When to treat

Really, really loved this Wired article about a physician who insists on being relentlessly empirical and evidence-based in determining the best course of treatment for his patients.  So much of our medical treatment is entirely unnecessary (as nicely detailed in the terrific book, Overtreated).  David Newman bases much of his practice of medicine based on a concept called NNT:

Developed by a trio of epidemiologists back in the ’80s, the NNT describes how many people would need to take a drug for one person to benefit. (The NNT for antibiotics in a case of acute bronchitis is effectively infinity, because the medicine is no better at curing the illness than a placebo.)

Consider a couple other examples: If your kid is throwing up and you take her to the hospital, she might get a drug called Zofran. The NNT for that is 5, meaning that only five kids need to take Zofran for one of them to stop throwing up. And if you look at Zofran’s “number needed to harm” (the number of people who would need to take a drug for one to have a bad side effect) the answer is … well, there really isn’t one—no one has a significant side effect.

Now, say you’re pushing 50. You’re healthy, but your doctor suggests you start taking a baby aspirin. Just in case, you know? That NNT is 2,000. That’s how many people have to take a daily aspirin for one (nonfatal) heart attack to be prevented. Statistically speaking: Not especially helpful.

They don’t have the NNT here for the PSA, but I’m damn sure it’s not good.  I think I have a favorite new medical care statistic (replacing mortality amenable to health care).  Check that– the article doesn’t have the PSA NNT, but I went over to the awesome NNT website and started playing around.  The NNT for the PSA is infinite (no benefit) whereas the number needed to harm is 5.  Um, yeah, no PSA.  Meanwhile, one of my friends just started warfarin for atrial fibrillation, and that gets the green light.  (NNT of 25).

Anyway, back to Wired, because there was more of the article worth sharing:

Newman has just arrived at work in the emergency department where he’s an attending physician, and he’s giving his residents the “Three Networks” spiel.

“ABC, always be closing. You want to be moving patients back home or into the hospital for treatment. At the ER, the front door is always open, but if the back door is closed, and you have people mounting up, things get missed, heart attacks occur, sepsis gets worse, and people die. Always be closing.” Then comes NBC, never be consulting—don’t call specialists if you can avoid it. Then CBS, close before signoff. There’s good evidence that medical errors are more likely to occur with handoffs. Discharge your cases before the end of your shift to avoid these errors, he tells his charges…

Newman wants to use science to protect his patients from treatments that are not justified by research and evidence, and he wants to impart that science to young medical residents. So he’s constantly grilling them on the assumptions that underlie their recommendations and diagnoses…

Habits—whether based on old literature, biased studies, or just educated hunches that get ingrained in protocol—die hard.

Indeed, more than 90 percent of doctors believe that their colleagues practice this kind of “defensive medicine,” according to a survey published in the Archives of Internal Medicine. You do what’s done because it is considered to be the so-called standard of care. And not adhering to the standard of care can be considered negligence if something goes wrong and you get sued for malpractice. The unfortunate result of this contorted logic, according to the Institute of Medicine, a policy research organization, is that the US spent $210 billion on unnecessary services in 2011 (some 8.4 percent of the more than $2.5 trillion we spend annually on health care), and untold numbers of patients are subjected to pain, anxiety, and even death as a result. The NNT could help prevent a lot of that suffering—physical, mental, and financial…

If Newman’s site continues to expand beyond its current number of about 200 write-ups, and if the NNT were included with every published article about a treatment, the result would be happier, healthier patients and less waste in our health care system.

Great stuff.  This won’t be easy because we are talking about changing a culture, and that’s never easy.  But we all stand to benefit if we do.  And given how much of health care expenses are paid by the government, there’s potentially a big role for public policy in making this happen (we could start with no Medicare reimbursement for red-light treatments).

Infographic of the day

The Atlantic has a very cool (and somewhat disturbing) set of Infographics that take a look at how “Black America” would fare in international rankings if it were a separate country, e.g.,

What Voter ID is really all about

Loved this column from Rob Christensen on the “common sense” voter reforms in NC, aka voter ID:

By 2000, North Carolina ranked 34th in the country in voter participation. The presidential campaign efforts of Barack Obama further enlarged voting participation, particularly by signing up under-registered populations, such as African-Americans and college students. So voter participation increased to 21st in the nation by 2008 and to 11th in the country by 2012.

