In November, 2009, a rancorous argument about screening mammography for women aged 40-49 was touched off by the publication of updated guidelines(1), supported by a systematic literature review(2) by the US Preventive Services Task Force (USPSTF). The guidelines suggested that yearly mammographic screening for women in that age group should not be automatic, but a decision made for individual patients after discussion between the patients and their doctors. This was based on a critical review of the best available data which suggested that the benefits of screening acrue to only a few patients. 1904 women would have to start screening and continue for multiple rounds to prevent one cancer death over 11-20 years of follow-up. These benefits had to be balanced against a number of potential risks, including the risks of treatment of cancers that might never behave malignantly, and the at least theoretical risk of generating new cancers through radiation exposure from mammography.
These seemingly reasonable recommendations generated heated responses. The debate, to be charitable, seemed to be at its core about how one should weigh benefits and harms in making individual and health policy decisions. Since different people value different outcomes differently, I was not sure at the time how to make a meaningful contribution to this debate, or whether the debate had to do with the issues we usually discuss on Health Care Renewal.
I should note that the USPSTF guidelines never said "do not screen" women under age 50, or that the government should not pay for such screening. They did say "the decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take pateint context into account, including the patient's values regarding specific benefits and harms." It is hard to see how anyone could argue with that as an expression empowering patients' choices and values. (For further discussion about how the recommendations were actually modest and reasonable, see Partridge and Winer.)(3)
Now that the dust has settled, it may be useful to reflect further on this. Doing so suggests that the rancorous US debate mainly obscured rather than illuminated the major issues regarding mammography screening, particularly about our lack of clear evidence from clinical research needed to make the best individual and policy decisions about mammography.
It seems to me that the main questions one must answer to make an individual or policy decision about screening mammography are:
Does it improve longevity?
This is not the same as asking whether mammography reduces mortality from breast cancer. It is theoretically possible that while decreasing mortality due to breast cancer, screening and its downstream consequences increases mortality from other causes. At least in theory, screening may detect small tumors that would never grow or metastasize. Treating such tumors could sometimes lead to premature death due to complications of surgery, radiation, or chemotherapy. Furthermore, screening also involves periodically exposing large numbers of women to radiation, which may sometimes cause new tumors. So reducing breast cancer mortality does not automatically mean that overall longevity would be improved.
There have been eight major trials of breast cancer screening which included women younger than 50. (See reference 2.) None demonstrated a statistically significant increase in overall survival (that is, an increase unlikely to have been due to chance alone) due to screening.
Does it reduce suffering, improve functioning or generally improve quality of life?
To my knowledge, no major trial attempted to answer this question. No such data is mentioned in the USPSTF systematic review.
Do the above benefits outweigh all its potential harms and risks?
So we cannot answer this question, because the benefits that might be most meaningful to patients (overall survival, symptom reduction, functional improvement, overall quality of life improvement) have not been clearly measured.
A Lack of Relevant Evidence
So the USPSTF guidelines, like other relevant guidelines, were based on the evidence that is available. Since the evidence did not directly answer the most important questions, the guideline writers were left doing the best they could with evidence that only indirectly addressed the main issues. No wonder they ended up unable to make a clear recommendation, and leaving the decisions to individual discussions, and individual discussions that would necessarily hinge on guesses about the unknown.
One would think that a big point of discussion about breast cancer screening would be why after eight trials enrolling a total of about 350,000 patients reported over 20 years we still cannot answer the big clinical questions. A related point for discussion in the US is why only one, and the earliest trial was conducted here. If we here in the US think breast cancer screening is such a major concern (and we should think so), why have we been unable to mount a single important trial of it since the HIP trial conducted more than 30 years ago?
Instead, the rancorous debate in the US included...
Anecdotes, Some Irrelevant
The press found a number of women who said they would not be alive were it not for screening mammography before age 50. With all due respect, one cannot tell whether an individual whose tumor was found on screening mammography would still have been diagnosed early enough for succesful treatment in the absence of screening mammography. (And also with all due respect, we have no idea whether there also are cases of women who died as a result of treatments of tumors that never would have progressed, or cases of women who died of tumors caused by radiation from multiple mammograms.) Reasoning from single cases when people, diseases, and treatment results vary so much is likely to mislead.
It is somewhat ironic that some of the cases cited were of women who had breast cancer diagnosed before age 40, even though the debate was supposedly about screening from ages 40-49. For example, in an inflammatory article that suggested that some "oncologists" might want the USPSTF sent to the prison at Guantanamo Bay, Washington Post editorialist Dana Milbank cited cancer activist Nancy Brinker, who mentioned her sister "whose breast cancer was found with a mammogram at age 37," (and apparently who tragically is no longer alive).(4)
Going Well Beyond the Evidence
As noted above, no trial has shown that screening mammography for women under 50 increases overall longevity. We all hope it does, but so far, there is no clear evidence that it does.
Yet multiple media reports included assertions that screening mammography saves lives. For example, the breast cancer activist mentioned above said, "mammography saves lives," apparently including mammography under age 50.(4) An op-ed column by Dr Alan Kaye, chairman of radiology at Bridgeport Hospital, asserted "large, multinational research studies have shown that mammography saves lives in all age groups covered by the current guidelines."(5) I would challenge him to show me a single such study that found a statistically significant increase in overall survival for patients under 50. A Texas radiologist stated, "I diagnosed a 40-year old woman with breast cancer last week. If she had waited 10 years, with pre-menopause breast cancer she would have been dead."(6) Unfortunately, since she was just diagnosed, how can he be certain that she will survive any given amount of time? How could he know that the cancer might not have become manifest, absent that single mammogram, later while still treatable?
I do not want to be too hard on patients who do not appreciate that the outcomes of testing and treatment for breast cancer are not certain. However, one would hope that physicians would be able to deal with this uncertainty.
Conflicted Opinions
Some of the more strident discourse came from those who may have had financial vested interests in promoting screening mammography. Fugh-Berman and Bell pointed out numerous "fact-free emotionally charged statements" made by people who appeared to "reading from the same script-book."(7) They identified that many of the loudest critics of the USPSTF guidelines were affiliated with not-for-profit organizations with impressive names, but also with substantial financial support from corporations that make products used in mammography. Also, some had personal financial relationships with such corporations.
An op-ed article by former US Food and Drug Agency (FDA) commissioner Dr Andrew von Eschenbach and Ms Nancy Desmond distorted the USPSTF guidelines to mean "most women should delay screening until they are 50," and claimed that was based on cost concerns, not clinical evidence.(8). Desmond is the CEO of and von Eschenbach is now a senior advisor to the Center for Health Transformation. The Center's members include numerous pharmaceutical and device manufacturing corporations, including several that make mammography equipment (e.g., GE Healthcare and Siemens).
Summary
Cancer, especially breast cancer, has major emotional connotations, and can be a difficult issue to deal with from many people. The conflicting emotions cancer brings out in many patients may understandably affect their physicians, as well as friends and family. Nonetheless, physicians, other health policy professionals, and health policy experts can serve patients better if they do not allow the patients' understandable affective responses cloud their understanding of the clinical and scientific issues.
Yet the late 2009 debate in the US about screening mammography included many responses in which emotion seemed to overwhelm reason. It may also be that some such responses came from people who had vested interests, or whose employers had vested interests that supported the emotional, rather than the reasoned approach. Meanwhile, no one seemed to acknowledge that a big reason we are still debating this topic is that we have not made the effort or expended the resources to do good trials of sufficient size to answer the questions that need answering. Of course, such trials might provide answers that would upset some people, or threaten others' incomes. (As one news article pointed out, mammography is now a $5 billion a year industry in the US.)(6)
So my end of annus horribilis 2009 message on Health Care Renewal is to better serve our patients, from 2010 onward we health care professionals need to try harder to put evidence and logic ahead of our own emotions, and certainly ahead of our financial self-interest.
Note that numerous bloggers have taken on this topic, so see posts on Respectful Insolence, GoozNews, Health Care Organizational Ethics, and the Evidence in Medicine blog.
References
1. US Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2009; 151: 716-726. [link here]
2. Nelson HD, Tyne K, Naik A et al. Screening for breast cancer: an update for the U.S. Preventive Services Task Force. Ann Intern Med 2009; 151: 727-737. [link here]
3. Partridge AH, Winer EP. On mammography - more agreement than disagreement. N Engl J Med 2009; 361: 2499-2501. [link here]
4. Milbank D. Feeling farther from the finish. Washington Post, Nov 24, 2009. [link here]
5. Kaye A. An alarming retreat on early detection. Hartford Courant, Nov 25, 2009 [link here]
6. Jacobson SJ. Dallas-area clinics ignore proposed rules, still push for mammograms. Dallas News, Nov 27, 2009. [link here]
7. Fugh-Berman A, Bell A. Mammography and the corporate breast. Bioethics Forum, Nov 24, 2009. [link here]
8. von Eschenbach A, Desmond N. Government panels can't put price on human life. Associated Press, Nov 24, 2009. [link here]
The Body Fat Setpoint
One pound of human fat contains about 3,500 calories. That represents roughly 40 slices of toast. So if you were to eat one extra slice of toast every day, you would gain just under a pound of fat per month. Conversely, if you were to eat one fewer slice per day, you'd lose a pound a month. Right? Not quite.
How is it that most peoples' body fat mass stays relatively stable over long periods of time, when an imbalance of as little as 5% of calories should lead to rapid changes in weight? Is it because we do complicated calculations in our heads every day, factoring in basal metabolic rate and exercise, to make sure our energy intake precisely matches expenditure? Of course not. We're gifted with a sophisticated system of hormones and brain regions that do the calculations for us unconsciously*.
When it's working properly, this system precisely matches energy intake to expenditure, ensuring a stable and healthy fat mass. It does this by controlling food seeking behaviors, feelings of fullness and even energy expenditure by heat production and physical movements. If you eat a little bit more than usual at a meal, a properly functioning system will say "let's eat a little bit less next time, and also burn some of it off." This is why animals in their natural habitat are nearly always at an appropriate weight, barring starvation. The only time wild animals are overweight enough to compromise maximum physical performance is when it serves an important purpose, such as preparing for hibernation.
I recently came across a classic study that illustrates these principles nicely in humans, titled "Metabolic Response to Experimental Overfeeding in Lean and Overweight Healthy Volunteers", by Dr. Erik O. Diaz and colleagues (1). They overfed lean and modestly overweight volunteers 50% more calories than they naturally consume, under controlled conditions where the investigators could be confident of food intake. Macronutrient composition was 12-42-46 % protein-fat-carbohydrate.
