Originally posted at: http://onyeije.posterous.com/
One of the many problems faced by the healthcare delivery system is the way in which doctors are reimbursed for their work and the relationship of this reimbursement to clinical outcomes. In a fascinating article in the New Yorker, Atul Gawande writes about the spectrum of physician practice patterns and reimbursement.
Dr. Gawande writes that in order to bring spending for medicine under control it will be necessary to encourage efficiency in spending. Essentially, how can we get great outcomes while spending less; rather than spending a great deal to get little or no benefit.
Dr. Gawande compares the expenditures iin McAllen Texas to those in El Paso and the Mayo Clinic.
Highlights from the article:
- McAllen - Extremely high medical costs.
- El Paso and Mayo - Much lower medical costs.
- Outcomes: McAllen patients DO NOT have appreciably better medical outcomes in comparison to those in El Paso or the Mayo Clinic.
- Reason for Discrepancy: McAllen doctors have an incentive to “do more” and treat patients as revenue streams
Another interesting perspective on this problem of Quantity vs. Quality was provided by Jay Parkinson in a recent edition of Fast Company.
Both articles are required reading for those interested in healthcare reform.
Researchers conclude that their findings do not indicate any adverse effects of exercise on the risk of a preterm birth and do not conflict with the current recommendations. In addition to the health benefits of exercise during pregnancy, light to moderate exercise can make you feel better as well as prepare your body for the rigors of childbirth. Even better, the more fit you stay while pregnant, the quicker your postpartum recovery and getting your pre-pregnancy body back.
http://www.sheknows.com/articles/805748.htm
Some more information from Mike roussell.
Okay,
This is somewhat confusing, but I guess the “take home point” is Working Harder is Better.
Check it out.
http://giving-birth.blogspot.com/2008/09/pregorexia_06.html
This is a post regarding pregorexia. After reading this post I am aware that pregorexia remains a concern.
Sent from Onyeije’s Verizon Wireless BlackBerry
Adapted from OB-Focus
17OHPC is a synthetic progesterone similar in structure to medroxyprogesterone acetate (MPA). Molecular weight: 428.62 [1].
17OHPC is used to decrease the chance of recurrent preterm birth.
In 1956 17 alpha-hydroxyprogesterone caproate (17 OHP-C) was approved under the trade name Delalutin® (NDA 10-347) for use in pregnant women for the treatment of habitual and recurrent abortion, threatened abortion, and post-partum “after pains”. In 2000 the Food and Drug Administration (FDA) withdrew approval for Delalutin® at the request of the holder of the New Drug Application (NDA), Bristol-Myers Squibb Co, because the company was no longer marketing the drug.
In 2003 a large randomized placebo-controlled trial conducted by the National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units Network found a significant reduction in recurrent preterm birth before 37 weeks for women who received 17OHP-C versus a control group receiving placebo (36.3% versus 54.9%) [14].
Treatment with 17-OHPC seems to be most effective in prolonging pregnancy in women with a history of previous spontaneous singleton delivery before 34 weeks gestation [5,6]. 17-OHPC appears to be ineffective in preventing preterm birth in multiple gestation in the regimens used to date [7,17].
When I first read this I thought it was a joke. I am still in a state of shock that a health care advisor for Republican candidate John McCain would actually say it.
But here it is, from McCain Healthcare advisor John Goodman as quoted in the Dallas News:
“…the numbers are misleading, … anyone with access to an emergency room effectively has insurance, albeit the government acts as the payer of last resort.”
“So I have a solution. And it will cost not one thin dime,” Mr. Goodman said. “The next president of the United States should sign an executive order requiring the Census Bureau to cease and desist from describing any American – even illegal aliens – as uninsured. Instead, the bureau should categorize people according to the likely source of payment should they need care.
“So, there you have it. Voila! Problem solved.”
WHAT ON EARTH IS THIS MAN TALKING ABOUT?
Mr. Goodman is the President and CEO for the National Center for Policy Analysis.
Mr Goodman. Emergency room health care for the indigent and uninsured IS NOT the same thing as a Government sponsored health insurance. Any novice in public health and government policy should see that.
- People without insurance are less likely to seek care
- Care that is obtained late (as an emergency) is more expensive and prone to less than optimal outcomes.
- Physicians providing this care in the emergency room are NOT compensated in the same manner as if they were providing care to insured patients.
- Emergency room care is not capable of providing ongoing chronic care, short term follow-up or subspecialty services. You cannot give prenatal care or chemotherapy in the emergency room.
Amazing.
You would think that he would know better.
