• Healthcare Triage News: Most People Don’t Need Vitamin D Supplements

    There’s a big study out from The Lancet Diabetes & Endocrinology. Systematic Review. Meta-Analysis. Trial sequential analysis. This one’s got it all!

    @aaronecarroll

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  • Healthcare Triage: Dissemination: Get Out There and Strut Your Stuff!

    Let’s say you’re in the habit of doing scientific research. Or maybe you’re an expert in a field who can concisely and coherently discuss research. Disseminate! There are more avenues than ever before to make your voice heard, and share the knowledge you worked hard to obtain.

    @aaronecarroll

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  • Is Medicare for All the Answer to Sky-High Administrative Costs?

    The following originally appeared on The Upshot (copyright 2018, The New York Times Company) and on page B6 of the print edition on October 16, 2018.

    Calls for a Medicare for All system are growing louder. Many Democrats have embraced it, while President Trump said last week that it would raise health care costs drastically.

    Democrats say that giving people the option to partake in Medicare — no matter their age — will actually cut costs.

    American administrative costs for health care are the highest in the world, and they argue that one advantage of Medicare for All is that it would save money because Medicare’s administrative costs are below those of private insurers.

    Does that argument hold up?

    Medicare’s administrative costs were $8.1 billion last year, or 1.1 percent of total spending, close to the proportion it has been in recent years.

    But some have argued that the actual cost is higher because of services performed for Medicare by other parts of the government that aren’t accounted for: The Social Security Administration collects premiums, the Internal Revenue Service collects taxes for the program, the F.B.I. provides fraud prevention services, and at least seven other federal agencies and departments also do work that benefits Medicare.

    The claim that these administrative costs are overlooked is false. As annual reporting of Medicare’s finances plainly states, they are accounted for.

    But there is something missing from the $8.1 billion Medicare administrative cost figure, as Kip Sullivan explains in a 2013 paperpublished in the Journal of Health Politics, Policy and Law. Although it accurately accounts for the federal government’s administrative costs, it does not include those borne by private plans that also offer Medicare benefits.

    In addition to the traditional (public) Medicare plan, Medicare is also available from private plans through the Medicare Advantage program. Today, one-third of people using Medicare are in such plans, up from about one-fifth a decade ago. Moreover, all Medicare drug benefits are administered through private plans.

    National Health Expenditure data shows both the government’s administrative costs for Medicare and those of Medicare’s private plans. Putting them together for the most recent year available (2016), they reach $47 billion, or 7 percent of total Medicare spending — well above the administrative costs borne directly by the Medicare program.

    Medicare’s private drug benefit plans incur administrative costs that are about 11 percent of their spending. All of this additional, private administrative cost is paid for by taxpayers and, through their premiums, people who use Medicare.

    Medicare’s direct administrative costs are not only low, but they also have been falling over the years, as a percent of total program spending. Yet the program’s total administrative costs — including those of the private plans — have been rising.

    “This reflects a shift toward more enrollment in private plans,” Mr. Sullivan said. “The growth of those plans has raised, not lowered, overall Medicare administrative costs.”

    Making an accurate estimate of the administrative costs of Medicare for All would depend, in part, on whether it would be more like an expansion of traditional Medicare (with its 1.1 percent administrative cost rate) or of all of Medicare, including its private plans (with a combined 7 percent administrative cost rate).

    Yet both figures are well below private insurers’ administrative costs, which run about 13 percent of spending (this also includes profit), according to America’s Health Insurance Plans, an advocacy organization for the industry.

    Some critics have argued that Medicare’s administrative cost rate appears artificially low because Medicare enrollees’ health spending is so high. Average Medicare spending per beneficiary is just over $12,000 per year; for an average worker in a private plan, it’s about $6,000. If you simply divide administrative costs by total spending, you will get a lower number for Medicare for this reason alone.

    This is true, but the government’s administrative costs for Medicare are still below those of private plans. The government’s administrative costs are about $132 per person compared with over $700 for private plans. One reason Medicare’s are so much lower is that it reaps economies of scale. It also benefits from not needing to do much marketing, and it doesn’t earn profits.

    @afrakt

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  • Healthcare Triage: The 2017 Flu Killed 80,000 in the US. Get a Flu Shot!

    Influenza killed 80,000 people last year in the United States. That is the highest number of deaths since the CDC started keeping records in the 1970s. Help protect yourself and those around you. Get a flu shot!

