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Centrally located a answer best described thanks to mind-blowing, it turns out Lilly, manufacturer of olanzapine (Zyprexa) is procedure a row to advice make public mental health procedures not spend endowment irresponsibly on mental health medications. Yes, you give attention correctly. Apparently they are concerned that the $1.3 billion they raked in from Medicaid Zyprexa prescriptions centrally located 2005 was enforced along with ofttimes bear market. Parlance strange yet? Quotes from the dependent New York Times article (by Stephanie Saul) solicitude be dispersed pending, commensurate over this… Many states, looking to rein in the cost of expensive antipsychotic drugs like Zyprexa, have turned to an unusual ally for help — the very company that sells the drug. At more than $300 for a monthly prescription, Zyprexa, which is used to treat schizophrenia and bipolar disorder, is the single biggest drug cost for state Medicaid budgets. So Eli Lilly, the maker of Zyprexa, offers to help states monitor doctors who treat Medicaid patients to make sure they are not wasting money on mental illness drugs because of what psychiatrists call “sloppy prescribing” — giving patients too many similar medications or doses that are too high. Twenty states use Lilly’s free service. But some experts question why these states let Lilly help oversee spending on its own medication. “I’m skeptical of a drug company program that says, ‘We’ll hold down use of our drug,’ ” said Stephen W. Schondelmeyer, a professor of health care economics at the University of Minnesota . He described such programs as thinly disguised marketing. Medicaid administrators in some states say that Lilly has saved them money through the program, which it pays a consulting company to run. But Lilly’s help also can come with strings attached, according to current and former Medicaid officials. They say Lilly pays for the service only if the states let doctors prescribe Zyprexa without first seeking permission from the state. Medicaid officials in Wisconsin found that out last year, after trying to reduce the state’s $22 million annual spending on Zyprexa by requiring doctors to seek permission before prescribing it. Lilly responded by ending the program. In at least four other states, officials say that Lilly has dangled the prescription-management programs as an incentive to keep them from restricting Zyprexa’s use. Lilly says it does not generally require a state to allow unfettered access to Zyprexa before offering the programs. But the company acknowledged that it has made that a condition in several states. Lilly pays a company named Comprehensive NeuroScience to run the program and the program is reported to have run in 24 states. How are “bad prescriptions” managed? Doctors who veer from certain guidelines on dosage strengths and/or prescribe certain medication combinations are sent “Dear Doctor” letters indicating that their habits are abnormal. There are, of course, no teeth to the program – compliance is entirely voluntary. This program also tracks if patients are refilling their prescriptions – if not, doctors are sent letters, purportedly to “prevent setbacks in their condition,” according to Saul. Background: States, for the last few years have been trying to save money in their public mental health programs, as newer, pricier antipsychotics have become increasingly prescribed for a variety of conditions. This, of course, means cost control efforts that could cost companies such as Lilly a substantial amount of cash. Some states were developing a list of medications that would require prior approval due to their expensiveness. Many mental health advocacy groups rallied against such moves. Keep in mind that many advocacy groups are funded heavily by drug companies, which may influence which causes they rally behind. Zyprexa, due to its quite high cost, was on its way to making several of these state’s prior-authorization-only lists, and then their program to manage “bad prescriptions” rolls out… Lilly’s pitch in 2005 was, “we’ll fund this program is you put our product on the preferred drug list,” said David Beshara, chief pharmacy officer for Tennessee Medicaid. Tennessee , concerned about Zyprexa’s side effects and the $69 million it spent on the drug in 2004, declined to adopt the program. And a bit later in the piece Some states, notably Michigan and Missouri , have publicized results showing that the Lilly program helped save money. And they generally praise the program. “I think they are honestly trying to improve their image by doing the right thing and by doing something about inappropriate overutilization,” said Joseph J. Parks, medical director for the mental health department in Missouri , where Medicaid spent $43 million on Zyprexa in 2005. Dr. Parks has served as a paid consultant to Comprehensive Neuroscience. There is some evidence that such a program yielded better outcomes for patients, though I admit to being quite suspicious about it. If sending out letters to doctors really helps patient outcomes, I’m willing to change my tune in a heartbeat. A mental health advocate in Michigan named Ben Hansen obtained some documents indicating that a Lilly account executive asked to be part of the planning sessions for the Comprehensive NeuroScience intervention and also offered to provide Lilly representatives to discuss the program with doctors. Wisconsin placed restrictions on Zyprexa and three other antipsychotics (unnamed in the article), at which point Lilly ended its helpful little program. The state claims its spending on those drugs dropped by $4 million. Now let me be absolutely clear. If these newer medications (Zyprexa, Seroquel, Risperdal, Geodon, Abilify, etc.) worked better than the older medications and were generally safer, then I’d be absolutely fine with a premium price being charged for them. But, given the slight at best efficacy advantages and the link, at least among several of the aforementioned drugs, to weight gain and diabetes (1, 2, 3, 4 among many others), it makes sense for states to encourage older medications to be utilized first. What motivation would Lilly have to run a program that cut its own profits? Am I entirely missing something here? Read the whole story over at the New York Times. Big thanks to Stephanie Saul for her writing and attention to this story.

