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US healthcare

William Cayley: Thinking about Ebola from the sidelines

7 Oct, 14 | by BMJ

bill_cayley_2Recently I was staring at two dramatically different bits of “news” on my computer screen. Yet another story on the spreading Ebola outbreak was in one window, and the latest update on our practice’s clinical performance metrics was in the next window. News of an out of control plague, juxtaposed with little red and green numbers telling me how well (or poorly?) I’m doing at “keeping” enough of my patients “in control” with their blood pressures, lipids, and the like. more…

William Cayley: Facing uncertainty

2 Oct, 14 | by BMJ

bill_cayley_2The first case of Ebola in the United States, a cluster of cases of “acute neurologic illness with focal limb weakness of unknown etiology in children,” and ongoing concern over enterovirus D68 in the US. As if economic uncertainty and ongoing conflicts around the globe were not enough to put one on edge, there is now a near daily stream of news about spreading infectious disease threats.

As physicians it seems we are at least implicitly expected to deal primarily with certainties. What is the right diagnosis? What is the risk threshold above which one should take a statin to prevent vascular “bad things?” What medication will prevent my patients getting badly ill from an influenza-like illness? What interventions will ensure my older patients don’t fall or get depressed?

How do we navigate the dicey waters between the scary bad things, and the desire for certainty in diagnosis and prevention? more…

The BMJ Today: A new era in transparency

2 Oct, 14 | by BMJ

A new era in openness and transparency—and arguments over data—has begun with the publication of the first tranche of data made available under the US’s Sunshine Act. The act makes all drug, device, or biological manufacturers declare money they give to doctors (if it’s above $10), including cash in kind, i.e. food or drinks, even if that money is routed to a charity.

It will take months to look through everything as the full data aren’t available yet (these first 4.4m payments only cover half of 2013). The Centers for Medicare and Medicaid Services aren’t happy with their completeness, and there are concerns from physicians that the data are misleading or incorrect. Read our first look at the data, Open Payments goes live with pharma to doctor fee data: first analysis, to find out about some of these problems and see some of the top line figures. more…

Richard Smith: Using data to improve care and reduce waste in health systems

30 Sep, 14 | by BMJ

richard_smith_2014Annual expenditure on healthcare in the United States is currently $2.8 trillion, and about a third of it is wasted, says the Institute of Medicine. The sum wasted is about five times the GDP of Bangladesh, a country of 160 million people. This is waste on a spectacular scale, and reducing it while improving the quality of care is the main aim of the information technology developed by Optum, the services part of the UnitedHealth Group, said Richard Migliori, a former transplant surgeon and chief medical officer of the UnitedHealth Group. I don’t come to tell you what to do, said Migliori speaking last week to the Cambridge Health Network, but I hope to at least elicit your sympathy. more…

Hugh Alderwick: The ups and downs on the road to health service improvement

19 Sep, 14 | by BMJ

hugh_alderwickParallels between the successful transformation of the Veterans Health Administration (VA) in the United States and the changes needed in the NHS in England have been made for a number of years. But recent troubles at the VA offer some important lessons for the NHS in the future, as explored in a roundtable discussion held at the King’s Fund last week.

The story of the transformation of the VA is familiar to many. Once a fragmented and hospital centred public healthcare system, changes made in the late 1990s helped the VA to become an organisation renowned for providing high quality, affordable care. more…

William Cayley: My Chief Complaint

18 Sep, 14 | by BMJ

bill_cayley_2My chief complaint . . . is with the chief complaint.

One of the hallowed concepts in medical history taking and documentation is the “chief complaint.” Supposedly a way to set the agenda for a medical visit, in current practice it often gets both distorted and treated as a boundary setter.

Ideally, in medicine, we hope to address our patients’ medical problems and cure their ills; and thus we obviously want to know why someone is spending his or her time coming to see us. In modern computer enhanced, team based care, however, the “chief complaint” often becomes further and further removed from what is actually on the patient’s mind. more…

Stuart Buck: Are scholars or journalists more to blame when correlation and causation are confused?

15 Aug, 14 | by BMJ

Stuart_BuckNews stories about everything from nutrition to epidemiology to family behavior often confuse correlation with causation. Drink coffee, we are told, and you will lower your risk of dying (or perhaps raise it, depending on the week). Get married, and you will have stronger bones.

Sophisticated news consumers in the know understand that it’s best to discount such stories, which do not report on randomized experiments or any other statistical model that could show causation. The articles are invariably about correlations—akin to demonstrating that sunburn goes up along with accidental drowning, which is true not because either one causes the other, but because both occur in the summer. more…

David Kerr: Self obsessing health technology

14 Aug, 14 | by BMJ

david_kerrHas the health tech industry and those who fund it lost the plot? Apparently, the next must have technology is the connected toothbrush. A “data driven oral health startup” company in the United States has just received a multi-million dollar investment to further develop a smartphone connected toothbrush.

With this toothbrush, an accelerometer measures how long a user brushes his or her teeth, and this information is then transferred to a smartphone that records teeth cleaning trends over time. The device can also play music during the suggested two minutes brushing time “to create a highly engaging user experience.” Whether this will be beneficial for the oral health of the nation remains to be seen, but this type of product is very likely to end up in one or two Christmas stockings this year. more…

William Cayley: Resilience, obstreperousness, and grit

1 Aug, 14 | by BMJ

bill_cayley_2Some people keep going, and going, and going . . . and some don’t. What makes the difference? I’m not sure we know, but I think it has something to do with resilience, obstreperousness, and grit.

This week there has been a bit of a debate going on in our department over appropriate blood pressure targets for the elderly. This debate started in light of the eighth Joint National Committee (JNC 8) guidelines, and has revolved mainly around balancing outcomes with adverse effects, NNTs, and patient engagement in medical decisions. As I’ve observed (and participated just a bit in) this debate, in the back of my mind I keep thinking of my patients who do not fit the expectations of JNC 8—or any other guidelines for that matter. more…

Saurabh Jha: How a fine-tooth comb is entangling Obamacare

30 Jul, 14 | by BMJ

Saurabh_JhaThe Affordable Care Act (ACA), which recently survived a major scare in the Supreme Court over the constitutionality of the individual mandate, has just met another potential nemesis. Halbig vs. Burwell is the latest lawsuit afflicting the ACA.

The suit has been filed by Jacqueline Halbig, former health policy advisor to the Department of Health and Human Services (HHS) under George Bush, and a group of private citizens and small businesses, against Sylvia Burwell, the secretary of HHS. The plaintiffs assert that insurance subsidies only apply when that insurance has been purchased in exchanges established by the states, not in exchanges established by the federal government (of which there are 36). more…

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