    @aaronecarroll

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  • That New Apple Watch EKG Feature? There Are More Downs Than Ups

    The following originally appeared on The Upshot (copyright 2018, The New York Times Company).

    The newest version of the Apple Watch will feature a heart monitor app that can do a form of an electrocardiogram. Many have greeted this announcement as a great leap forward for health. The president of the American Heart Association even took part in the product launch.

    For a more measured response, it’s worth looking at potential downsides, and it turns out there are a few.

    The upside potential is twofold. First, doctors could monitor — at a distance — how patients with known heart problems are functioning outside the office. Second, the device could diagnose heart problems in people who don’t know they have them, picking up abnormal heart rhythms earlier than would otherwise be possible.

    With respect to monitoring from a doctor, the Food and Drug Administration “cleared” the app — an easier hurdle to surmount than “approval.” But it specifically said people with diagnosed atrial fibrillation, one of the most common heart arrhythmias, should not be using the app.

    If that’s the case, the major potential for the device — which will arrive later this year — is to pick up arrhythmias in otherwise healthy people. That’s still a big selling point. Picking up abnormal function earlier could theoretically lead to improvements in health, such as reductions in strokes.

    But just because something seems like a good idea doesn’t mean it is. No screening test is perfect. In the simplest sense, whenever we consider the results of medical tests, they can be “positive” or “negative.”

    In general, we would like people who are sick to have a positive screening result, and people who are well to have a negative result. Unfortunately, people who are sick sometimes have a negative result. Those are false negatives. People who are well sometimes have a positive result. Those are false positives.

    Both of these outcomes are worrisome. A false negative might leave someone who needs medical help with a mistaken sense of assurance. Given that relatively few people have serious, undiagnosed arrhythmias with no symptoms (if people did, we would be screening for this more often), this isn’t the major concern. False positives are, because they cost us time and money, as well as cause emotional distress.

    The health care system is already busy, if not overloaded. No physician wants to field calls from patients who have no problems. Such patients will require visits and further testing, and will potentially receive interventions. They’ll generate bills and harms without benefits.

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  • Healthcare Triage Podcast: Breast Cancer, Genomics, and the Future of Treatment

    The next episode of the Healthcare Triage Podcast is up! This month we’re talking about breast cancer, specifically “triple negative breast cancer”:

    Dr. Bryan Schneider and Dr. Milan Radovich from the Indiana University Health Precision Genomics Program are talking to Aaron about breast cancer, and some of the cutting edge treatments that are in use, and on the horizon.

    The Healthcare Triage podcast is sponsored by Indiana University School of Medicine whose mission is to advance health in the state of Indiana and beyond by promoting innovation and excellence in education, research and patient care.

    IU School of Medicine is leading Indiana University’s first grand challenge, the Precision Health Initiative, with bold goals to cure multiple myeloma, triple negative breast cancer, and childhood sarcoma and prevent type 2 diabetes and Alzheimer’s disease.

    As always, you can find the podcast in all the usual places, like iTunes and Soundcloud.

    @aaronecarroll

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  • Uber, Lyft and the Urgency of Saving Money on Ambulances

    The following originally appeared on The Upshot (copyright 2018, The New York Times Company). It also appeared on page B5 of the print edition on October 2, 2018Research for this piece was supported by the Laura and John Arnold Foundation.

    An ambulance ride of just a few miles can cost thousands of dollars, and a lot of it may not be covered by insurance. With ride-hailing services like Uber or Lyft far cheaper and now available within minutes in many areas, would using one instead be a good idea?

    Perhaps surprisingly, the answer in many cases is yes.

    The high cost of an ambulance isn’t really for the ride. It comes with emergency medical staff and equipment, and those can be very important, of course, even lifesaving.

    But they are not things you always need, although you (and your insurer) pay for them with every trip.

    “Don’t reflexively call an ambulance,” said Anupam Jena, a physician and researcher with the Harvard Medical School. “Ambulances are for emergencies. If you’re not having one, it’s reasonable to consider another form of transportation.”

    The cost of ambulance rides adds up. In 2011, the United States spent about $14 billion on ambulance services, $5.3 billion of which Medicare paid for. Many of those trips might not have required an ambulance. Estimates of inappropriate use vary, but most are around 30 percent.