This may have been a triumph for democracy, but Republicans were shocked when Obama carried the state in 2008 – something they thought was impossible.

As U.S. Sen. Lindsay Graham, a South Carolina Republican, famously put it: “I’ll beat (Olympic champion) Michael Phelps in swimming before Obama wins North Carolina.”

So when the Republicans took power in Raleigh, they moved to restrict voting – reversing the trend of expanding voting opportunities.

The stated rationale was to improve the integrity of the voting process and reduce the possibility of fraud. But this was a political fig leaf. Virtually no significant voter fraud has been uncovered in North Carolina…

But the voter changes were never about voter fraud; they were about changing the election rules for the political gain of one party.

The GOP legislature voted to discontinue same-day voter registration and out-of-precinct voting. They also voted to require government-approved photo identification cards, reduce the voting period by a week (although not the number of hours), allow challenges outside a person’s precinct, and end a program that allowed 16-year-olds to preregister. The governor signed the bill into law.

In addition to the new law, several local election boards – now controlled by Republicans – have moved voting sites to less convenient locations for college students. Collectively, the measures make it harder for college students and young people to vote.

This is a reversal of generations of civic activity by Democrats and Republicans to encourage young people to become involved in politics. And it’s being done for short-term political gain.

Among the least defensible changes?  Ending the pre-registration of 16-17 year old kids in high school.   Here my awesome State Senator Josh Stein questions the not-so-awesome Bob Rucho on the matter.  Rucho argues that registration before they are actually 18 is just too confusing for high school kids (maybe for Rucho’s, given his father).

And an excellent editorial from the NYT:

Similar laws have been aggressively pushed in many states by Republican lawmakers who say they are preventing voter fraud, promoting electoral “integrity” and increasing voter turnout. None of that is true. There isvirtually no in-person voter fraud; the purpose of these laws is to suppress voting.

In Texas, where last week a federal judge struck down what she called the most restrictive voter ID law in the country, there were two convictions for in-person voter impersonation in one 10-year period. During that time, 20 million votes were cast. Nor is there any evidence that these laws encourage more voters to come to the polls. Instead, in at least two states — Kansas and Tennessee — they appear to have reduced turnout by 2 percent to 3 percent, according to a report released last week by the Government Accountability Office.

Voter ID laws, as their supporters know, do only one thing very well: They keep otherwise eligible voters away from the polls. In most cases, this means voters who are poor, often minorities, and who don’t have the necessary documents or the money or time to get photo IDs.

And, and how’s this.  A new study (via Vox) finds that when white people see images of Black people they are more in favor of Voter ID:

voter ID study white support

Anybody who tells you Voter ID is about “common sense reforms” or the integrity of elections is either shamefully ignorant or shamefully deceptive.

Quote of the day

Interesting Politico story about how rich Republican billionaires are increasingly giving money to outside Koch money groups that actually have to disclose their donors (the advantage being that these groups can more directly advocate for candidates), but I loved this quote:

“I just kind of decided that it was more important to support it than it was to maintain my privacy,” Cameron said. “I’m 69 years old. I’m much more concerned that my grandkids could be living under communism, or something like it, with the type of leadership that we have right now.”

Riiiiight.  Obama is just a hop, skip, and jump from Stalin and Mao.  Yet more evidence that you don’t actually need to be intelligent to be a billionaire.

“Pro” abortion

I enjoyed reading Hana Rosin’s take on Katha Pollit’s new book, Pro, which argues that women should be unashamedly in favor of abortion.  Right now, in ceding the moral and linguistic high ground, the pro-choice side is on the defensive:

Because frankly, in 2014, it should be no big deal that in a movie a young woman has an abortion and it’s no big deal. We shouldn’t need a book explaining why abortion rights are important. We should be over that by now.

The reason we’re not, according to Pollitt, is that we have all essentially been brainwashed by a small minority of pro-life activists. Only 7 to 20 percent of Americans tell pollsters they want to totally ban abortion, but that loud minority has beaten the rest of us into submission with their fetus posters and their absolutism and their infiltration of American politics. They have landed us in the era of the “awfulization” of abortion, Pollitt writes, where even pro-choicers are “falling all over themselves” to use words like “thorny,” “vexed,” “complex,” and “difficult” instead of doing what they should be doing, which is saying out loud that abortion is a positive social good…

n the years since Roe v. Wade, in fact, the left has time and again signaled retreat—a point my colleague Will Saletan also emphasizes in his 2004 book, Bearing Right: How Conservatives Won the Abortion War. “Safe, legal and rare,” “Permit but discourage”—these updated slogans have left the pro-choice side advocating the neurotic position that you can have an abortion but only if you feel “really really bad about it,” Pollitt writes.

