Medicine

Austin Frakt tells us:

The biggest hurdle may be state medical boards. Idaho’s medical licensing board punished a doctor for prescribing an antibiotic over the phone, fining her $10,000 and forbidding her from providing telemedicine. State laws that restrict telemedicine — for instance, requiring that patients and doctors have established in-person relationships — have drawn lawsuits charging that they illegally restrict competition. Georgia’s state medical board requires a face-to-face encounter before telemedicine can be delivered, while Ohio’s does not.

A study by Julia Adler-Milstein, an assistant professor at the School of Information and the School of Public Health, University of Michigan, found that such state laws and medical board requirements influence the extent of telemedicine use by hospitals. While 70 percent or more hospitals in Maine, South Dakota, Arkansas and Alaska use telemedicine, only 13 percent in Utah and none in Rhode Island do, for instance.

In a passionate commentary on the establishment’s hesitancy to embrace telemedicine, David Asch, a University of Pennsylvania physician, pointed out that the inconvenience of face-to-face care limits its use, but arbitrarily and invisibly. The costs of waiting and travel time and those borne by rural populations with poor access to in-person care don’t appear on the books. “The innovation that telemedicine promises is not just doing the same thing remotely,” Dr. Asch wrote, “but awakening us to the many things that we thought required face-to-face contact but actually do not.”

Here is the full NYT account.

Third-grader Andrew Calabrese carries his backpack everywhere he goes at his San Diego-area school. His backpack isn’t just filled with books, it is carrying his robotic pancreas.

The device, long considered the Holy Grail of Type 1 diabetes technology, wasn’t constructed by a medical-device company. It hasn’t been approved by regulators.

It was put together by his father.

Jason Calabrese, a software engineer, followed instructions that had been shared online to hack an old insulin pump so it could automatically dose the hormone in response to his son’s blood-sugar levels. Mr. Calabrese got the approval of Andrew’s doctor for his son to take the home-built device to school.

The Calabreses aren’t alone. More than 50 people have soldered, tinkered and written software to make such devices for themselves or their children. The systems—known in the industry as artificial pancreases or closed loop systems—have been studied for decades, but improvements to sensor technology for real-time glucose monitoring have made them possible.

The Food and Drug Administration has made approving such devices a priority and several companies are working on them. But the yearslong process of commercial development and regulatory approval is longer than many patients want, and some are technologically savvy enough to do it on their own.

Here is the Kate Linebaugh story, interesting throughout, via Adam Thierer and Eli Dourado.

We have heard a great deal about increases in mortality among white, non-hispanic, middle-aged Americans (especially women) but to state the case is also to note that this is one group among many. In an excellent new paper, Currie and Schwandt discuss the good news overall–life expectancy is up and health inequality is down, in some cases dramatically. Here, for example, is life expectancy at birth by gender and year.

Life expectancy 1Even more impressive is that life expectancy has increased significantly across all poverty groups (as measured by county poverty levels). In the graph below, for example, the blue triangles indicate life expectancy in 1990 (men on the left, women on the right). Note that as the poverty level of the county increases along the horizontal axis life expectancy falls. The green dots are life expectancy in 2010. Once again, as poverty increases, life expectancy falls. What’s remarkable, however, is how much life expectancy increased between 1990 and 2010 in counties of all poverty levels.

The news is good and may get better. Between 1990 and 2010 mortality rates for children ages 0-4 fell especially dramatically and especially so in poor counties. Moreover, since mortality at older ages is often baked in LifeExpectancy 2by poor health at younger ages there is significant opportunity for these gains to persist over time.

The New York Times also reported yesterday on inequality in life expectancy across race. It’s down.

Infant mortality is down by more than a fifth among blacks since the late 1990s, double the decline for whites. Births to teenage mothers, which tend to have higher infant mortality rates, have dropped by 64 percent among blacks since 1995, faster than for whites.

