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Saturday, August 29, 2009

We have become the ones: The passing of Sen. Edward Kennedy

Poverty is the biggest risk factor for poor health: poor people live shorter lives, with more disease and disabilities, than the rest of us. So for those who are passionate about improving public health, the loss of Teddy Kennedy is a particularly great setback.

He was influential in passing the State Children's Health Insurance Program (SCHIP) and the Americans with Disabilities Act, and raising the minimum wage, to name only three examples of laws that brought about big public health gains.

His compassion, tenacity, and joy, and his record of achievement, make him my hero.

With his passing, as Caroline Kennedy Schlossberg said in her eulogy, "we have become the ones who have to do all the things he would have done -- for us, for each other and for our country."

Read a blog post from last year aboutTeddy Kennedy’s final year.

Thursday, August 20, 2009

Using himself as an example: Plaintiff Howard Engle's Progeny

Dr. Howard Engle passed away on July 22 at age 89, from chronic obstructive pulmonary disease. He had smoked multiple packs of cigarettes a day since college. Though he tried many times to quit, he never succeeded, and continued to smoke until his death.

His medical specialty had been pediatric neurology, and he frequently worked with cerebral palsy patients. He preached to his patients about the dangers of smoking, using himself as an example. "He wanted to teach people, especially kids, that smoking is not a good habit," said his son David.

Among his patients in the 1980s were the children of two medical malpractice lawyers, Stanley and Susan Rosenblatt. In 1991, the Rosenblatts brought a class-action suit against tobacco companies on behalf of flight attendants who had inhaled secondhand smoke, winning a settlement that cost the companies $300 million. Dr. Engle took a keen interest in the case.

Because he was a smoker with emphysema who wished to publicize the addictive nature of smoking, he agreed to become the lead plaintiff in a second class action suit, filed by the Rosenblatts in 1994. In 2000, the plaintiffs received the largest punitive award ever decided by a jury, for $145 billion. An appeals court voided the award as excessive and said the class of plaintiffs was too disparate. Later, the Florida Supreme Court let that ruling stand, though it allowed individuals to bring suit. Thousands of individuals have done so, and courts are now beginning to decide their cases – which are known as the Engle Progeny.

Advice: Use your standing and your personal network to fight for public health. Sometimes you have to sue the B*ST*RDS.

Read a very different ">class action lawsuit story.

Thanks to Bruce Weber for the source obituary in the Boston Globe of July 25.

Tuesday, August 18, 2009

Intervening before there’s drama: Rapid Response Teams

"A trigger [for a rapid response team] is not about excitement and drama; it's about intervening before there's drama," said Jeanne Quinn, a senior nurse on a unit for post-surgery and trauma patients. Minutes earlier, Judy Wagoner, a 29-year-old nurse with 2.5 years experience, had activated a trigger when her patient's blood pressure plunged to 56.

As the senior nurse on the floor, Jeanne responded and helped Judy gradually raise Carol Emerson's pressure back into the 100s. The team ordered an electrocardiogram to rule out underlying heart problems and a blood transfusion, and kept the patient an extra night. About 80% of the nurses on the floor have less than two years of experience, while Jeanne has 15.

No one knows for sure if early intervention helped Carol, who was in the hospital so surgeons could repair broken bones in her left arm, avoid cardiac arrest. And Judy said she would have asked for Jeanne's help even before the new rules.

But doctors believe the key to reducing patient mortality is to intervene at the first sign of trouble, before the patient "[cardiac] arrests," an emergency where the heart or lungs — or both— shut down.

Dr. Michael Howell, an intensive care specialist, hopes the Rapid Response team will prevent delays like one he described a few years ago to the Beth Israel Deaconess board of directors: Doctors admitted an elderly man to the hospital for gastric bleeding. When his systolic blood pressure dipped into the 80s, his nurse and an intern gave him intravenous fluids to push it back up to normal range. His pressure climbed back into normal range. Over the next eight hours, his blood pressure kept falling, and they kept pumping in fluids. Low blood pressure is generally not life threatening until it dips into the 70s or 60s. But they failed to recognize that the subtler decline masked a more serious underlying problem: massive stomach bleeding. The next morning, a senior doctor did, and transferred the patient to the ICU, which has the staffing expertise and equipment to intervene more rapidly. But it was too late.

"I don't know that we would have saved him," Dr. Howell said. "But it's absolutely possible."

Advice to family members of hospitalized patients: Find out how the hospital activates a rapid response team.

Read about Massachusetts legislation enabling family members to activate rapid response methods in hospitals.

Thanks to Liz Kowalczyk for the source story in the Boston Globe of Nov. 27, 2005.