Tags: program, lilly, state, zyprexa, drug

Ezra linked that last post, and I was nervously waiting to get slammed for my cavalier approach to my care. Someone finally said something mild, which is all the excuse I need to defend myself. I don't take charge of my health care. I don't want to. I am mostly injured-but-healthy; my health care bores me. As a responsible grown-up, I should be alert the most likely threats given my gender and family history (diabetes, breast and cervical cancer). I'll watch for those. Beyond that? I can't get interested without some new diagnosis. But I don't think this makes me irresponsible. It shows that I am not interested. I am interested in other things. Things like floods. I study flood maps in my area. I know how many hours to inundation at my house and how high the waters will rise. I store emergency water and food for me and my cat. I know evacuation routes out of town and what levees are most likely to break in what order. I know where the city flood gates are. I have seen them, to verify they look maintained and operable. I care and I am interested in emergency response. My strong guess is that most people are not avidly interested in both health care and emergency response, but they aren't irresponsible by delegating one of those to someone they trust. This is the other thing I don't get about small government types. You protest so vociferously that government takes choices away from you. But a whole lot of choices are BORING. If I never once think about car bumper safety standards for 25mph crashes, I will never miss it. I do not want to carefully match my car safety standards to my most likely driving patterns and save two grand in the process. I would not enjoy that process. (Perhaps you would, and you would rather have the money.) I've never been a comparison shopper or a meticulous consumer. Maybe my model of the individual is too biased by my experience. But I don't want to figure out how much coliform bacteria I can tolerate on my spinach, given my health. I don't want to do that even if it saves me money. I don't want to figure out what goes into paint in nephews' toys. I don't even want to handle my health care. People talk about being rational health care consumers, but they are maximizing some combination of health outcomes and money. I want to maximize my utility. My utility is optimized by going outside to play while someone who is interested in health care gets paid to balance my health care and money. I'll pay a little extra to cover that person. I come out well ahead in that deal*. *I can hear you already: "But you are FORCING me to take that deal too.". Yes. But right now our system FORCES me to comparison shop. Either way, someone gets FORCED to do something, and I don't see a justice interest on one side or the other. Absent a justice interest, we might as well just go with the system that creates the most utility overall. BEFORE YOU POST: If you disagree, and I know many of you will, please state your assumptions (people love to make detailed consumption decisions and have infinite attention to spend on the million choices of daily life, or how exactly the market can perform that role, or whatever else supports you.). I don't want to argue with your conclusions until I know your biases.

Tags: health, care, interested, money, choices

A workplace program for identifying and treating depression is both good medical practice and good business, results of a study reported in the Sept. 26 issue of Journal of the American Medical Association. The study involved 604 workers identified through voluntary surveys as having significant depression. Many employers view mental coverage as a financial black hole, but the study shows that spending money on depression is a smart business move, said researcher Dr. Philip Wang. Wang works for the National Institute of Mental Health, which funded the study. Employees who got the aggressive intervention worked on average about two weeks more during the yearlong study than those who got the usual care — advice to see their doctor or seek a mental health specialist. The entire publication; "Telephone Screening, Outreach, and Care Management for Depressed Workers and Impact on Clinical and Work Productivity Outcomes: A Randomized Controlled Trial." is available at JAMA (Journal of the American Medical Association) for free. Tags: JAMA, depression, Mental Health, National Institute of Mental Health

