The Incidental Economist

The following post is by Rohan Rastogi, an MPH student in Health Policy at the Harvard T.H. Chan School of Public Health and a medical student at the Boston University School of Medicine. He tweets about health policy and medicine at @rorastog.

Your clinician’s hands pose the greatest risk for acquiring an infection while in the hospital. Despite adequate education, clinicians are notoriously non-compliant with hand hygiene guidelines, which recommend frequent use of alcohol-based hand sanitizer.

Though making hand sanitizer more accessible improves compliance, an unexpected antagonist may prevent hospitals from optimally locating dispensers—fire safety codes.

Historically, alcohol-based hand sanitizer was not always recognized as a key component of hospital hand hygiene. The 1983 CDC guidelines recommended using hand sanitizers only in emergency situations where a sink was not readily available.

More recent evidence, however, indicates that using alcohol-based hand sanitizer is usually better than traditional handwashing with soap and water. It’s faster, more accessible than sinks, less irritating to skin, and more effective at reducing transfer of the majority of dangerous bacteria.

Although hand hygiene is considered the single most important strategy to control infection transfer between clinicians and patients, health care workers sanitize less than half as often as they should. With one in every 31 patients acquiring an avoidable infection while in the hospital, understanding how to encourage clinicians to consistently use hand sanitizer has become a billion-dollar question.

In an experiment on behavior change, researchers found that easily accessible hand sanitizer dispensers doubled clinician hand hygiene compliance, while hand hygiene education, feedback, and patient awareness campaigns had no effect. A closer look on accessibility found that improving dispenser placement is more impactful than increasing the number of dispensers. All this to say, the real estate mantra of location, location, location holds true when it comes improving clinician hand sanitizer compliance.

Hand hygiene experts have gone to great lengths to find the perfect hand sanitizer dispenser location. In a particularly notable study, researchers suspended dispensers over patient beds using a trapeze-bar apparatus to improve visibility, which improved compliance compared to a traditional wall-mounted location.

When interviewed, clinicians say that hand sanitizer dispensers have to be in their line of sight, on their workflow route, unobstructed, standardized, within arm’s reach during procedures, and near the patient. A literature review recommended five dispenser locations to improve clinician hand hygiene compliance: outside the patient room, at the room entrance, immediately beside the point of care, immediately adjacent to the patient bed, and at the foot of every patient bed.

It’s unsurprising that placing dispensers as close to patient care activity as possible improves hand sanitizer use. And yet, controversy arose in the early 2000s, when fire marshals began forcing hospitals to move their dispensers.

Given that hand sanitizers must contain at least 60% alcohol by weight to be effective, alcohol-based hand sanitizers are flammable. Isolated incidents, such as the 2013 Oregon case and the 2002 Kentucky case, implicated hand sanitizers in burn injuries when a static spark ignited residual undissolved solution.

Despite these well-publicized events, fires involving alcohol-based hand sanitizer are exceedingly rare. A World Health Organization report states that “although alcohol-based hand rubs are flammable, the risk of fires associated with such products is very low.” The scientific community seems to agree that current hospital fire regulations “represent an abundance of caution.” As such, the minor fire risk must be weighed against the substantial potential benefit for hospital infection safety.

Answering the question of whether fire codes prevent optimal dispenser placement, and thereby hamper hand hygiene, requires a closer look at the codes. The Center for Medicare and Medicaid Services (CMS) and the Joint Commission (JC) adopted sections (18.3.2.6 and 19.3.2.6) of the National Fire Protection Agency’s 2012 Life Safety Code in 2016.

Among the rules: dispensers must be separated from each other by at least 4 feet of space and dispensers cannot be installed within 1 inch of an ignition source (e.g. electrical outlet, appliance, device). According to Dr. Eli Perencevich, an infectious disease physician and researcher from the Iowa Carver College of Medicine, however, these CMS/JC rules may serve as a template for more restrictive state and local fire marshal regulations.

The CMS ruling, in fact, explicitly allows this practice: “States and local jurisdictions may choose to retain stricter codes that prohibit or otherwise restrict the installation of [alcohol-based hand rub] dispensers in health care facilities. Facilities will still be required to comply with those stricter State and local codes.”

The end result—the practice of hospital hand hygiene stops at the patient doorway. A study in Dartmouth’s hospital found that only 37% of hand hygiene events involved in-room dispensers, of which 75% involved the dispenser located just inside the doorway…far away from the patient. This finding led the authors to conclude that there exists “a focus on hand hygiene before and after patient contact but not during patient care.”

