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Patrick Swayze Has Passed Away From Pancreatic Cancer

September 14th, 2009 by Dr. Val Jones in Announcements, Better Health Network, Expert Interviews, Health Policy, News, True Stories, Uncategorized
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Patrick Swayze, the popular actor perhaps known best for his role in the 1987 hit movie “Dirty Dancing,” died today of pancreatic cancer. My thoughts are with his family in this time of grief.

Pancreatic cancer is among the more deadly forms of cancer. I asked GI oncologist, Heinz-Josef Lenz, M.D., professor of medicine and professor of preventive medicine in the Division of Medical Oncology at the Keck School of Medicine at the University of Southern California, to explain why that’s so.

Dr. Val: Why is pancreatic cancer so much more deadly (i.e. less treatable) than many other forms of cancer?

Dr. Lenz: Unfortunately we don’t have very effective drugs for pancreatic cancer, which makes it one of the deadliest cancers of all. The median survival is about 8 months with metastatic disease. Even when the tumor is successfully removed there is a very high risk for tumor recurrence. We need more funding to better understand the risk for pancreatic cancer and identify and develop more effective therapies.

Dr. Val: Can you describe the typical course of metastatic pancreatic cancer?

Dr. Lenz: Unfortunately, the 5 year survival rate for pancreatic cancer is only 15 to 20%. The average survival after diagnosis is 12 to 19 months. The best predictor of long term survival is if the tumor is found and removed before it reaches 3 cm in size. Patients with metastatic pancreatic cancer are usually treated with a combination chemotherapy consisting of gemcitabine, tarceva, xeloda or oxaliplatin. However the response rates are (despite using aggressive combination therapies) low. Large clinical trials recently did not show any benefit from erbitux or avastin, again demonstrating that pancreatic cancer therapy is a difficult clinical challenge.

Dr. Val: Are certain populations at higher risk than others for pancreatic cancer?

Dr. Lenz: Age is the most important risk factor for this cancer. It is most common in individuals over age 50 and increases in frequency with age. Black men and women are slightly more likely to get pancreatic cancer (though the reasons for this are unclear), and men are slightly more likely than women to get the cancer. Other risk factors are smoking, diabetes, and obesity.

Dr. Val: If you suspect that someone is “high risk” for pancreatic cancer, what tests should he/she have?

Dr. Lenz:  Patients with a genetic predisposition for breast cancer known as BRCA are also at higher risk for pancreatic cancer. There is also a familial form of pancreatic cancer. These high risk families are being followed up with specific screening plans. However there is not a reliable test for pancreatic cancer. Imaging with CT or MRI can miss pancreatic cancer and there is no reliable blood marker. The most common used is CA 19-9, which can be used for monitoring and diagnosis but is not elevated in all patients.

Dr. Val: What if the cancer is caught very early? Does that increase likelihood of survival?

Dr. Lenz: Absolutely. The best chance of survival is when the cancer is limited to the pancreas, and is surgically removed before it reaches a size of 3 centimeters. There are certainly people who have been cured this way, but unfortunately it’s very rare to catch the cancer at such an early stage since it usually has no symptoms until it’s quite advanced.

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There is a wonderful advocacy group for those whose lives are touched by pancreatic cancer: PanCAN. One of PanCAN’s founders, Paula Kim, is a friend of mine and was inspired to create the organization after her dad was diagnosed with pancreatic cancer in 1999. At that time there was very little advocacy for this deadly disease. PanCAN helps people with pancreatic cancer find help and support.

Controversy: Can Twitter Cause Memory Damage?

September 14th, 2009 by Berci in Better Health Network, News
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*This blog post was originally published at ScienceRoll*

Emergency Medicine: Census and Sensibility

September 14th, 2009 by Emergiblog in Better Health Network, Opinion
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Emergency has something in common with Labor & Delivery.

Neither department has control over their census.

Medical/surgical, telemetry units and ICUs have a finite number of beds. When they are full, they are full; they cannot physically expand to more beds.

ED patients and laboring women are never turned away no matter how full the department may be. Oh, the ED may triage and L&D may send a patient in early labor home, but in both cases, eventually, all will be seen.

Labor and delivery has one advantage over the ED.

They can have someone on call.

I’ve never worked in an ED that has had an “on-call” nurse.

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I will never understand the logic behind staffing an ED based on the previous 24 hour census.

If the ED does not meet a pre-determined number of patients on one day, the break nurse for the next day is canceled and there is much wailing and gnashing of teeth as the department goes over budget.

