I’m 65 so I forget where I put my car keys and then remember that they’re in the ignition. And that I’m driving.

Well, no, it’s not that bad. But you know that thing where you click on your browser to look something up, you see what’s already loaded, and then it takes a minute to remember what you went there for? That was getting worse, and it was annoying.

I asked my doctor about it. It turns out that my B12 levels were scraping right along the minimum acceptable level — 181pg/ml is the minimum recommended (at least on the test results document I get) and I was at 190, and occasionally a bit lower. So at my doctor’s suggestion I started taking a supplement every day. That was about a year ago. My B12 levels are now 624 (914 is the highest recommended).

I have no external measurement of my short-term memory to go by, but it seems to me to be much better. Not perfect. I still won’t remember your name. But much better.

I ain’t no stinkin’ medical professional, but you can get B12 without a prescription. Best of all, if you take too much, you will pee a cheerful yellow.

By the way, my B12 levels might have been low because I’ve been a vegetarian for 35 years. There’s B12 in eggs and diary, but I probably wasn’t paying enough attention. (See my post about Soylent.)

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I am a delicate little flower. If my body temperature goes up 1%, I lose the ability to understand anything more complex than the Spartacus* series on Starz. I enter a recovery state that can only properly be called “wallowing.”

I have something a bit flu-like. It hit full force on Thursday afternoon. (To the person next to me on the plane: I am truly sorry.) I hope to be sort of back at work on Monday, and to be non-contagious enough to attend the family Seder that night. But in the interim, I’m on my back wondering just how much of my incapacity is due to my privilege. I can take days off. I can sleep in a warm spot. I can watch truly awful cable TV. I can let myself feel miserable.

And in fact, I’m not wondering at all. I know that self-indulgence is 90% of my illness. In fact, like many Americans, I have fond memories of sick days as a child, being brought cocoa and noodle soup by a loving mother, not only certain that I would be well soon, but also dreading the return to normalcy.

It must be a weird, modern, and isolated thing that a class of people can look on some types of illness as a respite, a luxury. When else in history have we had the confidence that a small disease would turn out well and the means to be so pampered while ill?

The new season of Spartacus is bad. In the first season (which I’m not proud of having watched), because the show was willing to kill off characters, there was something at risk in the fights. It was a bit like Project Runway with swords. This new season is all hackity hackity, constantly surly characters, gratuitous nudity, and low growling voices I can’t understand but don’t need to. It’s spurring me to get well so I won’t have to watch it.

If I could give the show three things, my gifts would be:

1. Definite articles

2. Indefinite articles

3. Some nice trousers. Maybe gaberdine.

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Science Commons, in its relentless drive for product line expansion (I kid because I love), has posted a white paper proposing a Health Commons. In it, the authors, Marty Tenenbaum and John Wilbanks, lay out the problems and suggest a solution.

They write:

We are no longer asking whether a gene or a molecule is critical to a particular biological process; rather, we are discovering whole networks of molecular and cellular interactions that contribute to disease. And soon, we will have such information about individuals, rather than the population as a whole. Biomedical knowledge is exploding, and yet the system to capture that knowledge and translate it into saving human lives still relies on an antiquated and risky strategy of focusing the vast resources of a few pharmaceutical companies on just a handful of disease targets.

After citing more problems with the current system, the authors propose a Health Commons:

Imagine a virtual marketplace or ecosystem where participants share data, knowledge, materials and services to accelerate research. The components might include databases on the results of chemical assays, toxicity screens, and clinical trials; libraries of drugs and chemical compounds; repositories of biological materials (tissue samples, cell lines, molecules), computational models predicting drug efficacies or side effects, and contract services for high- throughput genomics and proteomics, combinatorial drug screening, animal testing, biostatistics, and more. The resources offered through the Commons might not necessarily be free, though many could be. However, all would be available under standard pre-negotiated terms and conditions and with standardized data formats that eliminate the debilitating delays, legal wrangling and technical incompatibilities that frustrate scientific collaboration today.

The paper emphasizes the need for metadata standards: “Providing such standards, Heath Commons improves and extends the public domain by
integrating hundreds of public databases into a single framework…” The Commons also provides the needed “social and legal infrastructure,” and a portal that provides the right set of services.

They hope that by lowering research costs, some of the 5,000 tropical diseases currently “uneconomical to address,” for example, will become the target of pharmaceutical R&D. “Health Commons makes it cost effective for small groups of researchers to conduct industrial scale R&D on rare diseases by exploiting the economies of scale afforded by an ecosystem of shared knowledge…”

The authors see the benefits going beyond the Commons’ value to non-profits. “Every pharmaceutical company sits on a wealth of promising targets and leads that they won’t develop themselves.”

The Health Commons could be a huge step forward. But it will take some work. “To realize the full potential, existing companies need to rethink their business models to leverage the commons.” As an example, the paper points out that “Only six out of the 1800 biotechnology companies funded since 1980 have made more money than was cumulatively invested in them.” Rather than counting striking it rich with proprietary drugs discovered via proprietary R&D platforms, perhaps companies could profit by opening up their platforms and taking a cut of any drugs discovered with them.

Finally, Health Commons will provide a way to continuously publish research, along with comments, to supplement the traditional publishing model.