Tags: health care, politics, uninsured
This is interesting information and perhaps a change in the way that we evaluate patients for preterm labor.
The FDA has recently approved amniscreen as an at home test to determine whether or not a patient is leaking amniotic fluid:
This actually sounds like a fairly good idea for the proper patient. Currently, when a patient has fluid leakage from the vagina during pregnancy, she must either come in to the hospital or her doctor’s office to be evaluated by something called a nitrazine test. The test is similar to the amniscreen in that it uses a pH reaction to determine if the patient is actually leaking fluid (and is at risk for premature birth).
For many patient’s the nitrazine test is negative and the resultant evaluation has occupied time from the patient and resources from the doctor’s office and hospital staff. Moving the first part of this evaluation to the patient’s home (if done properly) will allow for improved triage and optimal utilization of resources.
This is an important study and perhaps much needed information regarding the difficult time that we as physicians have in determining the causes of premature birth.
This article has been recently quoted in a number of sources including:
US News and World Report , CBS News, and The Washington Post.
Here is a synopsis from Medpage
By Judith Groch, Contributing Writer, MedPage Today
Published: August 26, 2008
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San FranciscoSTANFORD, Calif., Aug. 26 — Previously unrecognized culture-resistant microbes in amniotic fluid may be a significant cause of premature birth, according to a retrospective study.
An analysis using both culture and polymerase chain reaction (PCR) of amniotic fluid from women in preterm labor found that 15% of the fluid samples harbored bacteria or fungi, a 50% increase over the 10% detected by conventional culture, Daniel B. DiGiulio, M.D., of Stanford University, and colleagues reported in the August 26 issue of PLoS ONE.
The heavier the burden of infection, the more likely the women were to deliver younger, sicker infants, the researchers said.
The clinical question that remains is whether or not TREATING amniotic fluid infections with antibiotics will improve outcomes for pregnant patients in preterm labor. Current evidence based recommendations suggest that patient’s with imminent preterm birth should recieve antibiotics to avoid infection with Group B Strep once they are in labor and in many hospitals, patient’s continue to recieve antibiotics with threatened premature birth. This study provides food for thought on a few fronts.
- It is concievable that many patient’s in premature labor actually receive antibiotics which are not effective against the agent that is causative of their preterm labor. In this situation, antibiotics are ineffectual at best and may worsen the situation by allowing growth of selective growth of resistant organisms at worst.
- Traditional teaching is that an infection in the uterus should be treated by antibiotics and evacuation of the contents of the uterus. We may be trying to keep fetuses in utero, which are best delivered.
- Perhaps the solution would be to determine which organism is present (if any) and then determine the optimal treatment (ie, antibiotics, delivery, tocolysis + antibiotics, antibiotics + delivery, etc)
Clearly, more research is necessary in this important area.
One of the most challenging aspects of being a physician in the era of instant access to information is the fact that patients can obtain unsubstantiated information from unreliable sources and give this evidence the same (or greater) weight as the considered experts of medical specialists.
For some time now there have been concerns that vaccines in general and the measles vaccine in particular are either related to or cause autism. To date, there is no definitive scientific evidence that that is the case. The proponents of such theories are often financially benefitting from these claims which mislead health care consumers. They also provide no justification or explanation as to why the medical community would knowingly place children at risk.
Now we have news from the CDC which indicates that the number of measles cases in the United States is rising; and that outbreaks are generally due to children that have not been immunized.
Within the blogosphere, there are already some authors, that are indicating that the rise in cases is not important.
Unfortunately, it is altogether too easy to lose sight of the significant benefits of the measles vaccine after years of it’s unmitigated success in the United States.
I would suggest that interested parties review this statistic:
Worldwide, the World Health Organization indicates that measles results in the s of 242,000 children annually. That represents 663 children per day or 27 children per hour.
Most of these cases occur in the developing world, and I am certain that those mothers would greatly appreciate the benefits of measles (or any other) vaccination.
Please correct me if I’m wrong, and I realize that this might be a pointless rant, but, I remain concerned that the focus on these (unseen) women who are starving themselves while pregnant will result in unintended consequences for the general population.
The fact of the matter is that from a nutritional point of view, far too many pregnant patient’s eat too much of the wrong things and do not exercise. This is a recipe for far greater public health problems than Pregorexia could ever become.
Certainly there are individuals with eating disorders for whom professional intervention will be necessary, but, it would appear that the hoopla regarding pregorexia is mis-placed and that we as a society should focus far more energy and attention on improving nutrition for the vast majority of pregnant patients.
Tags: fitness, pregnancy, pregorexia, weight loss