Never mind that the acuity level of the patients who were seen was through the roof. Or that 50% of them were admitted. Or that the next day, acuity again sky high, the nurses go without meals/breaks and the department is required to give penalty pay. Again, there is much wailing and gnashing of teeth for having to pay this penalty, a penalty that would never have been required had the break nurse not been canceled.

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Now if the ED is slow, staff can always go home early. But not too early, because you never know what is coming in through the doors. So maybe an hour, 90 minutes early, knowing that the remaining staff can handle whatever they need to handle until the next shift comes in.

But what happens when the patients overwhelm the staff, both in acuity and numbers?  Ambulance diversion doesn’t stop the walk-in critical patients. The MIs and the possible CVAs. The GI bleeders. The potentially septic. Trying to get patients out of the department and up to the floor doesn’t work when the floor won’t take the patient for four hours because it would put them “out of ratio”.

This is a huge issue on the night shift. When there is only one unit clerk/registrar, two nurses and an ED tech after 0300.

Of course, at night it is feast or famine.

Either the feces hits the proverbial fan or…it doesn’t.

Which is exactly why we need a nurse on-call.

The ED needs flexible staffing that accounts for those times when the acuity level/census is overwhelming. Not canceling the extra break nurse is one way of doing that on days and evenings; using the on-call system is another way that could be utilized at night. If it can be done in L&D, why can’t it be done in the ED? Surely the money saved in penalty pay for missed breaks and meals would make it budget neutral.

All I know is that trying to drop staff in an ED based on what happened the previous 24 hours makes zero sense.

(And don’t even get me started on why nurse-patient ratios are treated like unbreakable rules on the floors, but it’s okay for the ED to be waaaaay out of ratio and nobody blinks….that’s another whole post!)

*This blog post was originally published at Emergiblog*

Eight Quick Reactions To Obama’s Healthcare Speech

September 14th, 2009 by EvanFalchukJD in Better Health Network, Opinion
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Eight quick reactions to the President’s speech:

1.  It was a good speech.  Reaction around the blogosphere and elsewhere seems to be dependent on how you felt about reform plans going in.  If you were in favor, you thought it was terrific (warning strong language at the link); if you were against, you thought it was disingenuous.

2.  The interesting question is how people who weren’t sure will react.  By this I mean people who are anxious that reform will affect their health care in ways they don’t like.  There is still the mixed message that created this anxiety in the first place.  On the one hand, the President repeated “Nothing in this plan will require you to change what you have. “  Sounds like no big deal.  On the other hand, he quoted Ted Kennedy as saying the plan “is above all a moral issue; at stake are not just the details of policy, but fundamental principles of social justice and the character of our country.”  Sounds like a very big deal.  Which is it?

3.  The boorish Congressman who screamed “you lie!” at Obama during the address must have been confused and thought he was at a town hall meeting.  But I’ve always thought it would be cool if we had a “Question Time” like they do in the UK.  Presidents would have to face much more interesting and uncomfortable questions than they otherwise get, and it would make for a terrific spectacle.  Obviously this wasn’t the time or place for that sort of thing.  And if we ever do get an American Question Time, representatives will have to come up with better questions than “you lie,” too.

4.  The President talked about “30 million American citizens who cannot get coverage.”  This is different from the 46 million “uninsured” he usually talks about.  The Associated Press thinks the other 16 million are people who could buy or otherwise get coverage but choose not to, as compared to those who want coverage but can’t afford it.

5.  I was surprised to hear the President give more than just a nod to the Facebook health care status update meme.  I mean he quoted it directly: “in the United States of America, no one should go broke because they get sick.”  This must be the first time a President has ever quoted something from Facebook in an address to Congress – it’s some kind of a milestone for social media.  Thoughts on that meme are here.

6. The President talked about the uncompetitive insurance market, noting that “in 34 states, 75 percent of the insurance market is controlled by five or fewer companies.”  It sounds like he’s not just talking about the “public option” when he talks about creating competition in these markets.  His idea of insurance exchanges and a federal health insurance regulator seem to be direct challenges to the state-by-state system of insurance regulation.  It will be interesting to see the reaction of state insurance regulators to this speech.

7.  I was right: the President didn’t talk about the three things I said he wouldn’t talk about.  In fact, he said almost nothing about the delivery of care- it was all about how to pay for it.

8. The President got some laughs with his comment that he thinks “there remain some significant details to be ironed out.”  He’s right, and there’s the rub.  Whether and how that ironing out happens was the question before the President’s speech, and it’s still the question today.

*This blog post was originally published at See First Blog*

Is Physician Income At The Root Of Healthcare Inflation?

