Monday, November 26, 2007

Giuliani wrong on health care

Martin, J. (2007). Rudy: It's time to unmask Romney. Politico. November 26, 2007. Available online: http://www.politico.com/news/stories/1107/7029.html.

After months of provocation, Mayor Giuliani has finally responded to Governor Romney's attacks. Sadly, one of his counter-attacks misses the mark, badly.

“The one thing he’s known for is health care,” Giuliani said, referring to Romney’s signature initiative aimed at insuring all Massachusetts citizens. “And the health care is the thing he’s now abandoned for the rest of the country. It contained a very big mistake, which he realizes is a very big mistake, the mandate.”

The Massachusetts health care plan compels citizens to sign up for their choice of coverage and levies what Giuliani deemed “a tax” on those who don’t. The health care proposal Romney has laid out in the presidential contest includes no such mandate.

“That’s not the way to expand health care,” Giuliani continued. “The way to expand health care is through the program that I’ve talked about, which Mitt Romney has now adopted.”


While I previously applauded Giuliani on health care, here Rudy misses the point of insurance: the pooling of risk. Better and better bioscience, however, will reveal more and more risk, either allowing health care companeis to discriminate against the riskier, or allowing the less risky to opt-out of the system all together, or both. While this has always happened, this will be happening with a far higher degree of precision in the future as the cost of genome sequencing falls to around a thousand dollars.

Wednesday, September 26, 2007

The Cost of the War on Drugs

An Associated Press story, 3 Charged in PC Magazine Editor's Death:

Three men have been charged with murdering a senior editor for PC World magazine in what police said was an attempt to steal marijuana that the victim's son grew in their home for medical use.

Rex Farrance, 59, the San Francisco-based magazine's senior technical editor, was shot in the chest on Jan. 9 after masked men broke into his suburban home.


Prohibition kills.

Monday, September 17, 2007

The Good and Bad of the New Hillarycare

Good:

The former first lady says she has learned from the 1990s experience, which almost derailed Bill Clinton's presidency and helped put Republicans in control of Congress for years to come. Aides say she has jettisoned the complexity and uncertainty of the last effort in favor of a plan that stresses simplicity, cost control and consumer choice.

The centerpiece of Clinton's plan is the so-called "individual mandate," requiring everyone to have health insurance — just as most states require drivers to purchase auto insurance. Rival John Edwards has also offered a plan that includes an individual mandate, while the proposal outlined by Barack Obama does not.


Bad:

Clinton's plan builds on the existing employer-based system of coverage. People who receive insurance through the workplace could continue to do so; businesses, in turn, would be required to offer insurance to employees, or contribute to a government-run pool that would help pay for those not covered. Clinton would also offer a tax subsidy to small businesses to help them afford the cost of providing coverage to their workers.



Of all the candidates, Rudy Giuliani seems to have the best health care plan for the moment.

Friday, August 24, 2007

The End of Private Insurance

Remember my praise of Rudy Giuliani's federally-based health care plan, especially in contrast to John Edwards and Barack Obama's backwords company-centered plan?

Giuliani is not just on the side of the angels, he's on the side of history. At it becomes cheaper and cheaper to sequence a person's genome, we will either face a situation where insurance companies only provide insurance to people they know will be healthy or, atlernatively, only people who believe they will be sick will buy insurance. (In other words, just like now, or worse.)

The solution, however it comes, will have to be risk-pooling at a national level. Giualini's plan starts us down that road. Edwards and Obama, by contrast, offer only a tired repeat of the old industrial state.

Wednesday, August 01, 2007

Giuliani Right on Health Care

Sentora, M. (2007). Giuliani seeks to transform U.S. health care coverage. New York Times. August 1, 2007. Available online: http://www.nytimes.com/2007/08/01/us/politics/01giuliani.html.

Neither his plan nor the article covering it are perfect, but hard not to like this:

Rudolph W. Giuliani on Tuesday called for transforming the way health care coverage is provided in the United States, advocating a voluntary move from the current employer-based system to one that would grant substantial tax benefits to people who buy their own insurance.

..

And to help the poor or others struggling to afford health insurance, Mr. Giuliani said he would support vouchers and tax refunds, but he gave no details about how he would pay for them.

Mr. Giuliani’s vision stands in stark contrast to the plans offered by the leading Democratic candidates. Both Senator Barack Obama of Illinois and former Senator John Edwards of North Carolina have proposed bolstering the employer-based system by requiring corporations to buy insurance for their workers, and raising taxes or rolling back tax cuts to increase subsidies for health care for the poor.