After 6 weeks of massive overfeeding, both lean and overweight subjects gained an average of 10 lb (4.6 kg) of fat mass and 6.6 lb (3 kg) of lean mass. Consistent with what one would expect if the body were trying to burn off excess calories and return to baseline fat mass, the metabolic rate and body heat production of the subjects increased.
Following overfeeding, subjects were allowed to eat however much they wanted for 6 weeks. Both lean and overweight volunteers promptly lost 6.2 of the 10 lb they had gained in fat mass (61% of fat gained), and 1.5 of the 6.6 lb they had gained in lean mass (23%). Here is a graph showing changes in fat mass for each individual that completed the study:
.png)
We don't know if they would have lost the remaining fat mass in the following weeks because they were only followed for 6 weeks after overfeeding, although it did appear that they were reaching a plateau slightly above their original body weight. Thus, nearly all subjects "defended" their original body fat mass irrespective of their starting point. Underfeeding studies have shown the same phenomenon: whether lean or overweight, people tend to return to their original fat mass after underfeeding is over. Again, this supports the idea that the body has a body fat mass "set point" that it attempts to defend against changes in either direction. It's one of many systems in the body that attempt to maintain homeostasis.
OK, so why do we care?
We care because this has some very important implications for human obesity. With such a powerful system in place to keep body fat mass in a narrow range, a major departure from that range implies that the system isn't functioning correctly. In other words, obesity has to result from a defect in the system that regulates body fat, because a properly functioning system would not have allowed that degree of fat gain in the first place.
So yes, we are gaining weight because we eat too many calories relative to energy expended. But why are we eating too many calories? Because the system that should be defending a low fat mass is now defending a high fat mass. Therefore, the solution is not simply to restrict calories, or burn more calories through exercise, but to try to "reset" the system that decides what fat mass to defend. Restricting calories isn't necessarily a good solution because the body will attempt to defend its setpoint, whether high or low, by increasing hunger and decreasing its metabolic rate. That's why low-calorie diets, and most diets in general, typically fail in the long term. It's miserable to fight hunger every day.
This raises two questions:
* The hormone leptin and the hypothalamus are the ringleaders, although there are many other elements involved, such as numerous gut-derived peptides, insulin, and a number of other brain regions.
How is it that most peoples' body fat mass stays relatively stable over long periods of time, when an imbalance of as little as 5% of calories should lead to rapid changes in weight? Is it because we do complicated calculations in our heads every day, factoring in basal metabolic rate and exercise, to make sure our energy intake precisely matches expenditure? Of course not. We're gifted with a sophisticated system of hormones and brain regions that do the calculations for us unconsciously*.
When it's working properly, this system precisely matches energy intake to expenditure, ensuring a stable and healthy fat mass. It does this by controlling food seeking behaviors, feelings of fullness and even energy expenditure by heat production and physical movements. If you eat a little bit more than usual at a meal, a properly functioning system will say "let's eat a little bit less next time, and also burn some of it off." This is why animals in their natural habitat are nearly always at an appropriate weight, barring starvation. The only time wild animals are overweight enough to compromise maximum physical performance is when it serves an important purpose, such as preparing for hibernation.
I recently came across a classic study that illustrates these principles nicely in humans, titled "Metabolic Response to Experimental Overfeeding in Lean and Overweight Healthy Volunteers", by Dr. Erik O. Diaz and colleagues (1). They overfed lean and modestly overweight volunteers 50% more calories than they naturally consume, under controlled conditions where the investigators could be confident of food intake. Macronutrient composition was 12-42-46 % protein-fat-carbohydrate.
After 6 weeks of massive overfeeding, both lean and overweight subjects gained an average of 10 lb (4.6 kg) of fat mass and 6.6 lb (3 kg) of lean mass. Consistent with what one would expect if the body were trying to burn off excess calories and return to baseline fat mass, the metabolic rate and body heat production of the subjects increased.
Following overfeeding, subjects were allowed to eat however much they wanted for 6 weeks. Both lean and overweight volunteers promptly lost 6.2 of the 10 lb they had gained in fat mass (61% of fat gained), and 1.5 of the 6.6 lb they had gained in lean mass (23%). Here is a graph showing changes in fat mass for each individual that completed the study:
.png)
We don't know if they would have lost the remaining fat mass in the following weeks because they were only followed for 6 weeks after overfeeding, although it did appear that they were reaching a plateau slightly above their original body weight. Thus, nearly all subjects "defended" their original body fat mass irrespective of their starting point. Underfeeding studies have shown the same phenomenon: whether lean or overweight, people tend to return to their original fat mass after underfeeding is over. Again, this supports the idea that the body has a body fat mass "set point" that it attempts to defend against changes in either direction. It's one of many systems in the body that attempt to maintain homeostasis.OK, so why do we care?
We care because this has some very important implications for human obesity. With such a powerful system in place to keep body fat mass in a narrow range, a major departure from that range implies that the system isn't functioning correctly. In other words, obesity has to result from a defect in the system that regulates body fat, because a properly functioning system would not have allowed that degree of fat gain in the first place.
So yes, we are gaining weight because we eat too many calories relative to energy expended. But why are we eating too many calories? Because the system that should be defending a low fat mass is now defending a high fat mass. Therefore, the solution is not simply to restrict calories, or burn more calories through exercise, but to try to "reset" the system that decides what fat mass to defend. Restricting calories isn't necessarily a good solution because the body will attempt to defend its setpoint, whether high or low, by increasing hunger and decreasing its metabolic rate. That's why low-calorie diets, and most diets in general, typically fail in the long term. It's miserable to fight hunger every day.
This raises two questions:
- What caused the system to defend a high fat mass?
- Is it possible to reset the fat mass setpoint, and how would one go about it?
* The hormone leptin and the hypothalamus are the ringleaders, although there are many other elements involved, such as numerous gut-derived peptides, insulin, and a number of other brain regions.
The Body Fat Setpoint
One pound of human fat contains about 3,500 calories. That represents roughly 40 slices of toast. So if you were to eat one extra slice of toast every day, you would gain just under a pound of fat per month. Conversely, if you were to eat one fewer slice per day, you'd lose a pound a month. Right? Not quite.
How is it that most peoples' body fat mass stays relatively stable over long periods of time, when an imbalance of as little as 5% of calories should lead to rapid changes in weight? Is it because we do complicated calculations in our heads every day, factoring in basal metabolic rate and exercise, to make sure our energy intake precisely matches expenditure? Of course not. We're gifted with a sophisticated system of hormones and brain regions that do the calculations for us unconsciously*.
When it's working properly, this system precisely matches energy intake to expenditure, ensuring a stable and healthy fat mass. It does this by controlling food seeking behaviors, feelings of fullness and even energy expenditure by heat production and physical movements. If you eat a little bit more than usual at a meal, a properly functioning system will say "let's eat a little bit less next time, and also burn some of it off." This is why animals in their natural habitat are nearly always at an appropriate weight, barring starvation. The only time wild animals are overweight enough to compromise maximum physical performance is when it serves an important purpose, such as preparing for hibernation.
I recently came across a classic study that illustrates these principles nicely in humans, titled "Metabolic Response to Experimental Overfeeding in Lean and Overweight Healthy Volunteers", by Dr. Erik O. Diaz and colleagues (1). They overfed lean and modestly overweight volunteers 50% more calories than they naturally consume, under controlled conditions where the investigators could be confident of food intake. Macronutrient composition was 12-42-46 % protein-fat-carbohydrate.
After 6 weeks of massive overfeeding, both lean and overweight subjects gained an average of 10 lb (4.6 kg) of fat mass and 6.6 lb (3 kg) of lean mass. Consistent with what one would expect if the body were trying to burn off excess calories and return to baseline fat mass, the metabolic rate and body heat production of the subjects increased.
Following overfeeding, subjects were allowed to eat however much they wanted for 6 weeks. Both lean and overweight volunteers promptly lost 6.2 of the 10 lb they had gained in fat mass (61% of fat gained), and 1.5 of the 6.6 lb they had gained in lean mass (23%). Here is a graph showing changes in fat mass for each individual that completed the study:
We don't know if they would have lost the remaining fat mass in the following weeks because they were only followed for 6 weeks after overfeeding, although it did appear that they were reaching a plateau slightly above their original body weight. Thus, nearly all subjects "defended" their original body fat mass irrespective of their starting point. Underfeeding studies have shown the same phenomenon: whether lean or overweight, people tend to return to their original fat mass after underfeeding is over. Again, this supports the idea that the body has a body fat mass "set point" that it attempts to defend against changes in either direction. It's one of many systems in the body that attempt to maintain homeostasis.
OK, so why do we care?
We care because this has some very important implications for human obesity. With such a powerful system in place to keep body fat mass in a narrow range, a major departure from that range implies that the system isn't functioning correctly. In other words, obesity has to result from a defect in the system that regulates body fat, because a properly functioning system would not have allowed that degree of fat gain in the first place.
So yes, we are gaining weight because we eat too many calories relative to energy expended. But why are we eating too many calories? Because the system that should be defending a low fat mass is now defending a high fat mass. Therefore, the solution is not simply to restrict calories, or burn more calories through exercise, but to try to "reset" the system that decides what fat mass to defend. Restricting calories isn't necessarily a good solution because the body will attempt to defend its setpoint, whether high or low, by increasing hunger and decreasing its metabolic rate. That's why low-calorie diets, and most diets in general, typically fail in the long term. It's miserable to fight hunger every day.
This raises two questions:
* The hormone leptin and the hypothalamus are the ringleaders, although there are many other elements involved, such as numerous gut-derived peptides, insulin, and a number of other brain regions.
How is it that most peoples' body fat mass stays relatively stable over long periods of time, when an imbalance of as little as 5% of calories should lead to rapid changes in weight? Is it because we do complicated calculations in our heads every day, factoring in basal metabolic rate and exercise, to make sure our energy intake precisely matches expenditure? Of course not. We're gifted with a sophisticated system of hormones and brain regions that do the calculations for us unconsciously*.
When it's working properly, this system precisely matches energy intake to expenditure, ensuring a stable and healthy fat mass. It does this by controlling food seeking behaviors, feelings of fullness and even energy expenditure by heat production and physical movements. If you eat a little bit more than usual at a meal, a properly functioning system will say "let's eat a little bit less next time, and also burn some of it off." This is why animals in their natural habitat are nearly always at an appropriate weight, barring starvation. The only time wild animals are overweight enough to compromise maximum physical performance is when it serves an important purpose, such as preparing for hibernation.
I recently came across a classic study that illustrates these principles nicely in humans, titled "Metabolic Response to Experimental Overfeeding in Lean and Overweight Healthy Volunteers", by Dr. Erik O. Diaz and colleagues (1). They overfed lean and modestly overweight volunteers 50% more calories than they naturally consume, under controlled conditions where the investigators could be confident of food intake. Macronutrient composition was 12-42-46 % protein-fat-carbohydrate.