Blacks are still at a major health disadvantage compared with whites. But evidence of black gains has been building and has helped push up the ultimate measure — life expectancy. The gap between blacks and whites was seven years in 1990. By 2014, the most recent year on record, it had shrunk to 3.4 years, the smallest in history, with life expectancy at 75.6 years for blacks and 79 years for whites.

Part of the reason has been bad news for whites, namely the opioid crisis. The crisis, which has dominated headlines — some say unfairly, given racial disparities — has hit harder in white communities, bringing down white life expectancy and narrowing the gap.

But there also has been real progress for blacks. The rate of deaths by homicide for blacks decreased by 40 percent from 1995 to 2013, according to Andrew Fenelon, a researcher with the National Center for Health Statistics, compared with a 28 percent drop for whites. The death rate from cancer fell by 29 percent for blacks over that period, compared with 20 percent for whites.

The Currie and Schwandt paper is also very good on describing how these estimates are produced and some of the data issues with making these estimates. It’s a must read for those interested in these issues.

Deaths from opioid pain reliever overdose in the United States quadrupled between 1999 and 2013, concurrent with an increase in the use of the drugs. We used data from the Medical Expenditure Panel Survey to examine trends in opioid pain reliever expenditures, financing by various payers, and use from 1999 to 2012. We found major shifts in expenditures by payer type for these drugs, with private and public insurers paying a much larger share than patients in recent years. Consumer out-of-pocket spending on opioids per 100 morphine milligram equivalents (a standard reference measure of strength for various opioids) declined from $4.40 to $0.90 between 2001 and 2012. Since the implementation of Medicare Part D in 2006, Medicare has been the largest payer for opioid pain relievers, covering about 20–30 percent of the cost. Medicare spends considerably more on these drugs for enrollees younger than age sixty-five than it does for any other age group or than Medicaid or private insurance does for any age group. Further research is needed to evaluate whether payer strategies to address the overuse of opioids could reduce avoidable opioid-related mortality.

That is from Zhou, Florence, and Dowell, via the excellent Kevin Lewis.

Analysts who have concluded that inequality in life expectancy is increasing have generally focused on life expectancy at age 40 to 50. However, we show that among infants, children, and young adults, mortality has been falling more quickly in poorer areas with the result that inequality in mortality has fallen substantially over time. This is an important result given the growing literature showing that good health in childhood predicts better health in adulthood and suggests that today’s children are likely to face considerably less inequality in mortality as they age than current adults.

We also show that there have been stunning declines in mortality rates for African-Americans between 1990 and 2010, especially for black men.

That is from Janet Currie and Hannes Schwandt.

The BBC has an interesting report on ambulance services in Beijing.  Up until now, ambulance drivers could decide themselves how much to charge people for their services.  I’m assuming these weren’t listed or known beforehand either.  This seems ripe for abuse given that the patient will be desperately wanting to get to the hospital and in no state for bargaining.  According to the article, most Chinese on social media didn’t even know that ambulances charge at all.  That must come as a big shock then when they get hit up by the driver.

So what did authorities decide to do?  Decree that ambulances “be fitted with taxi-style meters in an effort to allay public concerns about overcharging.”  Hmm, this doesn’t seem to be the most incentive compatible policy either.  As one social media cynic (read: realist) pointed out, “Don’t rule out ambulances taking a detour when using the meter.”  At least when you’re in the backseat of a cab, you can watch where the driver is going.  In the back of an ambulance in an emergency situation, that’s not going to be very feasible!  Don’t get me wrong, I’m in no way advocating free ambulance services, but there has to be a better policy than this.

That is from Cherokee Gothic.

It is also an example of great achievements in light of a disability:

As a teenager, following a severe head injury—the result of her efforts to protect another slave—Tubman developed a lifelong, chronic condition, with debilitating symptoms that have been described as being similar to those of narcolepsy and temporal lobe epilepsy.

Here is that source.  Here are many other sources.

Now here’s the bad news: There is plenty in the media today about Tubman being female and black, but I haven’t seen a single story even mention this angle.  Will anyone cover it?  I hope so but I fear not.

So long, good Samaritans.