Monday, August 17, 2009

What it could and could not do: Universal health care through the British National Health Service

Sarah Lyall's story:
As an American who lives in Britain, occasionally writes about the health service, and uses public and private medicine here (as well as back home, occasionally), I have seen firsthand the arguments from all sides.

For me, the Health Service was a godsend when my husband suffered a severe stroke in the 1990s. He got exemplary critical care; I did not get a bill.

It was only in the aftermath – when I learned that, unusually in Britain, my husband's job came with private insurance – that I came to realize what it could and could not do. A little over one in ten Britons have some sort of private supplemental insurance; others pick and choose when to use the National Health Service and when to pay out of pocket for the top specialists or speedier care.

Told my husband needed a sophisticated blood test from a particular doctor, I telephoned the office, only to be told there was a four-month wait. "But I'm a private patient," I said. "Then we can see you tomorrow," the secretary said.

We should create a system in the U.S. that covers everyone, and gives everyone a choice or public or private insurance. That would be a huge improvement for many millions, though still far from perfect, like in Britain.

Thanks to Sarah Lyall for the source article in the Sunday New York Times.

Sunday, August 16, 2009

I've got the upper hand: The Cure and treatment for cancer

Michelle Grant-Epstein is a 52-year-old mother of three in Framingham, Massachusetts. Advanced colon cancer, diagnosed in 2005, had spread to an ovary, requiring extensive surgery and chemotherapy. Here's her story:

When I was first diagnosed, the doctors said my disease was treatable, but we just don't have a cure now. It was hard to hear.

I'm co-habiting with my cancer, and as long as I've got the upper hand, that’s OK. I'm a fully functional adult [exercising at home, spending time with family and friends, and working part-time at a local library].

Do I wish for a cure? Absolutely! But I know that it's complicated and each cancer is different. For now, I'm grateful for the drugs that are controlling my cancer, and I hope they're still working.

Advice: Live as fully as you can every day.

Read a thoughtful journalist's story about his life after prostate cancer.

Thanks to Michelle, whose story appeared in the Fall/Winter 2008 issue of Dana-Farber’s newsletter, Paths of Progress. This is an excerpt from the article about Michelle and two other cancer survivors who are patients of Dr. Robert Mayer.

Friday, August 14, 2009

I reject that categorization: Life during dialysis

Frank Sietzen, Jr.'s story:
Daniel Asa Rose says dialysis leaves patients "with an enervated excuse for a life." As one of the hundreds of thousands of Americans undergoing hemodialysis, I reject that categorization.

Dialysis isn't easy – there is pain each session when a pair of 15-gauge needles are inserted in my arm and removed three hours later, but if a patient follows the appropriate diet and fluid restrictions, the remaining part of life is no different from anyone else's.

I have energy and a zest for life, swim and exercise every day, and am on the transplant list (which involves a five- to seven-year wait in my region). I am often told how "well" I look.

My life – which I call my 65% life since dialysis and related care consume about a third of my time – is a life well worth living, especially considering the alternative.

Advice: Live a life well worth living, like Frank.

Read a story about a kidney transplant patient's choices after a transplant.

Thanks to the New York Times for printing Frank's letter to the editor on July 17.

Thursday, August 13, 2009

Mr. and Mrs. Republican: A lawmaker's response to their hospital acquired infection

Leo and Rita Pepino were married for almost 60 years. "She was my life," Leo says.

Rita died from bone cancer in 2005, after battling two other cancers. She was affectionately known in New Hampshire as "Mrs. Republican" for her political activism. Her husband Leo was the former Speaker of the New Hampshire House of Representatives.

Rita had acquired several painful infections while in the hospital, getting sicker from the place that was supposed to make her well, Leo said.

"Every time she went to the hospital, she always got an infection," he said. He got one, too, years ago from a different hospital when he had back surgery.

Also a Republican, he kept his word after Rita died, helping to marshal through a new law requiring New Hampshire hospitals to report to the state for public release their rates for the three most serious hospital-acquired infections.

New Hampshire Gov. John Lynch signed the bill into law in 2006, "in memory of Rita." However, public reporting has lagged: the state still does not publish the rates of individual hospitals' infections.

A year ago, Leo vowed at age 81 to run again for the seat he lost last time around to make sure consumers get information to compare hospital infection rates. It's for Rita, he said.

Advice to political activists: Be vigilant to ensure your new patient safety laws are implemented faithfully after they become law.

Read another story about Massachusetts'new law on reporting hospital acquired infections.

Thanks to Helen Haskell, and Nancy West for the source article in the New Hampshire Sunday News of August 10, 2008.

Tuesday, August 11, 2009

From three different insurers: Overlapping insurance coverage

Today we received another health insurance card in the mail for my 19-year-old son, and I realized that he'll have insurance coverage from three different insurers during a two-week period in late August.