In the US, this emphasis on sanitizing upon entering and exiting rooms originates from the most basic compliance monitoring strategy—direct observation at the doorway. The complexities of observing hand hygiene at the point of care have likely exacerbated its neglect.

The red tape of hand hygiene may be hindering hospitals’ ability to protect patients from their clinicians. Some suggest that hospitals should put the power to sanitize back into the hands of clinicians—provide them with personal carry sanitizer bottles. While the idea of sidestepping the wall placement regulations may be enticing, further studies will show whether it improves compliance or reduces infection transmission. Until then…ask your doctor about handwashing.

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There has been a lot of news lately about increasing crime in states where recreational marijuana has been legalized. Crime is rising in some of these states, but it doesn’t seem to be tied to the legal weed. We lay out all the relevant research.

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

@aaronecarroll

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Breakfast still isn’t the most important meal of the day. You also may have heard claims that eating breakfast somehow promotes weight loss. Well, there’s a new study out, and it looks like eating breakfast isn’t going to contribute to weight loss. Take that, Big Breakfast!

@aaronecarroll

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From a January 24 article by John Ingold in The Colorado Sun:

“We believe that the cost shift occurs because Medicare and Medicaid pay 69 cents on the dollar for our costs,” said Julie Lonborg, [a] spokeswoman [for the Colorado Hospital Association].

And,

the cost shift has grown over the past nine years, according to the state report. In 2009, Medicare and Medicaid in Colorado paid 78 cents and 54 cents, respectively, for every $1 worth of care their patients received. Privately insured patients paid $1.55 for every $1 worth of care

By the way if the reason for higher private payments is lower public payments, then what would you predict for hospital margins? Maybe you’d think they’d be close to zero. For what reason would the be higher if you believe that only cost shifting explains the public-private price gap? Or, at least maybe you’d think they’d hold steady. But, Colorado

hospital margins — the money left over after payments are taken in and expenses are paid — increased from $417 million to $1.2 billion [between 2009 and 2017].

The consistent way to explain all of this is pretty simple. (Whispers, “Market power.” Mumbles, “Price discrimination.”) There are several other weird explanations for increasing hospital margins in the article. None of them make sense to me.

The Aspen Times ran a related AP article on February 3.

“One conclusion could be that the benefits of Medicaid expansions and the ACA (have) not been passed onto commercial insurance, employers or commercial consumers,” the report states.

This is a rather devastating argument against cost shifting. If the reason private payments go up is because of public payment shortfalls, then when public programs pay more, shouldn’t private payments go down (at least relative to the counterfactual trend)? In all my years of focus on cost shifting,* I cannot recall a single example of a premium reduction dividend due to (as in, caused by) higher public payments. (If you know of one, let me know.)

I have not read the state report (titled “Cost Shift Analysis Report“). The Colorado Hospital Association has also recently released a report (titled “Health Care Costs and Hospitals: Drivers and Opportunities“). I have not read it either, but a word search reveals that it includes this:

Another possible factor suggested by external research (such as the most recent CHASE Cost Report) is the volume of cost shifting, as areas with very low Medicaid reimbursement rates may need to charge proportionally more of their private insurers—a cost that the insurers likely pass directly onto the patients.

I would be happy to discuss cost shifting with anyone involved in the Colorado debate (or that of any state, for that matter).

* If you’re new to the blog, we have a cost shifting tag, under which you will find everything I’ve ever done on the topic.

@afrakt

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About a month ago, a persistent screen tip showed up at the top of our site’s admin posts page. It’s annoying, in part because it take up real estate, but also because it NEVER changes and it’s a stupid tip:

TIP: Posts are the items in your website that have dates and categories/tags associated with them.
Typically, you are going to give a Post a category so it will show up in a certain area on the site. The order of the post is determined by its date, which you can change.
If you see any [shortcodes like this in brackets] please leave them alone.

None of this is useful. Most of it is blindingly obvious.

I’ve searched high and low on the internet, the page’s screen options, and in the site’s settings and plug-ins. I’ve asked the guy who does our tech support. Nowhere can I find a way to remove this tip. Anybody have a clue? Find me on Twitter or email me if you do.

@afrakt

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The following, by Austin Frakt and Aaron Carroll, originally appeared on The Upshot (copyright 2019, The New York Times Company). It also appeared on page A10 of the print edition on February 5, 2019.