The fog of regret has meant no one is able to confidently defend or even cleanly describe what’s actually going on: Three in 10 American women have abortions by the time they hit menopause. They are not generally victims of rape or incest, or in any pitiable situation from which they need to be rescued. They are making a reasonable and even admirable decision that they can’t raise a child at the moment. Is that so hard to say? As Pollitt puts it, “This is not the right time for me” should be reason enough. And saying that aloud would help push back against the lingering notion that it’s unnatural for a woman to choose herself over others.

Sorry, not working on me.  I was “pro-life” for a lot longer than you’d expect, but left that position long behind because it became quite clear that far too many on the pro-life side were pro-fetus and really had not much interest in helping women and children and also great interest in punishing women for having sex.  That said, although I know believe pre-viability abortion should be legal with minimal obstacles, I still don’t call myself “pro-choice” because I think far too many on the pro-choice side sufficiently wrestle with the complex, thorny, and difficult, ethical and moral questions involved.  You just cannot change the fact that you are ending a life, that in most-cases were nature to take it’s course, would emerge as fully human and vested with all the rights that implies.  I totally understand and appreciate all the reasons we keep abortion legal, but how can you refuse to admit this a complex moral issue?  One of my friends is an expert in the ethics of fertility (and quite pro-choice), and likes to characterize the issue thusly,”if you think it is an easy call either way, you haven’t thought hard enough about it.”

It is quite easy to put aside many of the ardent pro-lifers objections as they are full of illogic and contradictions, e.g.,

She cites one poll for example showing that 38 percent of people say abortion is as “bad as killing a person already born.” But in the same poll 84 percent say it’s fine to save the life of a mother. If you really think about it, this position is untenable. No one would say it was fine to kill a toddler if the mother needed its heart. The pro-life position, she concludes, involves a reflexive moralism but doesn’t really reflect what people know to be true, which is that the fetus and the mother have a complicated relationship, unlike any other.

but I have not ready anything of Pollit’s book that suggests that abortion is not actually a complex moral and ethical issue.  Simply saying otherwise does not make it so.

Would we have an Ebola vaccine

if NIH funding hadn’t been cut?  The Director thinks so.  First, the chart:

francis collins

Dr. Francis Collins, the head of the National Institutes of Health, said that a decade of stagnant spending has “slowed down” research on all items, including vaccinations for infectious diseases. As a result, he said, the international community has been left playing catch-up on a potentially avoidable humanitarian catastrophe.

“NIH has been working on Ebola vaccines since 2001. It’s not like we suddenly woke up and thought, ‘Oh my gosh, we should have something ready here,'” Collins told The Huffington Post on Friday. “Frankly, if we had not gone through our 10-year slide in research support, we probably would have had a vaccine in time for this that would’ve gone through clinical trials and would have been ready.”

It’s not just the production of a vaccine that has been hampered by money shortfalls. Collins also said that some therapeutics to fight Ebola “were on a slower track than would’ve been ideal, or that would have happened if we had been on a stable research support trajectory.”

“We would have been a year or two ahead of where we are, which would have made all the difference,” he said.

But, hey, why worry about funding something as trifling as public health when there are millionaires who need to pay less in taxes and battleships to be built.

Cable News is for old people

I already knew this was true, especially among Fox viewers, but this bit in this NYT story on the declining fortunes of MSNBC really is something:

The median age of the MSNBC viewer has also ticked upward. Five years ago it was 58; now it is 61. CNN has edged down a bit, from 62 five years ago to 59. Fox News has aged from 65 to 68.

Yowza.  Do they ever run ads for anything that’s not prescription drugs?  (I wouldn’t know, I never watch cable news– and I’m not going to when I’m 60 damnit).  As for MSNBC, lots of interesting reasons offered for their decline, but speaking for this particular liberal, I’m just not interested in “news” that seems more interested in making me feel good about my “team” than in actually informing me.

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