After 6 weeks of massive overfeeding, both lean and overweight subjects gained an average of 10 lb (4.6 kg) of fat mass and 6.6 lb (3 kg) of lean mass. Consistent with what one would expect if the body were trying to burn off excess calories and return to baseline fat mass, the metabolic rate and body heat production of the subjects increased.
Following overfeeding, subjects were allowed to eat however much they wanted for 6 weeks. Both lean and overweight volunteers promptly lost 6.2 of the 10 lb they had gained in fat mass (61% of fat gained), and 1.5 of the 6.6 lb they had gained in lean mass (23%). Here is a graph showing changes in fat mass for each individual that completed the study:
We don't know if they would have lost the remaining fat mass in the following weeks because they were only followed for 6 weeks after overfeeding, although it did appear that they were reaching a plateau slightly above their original body weight. Thus, nearly all subjects "defended" their original body fat mass irrespective of their starting point. Underfeeding studies have shown the same phenomenon: whether lean or overweight, people tend to return to their original fat mass after underfeeding is over. Again, this supports the idea that the body has a body fat mass "set point" that it attempts to defend against changes in either direction. It's one of many systems in the body that attempt to maintain homeostasis.OK, so why do we care?
We care because this has some very important implications for human obesity. With such a powerful system in place to keep body fat mass in a narrow range, a major departure from that range implies that the system isn't functioning correctly. In other words, obesity has to result from a defect in the system that regulates body fat, because a properly functioning system would not have allowed that degree of fat gain in the first place.
So yes, we are gaining weight because we eat too many calories relative to energy expended. But why are we eating too many calories? Because the system that should be defending a low fat mass is now defending a high fat mass. Therefore, the solution is not simply to restrict calories, or burn more calories through exercise, but to try to "reset" the system that decides what fat mass to defend. Restricting calories isn't necessarily a good solution because the body will attempt to defend its setpoint, whether high or low, by increasing hunger and decreasing its metabolic rate. That's why low-calorie diets, and most diets in general, typically fail in the long term. It's miserable to fight hunger every day.
This raises two questions:
- What caused the system to defend a high fat mass?
- Is it possible to reset the fat mass setpoint, and how would one go about it?
* The hormone leptin and the hypothalamus are the ringleaders, although there are many other elements involved, such as numerous gut-derived peptides, insulin, and a number of other brain regions.
On Automobile, and Health Care Companies Run by Finance People
The New Republic published "Upper Mismanagement" about what happens when businesses are run by people who do not understand their companies' businesses. Although the article was focused on the decline of manufacturing in the US, its applicability to health care is obvious:
Furthermore,
If business schools did little to teach about manufacturing, they did almost nothing to teach about health care. But at the same time the finance people were taking over manufacturing, health care organizations were pushed to turn over their leadership to business people to improve efficiency and break the physician's "guild." Would there be any reason to expect that a finance background would be better preparation to run a health care corporation than to run an automobile company?
For the latest thought- and wince-provoking example of how leaders of health care corporations seem to know almost nothing about the actual health care their companies provide, see a DailyFinance interview with Mr Kent Thiry, CEO of DaVita, a for-profit corporate provider of dialysis services. According to the company web-site, "prior to working for Vivra, Mr. Thiry was a partner at Bain & Company, an International management consulting company. He earned his BA degree, with distinction and Phi Beta Kappa, in Political Science from Stanford University in 1978, and his MBA, with honors from Harvard Business School in 1983" So he got his MBA from an elite US business school at the time in which finance was becoming dominant as described above.
Asked to explain his business model, Mr Thiry responded:
To be charitable, I do not think that would merit a "C" on a high school biology test. [Medical science cannot "replicate" hearts or lungs. Kidney function is not the same thing as "urinating." The functions of the kidney are far more complex than "cleaning out toxins."]
Does it make any sense to put someone who obviously understands so little about kidneys in charge of a kidney dialysis company? (On the other hand, see this post on accusations that DaVita's ruthless business practices treat patients like "dialysis dollars.")
So, if putting finance people in charge of automobile companies turned out to be a recipe for bankruptcy, why should we expect from putting finance people in charge of dialysis companies, or hospitals, or drug, biotechnology or medical device companies, or health care insurance companies, or health care information technology companies?
The CEOs of big health care organizations, most of whom have business, not health care backgrounds, have mainly been good at paying themselves and their cronies well. (For example, according to the 2009 DaVita proxy statement, in 2008, Mr Thiry owned over 2 million shares of stock, 1.9% of all shares outstanding, and received more than $11 million in total compensation. Clearly, he was not paid according to his knowledge of kidney biology.) Meanwhile, health care costs rise, access falls, and quality degrades.
If we really want to reform health care, maybe we should take a lesson from Toyota. Put the car guys and gals in charge of car companies. And put the health care guys and gals in charge of health care.
Harvard business professor Rakesh Khurana, with whom I discussed these questions at length, observes that most of GM’s top executives in recent decades hailed from a finance rather than an operations background. (Outgoing GM CEO Fritz Henderson and his failed predecessor, Rick Wagoner, both worked their way up from the company’s vaunted Treasurer’s office.) But these executives were frequently numb to the sorts of innovations that enable high-quality production at low cost. As Khurana quips, “That’s how you end up with GM rather than Toyota.”
How did we get to this point? In some sense, it’s the result of broad historical and economic forces. Up until World War I, the archetypal manufacturing CEO was production oriented—usually an engineer or inventor of some kind. Even as late as the 1930s, business school curriculums focused mostly on production. Khurana notes that many schools during this era had mini-factories on campus to train future managers.
After World War II, large corporations went on acquisition binges and turned themselves into massive conglomerates. In their landmark Harvard Business Review article from 1980, 'Managing Our Way to Economic Decline,' Robert Hayes and William Abernathy pointed out that the conglomerate structure forced managers to think of their firms as a collection of financial assets, where the goal was to allocate capital efficiently, rather than as makers of specific products, where the goal was to maximize quality and long-term* market share.
By the 1980s, the conglomerate boom was reversing itself. Investors began seizing control of overgrown public companies and breaking them up. But this task was, if anything, even more dependent on fluency in financial abstractions. The leveraged-buyout boom produced a whole generation of finance tycoons—the Michael Milkens of the world—whose ability to value corporate assets was far more important than their ability to run them.
The new managerial class tended to neglect process innovation because it was hard to justify in a quarterly earnings report, where metrics like “return on investment” reigned supreme. 'In an era of management by the numbers, many American managers … are reluctant to invest heavily in the development of new manufacturing processes,' Hayes and Abernathy wrote. 'Many of them have effectively forsworn long-term technological superiority as a competitive weapon.' By contrast, European and Japanese manufacturers, who lived and died on the strength of their exports, innovated relentlessly
Furthermore,
The business schools had their own incentives to channel students into high-paying fields like finance, thanks to the rising importance of school rankings, which heavily weighted starting salaries. The career offices at places like Harvard, Stanford, and Chicago institutionalized the process—for example, by making it easier for Wall Street outfits and consulting firms to recruit on campus. A recent Harvard Business School case study about General Electric shows that the company had so much trouble competing for MBAs that it decided to woo top graduates from non-elite schools rather than settle for elite-school graduates in the bottom half or bottom quarter of their classes.
No surprise then that, over time, the faculty and curriculum at the Harvards and Stanfords of the world began to evolve. 'If you look at the distribution of faculty at leading business schools,' says Khurana, '“they’re mostly in finance. … Business schools are responsive to changes in the external environment.' Which meant that, even if a student aspired to become a top operations man (or woman) at a big industrial company, the infrastructure to teach him didn’t really exist.
If business schools did little to teach about manufacturing, they did almost nothing to teach about health care. But at the same time the finance people were taking over manufacturing, health care organizations were pushed to turn over their leadership to business people to improve efficiency and break the physician's "guild." Would there be any reason to expect that a finance background would be better preparation to run a health care corporation than to run an automobile company?
For the latest thought- and wince-provoking example of how leaders of health care corporations seem to know almost nothing about the actual health care their companies provide, see a DailyFinance interview with Mr Kent Thiry, CEO of DaVita, a for-profit corporate provider of dialysis services. According to the company web-site, "prior to working for Vivra, Mr. Thiry was a partner at Bain & Company, an International management consulting company. He earned his BA degree, with distinction and Phi Beta Kappa, in Political Science from Stanford University in 1978, and his MBA, with honors from Harvard Business School in 1983" So he got his MBA from an elite US business school at the time in which finance was becoming dominant as described above.
Asked to explain his business model, Mr Thiry responded:
Most of us have a couple of kidneys. These kidneys are amazing organs -- some of the most complex, sophisticated organs in the human body, which is why they've been so difficult to replicate compared to other organs like the heart and lung and others. And when the kidney fails, you need to go on dialysis, unless you're one of the fortunate few to get a transplant. And we operate the centers that people come to if their kidney fails and they can't get a transplant.
And what we do in our centers is take care of these people typically three times a week -- four hours each time -- where we take their blood out of their body, clean out all the toxins that they would normally clean out themselves through the act of urinating. But you don't do that anymore once you've lost your kidney function. And we take that part out, take the toxins out and then put the blood back in with some other nutrients.
To be charitable, I do not think that would merit a "C" on a high school biology test. [Medical science cannot "replicate" hearts or lungs. Kidney function is not the same thing as "urinating." The functions of the kidney are far more complex than "cleaning out toxins."]
Does it make any sense to put someone who obviously understands so little about kidneys in charge of a kidney dialysis company? (On the other hand, see this post on accusations that DaVita's ruthless business practices treat patients like "dialysis dollars.")
So, if putting finance people in charge of automobile companies turned out to be a recipe for bankruptcy, why should we expect from putting finance people in charge of dialysis companies, or hospitals, or drug, biotechnology or medical device companies, or health care insurance companies, or health care information technology companies?
The CEOs of big health care organizations, most of whom have business, not health care backgrounds, have mainly been good at paying themselves and their cronies well. (For example, according to the 2009 DaVita proxy statement, in 2008, Mr Thiry owned over 2 million shares of stock, 1.9% of all shares outstanding, and received more than $11 million in total compensation. Clearly, he was not paid according to his knowledge of kidney biology.) Meanwhile, health care costs rise, access falls, and quality degrades.
If we really want to reform health care, maybe we should take a lesson from Toyota. Put the car guys and gals in charge of car companies. And put the health care guys and gals in charge of health care.