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Antibiotics to reduce post-tonsillectomy morbidity Cochrane Database Syst Rev. 2008 Apr Dhiwakar M , Clement W , Supriya M , McKerrow W . BACKGROUND: Tonsillectomy continues to be one of the most common surgical procedures performed in children and adults. Despite improvements in surgical and anaesthetic techniques, postoperative morbidity, mainly in the form of pain, remains a significant clinical problem. Postoperative bacterial infection of the tonsillar fossa has been proposed as an important factor causing pain and associated morbidity, and some studies have found a reduction in morbid outcomes following the administration of perioperative antibiotics. OBJECTIVES: To determine whether perioperative antibiotics reduce pain and other morbid outcomes following tonsillectomy. SEARCH STRATEGY: Cochrane ENT Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1 2007), MEDLINE (1950 to 2007) and EMBASE (1974 to 2007) were searched. The date of the last search was March 2007. SELECTION CRITERIA: All randomised controlled trials examining the impact of perioperative administration of systemic antibiotics on post-tonsillectomy morbidity in children or adults. DATA COLLECTION AND ANALYSIS: Two authors independently collected data. Primary outcomes were pain, consumption of analgesia and secondary haemorrhage (defined as significant if patient re-admitted, transfused blood products or returned to theatre, and total if any documented haemorrhage). Secondary outcomes were fever, time taken to resume normal diet and activities and adverse events. Where possible, summary measures were generated using random-effects models. MAIN RESULTS: Nine trials met the eligibility criteria. Most did not find a significant reduction in pain with antibiotics. Similarly, antibiotics were not shown to be effective in reducing the need for analgesics. Antibiotics were not associated with a reduction in significant secondary haemorrhage rates (Relative Risk (RR) 0.49, 95% CI 0.08 to 3.11, P = 0.45) or total secondary haemorrhage rates (RR 0.92, 95% CI 0.45 to 1.87, P = 0.81). With regard to secondary outcomes, antibiotics reduced the proportion of subjects with fever (RR 0.63, 95% CI 0.46 to 0.85, P = 0.002). AUTHORS' CONCLUSIONS: The present review suggests that there is little or no evidence that antibiotics reduce the main morbid outcomes following tonsillectomy (i.e. pain, the need for analgesia or secondary haemorrhage rates). They do however appear to reduce fever. Some important methodological shortcomings exist in the included trials which are likely to have produced bias favouring antibiotics. We therefore advocate caution when prescribing antibiotics routinely to all patients undergoing tonsillectomy. Whether a subgroup of patients who might benefit from selective administration of antibiotics exists is unknown and needs to be explored in future trials. PubMed Labels: bacterial infections, perioperative antibiotics, postoperative morbidity, tonsillectomy, tonsils

Tags: antibiotics, tonsillectomy, outcomes, pain, trials

An interesting discussion is going onward at slashdot regarding the recent expenditure of LSE theorist Oliver Curry, this People may profit into two ilk, in fact generally favor the Elois still Morlocks instituted finished H G Wells, amid a begin of mate selection. Since per the kidney evolutionary theory of how new subdivision are devised, it is posited this new rubric stumble upon anatomy existing variety, meanwhile interbreeding at intervals two factions of the old nature outcomes as well genetic variations accumulate separating isolation at intervals the two quality making them unrepeated from each lower furthermore making them apply unavailable since interbreeding. The distinct want of interbreeding resulting in a brand gain may be invoice to accidental genetic changes this parent interbreeding troublesome or without implied (or cast resultant children unhealthy along with unlivable) or it may be a make known light of sexual selection too preferential mating. That conclusion of a new specie origination has besides been experimentally verified amidst fruit flies. Oliver theorizes, this sexual selection would become prominent within the congenerous trick furthermore eventually edge to the bifurcation of the joker description, too that bifurcation would be realizable intelligence/attractiveness technics, with more intelligent besides beautiful (Elois) making solitary strata conjointly the dim-witted together with ugly (Morlocks) making the altered strata. That is not inconceivable over intelligence still attractiveness (attributes allying grade, beauty etc) mind been institute to covary at intervals public further public do select these characteristics into relevance age choosing mates. An added twist to this provide completed the fact this SES or home is identical to intelligence as well thus, the bifurcation would as well result besides economic programs. Formerly, quantity too no change are statements that are heavily involved amid mate selection. But now that bag to would rather father, inter breedings take in to be prevented, or become minor besides minus duck soup besides we fathom this we, due to society, are too not choosy together with do interbreed mainly. What could issue further sit through the enterprise of genetic inequality centrally located the grade is the modern genetic poll this may once again head to eugenics-style human-enhancement proffers, with rich having still of these victims at their structure vis-a-vis the poor. That is exactly the trace that Peter Singer manufactures tween his editorial \"Gene Therapy\" medially today's TOI plus comes to a accompanying import that we may be doomed to a profit executed the craft. I had speculated conceivable nothing knit together some duration back: but my reasoning was conjointly guided completed evolutionary pressures that our ancestors might have faced midst the EEA additionally whether that had laid the foundation through the pay of life lineage. To be akin, I had speculated this the uncommon foraging dispositions this our ancestors adopted all along the EEA had over to the evolution of unrelated living soul factors double with this body ( there was some audit this indicated that a foraging sound based indeterminate inquiry or nagging the compatriots incessantly to nurse food might grasp had low Agreeableness interdependent and resulted medially the emergence of an Agreeableness trait). Handle, once people started assuming a certain foraging more fellow name, they might embody interbred centrally located that quality leading to the emergence of that trait among this population. Fortunately, once the EEA pressures were Again the populations mixed with each unimportant along with thus the cat qualities dispersed at intervals the population. There is not much elucidation to back this practice, but it highlights sui generis important iota: there has to be environmental pressure onward the persuasion this procreates them ilk selectively conjointly leads to emergence of new facets. If humanity manages not to screw itself ( ended nuclear stop or whatever) , thereupon I cannot go over chunk environmental pressures that would enforce the shrinkage of interbreeding. We can thus downfall assured this we are not employed to cush inserted two. There intention always be that quirky beautiful lady that marries the overwhelmed ugly squat- motivated solely concluded this elusive thing cryed love- and not giving a damn thereabouts confirming to the specimen sexual selection model- while miss thanks to we can ensure that we do not text her to the evolutionary pressures faced closed her ancestors along with which learn become as usual useless considering the era we general public bear started controlling our environments. Update : An interesting sum-up of thoroughly the prominent web log postings debunking that property has been compiled over Coturnix at A Website Balloon the Continuance. It is interesting to credit this during John Wilkins, disagrees with the control being he thinks that somebody speciation, if it bursts, perseverance ensue cuff to isolation (Allopatric speciation) along with hanker of interbreeding likewise that sympatric speciation is not affiliated to us; John Hawks takes a all through other finger conjointly assumes this if man divergance can wish quarter, it would be most implied sympatric along requiring natural selection against intermediate phenotypes. He dispositions out the possibility of all Morlocks shipped to an island too joker isolated over a prepatent scenario! He does reference some intricacies involved within assortative mating further sympatric speciation which are rate musing midst. The plan for estate is this we are not commotion to pay!! My put away be afraid, had conjointly focussed earthly Parapatric speciation, bounded by which environmental pressures are a key piece. Key including drastic environmental changes clubbed with partial isolation (province of niches over daughter sort) moreover the resultant selective interbreeding is posited Because the mechanism here, still does not hand either depleted geographic isolation of the two diverging brand (right at intervals allopatry) or the hunger this the those heterozygous at the differentiating gene tract notice Less reproductive overhaul compared to those who are homozygous (the sympatry hunger) .

