Alzheimer’s Update

March 10th, 2010

Current Alzheimer’s disease research is focused on early diagnosis of the disease in the hopes of delaying progression of symptoms. The basis for this approach relies on detecting mild cognitive impairment and following up with imaging techniques and biomarkers that indicate presence of disease. If early evidence of Alzheimer’s is found, medicine may be used to delay loss of cognitive function.

Imaging techniques look at brain volume and functionality. Magnetic resonance imaging can measure total brain volume or look at specific areas of the brain that are affected by Alzheimer’s. Unusually small volumes or losses over time indicate a problem. Other techniques, including functional magnetic resonance imaging, magnetic resonance spectroscopy, and positron emission tomography, measure changes that relate to loss of function. Some of these methods are expensive and others are not widely available, but that may change with time.

Biomakers are used to search for the presence of chemicals of abnormal Alzheimer’s disease processes. The biomarkers are measured in the cerebrospinal fluid. Sampling cerebrospinal fluid can be painful. Some of the markers are not specific to Alzheimer’s but are indicative of several types of dementia.

If tests reveal that mild cognitive impairment related to Alzheimer’s is present, then drugs may be used to delay further loss of cognitive function. There are two types of medications available: acetylcholinesterase inhibitors and memantine. These medicines are moderately effective, but ongoing research may produce even more effective treatments.

Research on early detection techniques and treatment is very encouraging. As the US population ages and the numbers of persons with Alzheimer’s disease increases, this work will become critically important.

Posted in Alzheimer's disease, Dementia, Long-term Health Care, Medical Writing, Patient Education, Public Health | No Comments »

Supply-Sensitive Care

January 13th, 2010

What is supply-sensitive care? Basically, it means if you build it, they will come. With respect to health care, it means that available capacity, whether it is appointment times with your internist or available hospital beds, will be utilized. Why is this important? Because it contributes greatly to increasing health care costs. Rather than providing medical care based on scientific evidence, medical care is provided based on the availability of personnel, beds, and equipment. Interestingly, medical text books do not present clinical guidelines based on scientific evidence, that is well-controlled studies that demonstrate the effectiveness of treatment. With little guidance on appropriate treatment, the system is simply used to its maximum capacity. Milton Roemer noted the relationship between capacity and use in the early 1960s. This relationship is known as Roemer’s Law.

Dr. John Wennberg of the Dartmouth Atlas Project (DAP) has shown consistent correlations between capacity and usage. For example, when he looked at hospitalization rates for medical (non-surgical) conditions, he found that more than half of the variations in hospitalization rates could be explained by hospital bed capacity, not medical condition.

DAP presents other examples. In the case, of visits to cardiologists, about half of the variation in the number of visits per Medicare enrollee could be explained by the number of cardiologists practicing per 100,000 residents. There is a similar relationship with respect to visits to internists. In both cases, the number of visits is not related to health status but availability of medical personnel.

Does extra care result in better outcomes? Apparently not. In fact, more care may result in poorer rather than better results! Dr. Elliott Fisher and colleagues studied patient outcomes for persons who had a hip fracture, heart attack, and colon cancer. They followed patients for a period of five years and found that mortality rates were greater in those regions providing greater intensity of care. They also found that patients receiving more care actually rated the quality of care lower than patients in regions with lower-intensity care.

What can be done to ensure that appropriate, high quality care is provided? Accurate information on the effectiveness of care can go a long way towards ensuring appropriate care. Patients with access to information on the quality and effectiveness of care will select better practitioners. Roemer’s Law, however, ensures available capacity will still be used. How can excess resources be managed? Thirty-seven states require hospitals wishing to expand or purchase new equipment apply for a certificate of need through the state they are located in. This requirement should exist in all states.

DAP further recommends that Medicare should:

1. Direct resources away from acute care towards better coordinated and integrated care outside of hospitals. A greater emphasis should be placed on home health and hospice care rather than hospitalization.

2. Pay for performance instead of number of visits, tests, and procedures. Providers who successfully manage care for chronic illness using fewer resources should be rewarded.

The potential for savings in health care is great. The Dartmouth Atlas Project (DAP) notes that Medicare spending per person varies by as much as three-fold. More specifically, DAP examined Medicare spending at 226 of the largest hospitals in California over a five year period (1999-2003). They found that spending per patient during the last two years of life ranged from $24,722 to $106,254. They estimate that Medicare could save $1.7 billion in the Los Angeles area alone. They note that days of hospital treatment for persons during the last few months of life vary between six and 20 days–more than a threefold difference.

If better outcomes can be achieved with the use of fewer resources, perhaps rationing isn’t such a bad thing after all.

You can find the complete DAP report at http://www.dartmouthatlas.org/topics/supply_sensitive.pdf.

Posted in Health Care Reform, Long-term Health Care, Medical Writing, Public Health | 3 Comments »

Bending the Health Care Cost Curve

September 15th, 2009

Last week, President Obama identified his criteria for health care reform:

  • Provide universal coverage without increasing the federal deficit
  • Control health care costs
  • Stop denial of coverage due to pre-existing illness or new illness
  • Eliminate lifetime caps on coverage
  • Cap out-of-pocket expenses
  • Provide free preventive care

What he didn’t discuss in detail is how costs will be contained. The Engelberg Center for Health Care Reform at the Brookings Institution recently discussed reforms to contain costs (http://tinyurl.com/summitscience30). The center recommends several strategies for cost containment. Among the recommendations are:

  • Use evidence-based medicine to improve effectiveness of treatment and eliminate unnecessary treatment
  • Allocate funding for research on effectiveness to areas likely to reduce the disease burden and improve patient care
  • Encourage payment for performance and discourage fee-for-service payment; measure performance based on outcomes and patient experience
  • Protect providers from liability when they follow best practices
  • Encourage the use of allied health professionals such as nurse practitioners and physician assistants
  • Promote teaching of care practices that improve quality and coordination of care
  • Encourage patient-centered care through “medical homes”

Obama and Congress need to assure the nation that it is not only morally imperative to provide universal health care, but possible without breaking the bank. Visit http://tinyurl.com/summitscience30 for more details on the report.

Posted in Health Care Reform, Medical Writing, Public Health | 8 Comments »

Health care reform: what will it look like?

July 30th, 2009

Anxiety is growing over what health care reform will look like. Many people are asking, “I like my insurance plan. Will my benefits be less under the new plan? Will I have to pay more? Will my plan disappear all together?” These are real concerns. Over 80% of the US population already has insurance.

President Obama tells us that health care expenses will be unbearable if we do nothing and that under the new program, we can keep our current plans if we like them. At the same time, many of us are thinking there’s no free lunch. So what will we be giving up if we provide universal health care? Few details concerning the various proposals are coming out. Clearly, the estimated cost of $1 trillion or more over 10 years will have to be paid for, but how?

At the same time, it seems that there is little focus on how to reduce the cost of health care. Will we really be doing something to control costs as President Obama says we must? So far, there seems to be little evidence that Congress is addressing cost.

This is the biggest program our country has considered since Medicare and Social Security. A lot is at stake. Let your representatives in Congress know what your concerns and interests are.

Posted in Health Care Reform, Medical Writing, Public Health | 6 Comments »