Health Commons can and should be a big deal. It requires lots of pieces coming together over time, but its acknowledgment of the role of profit is encouraging, and it is in the hands of serious, committed, and wickedly smart people. [Tags: health science science_commons health_commons pharma everything_is_miscellaneous ]

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Ashish Jha at the Harvard School of Public Health is giving a Berkman lunch talk on “U.S. Healthcare: Can Information Drive Better Care?” [Note: I am typing quickly, getting things wrong, missing stuff…]

He says the first few minutes should leave us depressed about the state of health care in this country. A major problem underlying all this, he says, is a lack of transparency.

We spend $2.1 trillion dollars on health care in the U.S. in 2006. That’s about a sixth of the economy, about $7,000 per person (minimum wage is $11K/yr). It’ll be a fifth in the next decade. We spent a much bigger percentage of our GDP than other countries.

What do we get for this, Ashish asks. He cites a Rand study that came up with 439 “indicators of healthcare quality.” These are core, non-controversial treatments and practices. Rand found they get done about 54% of the time, suggesting “the care we get is pretty inadequate.” Even for privileged groups — e.g., white, wealthy, educated men — it doesn’t go much above 58%. “There’s a disconnect between what doctors think they do and what they actually do.” One of the listeners says that recent studies show that this is because there are typically 7 health care people involved with any one medicare patient, and they don’t get this done because they don’t know what others in the group are doing. “It’s completely about the system,” says Ashish.

He continues depressing us: About 10% of people admitted to hospitals suffer an injury there. One in four doctor visits lead to medication injury. (Ashish says he’s not confident in that study.) 44k-98k deaths come from medical errors.

His conclusion: The quality of care is unacceptable.

Why? 1. Because we pay for the quantity, not quality, of health care. 2. Care has gotten complex, but the health care systems haven’t kept up. 3. Little transparency. E.g., usually we don’t usually know how much our medical care actually costs (as opposed to what our co-pay is). We know how much health care for our pets costs, but not for our children. 4. No adequate feedback loop: Medical malpractice has been a failure and regulation sets the bar too low.

Ashish talks about one part of the response: The Ny State Cardiac Surgery reporting program. In the early 1990s, NY found huge disparities in cardiac surgery mortality across 31 hospitals: 1 in 200 dying vs. 1 in 14. So the state started publishing mortality info about every hospital and surgeon. As of about 2000, it’s all on the Internet. Over the course of 12 years, the rates dropped dramatically. Why? The market share of the hospitals didn’t change; the bad hospitals didn’t lose business. But the hospitals now had data that reinforced good practices. There’s anecdotal data that physicians began to learn from one another. Most dramatically, the rate of surgeons leaving their practices among the bottom fourth was way higher. Ashish’s project tracked them: Some quit, some moved. Even after adjusting for age, etc., people in the bottom quarter were 3x likely to quit.

People don’t check the ratings. Ashish thinks this is a place where the Internet could help.

90% of hospitals are still paper-based. Even those that are electronic can’t share info. The law says patients always have a right to get their records, but the doctor or the hospital owns the record. Patients can view it but it’s not in exportable, shareable form. (There’s a discussion about the state of electronic health records and why it’s a more complex problem than it seems.)

Ashish says that the HQA initiative has hospitals reporting on 23 quality indicators, and performance has improved steadily. HCAHPS makes patient experience data available.

Gene Koo: Health care decisions aren’t made by purely rational agents. All sorts of quirks come into it. So, how does the transparency of info help us?
A: Maybe consumer involvement in health care won’t work out. I’m looking for empirical data.

Q: What’s the role of the consumer in this? Are there data now that consumers are taking on more of the responsibility for their health care?,br>
A: People on the right say that consumers aren’t behaving like consumers because they don’t have any skin in the game. You don’t know how much things cost. So, we need transparency (they say), linked to having skin in the game (i.e., you pay for visits out of your pocket). But, few have high deductible health plans. My personal feeling (says Ashish) is that this isn’t going to be big. People are generally in them not because they want to be involved but because the plans are cheap.

Rob Faris: There’s a huge role for intermediaries. Intermediation is not working well right now. We need intermediaries who looks at outcomes and figures out what works and what doesn’t. And I’d like to see how quality considerations can be inserted into this.
A: We’re at the beginning of a very interesting journey. If someone like you can’t navigate the health care system…

Q: What do you think of the candidates’ positions?
A: They all talk about the uninsured, which is just one part of a complicated set of issues. We have 47M uninsured because health care is expensive. Most of the health experts I talk with think Clinton’s health plan is a little more realistic. But all of this falls apart if we can’t get a grip on healthcare costs. They’re rising at twice the rate of inflation, and neither Obama nor Clinton have gotten serious about healthcare costs.

Q: (me) How do you contain costs?
A: Electronic records would help. Payers should pay more for outcomes not for particular tests, etc. And there;s a whole “comparative effectiveness” movement. E.g., what do you do for someone with low back pain? You get different treatments based on locality. Payers should start taking more of an active role. But payers have not wanted to take up that responsibility.

A (person in the audience): Part of the answer is that the amt of money spent in the last 6 months of life is shockingly high. We should spend more earlier on preventative measures.

Ashish: You don’t always know when the 6 months are. And there’s a huge issue around managing expectations at the end of life. Plus, when someone else is paying…From a policy point of view, it’s very hard to fix this stuff. Even though health reform comes up every five years, it doesn’t get done because the status quo is everyone’s second choice. [Tags: berkman healthcare health ashish_jha ]

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