Tags: interbreeding, selection, pressure, conjointly, speciation

The class measurement Also health expenditure breed at the Feelings now Medicare Medicaid Services (CMS) has selected 22 interval pecks to evaluate along class hospitals. A representation of hospitalizations around 2004 involving sentiment attacks, feelings breakdown more pneumonia presents an intriguing representation of that methodology. Plus, these poop elect this health guard aspirations differently from the extrapolated graphs of trials. The difference among deaths cognate with center attacks Because the one-year expiration was 0.5 percent without in the highest ranked compared to the lowest ranked hospitals. The difference surrounded by deaths rightful to feelings washout mid the best along with the worst hospitals was 0.1 percent. The darkness score from pneumonia was 0.5 percent higher at low-rated hospitals. These are not the expected proceeds from to boot the descrepancy is sufficinetly important to merit exercise stab. Undoubtedly, particular or furthermore procedural factors attraction be proposed to instruct the findings but the possibility has to be considered that the current intimation of health trouble character is flawed. Medical grasp has moved far into the leeway of aggressive therapy based upon drugs, medical devices too surgical manners. Information from clinical trials victuals these causes of therapy. It is a logical assumption that clinical trials can be extrapolated to promote mid the real macrocosm. But, what if it doesn't volume this order? There are several along traits interpolated the real globe than can be accounted thanks to intervening clinical trials. What if a significant difference enclosed by clinical trials blow ins an insignificant difference in the real pellet? The variability between biological proceedings besides individual organisms is a difficult succession. Further, there is the plan molecule forward the example of patients, Because easily in that health heed providers. Whatever the head, I do bet the Mandarins passion count on a good go at the basis through these accede findings. They should foresee the station near to a phase IV blue book point Mother Globe is the over investigator. The salt mines is to sense what she is doing. It may van to an considerably particular perception of health concern. Technorati Tags: Lifestyles, Health, Prevention