    Although it’s not always clear when an ambulance is warranted, there is evidence of waste and fraud in the industry. Last year, ambulance companies collectively billed Medicare improperly for at least $700 million.

    In 2014, employees of a Philadelphia-area ambulance company received prison sentences for fraudulent bills. That same year, the owners of a Tennessee company were convicted of fraudulent ambulance billing. A 2015 O.I.G. report found that half of questionable billing of Medicare by ambulance companies is from four metropolitan areas: Philadelphia, Los Angeles, Houston and New York.

    Other recent evidence from New York suggests a substantial number of ambulance rides are taken for non-emergencies. Scholars from Georgia State University and the University of Colorado Denver studied ambulance rides in New York before and after the Affordable Care Act’s coverage expansion. After the expansion, dispatches for minor injuries rose considerably while those for more severe ones did not.

    By 18 months after the expansion, ambulance dispatches for minor injuries were up 150 percent.

    An explanation for the results is that a person’s insurance coverage tends not to affect a decision about calling an ambulance in a real emergency. But for minor injuries, people are more likely to call an ambulance if they have coverage than if they do not, even if they don’t really require that level of care.

    Using an ambulance also diverts attention and resources from true emergencies. Response times are longer than they could otherwise be if ambulances were used only when needed. One study found that the Affordable Care Act, by expanding coverage and financial access to ambulance rides, slowed ambulance response times by 19 percent.

    Uber and Lyft can’t disobey traffic laws the way ambulances can to speed people to a hospital in urgent situations. But they can broaden transportation options for patients and could disrupt the ambulance market. Both have announced new services to provide rides to medical appointments. This kind of non-emergency medical transportation is something many health plans already provide, but Uber and Lyft may be able to do it more cheaply, with better customer service and less waste.

    Uber Health would allow health care providers to order rides for their patients. As of March, over 100 health care organizations were using the service. Lyft Concierge is similar and already being used by a number of organizations that arrange rides for people in need of care.

    Of course, patients can request Uber or Lyft rides on their own, instead of an ambulance. And these services could help patients avoid missing appointments because of lack of affordable transportation. They may also help patients receive care in more appropriate and lower-cost settings, like a doctor’s office instead of an emergency department. One study found that Uber’s entry into a city reduced ambulance use by 7 percent.

    An advantage of arranging your own ride is that you can direct it to a hospital or doctor’s office of your choosing. In contrast, ambulances take patients only to hospitals — and typically to the nearest one, whether the patient would prefer that or not.

    This can actually degrade care. Evidence suggests that patients who return to the hospital where they received major surgery have a lower risk of mortality than if they go to another hospital. With an ambulance, there is no guarantee you’ll return to the same hospital.

    Although lack of affordable transportation is one barrier to care, it isn’t the only one. A randomized study of Medicaid patients at two Philadelphia-area clinics found that offering Lyft rides did not change missed appointment rates. Patients may miss appointments for other reasons, such as being unable to get off work or to obtain child care.

    @afrakt

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  • Healthcare Triage: Stop It! Why It’s Tough to get Doctors to Drop Treatments

    It takes a lot of ongoing training to get doctors to take up new treatments and techniques in their practice. But it turns out it’s REALLY difficult to get docs to stop using treatments when later studies show that treatment to be ineffective. Aaron talks about the difficulty of changing course in medicine.

    This episode was adapted from a column I wrote for The Upshot. Links to sources can be found there.

    @aaronecarroll

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  • Congratulations. Your Study Went Nowhere.

    The following originally appeared on The Upshot (copyright 2018, The New York Times Company).

    When we think of biases in research, the one that most often makes the news is a researcher’s financial conflict of interest. But another bias, one possibly even more pernicious, is how research is published and used in supporting future work.

    A recent study in Psychological Medicine examined how four of these types of biases came into play in research on antidepressants. The authors created a data set containing 105 studies of antidepressants that were registered with the Food and Drug Administration. Drug companies are required to register trials before they are done, so the researchers knew they had more complete information than what might appear in the medical literature.

    Publication bias refers to the decision on whether to publish results based on the outcomes found. With the 105 studies on antidepressants, half were considered “positive” by the F.D.A., and half were considered “negative.” Ninety-eight percent of the positive trials were published; only 48 percent of the negative ones were.

