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Tuesday, May 18, 2010

How Does Cuba Do It?

Cuba has achieved a life expectancy approximately equivalent to the US, despite a long standing embargo on food and medical supplies and despite spending a small fraction of the amount of money per person on health care than we do.

A Stanford social sciences researcher, Paul Drain, has studied Cuba's medical system and has identified a few factors that may be responsible for their success.  Cuba completely subsidizes medical training.  After high school, students who are interested in medical school and qualify for it attend 6 years of combined college and medical training, complete with a stipend for living expenses and then 3 years of postrgraduate training in primary care medicine.  Many do rural health residencies either before or after the postgraduate training. After becoming family practitioners, 35% of them do further specialty training and the rest remain primary care doctors.  There are many multi-specialty clinics which provide care in cities, and small primary care clinics that serve small neighborhoods.  Their vaccination rate is excellent as is their rate of professionally attended births.  Everyone sees a doctor at least once a year and sometimes these are home visits.  Doctors are not paid highly, but then they emerge from training without the usual multi-hundred thousand dollars of educational debt that they end up with in the US.

If one were to look at the economic incentives that have lead to our excessive health care expenses and our shortage of primary care doctors and effective preventive medicine, it is not hard to see how we have landed in our present circumstances.  It is a bit harder to see how we should escape from them.  Certainly subsidizing the training of primary care physicians would be a good start.

Paul Drain was interviewed for Wired, and published an article in the April 30 issue of Science magazine.  This is a link to the Wired article.

Sunday, May 16, 2010

vitamin D--the controversy

In the last year vitamin D has been making headlines. It is not a new vitamin. It was first synthesized in the 1920s and deficiency of the vitamin was known to be a cause of rickets, a bone deforming disease, associated with reduction of sun exposure with the movement to crowded living conditions with inadequate sun exposure during the industrial revolution. It is important in regulating absorption of calcium in the gut and deposition of calcium in bone as well as having a role in  supporting the immune system.  Vitamin D2 can be made by plants and was added to milk and cereals in order to prevent rickets in children starting in the late 1920s.

Vitamin D is available in relatively small amounts in various foods, especially fatty fish and beef liver. Normally these food supplement the vitamin D made in the skin when we are exposed to certain wavelengths of sunlight.  Dark skinned people are less efficient at producing vitamin D from a given amount of sun exposure, which partly accounts for the fact that evolution has put light skinned peoples at the extremes of northern and southern latitudes.  Even so, in the winter at the arctic circle, there is no radiant light sufficient to allow the skin to synthesize vitamin D.

Recently data has been piling up about the benefits of vitamin D and the various forms of ill health associated with vitamin D deficiency.  A study in 2008 published in the Archives of Internal Medicine showed a higher death rate in adults with lower vitamin D levels, for instance.  Other studies have shown and increased risk of influenza and possibly cancer in patients who are vitamin D deficient. Some high profile studies have shown an improvement in fall risk and fractures in elderly patients who are given vitamin D supplements, with or without calcium, but other studies have shown no effect at all.

I practice medicine in a town which is significantly north of the equator, thus providing little sunlight of a wavelength effective for production of vitamin D in the skin during the winter.  This combined with cold temperatures means that when I check the vitamin D levels of patients at the end of the winter, about half of them are significantly deficient.  This is huge. It implies that half of the patients I test are ill in some way, are courting fractures and other vitamin D related maladies such as infections and bone pain and overall sickliness.
Just this week an article published in the Journal of the AMA by Kerrie Sanders et al studied a group of community living people, aged 70 and over, who were given a huge dose of oral vitamin D once a year with the expectation that the resultant increase in vitamin D stores would reduce falls and fractures.  The results, however, were surprising. Significantly more of the vitamin D treated patients developed falls and fractures, especially in the 3 months following receiving the large dose. Interpretation of this finding included thoughts about odd physiological responses to huge doses of vitamin D, which seems plausible, and less plausibly, that since these people felt so chipper after getting their supplement, that they were out and about more and so fell down and broke bones.