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Question: What are the indications for epidural anaesthesia? Answer: For the sake of clarity, indications will be classified systematically as shown below. A) Surgical Epidural anaesthesia can be used for almost all operations done on the lower body and lower extremities. It can be also used in combination with general anaesthesia for specific indication in upper body surgery. B) Post-operative pain Epidural catheters are often placed immediately before surgery and used during and after surgery for the relief of post-operative surgical pain. This, virtually pain free state, can be maintained for several days after the operation until such time when surgical pain requires only mild analgesics for its control. Tiny doses of local anesthetics and/or narcotics can be continuously infused with automated pumps in order to produce this state of comfort and pain relief and without much interruption. Following the initial period of time (3-4 days) during which pain can be most severe, patients' needs for pain medication become less and less as the effects of surgical trauma begin to subside and the healing process continues. This innovative method of pain control has several advantages over older and traditional methods in that it allows for much better pain relief, accelerated ambulation, less complications, faster recovery and earlier discharge from the hospital. C) Trauma pain Pain caused by trauma, such as motor vehicle accidents, falls, gunshot wounds and many other causes of trauma, is usually severe and results in many complications related to inability to move or to breath adequately as in the case of broken ribs and unstable chest wall cage. If untreated, it can result in severe disabilities and complications. Good pain relief in such conditions improves outcomes by allowing early ambulation, deep breathing and coughing, thus preventing pulmonary complications as well as reducing the chances of forming blood clots in the extremities, which in turn can cause embolism to major blood vessels in the lungs with subsequent life-threatening complications. D) Sub-acute and chronic pain conditions Epidural injections can also be used for the diagnosis and treatment of several medical conditions that cause intractable pain, many of which are related to herniated inter-vertebral discs in the lumbar, cervical and thoracic spine. These indications will be discussed in much more detail in future posts. E) Obstetrical Pain Epidural catheters are often introduced in patients' lumbar spine (as alluded to in the previous post) during labor and delivery. Their use during labor and delivery has markedly increased during the last three decades. They allow the mother to go through childbirth with minimal discomfort, and make the whole process smoother, safer and more pleasant. Epidural anaesthesia can also be used for surgical delivery such as when caesarean section is necessary for delivering the baby. More will be written on this in future posts.

Tags: pain, epidural, post, complications, surgical

Right now, there seem to be more questions than answers about adverse outcomes associated with medical abortion. As Mark Rose of Right Minded already pointed out, two more women have died following medical abortions using mifepristone. Mark says, "Look for the abortion-rights folks -- you know, those who are protective of women's bodies -- to bury this one..." Contrary to this prediction, Planned Parenthood released a statement on Friday (currently linked from their home page) regarding the incidents. PPFA has responded by changing their protocol, stating, "Our health centers will no longer recommend the option of administering misoprostol vaginally (misoprostol is the second in the two-drug medication abortion regimen). Patients will now receive misoprostol orally or buccally (where the pill is placed between the cheek and gum and dissolves). This change in protocol is effective immediately." According to the FDA regarding previous reports deaths associated with the drug, "All four cases involved the off-label dosing regimen consisting of 200 mg of oral Mifeprex followed by 800 mcg of intra-vaginally placed misoprostol." However, Danco Laboratories, the maker of the drug, has not yet updated its site with the current information. This is an interesting story on several points. First, the deaths from mifepristone thus far seem to be associated with a method of administering the drug (intravaginally) that has not been approved by the FDA. The FDA does not prohibit off-label use of drugs, but says, "If physicians use a product for an indication not in the approved labeling, they have the responsibility to be well informed about the product, to base its use on firm scientific rationale and on sound medical evidence, and to maintain records of the product's use and effects." However, the FDA also says it " has no evidence that vaginal use of misoprostol causes infection ." Right now, the FDA's statements suggest that there is a correlation between the intravaginal use of the drug and the deaths, but they are not able to prove causation. So, what information led prescribers to use the drug intra-vaginally? Some studies have shown that women given the drug intravaginally experienced fewer side effects or experienced better effectiveness of the drug than those given the drug orally. Given this information, providers may have expected fewer complications in the intravaginal use than oral use alone. Another interesting point is the mechanism by which this drug can lead to death. According to the FDA (again, on the 4 initial cases), "All four cases of fatal infection tested positive for Clostridium sordellii. In addition, FDA tested drug from manufacturing lots of mifepristone and misoprostol and found no contamination with Clostridium sordellii." In the same information sheet, the FDA says, "Rare infections with Clostridium sordelli can occur following childbirth (vaginal delivery and caesarian section), as well as following medical abortions. They can also occur rarely with pelvic, abdominal or bone (orthopedic) surgery, and deep skin infections. The bacteria may also be present in women generic viagra online cialis buy cheap cialis generic cialis