This is no one's mistake: each is valid. Between the end of his year-long AmeriCorps service and the start of college is a gap of almost four weeks in July and August. So we got interim coverage through the Massachusetts Connector, with Harvard Pilgrim. His coverage through the college's health service starts in mid-August. And my wife's policy, through her employer, covers our family, including him, resuming in mid-August when he leaves for college.

Screwy, too, is the huge variation in the cost of the policies, of more than three orders of magnitude! There is no additional cost to us of the policy through my wife's employer; it's free. The college’s health service coverage costs $20/month. The Harvard Pilgrim plan costs us $143 a month. In the competitive U.S. market economy, it's hard to imagine any other product whose prices vary by three or more orders of magnitude.

(Incidentally, we had to buy the Harvard Pilgrim coverage for more than twice as long as needed, and pay double, because they require coverage to start at the start of the calendar month and end at month's end. That required us to duplicate my son's coverage in early July and late August. And they're a nonprofit!)

As I write this, I'm in the waiting room of my son's doctor's office, while Neil gets his physical. Annual physical exams are recommended at his age, and his college requires it. I've just had to pay a $25 copayment. Let's see, the purpose of the copayment is to discourage unnecessary use, and make consumers cost-conscious. I'm conscious, all right, though these prices are almost knocking me out!

So while many millions of Americans are uninsured, or under-insured, my son is, because of the system's requirements, briefly triply insured, at our expense. Single payer insurance, anyone?

Advice: Don't try to figure out health care insurance costs; it'll only give you a headache.

Sunday, August 2, 2009

He's the guy with the medical degree: Obama's vision of government's role on treatment options

President Obama outlined his vision for the healthcare system in an interview with Andrew Leonhardt, published in the New York Times Magazine:

Consumers have gotten more active in their own treatments in a way that's very useful.  That should continue to be encouraged, to the extent that we can provide consumers with more information about their own well-being.

When it comes to medical care, I know how to ask good questions of my doctor.  But ultimately, he's the guy with the medical degree.  If my doctor tells me, You know what, you’ve got such-and-such and you need to take such-and-such, I don't go around arguing with him or go online to see if I can find a better opinion than his.

And so, in that sense, there's always going to be an asymmetry of information between patient and provider.  And part of what I think government can do effectively is to be an honest broker in assessing and evaluating treatment options.  And certainly that's true when it comes to Medicare and Medicaid, where the taxpayers are footing the bill and we have an obligation to get those costs under control.  

When Peter Orszag and I talk about the importance of using comparative effectiveness studies as a way of reining in costs, that’s not an attempt to micromanage the doctor-patient relationship.  It is an attempt to say to patients, you know what, we've looked at some objective studies out here, people who know about this stuff, concluding that the blue pill, which costs half as much as the red pill, is just as effective, and you might want to go ahead and get the blue one.  And if a provider is pushing the red one on you, then you should at least ask some important questions.  

Thanks to Andrew Leonhardt for the source article in the NY Times Magazine.

Saturday, August 1, 2009

She was finally able to visit a specialist: Hip dysplasia treatment through Health Care for All

Barbara was born with a health condition called hip dysplasia, causing severe pain which affects her life in many ways. She works as a secretary at a landscape company and is a 22-year-old single mother. She can't walk well unless she takes a high number of very expensive medications.

She had been uninsured for two years and suffering without the medications that allow her to function normally when she was helped by a counselor at the Helpline of Health Care for All in Massachusetts. A few weeks after she filled out an application over the phone, she started her Commonwealth Care health insurance coverage and was finally able visit a specialist to take care of her health issues.

Barbara has been in treatment ever since. Pain medication is keeping her comfortable until her surgery scheduled for next month. She will have a hip replacement and the chance of success of her surgery is 98%. She is so excited about her new hip and stresses the important role that Health Care For All played in helping her through the whole process. Here is what Barbara has to say:

"We are so lucky to be Massachusetts residents. My daughter is 1 year-old and she was born with the same problem I have. But thanks to all the health care we receive, her health condition was diagnosed as soon as she was born and she had all the care necessary to fix her hips before she started having severe problems. She used a harness for a period of 4 months which helped to cure her problem. And through MassHealth she has the opportunity to go to the doctor for regular checkups. So I couldn't be happier about the health reform in Massachusetts and all the assistance and care I receive every time I call the helpline."

Advice to Massachusetts residents without health insurance: Call the HelpLine at 800- 272-4232.

Read a story of a young mother in another state who lacked insurance.

Thanks to Monika Lira Malhoit for the source blog post at A Healthy Blog.