    Outcome reporting bias refers to writing up only the results in a trial that appear positive, while failing to report those that appear negative. In 10 of the 25 negative studies, studies that were considered negative by the F.D.A. were reported as positive by the researchers, by switching a secondary outcome with a primary one, and reporting it as if it were the original intent of the researchers, or just by not reporting negative results.

    Spin refers to using language, often in the abstract or summary of the study, to make negative results appear positive. Of the 15 remaining “negative” articles, 11 used spin to puff up the results. Some talked about statistically nonsignificant results as if they were positive, by referring only to the numerical outcomes. Others referred to trends in the data, even though they lacked significance. Only four articles reported negative results without spin.

    Spin works. A randomized controlled trial found that clinicians who read abstracts in which nonsignificant results for cancer treatments were rewritten with spin were more likely to think the treatment was beneficial and more interested in reading the full-text article.

    It gets worse. Research becomes amplified by citation in future papers. The more it’s discussed, the more it’s disseminated both in future work and in practice. Positive studies were cited three times more than negative studies. This is citation bias.

    Only half of the research was positive. Almost no one would know that. Even thorough reviews of the literature would find that nearly all studies were positive, and those that were negative were ignored. This is one reason you wind up with 10 percent of Americans on antidepressants when good research shows the efficacy of many of the drugs is far less than believed.

    The preregistration of trials is supposed to help control for these biases. It works sporadically. In 2011, researchers examined cohorts of randomized controlled trials to see how well the published research matched what scientists said it was going to do beforehand. In some studies, they found, eligibility criteria for participants differed greatly from what was published.

    In some, they found that procedures had changed for how to conduct analyses. In almost all, the sample size calculations had changed. Almost none reported on all the outcomes that were noted in the protocols or registries. Primary outcomes were changed or dropped in up to half of publications. This isn’t to say secondary outcomes don’t matter; they’re often very important. It’s also possible that some of these decisions were made for legitimate reasons, but, too often, there are no explanations.

    In 2012, researchers re-analyzed 42 meta-analyses for nine drugs in six classes that had been approved by the F.D.A. In their re-analyses, they included data from the F.D.A. that was not in the medical literature. The addition of the new data changed the results in more than 90 percent of the studies. In those where efficacy went down, it did so by a median 11 percent. When efficacy went up — about the same rate that it went down — it did so by a median 13 percent.

    This problem is worldwide. In 2004 in JAMA, a study reviewed more than 100 trials approved by a scientific-ethical committee in Denmark that resulted in 122 publications and more than 3,700 outcomes. But a great deal went unreported: about half of the outcomes on whether the drugs worked, and about two-thirds of the outcomes on whether the drugs caused harm. Positive outcomes were more likely to be reported. More than 60 percent of trials had at least one primary outcome changed or dropped.

    But when the researchers surveyed the scientists who conducted the trials and published the results, 86 percent reported that there were no unpublished outcomes.

    There has even been a systematic review of the many studies of these types of biases. It provides empirical evidence that the biases are widespread and cover many domains.

    A modeling study published in BMJ Open in 2014 showed that if a publication bias caused positive findings to be published at four times the rate of negative ones for a particular treatment, 90 percent of large meta-analyses would later conclude that the treatment worked when it actually didn’t.

    This doesn’t mean we should discount all results from medical trials. It means that we need, more than ever, to reproduce research to make sure it’s robust. Dispassionate third parties who attempt to achieve the same results will fail to do so if the reported findings have been massaged in some way.

    Further, there are things we can do to fix this problem. We can demand that trial results be published, regardless of findings. To that end, we can encourage journals to publish negative results as doggedly as positive ones. We can ensure that preregistered protocols and outcomes are the ones that are finally reported in the literature. We can hold authors to more rigorous standards when they publish, so that results are accurately and transparently reported. We can celebrate and elevate negative results, in both our arguments and reporting, as we do positive ones. Unfortunately, getting such research published is harder than it should be.

    These actions might make for more boring news and more tempered enthusiasm. But they might also lead to more accurate science.

    @aaronecarroll

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  • Healthcare Triage News: Elmo Stickers, Apples, and the Pain of Retracted Research

    We’re once again talking about Brian Wasink, the Cornell Food and Brand Lab. They were in the news last year over a retracted study, and he’s back again with six more studies retracted. Nutrition research is hard. This is also not great for the public’s perception of science.

    @aaronecarroll

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