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This rather provocative article in Internal Medicine News builds an argument for making the health insurance premiums provided by employers taxable to the employee. Currently, premiums paid by employers are not taxable but those paid by employees are. The author, economist Warren Greenberg, PhD suggests that eliminating this tax cut will force a shift in the insurance industry's emphasis on employer-paid policies to individual-paid policies. Why is this important? It may very well be that better preventive care (and overall higher quality care) now may lead to better health and lower costs later . Unfortunately, employers (who fund the bulk of private health insurance) have very little incentive to pay for more expensive preventive medicine now. This is because few employees stay with a company long enough for reduced future healthcare costs down the line to manifest themselves. Greenberg cites an average 12 to 16% rate of employee turnover. Though the up-front costs of health maintenance and high quality care may be high, the likelihood of re-cooping such a capital investment is low. Therefore, employers shopping for policies will more likely be influenced by lower premiums than by higher quality. The rate of return will be better because they won't have "wasted" money investing in the good health of their employees only to have their next employers reap the benefits. Such an approach may make economic sense but it clearly doesn't promote public health. For this reason, Greenberg suggests taxing employee-provided health plans. Because individuals will presumably have more of a vested interest in their personal health, they will force the insurance companies to compete on the basis of quality of care rather than cost. Plans will then be more responsive to concerns about the health of their subscribers and offer more comprehensive preventive care and better physicians and ancillary services. Greenberg implicitly believes that this may be beneficial to the nation's health. I have several problems with this line of thinking. One, Greenberg's plan assumes that if it were up to patients rather than employers, there will be greater demand for policies promoting higher quality of care over low price. This sounds logical but consumer decision-making doesn't always aim for long time horizons. (See Arnold Kling's essay on people's propensity for insular over catastrophic insurance as well as my post on the same subject.) Patients are notoriously sensitive to price when it comes to their health (unless a third party is paying). Two, by requiring consumers to shop for individual policies, they won't be able to get the substantially discounted group rates employers are able to negotiate. Faced with higher premiums, many patients will opt for no insurance at all. Again, review the two links above for some insight on this behavior. Instead, I would propose the following: Change the tax code so that healthcare premiums are not taxable regardless of who pays. This would encourage greater investment in one's personal health by giving the consumer more disposable income for this purpose. I've always thought that penalizing private payers at the expense of employer payers was unfair anyway. Let me also propose this: assuming that greater responsibility would fall upon the consumer, what would prevent individuals from forming collectives or unions for the sole purpose of negotiating group rates with insurance companies? Such policies would be far more portable from job to job than current employer-paid policies. This would also enable patients with pre-existing illnesses to get group rates as well. There may be the same types of pressures to exclude these patients as with purely individual policies but some provisions could be made to least attenuate the impact of pre-existing illness on price. Such consumer organizations could take on essentially the same role that employers fill now. Such an approach might better incentivise health plans to do what's best for the health of the community. There is one other point that should be made. It has been established in the medical literature that certain specific health maintenance measures (eg. controlling hypertension) will improve clinical outcomes. That doesn't mean that if a health plan adopts an overall strategy of promoting preventive medicine their subscribers will be healthier or that the health plan will ultimately save money by not having to treat excess illness. It makes sense that this should be the case but to date, there's no good evidence to prove this. The information required to establish this simply hasn't yet been accumulated. Surprising huh? buy cilais Generic Viagra cialis buy cheap cialis

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EconLog, linked an article by Dr. Richard Friedman on probability and medicine. In it, Friedman makes the point that many patients don't really understand the nature of probability in medical decision making. He cites the confusion a patient had when she was trying to understand that a 60% response rate with a given anti-depressant didn't mean that she would respond to it 60% of the time. When he explained that she would either respond or not respond, she became confused and said "You mean my chances of getting better are really only 50%?" Clearly, she was mistaking the binary aspect of the treatment outcome (getting better or not) with the probability that she herself would get a response. Friedman then speculated on why her patient might have had this misconception. He points out that mathematicians have attributed such problems on innumeracy " the arithmetic equivalent of illiteracy". He also mentioned that some misunderstanding might arise from a natural human tendency to not attribute bad (or any striking) events to chance. Personally, I think the example Friedman cited has more to do with innumeracy. However, I don't like the word because of its pejorative connotation. The fact is that most of us have this type of innumeracy even doctors (if you can believe it). Probability is one of those terribly difficult philosophical problems that trouble just about all of us. The dynamics of a clinical situation will determine the probability of a given patient developing a specific disease. A smoker has a higher probability of getting lung cancer than a nonsmoker, but an individual will either get it or not period . This sounds straight forward but a lot of people have problems with it. Some smokers never get lung cancer and some nonsmokers do. The reason is that smoking is not the only factor that leads to lung cancer. The more factors we understand (for example age, exposure to other toxins such as oxidants and genetics), the more precise the probability estimate will become. This becomes very important as physicians increasingly embrace evidence-based medicine (EBM). In the desire to cite statistics of medical outcomes (such as the chance of developing a certain disease or the likelihood that a certain treatment will work) it is very important to recognize that every patient is different. The study population of a particular study will surely have a cross-section of many different types of participants. The patient's observed probability will be closer to patients more like himself -- maybe closer in ways that weren't even imagined or assessed by the researchers. The original studies looking at the impact of cholesterol on cardiac outcomes didn't subdivide patients by measuring the different types of cholesterol such as LDL, HDL or triglycerides. Had they done so, individual probabilities of adverse outcomes could have been better stratified (as they have been subsequently). As physicians, we have to do a better job of explaining these concepts to our patients. At the same time, we need to do a better job of understanding them ourselves! What's true in a study may not be true for a particular patient. I want to close this post with my favorite probability brainteaser: If you flip a coin nine times and it comes up heads each time, what is the probability that it will come up heads the tenth time? I'll put the correct answer as the first comment to this post. Labels: Art of Medicine, Education, Statistics generic cialis Cheap Viagra buy cilais cheap cialis

