, though we are still outpaced by Singapore, South Korea, and Taiwan).  The difference in hours worked is greater than the difference in paid leave (i.e., we don’t even use the little we get), suggesting that some of it is due to a cultural reluctance to get away from our jobs.  In many industries, it’s almost a badge of pride to be “on” constantly.  We talked with several people who were taking extended leave without pay, something few Americans do (or are permitted to do).
3. Health care. Even if an American wanted to take unpaid leave for an extended trip, she would in many cases have a pause in employer-provided benefits, especially health insurance.  Paying for coverage while on unpaid leave is too much of a financial burden for most people.  This is not an issue for people from countries with government-provided health care, like Canada, the UK, France, Germany, Australia, New Zealand, Belgium, Denmark, Norway, Switzerland, Spain, the Netherlands, etc., etc.

Which leads me to two other points.  First, among the folks I had the opportunity to talk with were a doctor from Argentina and a nurse from England.  Both had wonderful things to say about their national health systems, including that fact that while people do often carry private insurance for things like a nicer room in the hospital, or a shorter wait for an imaging test, people are enormously satisfied with the quality of care.  “Everyone knows that the best doctors are the ones that work for the National Health Service.”

Second, when they talk about their “free” health care, of course we know that it is not free.  People pay either through their insurance premiums, or out of pocket costs, or taxes.   But while we might gag at the tax rates in places like Scandinavia, a recent study shows that, when you add it all up, public and private sources, the US actually has the second highest total social expenditures (largely health care, but also unemployment, retirement, disability, etc.), after France but ahead of those tax-and-spend Nordic countries.

Oh, and the wine in Argentina is terrific and cheap!

I am still on vacation, so Happy Thanksgiving…

When I was growing up, family meals were not an everyday event.  My mother, a nurse, often worked evenings, so those days we obviously couldn’t all eat together.  But we did make an effort to eat as a family on the other days.  Similarly, when we were raising our kids, despite my working shifts and both my wife and I traveling a fair amount for our jobs, we also placed a premium on eating together whenever possible.  That often meant having dinner 5:30 some days and 8:30 on others, but it seemed worth it.  After all, the demise of the family dinner has been cited as one important factor in the obesity epidemic, along with a host of other societal ills.

A new study in Pediatrics suggests that when it comes to risk of obesity, at least, not all family meals are created equal.  Researchers at the University of Minnesota, using a mixed-methods study including direct observation of 120 primarily low-income families, identified aspects of mealtime that were associated with obesity in the children.  While non-overweight children tended to have somewhat longer meals, and were more likely to eat in the kitchen or dining room vs. family room, the differences were small, and most meals were short (< 20 minutes), and the majority of both groups ate in a dining area.  More important were the family dynamics.  After adjusting for demographic factors (including parental BMI), the most important factors associated with child overweight or obesity were presence of positive interactions among family members (for example, enjoyment of each others’ company, warm interactions, positive reinforcement), and the absence of negative ones (hostility, lack of discipline, etc.).  Interestingly, very few food-specific dynamics were relevant.  Only moralizing about food – for example, “Eat what I gave you – other children are hungry and would be happy to have it” – was associated with the child’s weight; children who were hectored were more likely to be overweight.

Good information for those of us with families, or who are providing advice to families.  Michael Pollan, author of The Omnivore’s Dilemma and a proponent of better eating (for the sake of our own health as well as that of the planet, sums his advice up succinctly into 3 rules: “Eat food.  Not too much.  Mostly vegetables.”  To which we might add a fourth “Eat with people you like and get along with..”

Ask your doctor if you might be suffering from “restless legs syndrome.” Or “low testosterone,” or “social anxiety disorder.”  We’ve all seen the ads suggesting that our legs cramps or aging or shyness might instead represent a disorder with a name.  One that, not coincidentally, could be helped by a medication manufactured by the sponsor of the ad.  A medication for which you can ask your doctor for a prescription.  But while doctors like to complain about Big Pharma’s “diagnosis mongering,” what if we are also part of the problem?

“Overdiagnosis: How Our Compulsion for Diagnosis May Be Harming Children,” in the November issue of Pediatrics, raises this question.  The authors here are not referring to the kind of pseudo-disorders pedaled by industry.  By overdiagnosis they mean the discovery of a true abnormality, where the diagnosis does not benefit the patient.  This may include minor forms of a condition that would neither benefit from treatment nor be expected to progress to something more severe, or conditions for which treatment has been shown not to affect outcomes.  Think of low levels of elevated bilirubin in a newborn, asymptomatic skull fracture due to minor accidental trauma, or positive IgE blood test results indicating a response to food allergens in the absence of clinical symptoms.  None of these is treatable, and even knowing the diagnosis isn’t helpful in any way.  Yet physicians often perform – and sometimes parents request – tests for these and other diagnoses.

What is behind this drive for a diagnosis that doesn’t matter?  The article cites a few groups of factors.  One is industry influence.  There is no doubt that advertising does drive some demand.  (There is a reason pharma spent $4.5 billion on direct-to-consumer advertising in 2009, in addition to support for various disease advocacy groups, with varying degrees of legitimacy.)  Another is incentives in the current health care system.  For one thing, providers are often financially rewarded for unnecessary testing and care.  A review of pediatric quality measures also shows a marked bias toward indicators focused on underuse of resources rather than overuse.  Public perception that diagnosis is more precise than it really is, coupled with an intuitive sense that it must be better to detect disease, as another factor.  But the largest influence, according to the authors, is physicians themselves.  We have a culture of intolerance of uncertainty.  We hate not having an answer, something that is ingrained from the earliest days of medical education where students are encouraged to develop a lengthy list of potential diagnoses and then exhaustively eliminate them one by one until finally arriving at the right one.  “Defensive medicine” is frequently cited, but most of the research suggests that this plays at most a minor role.

Cost is the obvious downside.  But there are others.  There are potential adverse physical effects, if having a diagnosis leads to treatment that will not benefit and might harm the patient.  Sometimes the tests ordered in search of a diagnosis are themselves risky (procedures requiring anesthesia, for example, or radiation exposure).  There is also real psychological harm in carrying a diagnosis.  The newborn who is a little yellow and has a mildly elevated bilirubin gets a diagnosis of  “hyperbilirubinemia.”  A child with nonspecific symptoms who tests positive for antibodies to shellfish and eggs is now labeled as “food allergic.”  Numerous studies have documented the “vulnerable child syndrome” in such children.  It results in increased utilization of health care, overprotective parenting, and bullying, among other consequences.

There are several efforts – from professional societies and academic medical centers – targeted at both providers and lay people to increase awareness of the presence and problems of overdiagnosis.  Traditionally, academic medicine has probably been more of a cause, but is now trying to be part of the solution.

Ask your doctor if you might be suffering from “adiagnosticophobia.”