Category: Medicine
Oncology versus palliative care
So I’ve just read this article in KevinMD about oncology and palliative care: The Tension Between Oncology and Palliative Care
Whilst I agree with the overall sentiment I think we can generally do better. First of all – this isn’t an issue unique to oncology – it is important for all sub-specialties and all patients/consumers where end-of-life is an issue.
Secondly this is a societal issue. Bottom-line is that nobody lives forever and so thinking about these things is important for both individuals and society. Society needs to get beyond the notion that technology trumps death.
Thirdly we need to move beyond palliative care as end-of-life care to the notion that supportive and symptomatic care is useful throughout the whole illness. This will both improve outcomes overall and prevent harm.
In an ideal world there is no oncology versus palliative care, there is just care.
Enough choppy choppy: how about spending a dollar to save a dollar in health
So I work in health and well to be frank health is not exactly thriving.
I am associated with 3 public hospitals with a collective EOFY debt of around 50 million dollars. The way the powers want to catch up is with cuts. But the problem with cuts is that it doesn’t actually deal with the fact that service needs to be delivered.
People being to hospital costs money so the logical way to deuce expense is to stop people being admitting to hospital is to reduce admissions. The only real way to achieve this is to stop people being admitted to hospital. The only way to achieve this is to provide outpatient services that otherwise meet the inpatient demand.
The problem is that ‘new’ outpatient services is a new expense and the system can’t countenance that.
Well I think I fact of life is that sometimes you have to spend a dollar to save a dollar.
The real issue is that health services want business cases: well tell me how much you are willing to spend to save a dollar. I’ve heard one dollar for 3 saved but this is a clowd-cuckoo-land number. I agree 1 for 1 isn’t a gain but 1 for 2 is a tangible benefit
Regardless of the breakpoint let’s get a number to inform our business cases.
Things they didn’t teach in medical school: Part 30 Continuing the conversation after the consultation
One of the things they didn’t teach in medical school is how to continue to the conversation of the consultation after the actual physical consultation is over. Supposedly shared decision making leads to better decision satisfaction and outcomes but what happens once the patient leave the consulting room.
In some cases they leave with a pile of printed information. They may have taken their own notes. Or a carer may have taken the notes and been the second pair of ears. But I know the wrong messages may have been taken away or there will be lots of questions.
One way to deal with the problem is to ensure that the patients have had an opportunity to ask the questions in the first place – question prompt lists can help with this.
Another potential way is to provide a record of the consultation. This can be a written summary or alternately it can be an audio record of the consult. Some doctors are set up to do this but these days it most commonly happens when patients ask me if they can record the conversation and then they use their mobile phone.
An alternate potentially useful method is to develop your own resources to refer the patients to. I’ve just started, albeit extraordinarily slowly due to time commitments, to develop videos using the Explain Everything platform. Hopefully my patients will find these useful both for innformation about their treatment and to inform decisions.
Here is my talk on Xeloda Side Effects
How Edward Snowden Might Impact Big & Small Data Use in Healthcare
In the two weeks before Edward Snowden broke news about PRISM I gave two lectures about research ethics. It is traditional to note that what is ethically acceptable is in constant flux as technology changes and also that ethical principles tend to emerge in times of crisis, e.g. human experimentation that is also genocide. An observation that I made during these lectures was that the next crisis is probably going to relate to the use of ‘big data’ repositories in health. Well I didn’t quite nail the health part but bingo! – the use, security and privacy of individual’s data, in this case meta-data from telecommunications, email and text messaging, became the topic of the day.
The public is now aware that there are large repositories of data about themselves. There will start to be greater awareness that some of these data repositories include health records that are collated electronically. Currently, in Australia, these repositories and most other healthcare systems, these repositories are not very detailed but they do record if you’ve been to hospital, why you’ve been to hospital and a host of demographic information. This data is collected legally and is used legally for public health and planning purposes and in many cases for medical research, usually under additional regulation through ethics review processes.
The other bit of information that the public will become aware of is that these repositories of data are linkable. This means that a dataset collected in one system like healthcare is potentially linkable to a dataset in another sector like finance, or the justice system.
The issue becomes how the public, how society reacts to this knowledge and what it believes is reasonable use. The argument in the op-ed pieces in the major publications is that programs like PRISM serve a purpose in protecting the public from security threats. Indeed, surveys of the public in the US suggest that generally speaking people support this assertion. So there are some ‘reasonable uses’ in the public interest. No doubt, the same will apply to health data. The question is where the thresholds lie and how much transparency there will be.
But let’s get back to all of that metadata. Clearly there might be uses for tracking terrorists or gun-owners. But there might be healthcare applications. The concept of small data has recently emerged. The example is the notion that your phone company can track your movements through your mobile phone. If an older person was less active this could show up in their small data and indicate that they are sick. Who does this data belong to? The person or the phone company?
At the moment there are no answers but no doubt there will be trickle down implications from the Snowden affair to other applications like healthcare.
