Category Archives: General Health

Predicting Survival Without Disability Among Preterm Infants

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A recent article (J Bourke et al. .J Pediatr 2019; 215: 90-7) made me wonder if my outlook on disability-free survival of preterm infants has been skewed by the population that I encounter.  That is, the outcomes from this large Australia study were better than I would have guessed.

This retrospective cohort study identified 720.091 live births from 1983-2010; in this group, 12,083 were diagnosed with a disability and 5,662 died. The authors sought to determine rates of intellectual disability or autism as identified by the IDEA (Intellectual Disability Exploring Answers) database.  Because this is a retrospective study, it did not capture milder and more common neurodevelopmental disorders like attention deficit hyperactivity disorder.

Key findings:

The probability of disability-free survival to 25 years was the following:

  • 4.1% for those born at 22 weeks gestation
  • 19.7% for those born at 23 weeks gestation
  • 42.4% for those born at 24 weeks gestation
  • 53.0% for those born at 25 weeks gestation
  • 78.3% for those born at 28 weeks gestation
  • 97.2% for those born full term (39-41 weeks)

Risk factors for lower rates of disability-free survival:

  • Aboriginal population (instead of Caucasian), low Apgar score, male sex, low socioeconomic status, and remote region of residence

My take: This data shows the marked improvement in outcomes with longer gestation age.

Year in Review: My Favorite 2019 Posts

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Yesterday, I listed the posts with the most views.  The posts below were the ones I like the most.

General/General Health:

Nutrition:

Liver:

Endoscopy:

Intestinal Disorders:

 

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Most Popular Posts of 2019

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The following are the most viewed posts from the past year:

Wishing friends, family and colleagues a healthy and happy New Year.

Morning in Sandy Springs, GA

 

Promoting Poorly-Equipped Medical Students

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An interesting commentary (SA Santen et al. NEJM 2019; 381: 2287-9): “Kicking the Can Down the Road –When Medical Schools Fail to Self-Regulate”

Key points:

  • Medical schools have only a ~3% attrition rate
  • Some students, perhaps 1 or 2 per class, matriculate even though the dean(s) “would not allow [them] to care for their family” due to either academic limitations or unprofessional behavior
  • The authors note that there is a low likelihood of legal liability of dismissal as long as there is adequate documentation and as long as schools do not deviate from due-process

My take: This concern of advancing the medical careers of problematic individuals is limited to a small number.  However, it is NOT limited to medical school but applies as well to residency & fellowship programs.  In addition, of course, promoting suboptimal individuals is not limited to the field of medicine.

Related blog posts:

Preserving the Patient-Physician Relationship

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A recent commentary (J Noseworthy. NEJM 2019; 2265-9) discussed the need to preserve the patient-physician relationship.  The author, who previously led the Mayo Clinic, makes a number of useful points.  Though, at the outset it is important to recognize that the care at the Mayo clinic is not representative of the care elsewhere.  In this institution, there is a selection bias both of patients and physicians.  Based on my knowledge of patients evaluated there (a small sample), patients are much more likely to undergo extensive evaluations.

Key points:

  • “Physicians in the United States are increasingly caught between the conflicting concepts of medicine as a humanitarian profession and health care as a competitive business.”
  • “Medicine’s most fundamental element remains the relationship between patient and physician…I believe it must remain central to medical practice even as medicine evolves.”
  • Principles include the following:
    • spending adequate time -to deal with uncertainty, treatment plans that are failing, and comfort those at the end of life
    • support the work of a coordinating physician -to address comprehensive care for patients with complex health issues

Related blog posts:

 

 

How The IRS Proved That Health Insurance Saves Lives

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NY Times: The I.R.S. Sent a Letter to 3.9 Million People, It Saved Some of Their Lives

Recently, economists have shown that an I.R.S. letter encouraging people to sign up for health insurance saved lives.  This letter was an inadvertent randomized trial as 600,000 people who were eligible for the letter did not receive it due to a budget shortfall.

An excerpt:

Three years ago, 3.9 million Americans received a plain-looking envelope from the Internal Revenue Service. Inside was a letter stating that they had recently paid a fine for not carrying health insurance and suggesting possible ways to enroll in coverage…

Obtaining insurance… reduced premature deaths by an amount that exceeded any of their expectations. Americans between 45 and 64 benefited the most: For every 1,648 who received a letter, one fewer death occurred than among those who hadn’t received a letter.

In all, the researchers estimated that the letters may have wound up saving 700 lives…

The results also provide belated vindication for the much-despised individual mandate that was part of Obamacare until December 2017, when Congress did away with the fine for people who don’t carry health insurance…

The uninsured rate for Americans is rising for the first time in a decade, as states tighten eligibility rules for Medicaid, and as the Trump administration cuts back on health care outreach…

Previous research has found a link between expanded health insurance access and fewer deaths. Multiple studies showed a decline in mortality rates after states expanded Medicaid, but none could tie the outcome directly to the policy change, since states typically cannot randomly pick which residents do and don’t receive Medicaid. That makes the Treasury experiment, an unintended result of a budget shortfall, distinctively useful.

My take: This analysis shows that prompting health care coverage by sending a single letter can save lives.  It is unfortunate that we are currently heading in the opposite direction.

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