In the first study of its kind, Cornell sociologists have found that people who have a medical emergency in a public place can’t necessarily rely on the kindness of strangers. Only 2.5 percent of people, or 1 in 39, got help from strangers before emergency medical personnel arrived, in research published April 14 in the American Journal of Public Health.

For African-Americans, these dismal findings only get worse. African-Americans were less than half as likely as Caucasians to get help from a bystander, regardless of the type of symptoms or illness they were suffering – only 1.8 percent, or fewer than 1 in 55 African-Americans, received assistance. For Caucasians, the corresponding number was 4.2 percent, or 1 in 24.

People in lower-income and densely populated counties were also less likely to get help, the researchers said. Conversely, those in less-densely populated counties with average socioeconomic levels were most likely to get assistance.

Here is more, via Charles Klingman.

More Lead, More Crime

by on April 16, 2016 at 7:28 am in Economics, Medicine | Permalink

In the second half of the nineteenth century, many American cities built water systems using lead or iron service pipes. Municipal water systems generated significant public health improvements, but these improvements may have been partially offset by the damaging effects of lead exposure through lead water pipes. We study the effect of cities’ use of lead pipes on homicide between 1921 and 1936. Lead water pipes exposed entire city populations to much higher doses of lead than have previously been studied in relation to crime. Our estimates suggest that cities’ use of lead service pipes considerably increased city-level homicide rates.

That’s from Feigenbaum and Muller in Lead Exposure and Violent Crime in the Early Twentieth Century. Lead, it ain’t just about Flint.

There is a new Raj Chetty paper out in JAMA ( with seven co-authors, including David Cutler), and it is garnering a lot of media attention.  Here is to my mind the main result, although it is not being presented as such (NYT here):

The JAMA paper found that several measures of access to medical care had no clear relationship with longevity among the poor. But there were correlations with smoking, exercise and obesity.

I enjoyed the NYC angle from Margot Sanger-Katz:

New York is a city with some of the worst income inequality in the country. But when it comes to inequality of life spans, it’s one of the best.

Impoverished New Yorkers tend to live far longer than their counterparts in other American cities, according to detailed new research of Social Security and earnings records published Monday in The Journal of the American Medical Association. They still die sooner than their richer neighbors, but the city’s life-expectancy gap was smaller in 2014 than nearly everywhere else, and it has shrunk since 2001 even as gaps grew nationwide.

That trend may appear surprising. New York is one of the country’s most unequal and expensive cities, where the poor struggle to find affordable housing and the money and time to take care of themselves.

But the research found that New York was, in many ways, a model city for factors that seem to predict where poor people live longer. It is a wealthy, highly educated city with a high tax base. The local government spends a lot on social services for low-income residents. It has low rates of smoking and has many immigrants, who tend to be healthier than native-born Americans.

Here is the accompanying NYT graphic about “your county.”  Here is Emily Badger and Christopher Ingraham, good graphics too:

The poor live shorter lives in Las Vegas, Louisville and industrial Midwest towns, such as Gary, Ind. Geography also matters much more for the poor than the rich. The health behaviors of the wealthy are similar wherever they live. For the poor, their likelihood of risky behaviors such as smoking depends a great deal on geography, on whether they live in a place where smoking is common or where, as in San Francisco, cigarettes have been shunted out of view.

It’s almost as if health care policy should be local in orientation.  The link to the paper includes three comments, including one by Angus Deaton.

After Easter was sedated, the surgeon recounted their dispute to the other doctors. “She’s a handful,” he said in the recording. “She had some choice words for us in the clinic when we didn’t book her case in two weeks.”

“She said, ‘I’m going to call a lawyer and file a complaint,’” he recalled with a laugh. (Easter said she never mentioned a lawyer.)

“That doesn’t seem like the thing to say to the person who’s going to do your surgery,” another male voice retorted.

The comments afterward became personal. The surgeon and the anesthesiologist repeatedly referred to her belly button in jest. “Did you see her belly button?” one doctor said, followed by peals of laughter.

At another point in the procedure, the anesthesiologist appeared to refer to Easter as “always the queen,” to which the surgeon responded, “I feel sorry for her husband.”