Repurposing old and unsuccessful medications
Sometimes drugs are tested in clinical trials and don’t meet their goals. In many situations this is the end of development for these drugs. Notably, given the amount of science that has gone into development of many agents it is not inconceivable that they could be repurposed to treat difference problems. Sildenafil (Viagra) is a case in point – it started as a treatment for hypertension and ended up being used for erectile dysfunction. This was a chance development and in reality most companies aren’t interested in pursuing further trials in other conditions given the cost of drug development.
In some circumstances there is a superimposed ethical problem. Some trials are stopped for overall lack of benefit but some participants may well have benefited. This often happens for orphan indications. This is actually probably true for most medications – they only work in some of the people that take them, in much the same way that they only cause adverse effects in some of the people that take them. The case of arbaclofen for treating Fragile X syndrome and autism is a recent example http://www.nytimes.com/2013/06/07/business/an-experimental-drugs-bitter-end.html?smid=pl-share
There are however potential ways to overcome the problem of withdrawing a ‘possibly effective therapy’. Regulators are now partnering with industry to deliberately encourage research into discarded medications. Medications which incidentally have been shown to be safe through previous clinical research but ineffective in their original target research. The NIH funds such a program http://www.ncats.nih.gov/research/reengineering/rescue-repurpose/therapeutic-uses/therapeutic-uses.html
A potential pathway in the case of arbaclofen to continue studies in these patients, and also supply of drug, would be crowdsourcing. The owner of the intellectual property – having decided that the product is worthless – could agree to either write-down its’ ownership and make the IP public domain or alternately allow public development with minimal claim on any patent royalties if the product is successfully developed or alternately to retroactively cover costs of development undertaken in the public domain through a limited buy-back of rights – all of these approached would be significantly less expensive than the traditional methods of developing the drug and financing that development. The drug manufacture could no doubt be cheaply outsourced to an Indian manufacturer and study data collection could move to open source models with independent review.
Developing novel methods to pursue drug development both of old and new drugs is important to ensure new treatments are developed and to ensure to viability of an industry which is increasingly poor at developing successful new drugs and increasingly unlikely to have them paid for by cash-strapped healthcare systems.
When policies are too big not to implement: the failure of evidence based policy making
So I attended another administrative meeting today. One of the jobs was to review (& approve) a policy that came from ‘above’. There was a lot of pressure from ‘above’ to implement this policy despite the intention of the Federal Government to support subsidiarity (put simply – local decision making). The fact is that the policy is poor and not-evidence based. Many parties outside our local health district oppose the policy. And in fact our local opponents to the policy could site evidence that it is poor policy. Our ‘local’ decision was to compromise and endorse the policy and produce an in-house business rule to overcome the short-comings of the policy – or, in other words, we’ll endorse it and ignore it. I’ve seen this happen several time before in other guises, for example, yes we endorse the policy but we have no money to implement so we will endorse and do nothing. In the National Standards good governance is the number 1 standard: unfortunately this will be about process rather than outcome. Surely it would be better to reject and develop good policy rather than adapt to bad policy.
Regulation of mHealth apps – let the debate begin
imedicalapps has reported that Apple may be starting to impose tighter restrictions on the approval of mHealth apps through the iTunes store. This follows on the appropriate oversight of the uCheck urine analyzer application (a way for automated reading of urine dipsticks).
The implication of the report is that Apple will only accept medicines information that is endorsed by the manufacturer of the medicine. Whilst this is a liability issue for Apple in some respects it is also fair guidance although one would argue that endorsement of the manufacturer might simply constitute dissemination of medicines information in accordance with the approved Product Information (PI) rather than written endorsement by the manufacturer.
Whilst such an approach is in keeping with law in actual medical practice a large number of medications are used according to valid evidence but outside information in the PI, also known as ‘the label’.
There is an urgency for a public debate about the best way to deal with this issue. Given the number of apps already in existence and the number of medications it is not likely that a regulator or an individual company has the resources to review everything in a timely fashion. The best approach might be to pursue (international) standards as proposed by organisations such as Happtique rather than a draconian regulatory approach.
Just as the NSA scandal has revealed the level of involvement of IT companies in our day to day lives we must also remember that these companies….Apple, Samsung, Google, etc, are now also the largest healthcare providers and the main conduits for health information both for practitioners and patients.
Things they didn’t teach in medical school: Part 28 Keeping up with technology & your patients
One of the things that medical school teaches is the importance of keeping up to date with the latest medical information. Well this is obviously important so that you are administering the most up-to-date treatments. What is not usually included in keeping up to date is keeping up with technology, and importantly, the technologies that your patients will be using. The doctors I know are often early tech adopters in their personal lives but not in work-related use…..healthcare is notorious for its’ slow uptake of electronic health records.
A lot of the technology that has emerged in the last 20 years is only starting to be used routinely in medical practice. Examples include websites to provide health related information or even management, text messaging and emails for communicating with patients, Skype consultations and apps on smartphones. Sometimes we need to take these technologies and use them creatively so that they are more than just electronic versions of paper. For example tablets provide an ideal opportunity to undertake shared decision making activities but more work needs to be done to make this more than eBooks and webpages.