The $20 Million Dollar Journal Editor
Last week, the Milwaukee Journal-Sentinel reported on a royally paid journal editor:
Here are some specifics:
Dr Zdelblick declined to comment for the Journal-Sentinel, but:
Of course, as the Journal-Sentinel pointed out, editors can make publication decisions independent of the recommendations of peer-reviewers. They also are free to select peer-reviewers who might have a particular viewpoint about a manuscript, its topic or authors, and to make and enforce editorial suggestions for changes in manuscripts. It is beyond me what good that disclosure of conflicts of interest to a for-profit publishing corporation does in the absence of further disclosure. Keep in mind also that the division of Wolters Kluwer that publishes the journals, Wolters Kluwer Health & Pharma Solutions, not only publishes journals and textbooks, but "provides marketing and publications services, business intelligence products, and advanced analytical tools and services" to pharmaceutical corporations.
Furthermore,
Just to add icing to the cake, Prof Margaret Soltan pointed out on her University Diaries blog that Dr Zdeblick is not only a journal editor, but a Professor and Chairman of Orthopedics and Rehabilitation at the University of Wisconsin. In addition, his web-page at the University notes that he is on the editorial board of another orthopedics journal, Spine, also published by Wolters Kluwer Health.
So here we go again. How should we assess the objectivity of an ostensibly scholarly medical journal whose editor was made rich by royalties from a company whose devices were often evaluated in the articles published in the journal? How should we assess the honesty of a journal editor who received millions in royalties from Medtronic, but who only deigned to disclose as an author in his own journal, "One or more of the author(s) has/have received or will receive benefits, (e.g., royalties, stocks, stock options, decision making position) for personal or professional use from a commercial party related directly or indirectly to the subject of this manuscript." (as in Zdelblick TA, Phillips FM. Interbody cage devices. Spine 2003; 28: S2-S7.) (Note that this sort of disclosure seems to be standard operating procedure for orthopedic surgeons who make millions from royalties and consulting fees, e.g. see this post.)
Prof Zdelblick had numerous opportunities to influence his colleagues, trainees, and students in his roles as journal editor, journal editorial board member, author of scholarly articles, and professor and chair of orthopedics. At the very least, the people who read his journal or his articles, listened to his lectures, or participated in his clinical teaching should have at least had the opportunity to judge for themselves whether being paid over $20 million might have just biased what he wrote and said a tiny bit. But can anyone doubt that $20 million dollars would profoundly influence one's thinking? Can anyone doubt that an inventor who got rich from royalties might not be more enthused about the use of the devicesthat generated the royalties than would an academic whose salary is unrelated to the use of any device? It seems to be an abuse of entrusted power for a journal editor, professor, and department chairman not to clearly disclose such huge conflicts of interests to readers, learners and colleagues.
This is just the latest vivid example of the conflicts of interest that permeate health care. When multi-million dollar men pretend to be unbiased editors and professors, is it any wonder that we regularly overuse and overvalue the devices and drugs that they are selling?
ADDENDUM (6 January, 2010) - See also comments on the Spine Blogger, and by Dr Howard Brody on the Hooked: Ethics, Medicine and Pharma blog.
In 2002, Thomas Zdeblick, a University of Wisconsin orthopedic surgeon who has pocketed millions of dollars in royalties from the spinal device maker Medtronic, took over as editor-in-chief of a medical journal about spinal disorders.
It would be the beginning of a beautiful friendship.
In the years to come, Zdeblick would receive more than $20 million in patent royalties from Medtronic for spinal implants sold by the company. And the medical journal he edited would become a conduit for positive research articles involving Medtronic spinal products, a Journal Sentinel analysis found.
Zdeblick took over editorship of the Journal of Spinal Disorders & Techniques seven years ago. Since then, studies involving Medtronic spinal products or that were funded by Medtronic appeared in the journal at least once per issue, on average.
Dozens of studies that mentioned Medtronic products have been published while Zdeblick has been editor. But in issue after issue, readers of the journal were not told that he was receiving millions of dollars in royalty payments from Medtronic at the same time.
Most of the time the articles, including some co-authored by Zdeblick himself about devices for which he gets royalties, had good things to say about the Medtronic products. Only on a small number of occasions did the articles find major problems with Medtronic devices.
And often the articles did not disclose financial ties the authors had to Medtronic.
Here are some specifics:
From 2003 through 2007, Zdeblick got more than $19 million in royalty payments for spinal devices from Medtronic, according to a January 2009 letter by U.S. Sen. Charles Grassley (R-Iowa), who has been investigating payments to orthopedic surgeons by Medtronic. In 2008, Zdeblick got another $2 million from Medtronic from royalties and working as a consultant, according to UW records.
To assess the relationship, the Journal Sentinel reviewed every article published in the journal since Zdeblick became editor.
The journal is published seven or eight times a year and typically has a dozen or so articles. The articles were searched to see if Medtronic products were used as a part of the study or if the study was funded by Medtronic.
At least 70 such articles were found in 56 issues of the journal from 2002 through October 2009.
• A 2005 study by researchers in France found favorable preliminary results with Medtronic's Maverick artificial disc.
In 2007, Medtronic paid Zdeblick $144,000 in royalties for the Maverick disc, according to Grassley's letter.
• In August 2009, Zdeblick co-authored a study that involved Medtronic's Premier Anterior Cervical Plate as well as the plate of another company, Synthes. The study involved using two different kinds of bone grafts with the plates. Zdeblick got $654,000 in Premier royalties from Medtronic in 2007.
• Zdeblick also co-authored three articles, in 2002, 2003 and 2005, involving Medtronic's BMP-2 and the LT-Cage, a device that paid him $1.4 million in royalties in 2007. None of those studies disclosed that he received millions of dollars in royalties from Medtronic.
Often articles in the journal had good things to say about Medtronic products:
• In the 2002 study, Zdeblick and the co-authors concluded that BMP-2 and the LT-Cage led to a solid union and high fusion rates. In the 2003 study they found that BMP-2 may become 'the new gold standard.'
• In a 2006 study, a different group of authors concluded that BMP-2 when used with a hip bone graft significantly improved the success of the fusion surgery with minimal risk to the patient. The 2005 French study of Medtronic's Maverick artificial disc that did not involve Zdeblick concluded it was a 'promising therapeutic technique.'
Dr Zdelblick declined to comment for the Journal-Sentinel, but:
In a statement, a spokesman for the spinal journal said Zdeblick has disclosed his financial relationship with Medtronic to the company that publishes the journal, Wolters Kluwer Health/Lippincott Williams & Wilkins.
All manuscripts submitted to the journal go through a rigorous review process using reviewers who have an objective viewpoint, Robert Dekker, director of communications with Philadelphia-based Wolters Kluwer Health & Pharma Solutions, said in a statement. 'Thanks to our strict peer review policies and processes, we have no concerns about the existence of this relationship,' Dekker said in an e-mail.
Dekker declined to provide a list of the reviewers used by the journal or information about their financial relationships with device companies. He also declined to comment on how Zdeblick made decisions about manuscripts and reviewers.
Of course, as the Journal-Sentinel pointed out, editors can make publication decisions independent of the recommendations of peer-reviewers. They also are free to select peer-reviewers who might have a particular viewpoint about a manuscript, its topic or authors, and to make and enforce editorial suggestions for changes in manuscripts. It is beyond me what good that disclosure of conflicts of interest to a for-profit publishing corporation does in the absence of further disclosure. Keep in mind also that the division of Wolters Kluwer that publishes the journals, Wolters Kluwer Health & Pharma Solutions, not only publishes journals and textbooks, but "provides marketing and publications services, business intelligence products, and advanced analytical tools and services" to pharmaceutical corporations.
Furthermore,
'It's absolutely a conflict,' said Richard Smith, the former editor of the British Medical Journal.
At a minimum, Zdeblick's conflict should be fully disclosed by his journal whenever a study involving a Medtronic product is published, said Smith, the author of 'The Trouble with Medical Journals.'
However, because he makes so much money from Medtronic royalties, he really should not be editing the journal at all, Smith said.
Just to add icing to the cake, Prof Margaret Soltan pointed out on her University Diaries blog that Dr Zdeblick is not only a journal editor, but a Professor and Chairman of Orthopedics and Rehabilitation at the University of Wisconsin. In addition, his web-page at the University notes that he is on the editorial board of another orthopedics journal, Spine, also published by Wolters Kluwer Health.
So here we go again. How should we assess the objectivity of an ostensibly scholarly medical journal whose editor was made rich by royalties from a company whose devices were often evaluated in the articles published in the journal? How should we assess the honesty of a journal editor who received millions in royalties from Medtronic, but who only deigned to disclose as an author in his own journal, "One or more of the author(s) has/have received or will receive benefits, (e.g., royalties, stocks, stock options, decision making position) for personal or professional use from a commercial party related directly or indirectly to the subject of this manuscript." (as in Zdelblick TA, Phillips FM. Interbody cage devices. Spine 2003; 28: S2-S7.) (Note that this sort of disclosure seems to be standard operating procedure for orthopedic surgeons who make millions from royalties and consulting fees, e.g. see this post.)
Prof Zdelblick had numerous opportunities to influence his colleagues, trainees, and students in his roles as journal editor, journal editorial board member, author of scholarly articles, and professor and chair of orthopedics. At the very least, the people who read his journal or his articles, listened to his lectures, or participated in his clinical teaching should have at least had the opportunity to judge for themselves whether being paid over $20 million might have just biased what he wrote and said a tiny bit. But can anyone doubt that $20 million dollars would profoundly influence one's thinking? Can anyone doubt that an inventor who got rich from royalties might not be more enthused about the use of the devicesthat generated the royalties than would an academic whose salary is unrelated to the use of any device? It seems to be an abuse of entrusted power for a journal editor, professor, and department chairman not to clearly disclose such huge conflicts of interests to readers, learners and colleagues.
This is just the latest vivid example of the conflicts of interest that permeate health care. When multi-million dollar men pretend to be unbiased editors and professors, is it any wonder that we regularly overuse and overvalue the devices and drugs that they are selling?
ADDENDUM (6 January, 2010) - See also comments on the Spine Blogger, and by Dr Howard Brody on the Hooked: Ethics, Medicine and Pharma blog.
Finnish EHR's Clumsy, Mission Hostile, Consume Doctors' Precious Time
It seems common wisdom in the U.S. that the "Europeans are way ahead of us" in computerized medicine.
Perhaps the common wisdom is not so wise. This from Finland:
Can health IT be any more mission hostile than this? (Unfortunately, the answer to what started as a rhetorical question is probably "yes." See this post on the US military's EHR AHLTA, and see my eight part series "Are Health IT Designers, Testers and Purchasers Trying to Harm Patients?" on mission hostile commercial HIT starting here.)
Reports of difficulty in EHR Utopia have leaked out of other European countries such as the Netherlands and Germany, not to mention the UK.