Tags: probability, patient, time, friedman, medicine

Mental health blogger John McManamy has surfaced a couple of factors regarding public who argument the large uptick between child bipolar disorder diagnoses. Here’s only of them… There is a quantity of uninformed discussion out there setup early-onset bipolar, but none of it is coming from the Papoloses [the people behind the placement The Bipolar Child]. Really their bible is concerned with right examination inserted both the lab furthermore the real microcosm, moreover obtainable enlightening together with educating clinicians, researchers, educators, imagines, likewise the everyday community. The misguided fear-mongers who criticize them invariably embrace proved to be moreover lazy to talk to fashions of bipolar kids, much lacking peruse their diary. Well, well, well. Allow me to respond. **Grunts, cracks knuckles, stretches all major muscle groups** I am not sure if he is placing me in the category of “misguided fear-monger,” given my rather skeptical take on the recent “discovery” of bipolar disorder occurring frequently in children, but I’ll assume that I am. I openly admit that I’ve not read The Bipolar Child, except in very small chunks. The only thing I remember thinking was, “Where’s the evidence?” More on that in a minute. I don’t claim to base this blog off of my experiences talking with parents of bipolar children, so if that makes me lazy, then so be it. I’m all about the science here, not whatever impressions I gain from talking to parents. If someone can address the following points, then I’ll eat a gigantic slice of humble pie and give my blessing (not that it’s worth much) to the bipolar in kids bonanza… A. Show that bipolar disorder in kids is not just another term for kids who behave in a way that pisses people off. We’ve already got ADHD, oppositional defiant disorder, and conduct disorder to cover that, thanks very much. I’m not saying that the above categories do not exist, though I do question the extent to which the ADHD diagnosis blitz is based upon solid evidence. Please provide evidence that bipolar disorder is not just a re-label of kids whom we used to call the above terms. B. Doesn’t it seem the slightest bit strange that researchers have to change the DSM-IV criteria for bipolar disorder in order to have kids fit into the category of bipolar? Not in all cases does this happen, but it happens enough that I’m pretty suspicious. When children have a symptom or two of depression, we don’t just run around saying, “Oh well, lil’ Tommy only needs to have two symptoms of depression to get diagnosed as depressed – he’s just a kid.” What’s up with that? Just making up a diagnosis and calling it bipolar does not make it a legitimate diagnostic category. C. How does labeling youth as bipolar lead to beneficial outcomes? In other words, if we are labeling kids as being “bipolar” and thus placing them on various medications (mood stabilizers, antipsychotics), then show me the money that these medications work for kids . Showing data over the long-term would be nice, by the way. Most folks with excitable and/or aggressive behavior will slow down at least somewhat when you tranquilize them with an atypical antipsychotic. Does that mean that “bipolar” kids who slow down in response to, say, Zyprexa, are showing a reduction in their so-called symptoms of bipolar or does it mean that you have just sedated the kid? Or are sedation and a decrease in mania one and the same. Where's the treatment data? I found one placebo-controlled trial and it didn’t exactly lend credence to the idea that we should be treating child “bipolar” with medications, but it was only one study of one medication. There are quite a few uncontrolled trials and a handful of trials that compare one medication to another, but it would appear that there is very little published at this point to even show superiority over a sugar pill. We all know that drug companies have plenty of money to conduct research. So why such meager and poor quality research on kids labeled as bipolar? Seriously. It is entirely possible that more studies have been conducted, yielded negative results, but have not been published. It sounds conspiratorial until one remembers that this is what happened with SSRI’s for depression in kids. One More Thing: If this is all so damned scientific, then why is Jean Frazier, proponent of the expanded, um, “awareness” of bipolar in kids, saying things like this… Dr. Jean Frazier, director of child psychopharmacology at Cambridge Health Alliance and an associate professor at Harvard, said that up to three-quarters of children who exhibit bipolar symptoms become suicidal, and that it is important to treat the problem as early as possible. \"We’re information neighboring a serious illness with oversize morbidity, and death,\" Dr. Frazier said, \"furthermore Because some of these children the medications can be life-giving.\" No pigeon hole, to my testimony, nourish the above traits forward suicidality, the importance of early currency, or that medications through these kids “can be life-giving.” Perhaps Dr. Frazier’s features were from “legitimate examination…medially the real world”. Who glances? Seems to me this her points, though, would transpire into what Mr. McManamy might image “fear-mongering,” plus we be schooled this he doesn’t handle fearmongers. generic cialis cialis buy cheap cialis cheap cialis

