Unnecessary Deaths

The UK health secretary says 1000 people are dying unnecessarily each week in Britain's NHS hospitals. Aside from the fact that this is intended to drive people in greater numbers to the (no more safer or efficient) private sector he is of course wrong. but then politicians often are and on healthcare issues they have a noble tradition of being wrong!
but he must have got this number form somewhere! Indeed he did. And the source was wrong as well.
How come?
Its easy to be wrong. There are lots of ways of being wrong but usually only one way of being right!

Hospitals make records of all the patients they see. The amount of information on each patient is quite small - typically it would include age, sex, times and dates of admissions and discharges, whether the patient died in hospital  and a list of the diagnoses reached by the doctors. This sounds fairly straightforward but recording the diagnoses is often wrong. The doctors may not have made the correct diagnoses(or indeed any at all), they may not have recorded their findings properly and what they have recorded is not correctly transmitted to the hospitals information system - this is done by applying a code to each diagnosis reached (and each major procedure carried out). This coding is done by hospital staff reading the doctors diagnoses and converting this into an agreed code. Sounds easy? It does -but it is not. There a re many reasons for it being wrong!  However let us assume all that is correct. What about the 1000 deaths?

Each hospital makes its records available to a central system, often a private company who analyses the information and compares hospitals one against the others.
For each diagnosis there will be a death rate for every hospital that had patients with that diagnosis. Sort these hospitals in order and one hospital will have the lowest death rate. Every other hospital will have higher death rates and if the lowest hospital is doing everything right why can't all the others. By this test all the deaths in all the hospitals apart from the lowest that are above the lowest rate are "avoidable". Do this for hundreds of diagnoses and in no time you have hundreds of "avoidable" deaths. Except you don't.  No one hospital will have the lowest rate for everything - indeed it is entirely possible that every hospital might have the lowest death rate for something!
Why? Things vary in ways the numbers collected cannot explain. Sure they can allow for the fact that one hospital might on average treat older or younger patient, more men or more women, more patients with multiple diagnoses and so on and this does help to make the information more understandable. But the collected information leaves out far more than it contains. it does not tell much about the patients' past lives, how fit they were before coming ill and crucially how ill they were on this occasion. Not all heart attacks are of the same severity, Not all bouts of pneumonia make the patient as unwell.  Not all patients with a given diagnoses come to hospital - some die at home - and so on.
There are not 1000 avoidable deaths each week. There are od course avoidable deaths - no system is perfect - but for now we do not know how many or indeed which deaths are avoidable. One day information gathering will improve and we may know the answer to that question. But not yey.

A Surprising Fact about Alternative Medicine

Suppose you had an ailment and were inclined to seek help from an alternative medicine practitioner. Many do. Who should you go to? Should you consult an osteopath, a chiropracter, a homoeopathist, an acupunturist or a herbalist or one of many more alternative medicine specialists? I imagine you might like to choose the one most likely to help your particular problem. But which is that?

The answer - no-one knows! An extensive review of published literature turned up no trials where one form of alternative medicine was compared with another. Whatever ails you will be treated exclusively by the method of the specialist you go to. No acupunturist will ever tell you that for your complaint a herbalist might be better, no chiropracter will tell you that you would be better off seeing a homoeopathist for there is no known difference in the effectivenes of the different modalities of alternative medicine. That seems an unlikely situation, but it is true - and for a simple reason- they are all similarly effective for they all rely totally on what orthodox medicine describes as the placebo effect. We all, when afflicted by a wide variety of conditions can get a degree of relief when someone listens to us and shows some kindness and gives us something that they tell us confidently will help. And that is all that alternative medicine has to offer. It is no more than normal medicine can do - and with less fuss and less cost. Normal medicine can also help with ailments caused by much more serious disorders. Trust your normal doctor. She can help in most situations and will be honest enough to tell you when she can't. Good Luck and keep well.