The most startling observation is that “software companies have started to become interested in listening to users only in recent years."
What manner of cavalier simpletons and opportunists populate such health IT companies?
-- SS
Addendum:
It appears AHLTA may be a bad as it is due in part to "politics as usual" a.k.a. corruption. See "Company won earmarked funds for work on military health records." If such conduct has been commonplace during AHLTA'a tortured history, it could explain just how AHLTA became as terrible as the senior military officials describe it in the linked article above.
Perhaps the common wisdom is not so wise. This from Finland:
HELSINGIN SANOMAT
INTERNATIONAL EDITION - HOME
Clumsy computer systems consume doctors’ time
When Arto Virtanen, a doctor at a public health clinic, wants to access the information of a young patient, 12 windows of different sizes open up on different parts of his computer screen. Virtanen has to deal with each of them every time a patient visits him for routine postnatal care.
“It used to be that a municipal doctor would see six or seven patients in an hour, when documentation was not at its present level”, Virtanen says. “Then there came more paperwork, and four patients were seen in an hour. Now if a doctor wants to read all the information about a patient in the information system, there would only be time for consultations with, say, two patients in an hour.”
Clumsy computer systems are already seen as a danger to patient security, says Tiina Lääveri, a member of the board of the Finnish Medical Association, who has acquainted herself with the various systems.
Clumsy retrieval of data is one source of danger. Important information can disappear into the nooks and crannies of the software.
“There can be 100 pages of text without any summary, out of which a doctor should find information in a couple of minutes."
In hospitals, the systems do not separately tell nurses about changed dosages of medicines.
“The information is there, mixed in the mass of all of the rest of it, where it gets lost.”
In addition to causing outright dangers, computer systems waste precious working hours. In addition to actual medical data, the computer requires the recording of various items of statistical information.
Patients can see the problem as well. Up to 43 per cent of time reserved for a patient with an appointment to see a public health doctor can be spent dealing with a computer, according to a study published earlier this year in Lääkärilehti, the publication of the Finnish Medical Assotiation.
A national health archive now under development would not help things, as data would still be handled with existing software.
“Software companies have started to become interested in listening to users only in recent years”, Lääveri says.
Virtanen in Rajamäki would like to see more compatibility between systems. “There could be a common database, which should be easily accessible by a network browser”, Virtanen says.
“It might also be constructed according to what this working process really is.” [You don't say? - ed.]
Can health IT be any more mission hostile than this? (Unfortunately, the answer to what started as a rhetorical question is probably "yes." See this post on the US military's EHR AHLTA, and see my eight part series "Are Health IT Designers, Testers and Purchasers Trying to Harm Patients?" on mission hostile commercial HIT starting here.)
Reports of difficulty in EHR Utopia have leaked out of other European countries such as the Netherlands and Germany, not to mention the UK.
The most startling observation is that “software companies have started to become interested in listening to users only in recent years."
What manner of cavalier simpletons and opportunists populate such health IT companies?
-- SS
Addendum:
It appears AHLTA may be a bad as it is due in part to "politics as usual" a.k.a. corruption. See "Company won earmarked funds for work on military health records." If such conduct has been commonplace during AHLTA'a tortured history, it could explain just how AHLTA became as terrible as the senior military officials describe it in the linked article above.
Are Dissmissive Industry and Government Reactions to Physician Concerns about EHR's and other Clinical IT Simply Perverse?
Yes, they are.
At the Nov. 10, 2009 essay "Academic Freedom and ED EHR's Down Under: Another Update and a Welcome Development" and preceding essays linked to it, I wrote about an Australian informatics professor's travails in writing about ED EHR's.
He wrote a mixed-method essay about the mission hostile user experiences ED physicians in NSW reported about the EHR's they were being compelled to use, in addition to similar negative commentary from ED physician experts in other lands. The latest version of the paper "A Critical Essay on the Deployment of an ED Clinical Information System ‐ Systemic Failure or Bad Luck" is here (PDF) or accessible from his department's webpage here.
The government attempted to censor the paper and likely censure the author, and I speculate the HIT industry was not far behind.
Below is an example from my own city on why I found the reactions to the evolving ED EHR paper - reactions that "blamed the doctors" or dismissed what appear to be frequently encountered ED physician concerns - perverse.
I use the term "perverse" in the most formal sense of the word:
The very, very last thing patients need is to have ED clinicians slowed down.
Concerns expressed by even a minority of ED physicians that EHR's slow them down or reduce their effectiveness ought to set off alarm bells and rigorous government investigations of the kind that would arise if airline pilots started to complain about lax security allowing passengers on board with bombs:
A patient recently died of a heart attack, sitting in the waiting room of a hospital where I once rotated during my internship, Frankford Hospital. He was not found until others in the waiting room stole the dead patient-in-waiting's wristwatch. The man sat unresponsive for nearly an hour in the waiting area of Aria Health Frankford Hospital before a visitor notified security and a doctor arrived.
I reiterate, the very last thing in the world ER clinicians need are ill-conceived and ill-implemented electronic health records systems that slow them down.
Instead of attempted censorship and spin control, such concerns should be addressed throughly, impartially and promptly if not immediately.
What could one call the arrogance or devil-may-care mindset in the government and health IT industry that dismisses such concerns so cavalierly, other than "perverse?"
-- SS
At the Nov. 10, 2009 essay "Academic Freedom and ED EHR's Down Under: Another Update and a Welcome Development" and preceding essays linked to it, I wrote about an Australian informatics professor's travails in writing about ED EHR's.
He wrote a mixed-method essay about the mission hostile user experiences ED physicians in NSW reported about the EHR's they were being compelled to use, in addition to similar negative commentary from ED physician experts in other lands. The latest version of the paper "A Critical Essay on the Deployment of an ED Clinical Information System ‐ Systemic Failure or Bad Luck" is here (PDF) or accessible from his department's webpage here.
The government attempted to censor the paper and likely censure the author, and I speculate the HIT industry was not far behind.
Below is an example from my own city on why I found the reactions to the evolving ED EHR paper - reactions that "blamed the doctors" or dismissed what appear to be frequently encountered ED physician concerns - perverse.
I use the term "perverse" in the most formal sense of the word:
Merriam-Webster dictionary:
Perverse (adj).
Etymology: Middle English, from Anglo-French purvers, pervers, from Latin perversus, from past participle of pervertere
Date: 14th century
1 a : turned away from what is right or good : corrupt b : improper, incorrect c : contrary to the evidence or the direction of the judge on a point of law
2 a : obstinate in opposing what is right, reasonable, or accepted : wrongheaded b : arising from or indicative of stubbornness or obstinacy
3 : marked by peevishness or petulance : cranky
4 : marked by perversion : perverted
The very, very last thing patients need is to have ED clinicians slowed down.
Concerns expressed by even a minority of ED physicians that EHR's slow them down or reduce their effectiveness ought to set off alarm bells and rigorous government investigations of the kind that would arise if airline pilots started to complain about lax security allowing passengers on board with bombs:
Dec 24, 2009The situation is actually even worse.
Philadelphia Inquirer
Philadelphia ERs seek solutions to crowding
By Marie McCullough
Inquirer Staff Writer
Two of the region's leading medical centers have racked up the city's highest number of "diversions" - periods when ambulances are advised to steer clear because the emergency room is so full.
The Hospital of the University of Pennsylvania and Thomas Jefferson University Hospital are working to reduce such diversions as the number of emergency rooms in the city has continued to fall. This year, Penn has reduced the disruptions by 22 percent and Jefferson by 28 percent.
As they seek solutions, the hospitals are examining their own practices, reflecting a national shift in efforts to address the perennial crisis of ER overcrowding.
Consider Jefferson. This year it reduced diversion hours even though the number of ER patients, the severity of their medical needs, and staffing stayed about the same. Jefferson relieved overcrowding by finding ways to move patients in and out of the ER - and the whole hospital - faster.
"That's where I'm focused, on improving efficiencies," said Rex Mathew, hired by Jefferson two years ago for the new job of vice president of emergency medicine clinical operations.
This is not to suggest that the nation's emergency medical-care system has been slacking. From 1992 to 2002, the number of annual emergency-room visits increased 23 percent, while the number of ERs decreased 15 percent, studies show.
In the Philadelphia region, the contraction has been more dramatic - from 62 ERs in 1993 to 38 now, a 39 percent decrease. The most recent loss was this year's closing of Northeastern Hospital, which had 45,000 emergency visits annually. The impact has been felt at Aria Health-Frankford Campus, where Joaquin Rivera died in the ER while waiting for care on Nov. 28.
While there is no evidence that overcrowding played a role in his death, Frankford had nearly as many diversions in November - 121 hours - as all of last year.
Emergency departments are beset by growing numbers of the uninsured, the chronically ill, and the aged.
Nonetheless, experts say it's time for hospitals to stop blaming ER overcrowding on economic, social, and demographic factors that are beyond their control, and start looking inward. A recent Government Accountability Office report found that even in life-and-death cases, large percentages of ER patients do not see doctors within recommended times.
"Many hospitals have done little to address the patient-flow obstacles that lead to overcrowded" emergency rooms, says a report by Urgent Matters, an ER improvement initiative funded by the Robert Wood Johnson Foundation.
Jefferson and Hahnemann University Hospital are among six U.S. hospitals using grants from Urgent Matters to develop practical strategies for reducing ER crowding. These will be shared nationally through newsletters, the Web, and conferences.
... Most fixes, however, are neither easy nor obvious. Sick patients may lie on gurneys for hours in ERs, uncomfortable and taking up precious space, while they wait for a hospital bed to become available.
... "The problem is not just physical space but effective space," said Robert McNamara, chair of emergency medicine at Temple University Hospital. "With hospital margins tight, there may be beds, but no staff to cover them. And hospitals try to keep staffing tight to keep costs down."
Temple has the city's busiest ER, with 74,000 adult and 20,000 pediatric patients this year - 24 percent of whom were admitted to the hospital, McNamara said. Anticipating a surge in demand following Northeastern's closure, Temple added ER staff and made a concerted effort to speed up testing and discharge procedures, he said.
This year, through November, Temple had 118 hours when ambulances were diverted.
The Hospital of the University of Pennsylvania, with about 60,000 ER patients and a 26 percent admission rate, was by far the city's leading diverter - more than 1,000 hours through November.
... the crowding conundrum continues to evolve. One question is whether health-care reform - which now seems imminent - may increase ER volume rather than reducing it, as millions more Americans become insured.
A patient recently died of a heart attack, sitting in the waiting room of a hospital where I once rotated during my internship, Frankford Hospital. He was not found until others in the waiting room stole the dead patient-in-waiting's wristwatch. The man sat unresponsive for nearly an hour in the waiting area of Aria Health Frankford Hospital before a visitor notified security and a doctor arrived.