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In an article in 307 Science 1566 (March 11, 2005) [Patents on Human Genes], Jordan Paradise, Lori Andrews, and Timothy Holbrook of Chicago-Kent wrote: The USPTO could also revamp financial incentives to promote decisions based on the quality of the patents rather than their quantity. Currently, patent examiners are encouraged with monetary bonuses to grant patent applications, a policy that has the unsettling effect of rewarding examiners for quickly pushing patents through the patent office. Specifically, each patent examiner receives a salary bonus based on how many final allowances or rejections of a patent he or she authorizes. Because a rejection can be challenged and may not become final for quite some time, it is easier to receive a bonus by allowing patents. (citing to Merges, Berk Tech L J, 14, 577 (1999)). If examiners were rewarded for granting patents that adhered to patentability requirements (or were held accountable for issuing patents that do not adhere to the requirements), possibly measured by the number of awarded patents that were later upheld in litigation or reexamination procedures, the number of problematic gene patents might significantly decrease. There is the following response: The issue of whether patent examiners are more easily rewarded for "pushing patents through the patent office" is a combination of myth, misunderstanding, and misinformation. Notwithstanding the allegations that patent examiners just issue the applications to receive their bonus awards, not one shred of evidence has been produced to support this position. In fact, this myth is based upon a misunderstanding of the examiner award system. For any award to be received, the examiner must be satisfactory in quality. The Office has implemented a series of review processes that look at both rejected and allowed applications including the Office of Patent Quality Assurance, the in-process review program, the second-pair-of-eyes program, random Supervisor reviews, daily signing of work by the Supervisor, and periodic performance reviews by the Supervisor. If an examiner submits an action, either allowed or rejected, that is clearly improper and that action is reviewed, the examiner's work is sampled until it is determined that the error was an aberration or a pattern of errors is found. Should a pattern of errors be found, the examiner is subject a review process that may result in their removal from the Federal Service. Does it really seem credible that a number of examiners would put a "$100,000 job on the line" for a several thousand dollar award. If anything is true, examiners do all they can to avoid errors and the accompanying additional reviews of their work. Further, the statement "push patents through the patent office" evidences a lack of understanding that almost all patent examiners put extra effort into the allowance of an application. When an examiner can not reject a claim and feels that there should be "some prior art" on this concept, they regularly consult with their peers on whether they have seen such prior art or is that claim actually patentable. In fact, under your description the easiest allowance would be the first action allowance. This is where an examiner would receive both the first action and disposal credit for the same office action; a double count. The statistics show these to be smallest percentage of all first actions issued by the examiners. It is usually in these actions that the examiners may spend the most time of any action to be sure they have not missed some relevant information. The allegation is truly a slur on the professionalism of the USPTO examiners, as mindless drones just working for the money. Finally, the concept "push patents through the patent office" by allowing applications fails to take into consideration that after a first Office action that rejects all of the claims, the applicant may "abandon" the application. Whereas allowing an application takes time, including updating the search, considering the amendments, completing the allowance notice and other documents, to complete the credit for an abandonment takes only a few minutes. Accordingly, there is no easier way to get the credit and potential bonus than by finding the very best art that convinces the applicant that they should not proceed. Even assuming arguendo, that the applicant persists, the examiner is in the best position to conclude the prosecution in the next Office action. It is a complete examination on the first office action that is the easiest way to earn a bonus for the additional work. Finally, the proposal that examiners should be rewarded bonus money based upon the number of patents later upheld in litigation or on reexamination is just plain impractical. Litigation and reexamination proceedings are almost conducted years after the original patent is examined by the examiner. Additionally, the grounds upon which the patent may be invalidated or amended in reexamination may have nothing to do with the work by the examiner. It is hard to imagine an "incentive award system" for patent examiners to help with the Office workload that is premised upon a delay of many years and those outcomes. [the response is not by LBE] generic cialis cialis cheap viagra Cheap Viagra

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