Too Much Money

In a recent piece in Science, the author seems to bemoan the reduction of budgets for AHRQ. The writer states:

Those who want to trim or eliminate AHRQ argue that its work overlaps with NIH research. To make his point, Representative Andy Harris (R–MD) points to the $1.37 billion that NIH spends each year on health services research and $1 billion for studies of patient safety .... Others say AHRQ overlaps with the Patient-Centered Outcomes Research Institute (PCORI), a nonprofit supported by a trust fund that was created by the 2010 Affordable Care Act. PCORI now spends about $500 million a year on studies looking at which of two treatments works better, an area known as comparative effectiveness research.

The real issue is not AHRQ, which Congress can control, but PCORI which lies outside of Congressional control. PCORI was setup by the Democrats as a petient input entity funded by the fees imposed in the ACA. PCORI is another of those unregulated by Presidentially appointed rogue entities whose value is highly questionable. Thus Congress targets AHRQ since it cannot do so to PCORI. The real question is; what value is PCORI? Its funding expires in 2018 so Congress believes if it reduces AHRQ, laudable because of putative duplication, then it can just let PCORI die on its own.

The author continues:

AHRQ has attracted critics in the past because its work can threaten the financial interests of some groups. In the 1990s, Republicans tried to shut down the agency after spine surgeons objected to a report that found rest and pain medications worked as well as surgery for back pain, notes one commentator. Simpson says it’s important to have a U.S. agency that keeps a close eye on health care quality, noting a 2011 Institute of Medicine report that found 30% of the $2.5 trillion the United States spends annually on health care is wasted on unnecessary services and other needless costs. “With that amount of waste, it’s shocking that people talk about duplication of AHRQ research,” she says.

This is really a red herring. The issue of lower back pain has been examined in multiple venues and this is in my opinion merely an attempt to justify AHRQ. The real issue is; how can anyone justify PCORI?

The Glitch

It seems that the term "glitch" has entered the US vocabulary with full force. Years ago we would have called it gross incompetence. The ACA web site had glitches. Frankly it was typical Government incompetence. A surgeon removing the wrong leg is not making a glitch, he should be hanged!

The NYSE collapsing from a glitch is likewise cause for massive rearrangement of management. Maybe it would include the Board as well. You see this is not new. When one fields a new Software release there is always a Plan B, namely if it collapses we just switch back to the previous release. But that seems not to be the case any longer. Microsoft sends out updates that crash computers. God knows what is in our autos. Then there is the EHR stuff mandated by the Government nder the management of a pediatrician! Watch that puppy run wild.

When we did the software for Apollo missions we had a plan B and C and D. I guess I got D. The manual return method, assuming the computers and software dies. It was the sextant. It worked for centuries so stick one on just in case. And then Apollo XIII! Took the guys home after the Plan A thru C got blown up.

But the NYSE, United, the ACA folks never even had a Plan B.

The EHR and Big Data

In a recent study by MIT staff there is a result that claims to have the ability to gain significant insight from EHR data.

They state:

The results are quite interesting: This is one of the first analyses of large data you get from using electronic health records, and it just became available. This is a big amount of data we got from General Electric. What we tried to look at is, when you go to see the doctor, you’ve got a certain [medical] history, and you’re perhaps looking at a [medical] problem. When you look at that problem, is there any predictive power in the history that comes before? We looked at that from a pure computer science point of view — and it turns out there is predictive power....At the level of the individual, this allows you to compare the medical history to other people, and give additional information to the doctor. Doctors can get additional input from this analysis of the medical history. Of course this is what doctors already do — they look at the past in order to understand what might be the problem. But it’s a mathematical way that guides you, gives you more [than] than you might get by going through [one patient’s medical history].

 Now there are several concerns here.

1. The EHR has become a cut and paste system. EHR records have become extensive restatements by rote of what may be patient complaints or conditions. Physicians all too often just sit and "take" a patient history of a chronic disease such as Type 2 Diabetes by cutting and pasting what they did the last several visits. Perhaps the HbA1c data is changed but otherwise the rest if the same.

2. EHRs for the most part do no provide or encourage a key element in medical analysis; namely examining changes. Patient health all too often is determined by something that has changed. Did the patient gain or lose weight, gain or lose endurance, gain or lose sleep. Simple issues, some of which are quantitative and many subjective.