Dec. 1, 2009
Philadelphia Inquirer
Waiting to be seen at hospital, dying Joaquin Rivera was robbed, police say
... According to Philadelphia police, Rivera walked into Aria Health's Frankford Campus, on Frankford Avenue near Harrison Street, about 10:45 p.m. Saturday.
He was alone, and apparently had walked from his nearby home on Duffield Street near Foulkrod, his son said.
Rivera complained of feeling pain in his left arm and abdomen, and was told to sit in the waiting area, said police spokesman Lt. Frank Vanore. [A middle aged man with left arm and abdominal pain told to 'sit in the waiting room?' One wonders who would qualify for sitting under medical observation - ed.]
At some point during the next hour, Rivera, a longtime bilingual counselor at Olney High School, lost consciousness. He inadvertently became a target, Vanore said, to three other people in the waiting room...
[One of the other people] signed up to be seen by a doctor, while his two cohorts sat near Rivera. "At some point, [one of the people] is observed taking the victim's watch and passing it to the other man," Vanore said.
When a witness ran to notify a security guard of the crime and Rivera's condition, the limping man and his female partner fled, Vanore said. Hospital personnel rushed to Rivera's aid, but it was too late.
He was pronounced dead shortly after midnight Sunday. Vanore said police have not yet learned of Rivera's cause of death.
The family said he was believed to have died of a heart attack.
I reiterate, the very last thing in the world ER clinicians need are ill-conceived and ill-implemented electronic health records systems that slow them down.
Instead of attempted censorship and spin control, such concerns should be addressed throughly, impartially and promptly if not immediately.
What could one call the arrogance or devil-may-care mindset in the government and health IT industry that dismisses such concerns so cavalierly, other than "perverse?"
-- SS
Rabbits on a High-Saturated Fat Diet Without Added Cholesterol
I just saw another study that supports my previous post Animal Models of Atherosclerosis: LDL. The hypothesis is that in the absence of excessive added dietary cholesterol, saturated fat does not influence LDL or atherosclerosis in animal models, relative to other fats (although omega-6 polyunsaturated oils do lower LDL in some animal models). This appears to be consistent with what we see in humans.
In this study, they fed four groups of rabbits different diets:
Total cholesterol was also the same between all groups except the cholesterol-fed group. TBARS, a measure of lipid oxidation in the blood, was elevated in the cholesterol and sunflower oil groups but not in the chow or coconut groups. Oxidation of blood lipids is one of the major factors in atherosclerosis, the vascular disease that narrows arteries and increases the risk of having a heart attack. Serum vitamin C was lower in the cholesterol-fed groups but not the others.
This supports the idea that saturated fat does not inherently increase LDL, and in fact in most animals it does not. This appears to be the case in humans as well, where long-term trials have shown no difference in LDL between people eating more saturated fat and people eating less, on timescales of one year or more (some short trials show a modest LDL-raising effect, but even this appears to be due to an increase in particle size rather than particle number). Since these trials represent the average of many people, they may hide some individual variability: it may actually increase LDL in some people and decrease it in others.
Merry Christmas!
In this study, they fed four groups of rabbits different diets:
- Regular low-fat rabbit chow
- Regular low-fat rabbit chow plus 0.5 g cholesterol per day
- High-fat diet with 30% calories as coconut oil (saturated) and no added cholesterol
- High-fat diet with 30% calories as sunflower oil (polyunsaturated) and no added cholesterol
Total cholesterol was also the same between all groups except the cholesterol-fed group. TBARS, a measure of lipid oxidation in the blood, was elevated in the cholesterol and sunflower oil groups but not in the chow or coconut groups. Oxidation of blood lipids is one of the major factors in atherosclerosis, the vascular disease that narrows arteries and increases the risk of having a heart attack. Serum vitamin C was lower in the cholesterol-fed groups but not the others. This supports the idea that saturated fat does not inherently increase LDL, and in fact in most animals it does not. This appears to be the case in humans as well, where long-term trials have shown no difference in LDL between people eating more saturated fat and people eating less, on timescales of one year or more (some short trials show a modest LDL-raising effect, but even this appears to be due to an increase in particle size rather than particle number). Since these trials represent the average of many people, they may hide some individual variability: it may actually increase LDL in some people and decrease it in others.
Merry Christmas!
Rabbits on a High-Saturated Fat Diet Without Added Cholesterol
I just saw another study that supports my previous post Animal Models of Atherosclerosis: LDL. The hypothesis is that in the absence of excessive added dietary cholesterol, saturated fat does not influence LDL or atherosclerosis in animal models, relative to other fats (although omega-6 polyunsaturated oils do lower LDL in some animal models). This appears to be consistent with what we see in humans.
In this study, they fed four groups of rabbits different diets:
Total cholesterol was also the same between all groups except the cholesterol-fed group. TBARS, a measure of lipid oxidation in the blood, was elevated in the cholesterol and sunflower oil groups but not in the chow or coconut groups. Oxidation of blood lipids is one of the major factors in atherosclerosis, the vascular disease that narrows arteries and increases the risk of having a heart attack. Serum vitamin C was lower in the cholesterol-fed groups but not the others.
This supports the idea that saturated fat does not inherently increase LDL, and in fact in most animals it does not. This appears to be the case in humans as well, where long-term trials have shown no difference in LDL between people eating more saturated fat and people eating less, on timescales of one year or more (some short trials show a modest LDL-raising effect, but even this appears to be due to an increase in particle size rather than particle number). Since these trials represent the average of many people, they may hide some individual variability: it may actually increase LDL in some people and decrease it in others.
Merry Christmas!
In this study, they fed four groups of rabbits different diets:
- Regular low-fat rabbit chow
- Regular low-fat rabbit chow plus 0.5 g cholesterol per day
- High-fat diet with 30% calories as coconut oil (saturated) and no added cholesterol
- High-fat diet with 30% calories as sunflower oil (polyunsaturated) and no added cholesterol
Total cholesterol was also the same between all groups except the cholesterol-fed group. TBARS, a measure of lipid oxidation in the blood, was elevated in the cholesterol and sunflower oil groups but not in the chow or coconut groups. Oxidation of blood lipids is one of the major factors in atherosclerosis, the vascular disease that narrows arteries and increases the risk of having a heart attack. Serum vitamin C was lower in the cholesterol-fed groups but not the others. This supports the idea that saturated fat does not inherently increase LDL, and in fact in most animals it does not. This appears to be the case in humans as well, where long-term trials have shown no difference in LDL between people eating more saturated fat and people eating less, on timescales of one year or more (some short trials show a modest LDL-raising effect, but even this appears to be due to an increase in particle size rather than particle number). Since these trials represent the average of many people, they may hide some individual variability: it may actually increase LDL in some people and decrease it in others.
Merry Christmas!
Boston Scientific (Again) Settles - This Time, Charges of Kickbacks Disguised as Clinical Studies
One would think that the stories about bad behavior by health care organizations would quiet down just before Christmas, but no...
As reported by the AP:
So here we have an example of a "seeding study," that is, a marketing effort to persuade physicians to prescribe a product disguised as a clinical research study, but for medical devices, not drugs. Seeding studies seem to combine multiple kinds of unethical behavior, deceptive marketing and manipulated research. There had been some question in the past whether seeding studies exist, but this is the second recent example to come to light, suggesting that not only do they exist, but that they are used by device as well as pharmaceutical companies.
Note that, as Bloomberg reports, this is the third major settlement of allegations of bad behavior made by Boston Scientific,
I submit that would-be health care reformers who want to improve care, reduce costs and improve access should advocate for real negative consequences for people who implement, direct or approve the various versions of fraud, kickbacks, and miscellaneous corruption and malfeasance we have discussed on Health Care Renewal.
By the way, the board of directors of Boston Scientific includes two noted academics with leadership roles in academic health care. Marye Anne Fox is the Chancellor of the University of California - San Diego, and hence the leader of a major medical school and academic medical center. The university's mission statement, alongside which sits her picture, proclaims it "strives to maintain a climate of fairness, cooperation, and professionalism." Uwe Reinhardt, Professor at Princeton, is a noted health care economist, and blogger on the Economix blog for the New York Times. Perhaps such august academic personages could tell us how they are assuring that the company they are paid well to oversee upholds, rather than undermines professionalism and fairness.
As reported by the AP:
U.S. attorneys in Boston said Wednesday heart device maker Boston Scientific will pay $22 million to resolve allegations its Guidant division paid kickbacks to doctors to get them to use its heart devices.
The U.S. Department of Justice said Guidant paid physicians $1,000 to $1,500 each in 2003 and 2004 to participate in four studies, called RaCE, RaCE II, RaCE III, and MERITS. It said the studies were designed to increase sales of pacemakers and defibrillators.
Federal officials said the company targeted doctors who favored products made by other companies, hoping the payments would induce them to use Guidant devices more often. They said Guidant submitted claims for payment on the devices to Medicare.
Boston Scientific did not admit wrongdoing as part of the civil settlement. Under the agreement, its cardiac rhythm management division will have to publicly disclose payments to physicians on a Web site. Boston Scientific also entered into a corporate integrity agreement.
So here we have an example of a "seeding study," that is, a marketing effort to persuade physicians to prescribe a product disguised as a clinical research study, but for medical devices, not drugs. Seeding studies seem to combine multiple kinds of unethical behavior, deceptive marketing and manipulated research. There had been some question in the past whether seeding studies exist, but this is the second recent example to come to light, suggesting that not only do they exist, but that they are used by device as well as pharmaceutical companies.
Note that, as Bloomberg reports, this is the third major settlement of allegations of bad behavior made by Boston Scientific,
The company agreed last month to pay $296 million to settle a Justice Department probe into Guidant’s handling of heart devices and restated third-quarter results. [See post here.] In 2007, Boston Scientific agreed to pay $240 million to settle more than 8,000 lawsuits claiming Guidant hid defects in defibrillators, which are devices that shock the heart back into regular rhythm.Cataloging legal settlements seems to be a useful way to assess the sorts of bad behavior manifested by large health care organizations (see some posts here). However, as we have said frequently, such settlements, including the "corporate integrity agreements" now frequently attached to them, seem to have done little to deter bad behavior. Usually, the companies involved only need to pay fines, and no individual who performed, directed or approved unethical or illegal acts will suffer any negative consequences. I submit once again that such fines are viewed merely as costs of doing business by the affected companies, and do not deter future bad behavior.
I submit that would-be health care reformers who want to improve care, reduce costs and improve access should advocate for real negative consequences for people who implement, direct or approve the various versions of fraud, kickbacks, and miscellaneous corruption and malfeasance we have discussed on Health Care Renewal.