Corporatism, the idea that companies should be simultaneously protected by the government but expected to fund welfare societies for their workers and dependents, is one of those bad ideas that are just hard to killed. From China's State-Owned Companies to Detroit's dinosaurs, too many enterprises and too many workers have been dragged down because governments made the stupid prediction that large companies cannot possibly go bankrupt.

There needs to be some form of universal healthcare, and it should be at least funded by the government through the income tax. Calls for "employer-based healthcare," like from the junior Senator from Illinois and former junior Senator from North Carolina, are steps in the wrong direction.

Wednesday, June 06, 2007

Avandia has a moderate-to-very-large practical effect on heart failure

Home, P.D., et al. Rosiglitazone evaluated for cardiovascular outcomes -- an interim analysis. The New England Journal of Medicine. 5 June 2007. Available online:http://content.nejm.org/cgi/content/full/NEJMoa073394 (via Medical News Today).

Avandia is a drug designed to treat Type II Diabetes. Type 2 Diabetes leads to heart attack, death, and a lot of other bad things. A safe drug that treats it would be very good. Many people think that Avandia (rosiglitazone maleate) is that drug. However, a recent article in The New England Journal of Medicine reported that Avandia has a large-to-very-large effect on patient death. Because this is important news, a new article was rushed to the New England Journal that reported results-so-far of a study that's not completed.

The results section is statistics-y:

Because the mean follow-up was only 3.75 years, our interim analysis had limited statistical power to detect treatment differences. A total of 217 patients in the rosiglitazone group and 202 patients in the control group had the adjudicated primary end point (hazard ratio, 1.08; 95% confidence interval [CI], 0.89 to 1.31). After the inclusion of end points pending adjudication, the hazard ratio was 1.11 (95% CI, 0.93 to 1.32). There were no statistically significant differences between the rosiglitazone group and the control group regarding myocardial infarction and death from cardiovascular causes or any cause. There were more patients with heart failure in the rosiglitazone group than in the control group (hazard ratio, 2.15; 95% CI, 1.30 to 3.57).


Several results are reported here. The most important to consider are practical signifiance and statistical significance . From my statistics notes:

Statistical significance is concerned with whether an observed mean difference could likely be due to sampling error
Practical significance is concerned with whether an observed effect is large enough to be useful in the real world


For instance, imagine that you wish to be more productive, so you buy a new computer . You notice that you get twice as much done in an hour with the computer than without it. The practical significance would be very large (double!). However, you didn't look at enough people to reject the notion that maybe it was just a fluke. So there would not be statistical significance.

A similar thing happened in this study. The last part of the quoted paragraph ("hazard ratio, 2.15") means that, practically speaking, for every heart attack for diabetes type 2 patients who aren't taking Avandia, patients taking Avandia have 2.15 heart attacks. However, the study did not meet statistical significance -- the new research did not look at enough people to say whether or not this very large practical effect was due to chance or not.

A problem with the study -- that the authors note -- is that they are reporting their results too soon. (They are doing this because there is talk of forcing Avandia off the market, which would effect all patients who currently take Avandia and obviously hurt GlaxoSmithKline, the company that makes it.) I have heard anecdotes that one of the side-effects of Avandia is "preamature-aging." If this is true, the negative effects of Avandia would get worse and worse over time. Thus, future research may go from the current two (where all find practical significance, but only one finds statistical significance) to a situation where all find statistical significance.

09:31 Posted in Health Care | Permalink | Comments (0) | Tags: avandia, glaxo, statistics

Thursday, May 31, 2007

A Medical No-Fly List?

Responding to the case of Andrew Speaker -- the carrier of drug-resistant TB who flew on an intercontinental jet and potentially infected fellow passengers from all over the world, Cecilia writes:

The Atlanta lawyer who went to Europe for his wedding and honeymoon despite knowing he had drug-resistant tuberculosis and having been told not to travel is a selfish idiot. I'm sure having to postpone his wedding and honeymoon would have been a hassle, but now a lot of people might be infected, including his wife! TB is a serious illness, it's not something minor like a cold from which people recover after a few days. People could die as a result of his actions.


It's hard to disagree. We have an (admittedly faulty) TSA No-Fly list for potential terrorists, so a Medical No-Fly list is the next logical step in protecting ourselves. Indeed, the attacks of 9/11 may end up making it easier to institute such a No-Fly list because the political fight to keep certain individuals from flying has already been won.