In so many domains, life is improving across the world.

It doesn’t always feel that way. In surveys, Americans overwhelmingly believe that world poverty is getting worse or staying the same (it’s getting much better). And they tend to underestimate, by a wide margin, the percentages of children in the developing world who are receiving vaccines.

Public health campaigns have been a big reason for major improvements, but urgent priorities remain.

Big challenges, and successes

The biggest area of need is probably in infectious disease prevention and treatment.

Devi Sridhar, a professor of global public health at the University of Edinburgh, said we need to focus on respiratory diseases.

“Childhood pneumonia is the leading infectious cause of death in under-5 children and kills more kids than malaria and diarrhea combined,” she said. In 2016, the disease killed an estimated 880,000 children, most under age 2, deaths that could have been prevented with vaccination or antibiotics.

But there has been progress in the fight against some other major killers.

Ashish Jha, a physician with the Harvard T.H. Chan School of Public Health and the director of the Harvard Global Health Institute, said there have been major drops in the mortality of children under 5 (down more than 50 percent in the last three decades), and he pointed to other encouraging advancements:

• the halving of deaths of women at childbirth

• significant decreases in death from malaria

• a turnaround in the H.I.V. epidemic

• increased life expectancy in every country

Funding science research has led to new therapies, and global funding programs like Pepfar in the United States have made those medicines widely available, Dr. Jha said. Pepfar, begun under the administration of George W. Bush to combat the H.I.V. epidemic, says it has saved more than 16 million lives, primarily in Africa.

Establishing regional organizations to respond to outbreaks is also important, “as the 2014 to 2015 West African Ebola epidemic taught us,” said Peter Piot, a physician and director of the London School of Hygiene and Tropical Medicine.

The introduction of the Africa Centers for Disease Control and Prevention in 2017 “marks an important step toward strengthening capacity and preparedness across the continent,” he said.

Some investments may not even seem to focus on health. Dr. Jha singled out girls’ education as the thing he’d invest in first. “Beyond its big effects on economic prosperity, it also leads to smaller family sizes, lower infant mortality, more stable families and communities, and likely lower levels of disease burdens like H.I.V.”

Improving health care systems can be crucial. Shoddy ones can actually cause harm — never mind failing to heal the sick. A 2012 study in Health Affairs showed that in rural areas of India, two-thirds of health professionals had no medical qualifications whatsoever. Incorrect diagnoses and treatments were more common than correct ones.

The downsides of Western ways

In some cases, the West may be hurting, not helping, the health of developing nations.

Dr. Piot said sustained action was needed “to tackle growing epidemics of obesity and diabetes.”

The New York Times reported on a practice, with roots in the West, in which nutritionists in developing countries take money from food giants. These international food companies have formed some alliances with scientists and government officials. In some of these countries, obesity is now common as American-style eating habits gain popularity.

Nearly all the experts we talked to agreed that cigarette smoking was a major problem. Dr. Piot said, “We need an all-out effort against smoking.”

In the United States, rates of cigarette smoking recently have fallen to a record low. But as smoking rates have declined in many Western nations, some companies have sought to maintain access to fast-growing markets in developing countries by working to limit antismoking laws, as The Times has reported.

As in the United States, antibiotic overuse and abuse cause problems in the developing world. Dr. Sridhar said, “Here public health investment does not necessarily mean health system investment — it also means investment in regulating agricultural (and food production systems) and effluents from pharma factories.”

How wealthy countries can help the most

Some months ago, we illustrated that while public health has phenomenal returns on investment in the United States, America puts relatively few dollars into it. We then asked experts about the biggest remaining U.S. priorities. (Readers chimed in, too).

Developing nations have differing needs. Poverty is obviously linked to the politics of those nations — whether they have democratic and stable institutions. Beyond supporting those institutions, what else can the West do to help?

Dr. Jha said we could assist in funding the development of drugs and diagnostic tests for diseases threatening poorer countries to a greater extent than wealthier ones, such as tuberculosis. He said helping fund the expansion of health care workers was another worthy priority: “Most developing countries have few public health officials and no programs to train them.”

Dr. Sridhar concurred. “First, fund and invest in research and development of neglected diseases and conditions in order to develop better diagnostics, vaccines and treatments.” She went further: “We need to continue to support institutions like the World Health Organization and the Global Fund to fight H.I.V./AIDS, tuberculosis and malaria.”