By the way, the board of directors of Boston Scientific includes two noted academics with leadership roles in academic health care. Marye Anne Fox is the Chancellor of the University of California - San Diego, and hence the leader of a major medical school and academic medical center. The university's mission statement, alongside which sits her picture, proclaims it "strives to maintain a climate of fairness, cooperation, and professionalism." Uwe Reinhardt, Professor at Princeton, is a noted health care economist, and blogger on the Economix blog for the New York Times. Perhaps such august academic personages could tell us how they are assuring that the company they are paid well to oversee upholds, rather than undermines professionalism and fairness.
How to Give a Course on Corruption in the Health Sector
Just out from the U4 Anti-Corruption Resource Center is a brief paper on "Approaches to teaching and learning about corruption in the health sector." (Note that U4 has a very useful web-page on corruption health care, also now appearing in the links in our side-bar.)
The paper begins by describing the overall goals of such a course:
Then it lists a set of learning objectives:
The rest of the paper was devoted to specific content that might be included in such courses, and various activities that could facilitate learning.
Although the paper seems to be aimed at people in developing countries, I would submit that its content, and the sort of courses it proposes, would be equally useful in developed countries, including the US. After all, Transparency International has pointed out that health care corruption seems to plague most countries regardless of income, level of economic development, or type of organization of health care systems. The details of how corruption occurs just vary from country to country according to these factors. On Health Care Renewal, we certainly have documented some striking instances of corruption in developed countries, mainly in the US, as well as corruption's little siblings, conflicts of interest and self-interested mismanagement.
However, I suspect that courses about health care corruption are rare, if not completely non-existent, in US medical schools, as are courses about corruption occuring "within country" at US public health schools. In fact, the only "politically correct" way to talk about health care corruption in most developed countries is to talk about how it affects other, usually less developed countries.
At least the author of the paper, Taryn Vian, has the courage to teach her course in the US, at the Boston University School of Public Health. (She also drew on experience giving professional workshops in several countries.) However, while the course does include examples from the US and developed countries, it is aimed at students interested in international public health. I would guess that no one has invited Ms Vian to each the course for US medical students at BU or elsewhere. (And if anyone knows about similar courses taught at US medical schools, US public health schools directed at in-country problems, or at medical or public health schools in other developed countries, please let us know.)
It is a striking example of the anechoic effect that corruption in health care is not considered an important topic for US medical schools. Of course, as long as we do not talk about the problem, we can pretend it does not exist. Is it any wonder that our health care continues to get more expensive and less accessible?
The paper begins by describing the overall goals of such a course:
The overall goals for training in anti‑corruption in health are to help people develop the knowledge, skills, and attitudes they will need to identify and understand problems of corruption in health, design anti‑corruption strategies, strengthen health systems for good governance,
transparency, and accountability, and advocate for integrity in governance. An additional goal is to prepare people to respond to individual experiences they may have with corruption, such as how to react when they suspect someone has engaged in corruption, when they are asked
to pay or accept a bribe, or other situations.
Then it lists a set of learning objectives:
- Define corruption.
- Identify the types of corrupt activities that occur in the health sector, and their scope and seriousness.
- Explain why corruption occurs, applying principles of economics, governance, and crime prevention to understand the issues involved.
- Assess risks and vulnerabilities which make corruption more likely in certain settings.
- Identify the consequences which can result from corruption.
- Discuss cultural differences in defining morality and corruption, including the blurred line between corruption and trading favours, giving gifts, using contacts, etc.
- Describe the core elements of corruption prevention and control programmes.
- Given a particular country situation or programme, explain how corruption can be reduced in drug supply, financial systems, and delivery of health services.
- Become an effective advocate for anti‑corruption strategies and reforms to promote accountability and transparency in health programmes.
The rest of the paper was devoted to specific content that might be included in such courses, and various activities that could facilitate learning.
Although the paper seems to be aimed at people in developing countries, I would submit that its content, and the sort of courses it proposes, would be equally useful in developed countries, including the US. After all, Transparency International has pointed out that health care corruption seems to plague most countries regardless of income, level of economic development, or type of organization of health care systems. The details of how corruption occurs just vary from country to country according to these factors. On Health Care Renewal, we certainly have documented some striking instances of corruption in developed countries, mainly in the US, as well as corruption's little siblings, conflicts of interest and self-interested mismanagement.
However, I suspect that courses about health care corruption are rare, if not completely non-existent, in US medical schools, as are courses about corruption occuring "within country" at US public health schools. In fact, the only "politically correct" way to talk about health care corruption in most developed countries is to talk about how it affects other, usually less developed countries.
At least the author of the paper, Taryn Vian, has the courage to teach her course in the US, at the Boston University School of Public Health. (She also drew on experience giving professional workshops in several countries.) However, while the course does include examples from the US and developed countries, it is aimed at students interested in international public health. I would guess that no one has invited Ms Vian to each the course for US medical students at BU or elsewhere. (And if anyone knows about similar courses taught at US medical schools, US public health schools directed at in-country problems, or at medical or public health schools in other developed countries, please let us know.)
It is a striking example of the anechoic effect that corruption in health care is not considered an important topic for US medical schools. Of course, as long as we do not talk about the problem, we can pretend it does not exist. Is it any wonder that our health care continues to get more expensive and less accessible?
What's the Ideal Fasting Insulin Level?
Insulin is an important hormone. Its canonical function is to signal cells to absorb glucose from the bloodstream, but it has many other effects. Chronically elevated insulin is a marker of metabolic dysfunction, and typically accompanies high fat mass, poor glucose tolerance (prediabetes) and blood lipid abnormalities. Measuring insulin first thing in the morning, before eating a meal, reflects fasting insulin. High fasting insulin prevents the escape of fat from fat tissue and causes a number of other metabolic disturbances.
Elevated fasting insulin is a hallmark of the metabolic syndrome, the quintessential modern metabolic disorder that affects 24% of Americans (NHANES III). Dr. Lamarche and colleagues found that having an insulin level of 13 uIU/mL in Canada correlated with an 8-fold higher heart attack risk than a level of 9.3 uIU/mL (1; thanks to NephroPal for the reference). So right away, we can put our upper limit at 9.3 uIU/mL. The average insulin level in the U.S., according to the NHANES III survey, is 8.8 uIU/mL for men and 8.4 for women (2). Given the degree of metabolic dysfunction in this country, I think it's safe to say that the ideal level of fasting insulin is probably below 8.4 uIU/mL as well.
Let's dig deeper. What we really need is a healthy, non-industrial "negative control" group. Fortunately, Dr. Staffan Lindeberg and his team made detailed measurements of fasting insulin while they were visiting the isolated Melanesian island of Kitava (3). He compared his measurements to age-matched Swedish volunteers. In male and female Swedes, the average fasting insulin ranges from 4-11 uIU/mL, and increases with age. From age 60-74, the average insulin level is 7.3 uIU/mL.
In contrast, the range on Kitava is 3-6 uIU/mL, which does not increase with age. In the 60-74 age group, in both men and women, the average fasting insulin on Kitava is 3.5 uIU/mL. That's less than half the average level in Sweden and the U.S. Keep in mind that the Kitavans are lean and have an undetectable rate of heart attack and stroke.
Another example from the literature are the Shuar hunter-gatherers of the Amazon rainforest. Women in this group have an average fasting insulin concentration of 5.1 uIU/mL (4; no data was given for men).
I found a couple of studies from the early 1970s as well, indicating that African pygmies and San bushmen have rather high fasting insulin. Glucose tolerance was excellent in the pygmies and poor in the bushmen (5, 6, free full text). This may reflect differences in carbohydrate intake. San bushmen consume very little carbohydrate during certain seasons, and thus would likely have glucose intolerance during that period. There are three facts that make me doubt the insulin measurements in these older studies:
We also have data from a controlled trial in healthy urban people eating a "paleolithic"-type diet. On a paleolithic diet designed to maintain body weight (calorie intake had to be increased substantially to prevent fat loss during the diet), fasting insulin dropped from an average of 7.2 to 2.9 uIU/mL in just 10 days. The variation in insulin level between individuals decreased 9-fold, and by the end, all participants were close to the average value of 2.9 uIU/mL. This shows that high fasting insulin is correctable in people who haven't yet been permanently damaged by the industrial diet and lifestyle. The study included men and women of European, African and Asian descent (7).
One final data point. My own fasting insulin, earlier this year, was 2.3 uIU/mL. I believe it reflects a good diet, regular exercise, sufficient sleep, a relatively healthy diet growing up, and the fact that I managed to come across the right information relatively young. It does not reflect: carbohydrate restriction, fat restriction, or saturated fat restriction. Neither does the low fasting insulin of healthy non-industrial cultures.
So what's the ideal fasting insulin level? My current feeling is that we can consider anything between 2 and 6 uIU/mL within our evolutionary template, although the lower half of that range may be preferable.
Elevated fasting insulin is a hallmark of the metabolic syndrome, the quintessential modern metabolic disorder that affects 24% of Americans (NHANES III). Dr. Lamarche and colleagues found that having an insulin level of 13 uIU/mL in Canada correlated with an 8-fold higher heart attack risk than a level of 9.3 uIU/mL (1; thanks to NephroPal for the reference). So right away, we can put our upper limit at 9.3 uIU/mL. The average insulin level in the U.S., according to the NHANES III survey, is 8.8 uIU/mL for men and 8.4 for women (2). Given the degree of metabolic dysfunction in this country, I think it's safe to say that the ideal level of fasting insulin is probably below 8.4 uIU/mL as well.
Let's dig deeper. What we really need is a healthy, non-industrial "negative control" group. Fortunately, Dr. Staffan Lindeberg and his team made detailed measurements of fasting insulin while they were visiting the isolated Melanesian island of Kitava (3). He compared his measurements to age-matched Swedish volunteers. In male and female Swedes, the average fasting insulin ranges from 4-11 uIU/mL, and increases with age. From age 60-74, the average insulin level is 7.3 uIU/mL.
In contrast, the range on Kitava is 3-6 uIU/mL, which does not increase with age. In the 60-74 age group, in both men and women, the average fasting insulin on Kitava is 3.5 uIU/mL. That's less than half the average level in Sweden and the U.S. Keep in mind that the Kitavans are lean and have an undetectable rate of heart attack and stroke.
Another example from the literature are the Shuar hunter-gatherers of the Amazon rainforest. Women in this group have an average fasting insulin concentration of 5.1 uIU/mL (4; no data was given for men).
