Prevention

If you ran a summer camp that never reported the vast majority of times that you hurt one of your campers, you'd probably be shut down, arrested, or worse. The situation would be similar if a restaurant repeatedly made customers sick, or if a skydiving business habitually gave people the wrong parachutes.

Why, then, do hospitals only report about one in seven of the hundreds of thousands of medical errors, infections, and other adverse events that harm patients every year? And why can they get away with it?

That's a crucial question posed by Shannon Brownlee's most recent piece on TIME Ideas: An American Hospital: The Most Dangerous Place? Brownlee addresses the recent report from the US Department of Health and Human Services, which catalogued problems with the reporting system for medical errors and other patient harm. She argues that the reporting problems are only a piece of a larger quality and safety problem, and that hospitals need to move quickly to adopt checklists and other types of safety mechanisms:

"Some hospitals have made great strides in reducing errors and infections using — you guessed it — checklists. About 10 years ago, Dr. Peter Pronovost, an intensive-care specialist at Johns Hopkins Hospital in Baltimore, and a team of colleagues put together a series of checklists for some of the most common procedures performed in the intensive-care unit. For example, they created a list of steps for how to put in a central line — a tube for delivering medication directly into a vein in the patient’s chest — in a way that reduced the risk of infection. They made a checklist to prevent patients on a ventilator, or breathing machine, from contracting pneumonia. When Pronovost was given a grant to get every ICU in the state of Michigan to use just three of his checklists, the result was 1,500 lives saved and the state of Michigan saved $100 million."

You can read the full story here: http://ideas.time.com/2012/01/09/american-hospitals-the-most-dangerous-place/

It's just a guess, but I doubt concrete would rank high on a list of the world's most loved materials. From Belgrade to Brixton, the antiseptic, brutalist tower blocks of wannabe Le Corbusiers have become eyesores -- vertical slums infested with graffiti and gangs. Twenty-lane highways in Houston are not generally considered a thing of beauty to anyone but transportation engineers. And for each megawatt of electricity produced by China's enormous Three Gorges Dam -- the world's largest concrete construction project -- roughly 77 people were booted from their homes.

During one of our recent events, Sheldon Garon of Princeton University and Ray Boshara of the Federal Reserve Bank of St. Louis referred to the weak household balance sheet as one of the core economic challenges of our time, suggesting that households must focus on asset-building rather than rely on credit and debt.

This made our day yesterday. Many thanks to the astute reader who sent it in.

Shannon Brownlee's recent piece on TIME Ideas is sure to provoke some vehement reactions. Here's her conclusion:

"Maybe it’s time to be at least a little more willing to similarly demonize excess poundage. Our rapidly rising rate of obesity harms us financially, because we pay for health care collectively. Insurance premiums paid by the healthy subsidize the care of the sick. That means we are all paying for the costs of treating obesity and that treatment is one of the things that is helping to send health care spending through the roof. The war on smoking worked because it made smoking shameful and the public health measures needed to fight it permissible. It may take an even tougher approach to combat obesity, beginning with the recognition that it’s bad for all of us."

We definitely see the value of social pressure as a means of changing behavior. Brownlee is right that the social pressures are an important reason why people stopped smoking, and why more people don't start now. UCLA professor Mark Kleiman commented earlier this month on The Reality-Based Community that a similar. more severe transition has happened for any number of other activities. However, it's crucial that such social pressure is directed at behaviors, not at people. Berating fat people and promulgating the idea that the obese are morally inferior is not the goal. Rather, public health advocates should focus on curbing unhealthy behaviors like overeating and inactivity.

Everybody knows obesity is a massive problem in the U.S. It rivals smoking in terms of its health hazards, according to a report in the February 2010 American Journal of Preventative Medicine. As a society, we’ve made great strides, giant leaps even, in reducing rates of smoking. Smoking bans on airplanes, in public buildings, in restaurants, have helped. So have negative ad campaigns aimed at teenagers, higher insurance premiums for smokers and higher taxes on cigarettes.

We at New Health Dialogue are emphatically not anti-vaccine. The development of vaccines for smallpox, polio, and dozens of other diseases has produced an incalculable reduction in human misery. The overwhelming majority of anti-vaccine messages (claims that the MMR vaccine caused autism) were based on junk science, and posed an irresponsible risk to public health.