She added one more item: “To manage the threat of drug-resistant infections which is already a major problem in poor countries, lobby all governments to adopt a binding United Nations agreement to regulate the use of antibiotics in humans, agriculture and the environment, particularly middle-income countries.” Such an action, of course, would help nations across the board.

A sense of hopelessness can sometimes weaken efforts to help the poor. The giant strides that have been made in recent years show things are far from hopeless, and point the way toward the possibility of more progress.

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Being sick enough to go to the hospital is not a great experience. You know what’s worse? Staying overnight in the hospital. There’s a very good chance you’re going to get your sleep interrupted frequently, and that’s not going to speed up recovery. Let’s look at the research.

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

@aaronecarroll

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Titian’s Assumption of the Virgin in the Frari church, Venice.

My wife and I were in Venice recently. You may have heard about the city’s crowds and the smell of stagnant water. Visit in January when it’s cold. You could find yourself alone in a church, in front of the most beautiful painting you have ever seen.

Unfortunately, AirCanada lost our luggage for several days. We hadn’t thought to put our power adapters in our carryon bags, so we couldn’t charge our devices.

Letting our devices die was wonderful. We had no email, social media, podcasts, recorded books, or GPS-powered maps. Exploring a city without Google maps is interesting. Venice is a random graph, traversable only by foot or by boat. Piazzas are connected by canals, alleys, bridges, and little tunnels. There are no right angles. After a few days, however, we could find our way around. Perhaps it was because we were looking at the city instead of our phones.

1572 map of Venice.

The best thing was what happened to my writing. I rose early for a couple of hours each morning, working in black ink on graph paper. Outlines for several papers flowed quickly onto the pages. In part, I was stimulated by the setting. But I also benefited from what Cal Newport calls digital minimalism. Newport argues that disconnecting from the internet helps you concentrate.

[Y]ou should avoid wasting your limited time and attention on low-value online activities, and instead focus on the much smaller number of activities that return the most value for your life. This is a basic 80/20 analysis: doing less, but focusing on higher quality, can generate more total value.

The reason is that

You have a finite amount of attention to expend each day. If aimed carefully, your attention can bring you great meaning and satisfaction. At the same time, however, hundreds of billions of dollars have been invested into companies whose sole purpose is to hijack as much of your attention as possible and push it toward targets optimized to create value for a small number of people in Northern California.

Cut off from the internet, my brain was not processing research messages, reviews for the hospital ethics committee, diverse tasks for the journal I help edit, or Twitter’s perpetual turmoil. Sheltered from this turbulence, I had more capacity to see and lay out extended arguments.

So now I’m home in Canada with a commitment to shelter more time from the internet. But how much? Newport acknowledges that few of us can or should completely disconnect. He is an applied mathematician and solitude is an ideal work environment for proving theorems. But I can’t become a digital hermit. Running a lab, doing administrative service, and trying to drive clinical practice change are all practices that require digital media.

However, those activities don’t account for all the time I spend online. Newport asks us to reflect on what will “return the most value for your life” and to focus on that. So I’ll start by asking what was the point of the blogging and — God help me — tweeting?

And there was a point. Through the health policy blogosphere, I have made friendships with people whom I wouldn’t have encountered otherwise in disciplines I barely knew. I’ve learned a lot and it has improved everything I’ve done in the last decade.

Moreover, I claim that TIE itself has, in a small way, changed the world by showing researchers and journalists how to disseminate research. Our goal has been to make health services research available to clinicians, health organization leaders, policymakers, other academics, and intelligent laypeople through writing that is, as Austin put it, “fast, accessible, knowledgeable, relevant, [and] credible.” TIE has informed many of the last decade’s key health policy debates. At the Times, Aaron and Austin are now bringing the style they honed here to millions of readers.

These days, however, the suggestion that science could influence US health policy seems like a joke in questionable taste. The government can’t keep the National Parks open, and it’s going to tackle health care? In 2017, a bill to repeal and replace the ACA was voted on the same day it was introduced and came within one Senate vote of passing.  There is a temptation to withdraw from the public sphere, focus on research, or maybe just enjoy life.

That choice seems wrong. I recall how the Hungarian Marxist literary critic György Lukács scorned the detached, elitist academic leftism of Theodor Adorno and other Frankfurt Schule philosophers.