I found a couple of studies from the early 1970s as well, indicating that African pygmies and San bushmen have rather high fasting insulin. Glucose tolerance was excellent in the pygmies and poor in the bushmen (5, 6, free full text). This may reflect differences in carbohydrate intake. San bushmen consume very little carbohydrate during certain seasons, and thus would likely have glucose intolerance during that period. There are three facts that make me doubt the insulin measurements in these older studies:
- It's hard to be sure that they didn't eat anything prior to the blood draw.
- From what I understand, insulin assays were variable and not standardized back then.
- In the San study, their fasting insulin was 1/3 lower than the Caucasian control group (10 vs. 15 uIU/mL). I doubt these active Caucasian researchers really had an average fasting insulin level of 15 uIU/mL. Both sets of measurements are probably too high.
We also have data from a controlled trial in healthy urban people eating a "paleolithic"-type diet. On a paleolithic diet designed to maintain body weight (calorie intake had to be increased substantially to prevent fat loss during the diet), fasting insulin dropped from an average of 7.2 to 2.9 uIU/mL in just 10 days. The variation in insulin level between individuals decreased 9-fold, and by the end, all participants were close to the average value of 2.9 uIU/mL. This shows that high fasting insulin is correctable in people who haven't yet been permanently damaged by the industrial diet and lifestyle. The study included men and women of European, African and Asian descent (7).
One final data point. My own fasting insulin, earlier this year, was 2.3 uIU/mL. I believe it reflects a good diet, regular exercise, sufficient sleep, a relatively healthy diet growing up, and the fact that I managed to come across the right information relatively young. It does not reflect: carbohydrate restriction, fat restriction, or saturated fat restriction. Neither does the low fasting insulin of healthy non-industrial cultures.
So what's the ideal fasting insulin level? My current feeling is that we can consider anything between 2 and 6 uIU/mL within our evolutionary template, although the lower half of that range may be preferable.
What's the Ideal Fasting Insulin Level?
Insulin is an important hormone. Its canonical function is to signal cells to absorb glucose from the bloodstream, but it has many other effects. Chronically elevated insulin is a marker of metabolic dysfunction, and typically accompanies high fat mass, poor glucose tolerance (prediabetes) and blood lipid abnormalities. Measuring insulin first thing in the morning, before eating a meal, reflects fasting insulin. High fasting insulin prevents the escape of fat from fat tissue and causes a number of other metabolic disturbances.
Elevated fasting insulin is a hallmark of the metabolic syndrome, the quintessential modern metabolic disorder that affects 24% of Americans (NHANES III). Dr. Lamarche and colleagues found that having an insulin level of 13 uIU/mL in Canada correlated with an 8-fold higher heart attack risk than a level of 9.3 uIU/mL (1; thanks to NephroPal for the reference). So right away, we can put our upper limit at 9.3 uIU/mL. The average insulin level in the U.S., according to the NHANES III survey, is 8.8 uIU/mL for men and 8.4 for women (2). Given the degree of metabolic dysfunction in this country, I think it's safe to say that the ideal level of fasting insulin is probably below 8.4 uIU/mL as well.
Let's dig deeper. What we really need is a healthy, non-industrial "negative control" group. Fortunately, Dr. Staffan Lindeberg and his team made detailed measurements of fasting insulin while they were visiting the isolated Melanesian island of Kitava (3). He compared his measurements to age-matched Swedish volunteers. In male and female Swedes, the average fasting insulin ranges from 4-11 uIU/mL, and increases with age. From age 60-74, the average insulin level is 7.3 uIU/mL.
In contrast, the range on Kitava is 3-6 uIU/mL, which does not increase with age. In the 60-74 age group, in both men and women, the average fasting insulin on Kitava is 3.5 uIU/mL. That's less than half the average level in Sweden and the U.S. Keep in mind that the Kitavans are lean and have an undetectable rate of heart attack and stroke.
Another example from the literature are the Shuar hunter-gatherers of the Amazon rainforest. Women in this group have an average fasting insulin concentration of 5.1 uIU/mL (4; no data was given for men).
I found a couple of studies from the early 1970s as well, indicating that African pygmies and San bushmen have rather high fasting insulin. Glucose tolerance was excellent in the pygmies and poor in the bushmen (5, 6, free full text). This may reflect differences in carbohydrate intake. San bushmen consume very little carbohydrate during certain seasons, and thus would likely have glucose intolerance during that period. There are three facts that make me doubt the insulin measurements in these older studies:
We also have data from a controlled trial in healthy urban people eating a "paleolithic"-type diet. On a paleolithic diet designed to maintain body weight (calorie intake had to be increased substantially to prevent fat loss during the diet), fasting insulin dropped from an average of 7.2 to 2.9 uIU/mL in just 10 days. The variation in insulin level between individuals decreased 9-fold, and by the end, all participants were close to the average value of 2.9 uIU/mL. This shows that high fasting insulin is correctable in people who haven't yet been permanently damaged by the industrial diet and lifestyle. The study included men and women of European, African and Asian descent (7).
One final data point. My own fasting insulin, earlier this year, was 2.3 uIU/mL. I believe it reflects a good diet, regular exercise, sufficient sleep, a relatively healthy diet growing up, and the fact that I managed to come across the right information relatively young. It does not reflect: carbohydrate restriction, fat restriction, or saturated fat restriction. Neither does the low fasting insulin of healthy non-industrial cultures.
So what's the ideal fasting insulin level? My current feeling is that we can consider anything between 2 and 6 uIU/mL within our evolutionary template, although the lower half of that range may be preferable.
Elevated fasting insulin is a hallmark of the metabolic syndrome, the quintessential modern metabolic disorder that affects 24% of Americans (NHANES III). Dr. Lamarche and colleagues found that having an insulin level of 13 uIU/mL in Canada correlated with an 8-fold higher heart attack risk than a level of 9.3 uIU/mL (1; thanks to NephroPal for the reference). So right away, we can put our upper limit at 9.3 uIU/mL. The average insulin level in the U.S., according to the NHANES III survey, is 8.8 uIU/mL for men and 8.4 for women (2). Given the degree of metabolic dysfunction in this country, I think it's safe to say that the ideal level of fasting insulin is probably below 8.4 uIU/mL as well.
Let's dig deeper. What we really need is a healthy, non-industrial "negative control" group. Fortunately, Dr. Staffan Lindeberg and his team made detailed measurements of fasting insulin while they were visiting the isolated Melanesian island of Kitava (3). He compared his measurements to age-matched Swedish volunteers. In male and female Swedes, the average fasting insulin ranges from 4-11 uIU/mL, and increases with age. From age 60-74, the average insulin level is 7.3 uIU/mL.
In contrast, the range on Kitava is 3-6 uIU/mL, which does not increase with age. In the 60-74 age group, in both men and women, the average fasting insulin on Kitava is 3.5 uIU/mL. That's less than half the average level in Sweden and the U.S. Keep in mind that the Kitavans are lean and have an undetectable rate of heart attack and stroke.
Another example from the literature are the Shuar hunter-gatherers of the Amazon rainforest. Women in this group have an average fasting insulin concentration of 5.1 uIU/mL (4; no data was given for men).
I found a couple of studies from the early 1970s as well, indicating that African pygmies and San bushmen have rather high fasting insulin. Glucose tolerance was excellent in the pygmies and poor in the bushmen (5, 6, free full text). This may reflect differences in carbohydrate intake. San bushmen consume very little carbohydrate during certain seasons, and thus would likely have glucose intolerance during that period. There are three facts that make me doubt the insulin measurements in these older studies:
- It's hard to be sure that they didn't eat anything prior to the blood draw.
- From what I understand, insulin assays were variable and not standardized back then.
- In the San study, their fasting insulin was 1/3 lower than the Caucasian control group (10 vs. 15 uIU/mL). I doubt these active Caucasian researchers really had an average fasting insulin level of 15 uIU/mL. Both sets of measurements are probably too high.
We also have data from a controlled trial in healthy urban people eating a "paleolithic"-type diet. On a paleolithic diet designed to maintain body weight (calorie intake had to be increased substantially to prevent fat loss during the diet), fasting insulin dropped from an average of 7.2 to 2.9 uIU/mL in just 10 days. The variation in insulin level between individuals decreased 9-fold, and by the end, all participants were close to the average value of 2.9 uIU/mL. This shows that high fasting insulin is correctable in people who haven't yet been permanently damaged by the industrial diet and lifestyle. The study included men and women of European, African and Asian descent (7).
One final data point. My own fasting insulin, earlier this year, was 2.3 uIU/mL. I believe it reflects a good diet, regular exercise, sufficient sleep, a relatively healthy diet growing up, and the fact that I managed to come across the right information relatively young. It does not reflect: carbohydrate restriction, fat restriction, or saturated fat restriction. Neither does the low fasting insulin of healthy non-industrial cultures.
So what's the ideal fasting insulin level? My current feeling is that we can consider anything between 2 and 6 uIU/mL within our evolutionary template, although the lower half of that range may be preferable.
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As in my post "More On Healthcare Management By Domain Neutral Generalists", Roy Poses' post "Health Care Leaders: Don't Know Much About Health Care" and many others on the topic of ill informed healthcare management (query link) at Healthcare Renewal, a common theme is lack of appropriate education and background in many of today's healthcare leaders.
ONC, the Office of the National Coordinator of health IT at HHS, has apparently now defined a taxonomy of health IT leadership in their funding opportunity announcements (FOA's).
Note the formal educational recommendations I've highlighted. Seems they’ve heard the message about the importance of cross-disciplinary -- and formal -- education for health IT leaders and even lower level workers:
From the Founding Opportunity Announcement "Program of Assistance for University-Based Training" at http://healthit.hhs.gov/portal/server.pt?open=512&objID=1428&mode=2
They've also called on Community Colleges to take the lead in producing worker bees:
http://healthit.hhs.gov/portal/server.pt?open=512&objID=1414&mode=2
It is also recommended that the teachers of these worker bees have a formal cross disciplinary background.
These are encouraging signs, as they lend significant formalism to the current marketplace where, completely alien to the culture of medicine itself, anyone of any educational background (or no educational background) can be a healthcare IT / informatics "expert" and leader.
Even with these definitions, doing health IT "right" is still far, far harder than it looks, but at least the rigor of medicine is starting to be applied to the "anything goes" world of healthcare IT and IT workers in healthcare-related roles.
That domain has long suffered striking inattention to education and qualifications requirements, and a healthcare-dyscompetent leadership that I believe has significantly fueled healthcare IT difficulty and failure.
This is a helpful stance against devil-may-care attitudes such as those of major health IT leadership recruiters. From an article a number of years ago in the journal “Healthcare Informatics”:
Now, if only ONC's thinking can percolate to the highest levels of healthcare and pharmaceutical leadership, including the "C" level and the boards of directors.
-- SS