3. EHRs are distributed and dissonant. Namely a patient may be seeing several physicians. Take the Type 2 Diabetic patient. The ophthalmologist for retinal deterioration, while seeking a dermatologist for follow ups on a melanoma excision. Does the ophthalmologist look for ocular melanomas as well?

4. Images and imaging are frequently left out. This includes both classic imaging as well as pathology images. It may also include genetic results.

Thus the data may be very noisy, may be inaccurate, may contain the wrong results, and thus may be misleading. Moreover the data may become a baseline for policy, such as the PSA test. And the data like the PSA may be all wrong. One should remember the recent SEER data disaster!

Does Anyone Teach History In Today's World?

In a piece in the web blog Vox I ran across one that seems to be disconnected from reality. Namely the author suggests we would have been better off having stayed with England.

The author states:

But I'm reasonably confident a world where the revolution never happened would be better than the one we live in now, for three main reasons: slavery would've been abolished earlier, American Indians would've faced rampant persecution but not the outright ethnic cleansing Andrew Jackson and other American leaders perpetrated, and America would have a parliamentary system of government that makes policymaking easier and lessens the risk of democratic collapse.

 Perhaps the authors has missed a few facts. First in the English Parliamentary system only member of the Church of England can become Prime Minister. The Head of State is also the Head of the Church. How would that one fly in today's world!

Second, has the author somehow forgot Ireland. Read de Tocqueville. In his account of Ireland one sees a people not allowed to own land, forced to work for wages not enough to eat on, land taken away from the, religious persecution, not allowed to be educated, and the list goes on. If you think this relates to Ireland only ask any one from India. The Brits were brutal!

Then there is the "Class" system. One's family heritage counts more than anything else. Try that one on in this author's America cum England. Immigrants would not be second class, they would be no class.

I guess it is helpful to live in ignorant bliss and create one's own history.

PSA Awareness and the ACA

For a few decades the routine annual measurement of PSA was common. Then along came the USPTF and the use of faulty studies on PSA to justify assigning PSA measurements a low grade, namely being considered as useless. One may reasonably see this as a means to get rid of the old men as fast as one can. Really.

Now in today's NY Times a NY physician reiterates what I had written a few years ago, before the USPTF nonsense. The author states:

But men should not wait for a government agency to tell them what’s best. My own strongest recommendation is that men insist on a baseline PSA test while in their 40s. From this baseline, a personalized screening regimen that considers risk factors and other indicators can be developed. Men must understand that screening does not commit them to further testing or treatment, even if abnormalities are found. Screening, followed up with today’s sophisticated tools, simply provides information that helps them and their doctors make sound decisions — which could prolong their lives, or leave them reassured that they have little to fear from an indolent tumor.

Yes, men should not pay attention to the rantings of morbidly obese GS9 whose sole purpose is to "reduce costs". 

PSA testing is complex. It requires a history, and the baseline must reflect prostate size as well. However death from PCa is rather painful as it moves into the bones and your spine collapses.

Perhaps this added awareness may help some men. One should also contrast this to the response to the USPTF attempt to curtail breast exams. Men should become more aware, and more responsive.

Some Thoughts on Greece

I know Greece. I speak Greek, a little, I have had a company in Greece, my best man is Greek, my Godfather was Greek. I have spent time in parts of Greece that most non-Greeks never go to. The Greeks who are outside of Greece are all successful. Those in Greece are successful with their projects outside of Greece.

But Greece is a mess. There is an overload of Government employees, direct and indirect. Greek political overhead is almost as great as a US Hospital or Academic University. Our Government is rapidly moving to the Greek model. New Jersey is a bit like Greece. Political types have three or four State jobs, each entitling them to a pension and health care. So one can say we have our own clusters of Greece here at home.

Ireland got its act together, and is now rebounding. Yet Ireland never had the Greek disease, namely overstuffed Government employees. Iceland got its act together, and Iceland is not the Disney World of Europe, at best it has rocky hot baths.

So what is Greece to do. I have seen dozens if not hundreds of analyses. None will tell the true tale. Greek politicians are grand manipulators, but the drachma will return. It will again cost 5,000 drachma for a cup of coffee. I still have drachmas, but not enough for that cup of coffee.