A considerable part of the leading German intelligentsia, including Adorno, have taken up residence in the ‘Grand Hotel Abyss’ which I described in connection with my critique of Schopenhauer as “a beautiful hotel, equipped with every comfort, on the edge of an abyss, of nothingness, of absurdity. And the daily contemplation of the abyss between excellent meals or artistic entertainments, can only heighten the enjoyment of the subtle comforts offered.”

View from the abyss.

The image of the Grand Hotel hits close to home: I drafted this post in the bar of the Palazzo Sant’Angelo on Venice’s Grand Canal. Contrary to Lukács’, I don’t want to be an activist or partisan. But neither do I wish to withdraw. My goal has been to write about health and well-being from the viewpoints of empirical research and analytic moral philosophy, to write for non-specialists, and to engage policy on a longer time frame than an immediate political battle. This can only be done online: Humanity is digitally-mediated and will only become more so.*

The challenge is to find a strategy for disciplined disconnection to enhance focus, followed by selective reconnection to stay in the stream of discourse. I’m looking forward to reading Newport’s book when it comes out this week.

*This is tangential, but I can’t resist. I have been part of the internet for a long time: I began using email and Usenet (a Unix-based global discussion platform) as a graduate student in the early 1980s. In 1990, I published an article in Psychological Science arguing that scientific publishing should move to hypertext on the internet. Perhaps you think that this idea would have been obvious in the late 1980s, but not so. At the time, there were no working examples of internet-scale distributed hypertext. Unknown to me or anyone else, Tim Berners-Lee invented the World Wide Web in 1989 while working as an IT wonk at CERN. He built the first internet browser in 1990. His descriptions of this work were published in obscure places in 1992. The idea for electronic scientific publishing that competed with mine involved the delivery of journals on CD-ROMs sent through the mail. I was a programmer, but not skilled enough to build a hypertext journal, and the quantitative psychologist Peter Bentler wisely talked me out of trying. My article was ahead of its time, has attracted only 30 citations, and is forgotten. I point this out only because it was such fun to write it, and because it provides evidence that at least once, I had insight into where things were going.

@Bill_Gardner

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There’s another measles outbreak in the US, this time in Washington state. This is a beatable disease. We’d come so close to eradicating it. Please, vaccinate your children.

@aaronecarroll

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Do you enjoy the blog? Do you enjoy my columns, Healthcare Triage videos or podcasts? Would you like to learn how to do all of that? Come and work with me!!!

I’m looking to hire a postdoc (or really talented predoc) for a 2-year stint. To be honest, I’m open to candidates from a host of disciplines. It never hurts to ask. Here’s what I’m offering:

• Two-year (12 mo per year) position with a competitive salary and benefits
• Funds to attend appropriate meetings
• Space in our offices to work
• Time to work on YOUR research, as long as you involve me and let me help. I need to learn new stuff.

Here’s what you’ll help me with:

• Writing Healthcare Triage scripts, especially on funded projects
• Producing the podcast, especially if we get funding on a pending NIH grant in that area (I’m optimistic)
• Background research for other writing
• Preparation for radio shows

Travel for funded projects will be included (ie if we have to go tape podcasts elsewhere, I’ll cover your travel). Anything new I try, you’ll be invited to join. I imagine there will be opportunities to work with Austin as well. We’ll figure that out.

My hope is that this should be an amazing opportunity to develop your science communication skills. You’ll get to meet fascinating people. You’ll make amazing contacts. You’ll learn how to balance all of this in an academic career. You’ll have time to develop your own research portfolio. If that costs money, I’ll likely pay for that, too, if you can convince me it’s important and let me be involved.

I work with awesome people in the School of Public Health, the School of Public and Environmental Affairs, and (of course) the School of Medicine. I’ll plug you in as appropriate. I also know people in lots of social science disciplines. DO NOT BE AFRAID TO CONTACT ME AND SEE IF YOU’RE A GOOD FIT. My IU email is aaecarro at iu.edu. Or, just DM me on Twitter @aaronecarroll.

I’m somewhat flexible on start dates. Heck, all of the above is negotiable. All I’ll want is a CV and a letter of application telling me what you do and why you’re interested. If we get further, I’ll need some references, but don’t do too much work up front.

For the record, you will be my first post-doc. We’ll figure this out together. But if you want to talk to any of my faculty to see what kind of work environment we’ve got here, or how I mentor, I’m happy to provide you with names as well.

@aaronecarroll

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