I find the best way to keep up with technology is partly by using it and being an early adopter but also by having diverse information sources. Visual RSS aggregators like Flipboard are great way to find this information, as is subscribing to less than traditional medical journals like The Economist, Wired and Harvard Business Review. The latest place to look is Crowdsourcing websites like Kickstarter and Indiegogo.
Remember….we all like new toys, and some of them are useful.
Jobs for the 21st Century Hospital & Healthcare Systems: Social Media Manager
One of the positions required in the 21st Century is SOCIAL MEDIA MANAGER.
Hospitals may have Communications Managers or Public Relations Managers or occasionally press officers for really large institutions. In my experience these positions are largely about reducing, not increasing, communication with the public and with the hospital’s relevant communities – unless of course there is a good news story.
In the age of social media the hospitals will need social media managers because if they don’t have them their communities will be incorporating them (hospitals) into social media commentary without their input.
Hospitals will worry about negative comments but in general that is fine….in fact some might consider it to be called ‘accountability’. Interestingly social media may help identify hospitals providing quality care: Bardach NS, Asteria-peñaloza R, Boscardin WJ, Adams dudley R. The relationship between commercial website ratings and traditional hospital performance measures in the USA. BMJ Qual Saf. 2012. In this study high Yelp scores correlated with lower readmission rates and mortality.
Social media provides an avenue for the public to provide feedback on hospital performance that may help hospitals undertake quality improvement: so social media is part of a consumer engagement strategy. In addition social media is a channel to keep the community informed about important health information, e.g. a flu-outbreak. Social media could be used to keep the community appraised of opportunities to participate in research. And of course there are fund-raising opportunities.
For the moment the hospital I work in won’t allow staff to access social media at work so I’m not expecting a social media manager any time soon. Sooner or later we’ll have to join the rest of the world.
The business model and bioethics of the anti-aging drug development
In the last month I’ve been to @TEDMED and seen Laura Deming talk about prolonging life. I’ve also been to #TEDxSydney and seen David Sinclair discuss his research in anti-aging drug development. Each week there seem to be new publications in the scientific journals and reaching the mainstream media. There has been success in animals and human trials are in progress.
I don’t need to tell you how obsessed the world is with aging and slowing it down. Even if we get past the issue of vanity the key metric of economic prosperity is probably not per capita GDP but the life expectancy of its’ citizens.
Let me propose that an actual treatment, and I assume it ill be a drug, that slows aging, will be a game changer for how the pharmaceutical industry functions.
If we look at the history of prolonging life expectancy we can really identify a few key transition points that include:
– basic sanitation and food and water security are probably the single most important things for prolonging life. Keeping clean and having regular access to safe food and drink is the starting point. Value adds include refrigeration, electricity (to support heating and cooling) and running potable water). The main impact of these ‘innovations’ is to reduce infectious disease.
– second order innovations include vaccination and antibiotics to fight infectious disease
– the third tier of innovations is prevention and treatment of diseases related to abundance i.e. heart disease, tobacco related illness and although it hasn’t been properly tackled yet, morbidity related to obesity.
I like to say to my patients that they didn’t die from infectious disease in childhood and their heart specialist kept them alive after their heart attack so they can live long enough to get cancer or dementia (or death from complications of frailty). Successful anti-aging drugs will need to not only prolong life but reduce the chances, or at least, not increase the chances of cancer or dementia, and do so in the context that the chronologically aging but not physically aging person is staying fully functional. This is a very important distinction: often doctors will refer to a ‘good 85 year-old’ versus the ‘poor 75 year-old’ as a reference to physiological age not chronological age.
So lets assume this ideal anti-aging drug can be developed and lets assume it is actually very successful i.e. it prolongs functional life in good health by a meaningful period of time….let’s say a decade. What does it mean for the pharmaceutical industry?
Well I think we need to look back at the other game changers in longevity promotion listed above. Access to food, water and sanitation is considered a basic human right. The second and third levels of innovation probably haven’t quite become universal human rights but only in the sense that they are contingent on the first innovation and the reality is that those without access to the 2nd and 3rd set of innovations often haven’t had their universal human rights fulfilled.
So I would make the case that should an anti-aging drug become available, and if it demonstrates tangible flow on health (an other benefits) then access to the drug will become a right rather than a privilege based on economic advantage. In this case there might not be the usual monopoly advantage that pharmaceutical giants usually exert as populations won’t accept it. And remember, it is more than likely the drugs will need to be taken forever, from what ever age is deemed acceptable.
Now it could play out that the usual pathway of drug access occurs and that actually by the time we are really understanding the pros- and cons- of these agents the patents are expiring but I don’t think this is really going to happen. These drugs, if they really meet the aims of prolonging life without complications, will be marketed like Viagra-on-steroids.
Clean water is a universal human right. Who would have thought that internet access would become a universal right but it is rapidly becoming so. A successful anti-aging medication would probably also become a universal right.
Addendum: people will argue we shouldn’t use such drugs because it isn’t how things are meant to be (i.e. we have a natural lifespan). We maybe so but this quite simply isn’t what humans do….we meddle with nature to try and make it (and ourselves) better…..there may be a philosophical argument but it will be trumped by reality.
winstonliauw 