Category Archives: General Health

Build the information medical highway and expect more traffic

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A recent article indicates that increased patient access to online records was associated with increased in-person and telephone contacts (JAMA 2012; 308: 2012-19).

Background (from study introduction): The Institute of Medicine’s report on “Crossing the Quality Chasm” indicated that electronic patient-physician messaging was a promising technology to improve quality and efficiency.  Furthermore, previous studies have suggested that 25-70% of all visits to physicians do not require face-to-face appointments.

Design: To explore this topic further, the authors performed a retrospective cohort study on the use of health care services between 2005-2010 at Kaiser Permanente in Colorado.  This study examined patients ≥18 years old and looked at health care utilization before and after initiation of MyHealthManager (MHM). Users of MHM were compared with nonusers.  And, both groups (users and nonusers) were examined with regard to their health care utilization before and after MHM rollout. The first 30 days before and after activation of MHM were excluded from analysis to minimize the effect of increased utilization at the initiation of MHM.

Results:

  • By June 2009, patient use of MHM had increased to 53.8%.  In total, 87,206 MHM patients were identified and 71,663 nonusers were identified for study participation. 
  • MHM users were slightly older and more likely to be female.
  • After initiation of MHM, the rate of office visits increased by 0.7 per member per year (p<0.001) and the number of telephone encounters increased by 0.3 per member per year (p<0.001).  
  • The authors breakdown this data based on age, absence of chronic disease, presence of specific diseases (diabetes, coronary artery disease, congestive heart failure).  In all of these scenarios, MHM users had increased visits after initiation of MHM.  Nonusers generally had the same or less visits at the same time.
  • Figure 2 shows that MHM and nonusers had identical health care utilization beforehand.  Afterwards, the MHM users maintained a parallel line of increased usage that was fairly consistent for a year after rollout.

Why did this happen?  The authors note that the result was contrary to their expectations.  They speculate that individuals may have increased their in-person use after developing additional concerns following their review of information online and that individuals may sign up who are already more likely to use services.  Online access, in these individuals, may facilitate access to more frequent visits.

I think this article points to a more pervasive miscalculation of the effect of information technology and health care utilization.  While electronic health records (EHRs) can help organize and communicate vast amounts of information, the proposition that they will ultimately reduce health care costs/utilization or improve efficiency is looking dubious.  In my opinion, the best we can hope for is that EHRs, when used optimally, will improve the quality of the care.  It is equally possible, however, that EHRs could result in more legible but less accurate information due to well-recognized issues like copy-forwarding with inadequate editing.

Related blog posts:

Global Justice and Vaccine Policy

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I definitely was piqued by the editorial titled “Global Justice and the Proposed Ban on Thimerosal-Containing Vaccines.” (Pediatrics 2013; 131: 154-156) I wondered how vaccine policy could affect global justice.

In high-income countries, vaccines have shifted increasingly to preservative-free single-dose vials.  Whereas in poorer countries, vaccines have continued to rely on multidose vials which frequently contain thimerosal as a preservative.  The move away from thimerosal which contains ethyl mercury “was a precautionary move in response to theoretical concerns, now known to be unfounded.”

Currently, a multinational environmental treaty is close to finalization and this treaty aims to restrict human and environmental exposure to mercury.  The World Health Organization and the broader public health community have recommended that thimerosal be exempt from the treaty to avoid disruption in the global vaccine supply.  However, some nongovernmental groups have objected to the use of thimerosal in poorer countries when it has been phased out in wealthier countries.

Why Thimerosal Should be Exempt from this Ban:

  • No credible scientific evidence of any risk to human health from thimerosal
  • Vaccines with thimerosal are used in >120 countries to immunize ~84 million children every year.  It is estimated that these vaccines save 1.4 million children every year.
  • Potential vaccines affected include hepatitis B, tetanus, and diptheria-tetanus-pertutsis
  • “Although there are other preservatives…, none are yet viable alternatives to thimerosal”

The individuals and organizations who have opposed thimerosal come from wealthier countries and would not suffer the consequences of a potential ban.  “Where’s the justice in that?”

Related references:

  • Pediatrics 2013; 131: 149-151. Public health experts recommend the ongoing use of thimerosal as a preservative.
  • Pediatrics 2013; 131: 152-153.  Provides context for previous AAP joint statement on thimerosal in 1999.

Related blog entry:

Vaccine successes and ambitions | gutsandgrowth

Aptly titled “The Cost of Technology”

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A brief commentary in JAMA makes some real useful observations regarding the effects of the electronic medical record on patient care (JAMA 2012; 2497-98).   The article describes a drawing by a 7-yer-old girl of her doctor who has an outstanding reputation among his peers.  Yet, in the drawing he is staring at the computer, and his back is to the patient.

The author notes that “when a physician focuses on a patient with complete attention, this simple act of caring creates a connection between two human beings. Almost immediately, the patient begins to feel, well, cared for, and this becomes a first step toward helping that person feel better.”

The computer is now a third player in this dynamic.  We “find ourselves entering more and more data while we are trying to listen to and talk with our patients.”  “By default, the patient moves down to second place…it is becoming the new reality.”

Physicians have to develop electronic records that allow us to record our thinking and improve efficiency so that we have more time to communicate with patients.  Can this be accomplished?

Related blog entry:

Smoking-related mortality

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“The time is always right to do what is right.”  Martin Luther King

When it comes to almost any situation, including smoking cessation, this quote is probably appropriate.  The hazards of smoking are detailed in recent several articles/editorial (NEJM 2013; 368: 341-350, 351-64, 389-90).

In the first article, the authors reviewed smoking-cessation histories from 113,752 women and 88,496 men.  All participants were older than 25 years and interviewed between 1997-2004.  These participants were from a cohort in U.S. National Health Interview Survey (NHIS).  The NHIS is a nationally representative cross-sectional health survey.

The second study involved large populations from the Cancer Prevention Study I (CPS I) which started in 1959 and CPS II which started in 1982.  These were prospective studies followed the mortality associated with smoking.  In all, the populations of these two studies exceeded 1.2 million.

What were the key findings?

1. The benefits of smoking cessation were noted in all age groups.  Those who quit between 25-34 years of age lived 10 years longer.  Those who quit between 35-44 years of age lived 9 years longer. Those who quit between 45-54 years of age lived 6 years longer. Those who quit between 55-64 years of age lived 4 years longer.

2. Smokers mortality worsened compared to the general population over a 50-year period. During the three time periods (1959-65, 1982-88, 2000-10), the mortality dropped by 50% in the overall study population.  However, female smokers mortality remained unchanged and male smokers experienced only a 24% reduction.

Specific hazard ratios (HR) for a large number of conditions are detailed in these studies.  For example, among men, the HR for death due to lung cancer was 24.97 in the contemporary cohort.  Due to the nature of these large cohorts, there are many limitations and it is difficult to draw conclusions about a specific threshold in terms of amount of smoking.  However, the conclusions may actually underestimate the effects of smoking due to undersampling of certain high risk populations, like incarcerated persons and those with mental illness.

The editorial notes that more women die from lung cancer than breast cancer.  Yet, due to smoking’s stigma, there are no ‘race for the cure’ promotions.  In addition, increasingly smoking is a behavior concentrated in persons of lower social status.  As such, it “risks becoming invisible to those who set health policies and research priorities.”

Even Nick Naylor might consider a career change if he read these studies (Thank You for Smoking (film) – Wikipedia, the free encyclopedia).