All that said, we have to be equally critical of the evidence in favor of vaccination, especially when the evidence is new and uncertain. Jeanne Lenzer, a longtime colleague of Shannon Brownlee, took up that task in a column for Discover Magazine yesterday. In addressing the recent CDC recommendation that 11- and 12-year-old boys should get the Gardasil vaccine against Human Papilloma Virus, she chronicles the methodological  problems with Merck's studies backing the drug. In particular, Lenzer takes issue with their exclusion of the numerous participants who didn't follow the treatment protocol exactly. In evaluating a public health issue like vaccination, it's important to understand how well the intervention works in reality--not just in the idealized world of a clinical trial. There's also some question about whether or not the vaccine protects not just against HPV, but against cervical cancer, which is the condition that the vaccine is intended to prevent. On top of that, there is real uncertainty (because the condition is so infrequent) about whether the vaccine is related to Guillain-Barré syndrome--a serious paralyzing condition which can be fatal.

Ultimately, Lenzer focuses on the dubious cost-effectiveness of the new recommendation. The risks associated with HPV in men are relatively small, and Pap smears and early treatment are effective at preventing cervical cancer death in women. At a few hundred bucks each for millions of kids, universal HPV vaccination isn't a cheap endeavor. We need to consider other efforts that might be more cost-effective--otherwise, as Lenzer puts it, "the hope that we would undertake low-tech, high-yield public health efforts might be the real pie in the sky thinking."

Editor’s Note: This is part of a series of posts contributed by Andrew Wickerham, who attended the 139^th Annual Meeting of the American Public Health Association this week in Washington, DC.

Think back to high school or college when a teacher would offer comments on a test or essay, along the lines of,  “B-, could have included more background on FDR’s reason for passing Social Security.”  That's not far off from the exercise the Department of Health and Human Services (HHS) undergoes periodically as part of its HealthyPeople Leading Health Indicators (LHIs) program, only the note to the country is more alongs the lines of,  “C-, work on diet, exercise, and making sure people with high blood pressure take their medication.” 

Unfortunately, most Americans, like bored, uninterested students in history class, don't seem to care. We have yet to make improvements to our health—and by many measures are worse off than we were a decade ago. So why does the federal government bother with the regular (read: expensive) process of revising the HealthyPeople guidelines?

HealthyPeople (HP)  started with a 1979 Surgeon General’s report intended to focus America’s public health agenda, prevent disease, and promote overall wellness. Three reports—HP1990, HP2000, and HP2010—followed, offering a decennial update to the national health improvement framework. Each report listed a series of LHIs, with the intent of focusing efforts for the coming decade. HP2020 launched in December 2010, and on Monday, HHS Assistant Secretary for Health Howard Koh, MD, MPH announced the newly updated list of 26 LHIs during a press conference at the American Public Health Association annual meeting.

Now, goals and objectives are certainly good things—they can serve to guide policy and reinvigorate practice. “The Leading Health Indicators imply priorities,” former Texas Commissioner of Health Eduardo J. Sanchez, MD, MPH, said at Monday’s event. Yet, the process of setting new goals for HealthyPeople seems rather conflicted.

Early reports on the relative successes and failures of HP2010 suggest that only a few hundred out of almost 1,000 HP2010 goals were achieved, and that ground was lost in the critical area of chronic disease management, with Americans suffering higher rates of obesity and hypertension. Nevertheless, HP2020 rolls out hundreds of new goals and objectives, in addition to the new LHIs.

There was one bright spot at the meeting. For the first time HP2020 includes consideration of the social determinants of health—the non-clinical factors that affect human health—as part of the LHIs. Socioeconomic disparities are widely recognized health indicators because disparity affects ability to access health care, self advocate, and make healthier behavior choices.  High-school graduation rates will be tracked as an LHI under HP2020 as a way to study the socioeconomic factors that influence health, and to encourage policymakers and providers to take a more holistic approach to improving population health.

We've talked before on the blog about how where you live can have a huge effect on the kind of medical care you get. Unsurprisingly, it also affects how healthy you are to begin with.

A new study from the New England Journal of Medicine reports the results of a three-year randomized trial performed by the US Department of Housing and Urban Development (HUD). According to the study, people who live in lower-poverty areas are somewhat less likely to become obese or develop diabetes than those in higher-poverty areas.

The study was most notable for its methodology. The families in the study were all headed by women, with children under 18 in the household, and were drawn from public housing in cities across the country. Eligible families who applied were randomly selected to receive a standard housing voucher, a voucher that was only usable if they moved to a low-poverty area (a census tract with a poverty rate of 10 percent or lower), or no voucher. Because the families were drawn from comparable populations and randomly assigned vouchers for low-poverty areas or not, it's unlikely that the obesity effects of living in lower-poverty areas were the result of pre-exisitng motivation to leave their area or to stay fit.* That design allows the researchers to look at health differences based on where the participants in the study lived separately from the health effects of additional income from the voucher.

We don't often post raw links or pictures without commentary, but the last few weeks have involved a few great ones that we couldn't pass up.

First: via the new Washington Post Wonkblog (congrats on the new site, guys!), Dr Seuss explains the medical arms race in the video to the right! (Watch it fullscreen--it's worth it!)