September 14th, 2009 by Shadowfax in Better Health Network, Health Policy
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Ezra Klein – The Provider Problem

Medicare keeps costs down somewhat better than private insurers, though not as well as private insurers did in the ’90s, and they do it by paying providers less money. Providers hate them for it, and that’s why doctors and hospitals and drug companies and device manufacturers have been so aggressive in opposing a public plan able to use Medicare rates. It’s also why Medicare’s growth rate is totally unsustainable — Congress keeps delaying the cuts in doctor’s payments that the Medicare law requires.

Ezra has an interesting post in which he posits that the problem in health care economics is that the rate of inflation of health care persistently exceeds the general rate of inflation.  Fine; I do not think anybody is in disagreement on that point any more.  He goes a bit further, wrongly, I think, in implying that the solution is just to pay doctors less.

The background here is that in the late ’90s, Congress decided to impose a cap on how much medicare expenses for physician services could increase in any given year, using a complicated formula called the Sustainable Growth Rate, which was indexed to GDP growth.  I should note that for some reason, Congress decided not to cap the increase in expense on hospital services, but to let the growth of Medicare Part A accelerate unrestrained.  (The hospital industry must’ve had better lobbyists.)

The SGR ran into trouble immediately, and required pay cuts for physicians, and Congress repeatedly caved and canceled the pay cuts.  So, Medicare Part B grows year over year, at a rate ahead of that of inflation, and the logic seems simple: we need to pay physicians less!

But that ignores the fact that much of physician’s revenue does not go to that physician’s income.  Most doctors (ER docs being an exception) have offices to maintain, nurses and assistants to pay, healthcare premiums for this employees, in addition to the malpractice insurance and billing expenses.   Medicine is not a low-overhead game any more!  My gut feeling was that physician income has been stagnant-to-declining over the last decade.

So I went to the Bureau of Labor Statistics and I manually pulled the data on physician income over the 1999-2008 timeframe, and the inflation rate for the same time span and saw that I was more or less right:

Note that for the first six years, physician income was less than inflation, and 2006-7 was only a little bit above the overall inflation rate.  Also note that for two years physician income was actually negative.   2008 was the only year in which physician income increased faster than inflation.

A note as to methodology: the BLS tracks doctor’s income by specialty, not as a single profession.  I pulled the data for General Internal Medicine, Family Practice, and Surgery, and averaged them.  Including surgery, unsurprisingly, greatly improved the income figures.  Internists’ and Family docs’ income lagged inflation every year but 2008.  This was not weighted, either — there are many more Internists and FPs than surgeons, while I weighted them equally.  (Also, the BLS changed data collection methods in 2002, creating a spurious increase of 33% that year, so I threw out that year and interpolated for the above graph.)  This is not a rigorous analysis, but it gets the point across that individual physician income has not been the driver of overall healthcare inflation. If anything, I think these methods tend to understate the degree to which physician income has stagnated during this period.

So why have global physician expenditures gone up so fast during the last ten years when physicians are, by and large, not seeing the increase in their bottom lines?  Several reasons, I think:

• As overhead costs increase, doctors squeeze more work into the day just to keep up with rising expenses.
• As the baby boomers age, and as lifespans continue to increase, patients are older & sicker, and physicians appropriately provide more intense care to this needier population.
• As new technologies, procedures and therapies are developed, physicians employ them more, generally at increased cost.
• For Medicare in particular, the graying of America simply means there are more people enrolled in Medicare.

So while doctors are providing more services, the increases are in low margin services or the increases are consumed by increased practice expenses.   I am sure there are more factors as well.

So, Ezra’s suggestion that simply paying doctors less (i.e. implementing the SGR-mandated cuts) would have some effect on reducing the global expense for physician services, it would do little to change the trendline towards increasing costs.  Put another way, it would lower the setpoint of the curve without changing its slope.  It would also, incidentally, have a dramatic effect on physician compensation, since the other costs of a medical practice are fairly inelastic, and the lost revenue would come directly out of doctor’s salaries.

I don’t have a solution to the costs problem, and I am not sure anybody else does either.  Cutting hospitals’ reimbursement would have terrible effects; hospitals are under tremendous economic stresses as it is, and I know most hospitals have razor-thin profit/surplus margins.  Medical devices are expensive, but they are so critical to the improvements in health care that I do not think anybody has the stomach to cut them.  Pharma probably should be cut, but their lobby has defended them very well.  There’s no good answer.

But it is overly simplistic to think that doctors’ compensation is at the root of the runaway costs problem.

*This blog post was originally published at Movin' Meat*