As has been said before:

Rule #1: Super-empowered individuals may rule vertical scenarios, but nation-states still rule horizontal scenarios.


In other words: individuals are able to do great damage in a short amount of time. But countries do great good over long periods of time.

Osama bin Laden and Andrew Speaker are both super-empowered individuals who exploited the modern world to achive their goals, and ended creating outrage. Yet by exposing problems to solutions, they end up making the system more safe and secure than it was before.

Wednesday, May 23, 2007

A "Large" to "Very Large" Effect Size

Those who have been reading tdaxp over the past few months will know why this story is personal.

My first reaction is that the 43% higher risk of heart attacks

Pooled results of dozens of studies on nearly 28,000 people revealed a 43 percent higher risk of heart attack for those taking Avandia compared to people taking other diabetes drugs or no diabetes medication, according to the analysis published online Monday. The study, published by the New England Journal of Medicine, also found a trend toward more heart-related deaths.


Presumably means that .30 of the variation in heart attacks is explained by taking Avandia. This is a "large effect size." It should show up in smaller sized studies. Unless the most recent study is an outlier, it's strange that the effect has not been seen before.

Among worst cases, the increased risk is 64% (presumably, .38 of the variation is explained by taking Avandia). And indeed, apparently the FDA has known about this since 2002:

In 2002, U.S. Food and Drug Administration staff scientists called for reports of congestive heart failure to be included on the label of Avandia as well as Actos, made by Takeda Pharmaceutical Co. Ltd., the group said, citing an internal FDA document.

The group released the memo one day after researchers reported Avandia, or rosiglitazone, raises the risk of cardiovascular-related death by 64 percent and the risk of heart attack by 43 percent.


To me, though, blaming the FDA is like blaming the traffic police for a hit-and-run.

Glaxo strongly objected to the results and defended use of the drug, which treats type 2 diabetes.


I imagine I'll be following this for a while.

03:09 Posted in Health Care | Permalink | Comments (6) | Tags: avandia, glaxo

Thursday, February 08, 2007

Thank you, Mr. Sanford

T. Denny Sanford is a South Dakotan who has done well. He built First Premier Bank and Premeir Bankcard. When he decided to give his fortune away, he attempted to give millions of dollars to the University of Minnesota. However, the Minnesotans rejected his gift. Bad for them, good for us.

Mr. Sanford repurposed most of the money that would have gone to the U of M to the University of South Dakota, helping to expand the medical school at my alma matter.



Then just this month, Denny Sanford made news around the world. He gave four hundred million dollars to Sioux Valley Hospital, (one of the two hub hospitals in Sioux Falls, along with Avera McKennan). The great news hit the New York Times, hit the blogsv, and even hit the Chinese press.



From the Times:

Now, T. Denny Sanford, a low-key billionaire who made his home and fortune here, will help sustain the state’s economic boom with a $400 million gift to the Sioux Valley Hospitals and Health System, the state’s largest employer. Hospital officials hope the gift — the largest ever to a hospital, according to the Center for Philanthropy at Indiana University — will help transform Sioux Valley Hospitals, which will change its name to Sanford Health, into a national institution that will eclipse Johns Hopkins and the Mayo Clinic.

“He told me he doesn’t want this to be just another Mayo,” said Kelby K. Krabbenhoft, Sioux Valley’s chief executive.

It has four stated goals: to build five pediatric clinics around the country; to expand research, especially in pediatrics; to build a health care campus with more than 20 separate facilities, and to identify a promising line of medical research and follow it to a cure, much the same way John D. Rockefeller’s money found a cure for yellow fever and Bill Gates is searching for a cure for H.I.V./AIDS...

Mr. Sanford’s gift is greater than the total assets of $256 million held by South Dakota’s 126 foundations in 2004, according to data compiled by the National Center for Charitable Statistics.



Bigger than Mayo?


Thank you, Mr. Sanford.

Tuesday, February 06, 2007

Information on Pseudomyxoma peritonei

A very close friend of mine gave me the following message yesterday:

you have a larger network than me, could you leave a msg about PMP cancer on your blog somewhere, so if anybody have information, we could get more information

I know it's not appropriate, not necessarily on your blog, any public websites


I've met the sufferer of Pseudomyxoma peritonei and am afraid that I don't know anything more than what's on the wikipedia and national health service pages. It seems very scary and unformtable, but if you have any additional information about this illness, I would appreciate a comment or an email.

22:22 Posted in Health Care | Permalink | Comments (3) | Tags: pmp, cancer, health

1 2 Next