The surgeon also used the name “Precious” several times in a manner that Easter interpreted as racial.

…After the doctors concurred that there had been many “teaching moments” that day, the anesthesiologist asked, “Do you want me to touch her?”

“I can touch her,” the surgeon is heard saying.

“That’s a Bill Cosby suggestion,” someone interjected. “Everybody’s got things on phones these days. Everybody’s got a camera.”

Here is the full story.

There is a new NBER paper on this topic, by Victoria Y. Fan, Dean T. Jamison, and Lawrence H. Summers, here is the abstract:

Estimates of the long-term annual cost of global warming lie in the range of 0.2-2% of global income. This high cost has generated widespread political concern and commitment as manifested in the Paris agreements of December, 2015. Analyses in this paper suggest that the expected annual cost of pandemic influenza falls in the same range as does that of climate change although toward the low end. In any given year a small likelihood exists that the world will again suffer a very severe flu pandemic akin to the one of 1918. Even a moderately severe pandemic, of which at least 6 have occurred since 1700, could lead to 2 million or more excess deaths. World Bank and other work has assessed the probable income loss from a severe pandemic at 4-5% of global GNI. The economics literature points to a very high intrinsic value of mortality risk, a value that GNI fails to capture. In this paper we use findings from that literature to generate an estimate of pandemic cost that is inclusive of both income loss and the cost of elevated mortality. We present results on an expected annual basis using reasonable (although highly uncertain) estimates of the annual probabilities of pandemics in two bands of severity. We find:

1. Expected pandemic deaths exceed 700,000 per year worldwide with an associated annual mortality cost of estimated at $490 billion. We use published figures to estimate expected income loss at $80 billion per year and hence the inclusive cost to be $570 billion per year or 0.7% of global income (range: 0.4-1.0%).

2. For moderately severe pandemics about 40% of inclusive cost results from income loss. For severe pandemics this fraction declines to 12%: the intrinsic cost of elevated mortality becomes completely dominant.

3. The estimates of mortality cost as a % of GNI range from around 1.6% in lower-middle income countries down to 0.3% in high-income countries, mostly as a result of much higher pandemic death rates in lower-income environments.

4. The distribution of pandemic severity has an exceptionally fat tail: about 95% of the expected cost results from pandemics that would be expected to kill over 7 million people worldwide.

In other words, in expected value terms an influenza pandemic is a big problem indeed.  But since, unlike global warming, it does not fit conveniently into the usual social status battles which define our politics, it receives far less attention.

Most people dread going to the dentist’s for a check-up.

But the London-based dental boutique YourDentist.co.uk is changing dentistry’s reputation by offering nervous patients a luxury experience that includes a Bentley car service, a concierge lounge, and accommodation in 5-star hotels.

The high-end practice — which claims to be one of the world’s only 7-star dental boutiques on its website — was established in 2013, and moved to its flagship location on Harley Street in 2015.

The surgery also partners with clinics across the UK that “fit within a luxury private practice environment,” and considers its business model as “very similar to Uber or Airbnb.”

The story is here, via the excellent Samir Varma.

Catherine Rampell’s excellent column considers the case for a soda tax in Britain.  Here is one bit:

Why not just target the output, rather than some random subset of inputs? We could tax obesity if we wanted to. Or if we want to seem less punitive, we could award tax credits to obese people who lose weight. A tax directly pegged to reduced obesity would certainly be a much more efficient way to achieve the stated policy goal of reducing obesity.

Of course, “fat taxes,” even when framed as weight-loss tax credits, seem pretty loathsome. Why is . . . unclear.

We tax soda instead, even though that is less effective, for instance because soda drinkers may substitute into other sugary beverages.  We are unwilling to humiliate the obese by taxing them directly, and so our chosen policies do less to help…the obese.  (That’s assuming that attempting to shift their consumption behavior helps them at all, which is debatable.)  As Robin Hanson has told us many times, politics isn’t about policy…

Opportunity!  That is from Justin Wolfers.