There are many issues brought up by this article, which are especially relevant in this year when vitamin D has ridden into the practice of medicine like a handsome sheriff with a white hat.

1. Do we trust laboratory tests of vitamin D levels to tell us if a person needs vitamin D supplementation?  Darker skinned people routinely have lower vitamin D levels, but aren't clearly sick because of it.  In my experience, deficient levels of vitamin D are randomly associated with skin color, diet or sun exposure, and not usually associated with overall health of the patient. I have been told that laboratory levels are not necessarily consistent from test to test.

2. How should we supplement vitamin D? The studies that have shown good effects of supplementation used daily doses of around 800 units, yet many of my patients who already take this dose daily are found to be deficient. Normally we replete vitamin D levels with 50,000 units of vitamin D twice weekly for 6 weeks, followed by recommendations to take at least 1000 units of vitamin D thereafter. Is this method wrong?

3. Is it cost effective to test for vitamin D deficiency, or should we just supplement everyone's diet with oral vitamin D? Not everyone's insurance pays for a vitamin D level and the test can run up to $150.  If we do test for deficiency, do we need to re-test to make sure the person is adequately repleted and if so, how often? If we want to achieve the goal of maximum health for minimum time , money and anxiety spent, how best should we do this with regard to vitamin D?

Vitamin D in a form that a person with a healthy liver and kidneys can use is inexpensive, but the widespread treatment of what may or may not be a disease is presently consuming huge amounts of resources of time and perceptions of health.

Wednesday, May 5, 2010

Why does Congress try to cut Medicare spending every year and then not do it at the last minute?

Pending huge cuts in Medicare make headlines yearly.  “Doctors sweating bullets: Medicare spending due to be cut by 21%!”  In the medical rags we hear that “this year the cuts will really occur and then no doctor will provide care to patients on Medicare.” But then, sure as spring follows winter, the cuts are forestalled. Does this seem silly to anybody else?

This week’s New England Journal has an article that addresses this problem clearly.  I read the article, written by Dr. Bruce Vladeck, as saying that we are stuck in a legislative bind with regard to medicare spending, both because we spend too much on medicare, mainly due to the fact that we overspend in general without adequately supporting primary care, and also due to rules we established years ago regulating overall expenditures for the Medicare program.  The rules were good, if a bit optimistic, and required that we curb overall outlay for Medicare year by year.  Each year that we fail to live by the formula that cuts Medicare spending increases the required cuts for the next year, so that required cuts have become virtually unimaginably large at this point.  Many of the things that we spend money for in the Medicare program are overpriced, but we are trapped at this point by a relative value scale that favors payments for procedures and specialty care over the thinking, listening and prescribing that is involved in primary care.  The formula that governs our medicare payments is called the Sustainable Growth Rate (SGR) and clearly needs some very fundamental revision.

This last weekend I was on call and had direct experience with what it means to be paid well for performing procedures.  I had a pretty busy weekend, but most of it was managing issues over the phone.  I make no money for that, but it is one of the most useful things I do. I don’t mind providing this service, but it does not feed my family.  I spoke to a woman whose mother was dying at home and having the agitated delirium that is so common in the last few days of life.  We arranged for her to get appropriate medications and I attempted to get her set up with hospice, which wasn’t possible on a Sunday. I helped arrange for the Red Cross to pay for and obtain medications for a man whose house had burned down, pawing through his computer records, speaking with his wife, and negotiating which of his many pills were vital. Then I was called in to the intensive care unit twice due to a potentially fatal heart arrhythmia in a patient on a ventilator recovering from a severe lung infection.  As part of his treatment his heart needed to be shocked into a more stable rhythm on 3 occasions. This involved the nurses placing sticky patches on his chest and back, hooking him up to a cardioversion machine, and pressing a button at my request.  I spoke 3 words “100 joules, unsynchronized” and received hundreds of dollars for that each time.  I guess it all evens out in the end, but it’s a pretty screwy payment system.

I am attaching a link to the article which addresses the SGR much better than I can.