Expensive Healthcare

American healthcare is the most expensive in the world. That seems to be established. Is it the best? Debatable. How would we know? By looking at specific aspects we as users would value - accessibility, timeliness, cost, effectiveness, kindness, safety confidentiality and so on.
A recent study by the Commonwealth Fund using such an approach suggests it is not the best - indeed it came last in study of a number of countries worldwide. Other studies have found similar results when looking at the health of the citizens but wrongly make the jump from healthcare to health. Expensive health care should mean a healthy populace they seem to expect. Wrong! Even excellent albeit costly healthcare cannot make a population healthy. It can help those whose ill  health becomes a major issue. It cannot beyond advice, education and exhortation make a society behave in a manner which will promote good health. And here is the kicker - if we live badly and make poor choices we will have poor health, we will make extra demands on healthcare which will in turn cost more!
Expensive healthcare is not just about inefficiency, profligacy or exploitation - it is also about levels of demand which in turn are driven by the health of the population.

Healthcare Objectives

Healthcare  is a network of individuals and organisations.
Each has its own portfolio of objectives.
In these the improved care of patients today or tomorrow may not be uppermost.
Return on effort/investment might be a high priority and that in the shortest possible time.
Commercial companies must satisfy their shareholders first and foremost and while classical economics might suppose that they would best achieve this by satisfying their customers - in this case patients, healthcare professionals, or organisations, the reality is more complex.
Goldacre takes big pharma to task for its manifest failure to hold the welfare of patients as its highest good and attending instead to its perceived best, its duty to its shareholders. In the end by whatever route a commercial company must attend to the needs of the shareholders who are the best organised of the three contributors (shareholders, staff and customers) to the company and can most readily affect performance and effect change.
This is uncomfortable reading for those of us who would wish to see patient welfare as the highest good and accordingly must encourage us to reflect on current models of provision. The private sector may not be the best model
'via Blog this'

What's it Worth?

Today we learn of a small child with a debilitating lifelong disease - Atypical haemolytic uremic syndrome.

Her quality of life can, we are told, be markedly improved by a new vastly expensive medicine costing around £250000 per year, though there might be costs of her current treatment which might be avoided.

Can she have it in a communally funded system?
The details of course need scrutiny - is her quality of life that poor without and would it be much better with the medicine? Is the pharmaceutical company charging a reasonable price? And so on. But supposing they are all true?

And supposing we agree she should have the medicine?

Can we make savings elsewhere?  What about children not yet conceived? How much should we spend on assisted conception? If the parents to be, on investigation, show no tangible disorder apart from advancing age should we still fund treatment? How good are the results of assisted conception in parents of a certain age who have returned broadly normal findings on investigation? Is investment here worthwhile? Have such intending parents perhaps just waited too long to start a family and foregone their opportunity? Should a communally funded system just accept such a situation?

Perhaps we could fund that little girl after all.

Doing Without.

No not doing without healthcare - though many indeed do without.
No
Healthcare is doing without crucial help which would massively improve the help it can give to you and I. The illnesses we experience and the diseases which often are the cause of these illnesses are intimately affected by how we live together. They have a profound social dimension - part political, economic, psychological, chemical and physical. Our social situation is a major element in our well-being - or lack of it. Healthcare would be enormously improved if we had a reasonable understanding of what the social dimensions were and how they operated. For that we need social science. And there is none that is useful. There are of course social scientists aplenty, reading and writing all about healthcare. But nothing that is of the slightest value.
Social science is hard. It is much harder than physical science. It needs the sharpest minds and the most diligent workers. It has neither. Social science is seen in universities and the like as "soft science" and attracts students so motivated.  Social science (or sociology) grasps an issue, gathers a (very) few data, looks up its index of theories, makes the connection comes to the wrong conclusion and publishes. Mercifully few ever read the outpourings. So far so harmless.
Except
Social science is crucial for the improvement of healthcare. Healthcare needs to accept this and get together with universities to devise a programme of teaching, education and research which will address the real and compelling issues which continue to afflict patients and limit their chances of making a full recovery.
It will not happen soon, and the results when it does will be slow to appear (if it is done properly), but we must hope it will happen and our descendants at least will benefit.

Epidemic Obesity

There is an epidemic of obesity.
The core correctives are well known. Eat less and exercise more. Simple, affordable, effective. Eating less is by far the more important. To lose weight solely by exercise is close to impossible for normal individuals.
A couple of points. In eating less keep going with fruit and vegetables and leave off the big starchy foods - bread, potatoes, rice, pasta etc and of course the sugary drinks.
In exercising more, stick to walking - anything else will bring its own problems. Walking more will have most effect in a hilly environment and in colder climes.