Author Archives: Eve Harris

Who Should Pay for Lung Cancer Screening?

A CT imaging system. (Derek K. Miller: Flickr)

CT imaging system. (Derek K. Miller: Flickr)

Looking for unique ways to spend your money? Straight outta Compton this week, an announcement: CT scans available at a local medical center for people who are at risk for lung cancer. Cost is $295.

Or, if you live near San Jose, you can walk into a free-standing imaging center that will charge you $349, but according to the center’s website, “check for promotional pricing.” The private imaging center started offering this test six years ago, even though the test was only validated by the medical community last year.

CT — Computed Tomography — is a type of powerful X-ray that makes 3-D images. It has been successfully used since the 1970s to visualize structures inside the body, including abnormalities like tumors. These exams are usually painless.

Only some insurers cover the scan. The rush to provide the test was reignited in June with the publication in JAMA of findings from several studies. There was good news, for sure: as previously reported the National Lung Screening Trial (NLST) showed that lung cancer deaths could be reduced by 20 percent by screening people at high risk — mostly those with a serious cigarette addiction. Continue reading

In Medicine, Don’t Believe Everything You Know

(Pmccormi: Flickr)

(Pmccormi: Flickr)

By Eve Harris

How do you know your doctor is right? Ideally you and your doctor have a relationship based on trust. That is, you believe she knows the best options to recommend to you. You may think your doctor is right, but — how does your doctor know she’s right? We’d like to think physicians are relying on the latest evidence of medical practice. But not all physicians do that.

I recently joined in a robust, four-day discussion designed to address this issue at the 14th Rocky Mountain Workshop on How to Practice Evidence-Based Health Care. Doctors, policy makers and yes, journalists gathered to explore what many patients might have thought they were already getting: evidence-based health care, also called evidence based medicine.

In evidence based medicine, a hierarchy of evidence guides decisions about patient care. But at the same time, evidence based medicine recognizes that evidence alone is not sufficient. That’s because treatment options come with risks, and different patients will react differently to different risks. It’s not a simple matter of “Drug X” or “Treatment Y” has a five percent higher likelihood of success. If “Treatment Y” involves a risk or side effect a patient finds unacceptable, then this patient’s preference is part of the decision process.

Decision makers must always acknowledge these trade offs.

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Primary Care Efforts to Involve Patients in Decision Making

(Mercy Health: Flickr)

(Mercy Health: Flickr)

All day, every day, people make medical choices that have repercussions for common yet dangerous conditions like asthma, heart disease and diabetes.  Although chronic disease takes a greater toll [PDF] on people with lower socioeconomic status, chronically ill patients are part of every community. In California and across the country, public health officials and physicians keep searching for the best way to get patients involved in improving their health.

Some patients naturally want to be involved with their care. Other times it’s doctors and nurses who must try to encourage more engagement by their patients. “Whether to exercise or change their diet, take medication,” Dr. David Thom told me recently, “those are the bread and butter decisions that go into primary care.”

Thom, director of research in the UC San Francisco department of Family and Community Medicine, is launching a new study, exploring how patients make decisions when they work with a “health coach.” Often health coaches are trained medical assistants who join the primary care team. “Our belief is that health coaches are going to have a fairly different relationship with patients than providers do,” he says. “Their role in helping the patients make decisions will be clearly different than the providers’ role.” Continue reading

What Do ‘Engaged’ Patients Do?

(Seattle Municipal Archives: Flickr)

(Seattle Municipal Archives: Flickr)

Desiree Basila was 52 when her stage zero breast cancer — also called ductal carcinoma in situ —  was diagnosed. While her cancer was found very early, she was ultimately diagnosed with the disease in both breasts. In addition, it was found in several locations. For Basila, doctors said her only realistic treatment option was double mastectomy — which Basila opposed. “If I die at 75 instead of 95 I think I can live with that,” she told me recently. “I did not really want to have a double mastectomy.”

Basila is strong evidence that individuals react differently to their treatment choices. The new healthcare buzzword is the engaged patient, generally referring to someone who is collaborating with doctors in the decision-making process and, conversely, where a patient’s individual preferences are respected.

Basila became just such an engaged patient. After a cancer diagnosis, people usually have a few weeks to investigate treatment options, options that may be life altering. While Basila had little prior experience with cancer, she had been a science teacher and put her skills to use, digging into the research. She sought a second opinion at UC San Francisco and discovered a new Continue reading

The Perils of Medical Jargon

in California low health literacy predicts lack of medical insurance. (American Cancer Society/Getty Images)

In California, low health literacy predicts lack of medical insurance. (American Cancer Society/Getty Images)

When a doctor can’t explain their patients’ diagnoses and treatments in plain language, people suffer.

Poor health literacy — a patient’s inability to understand health information – was first linked to poor health a decade ago. People who find their doctor’s advice confusing don’t manage their chronic diseases as well and are more likely to wind up hospitalized; among the elderly, the death rate is higher.

The public budget also suffers when patient and doctor don’t understand one another: in California low health literacy predicts lack of medical insurance, according to a first-of-its-kind survey published in the May issue of Health Affairs. Regardless of ethnicity, income or availability of employment-based insurance, if someone can’t understand their doctor or their pharmacist, they are less likely to have medical insurance. At the national level, health care expenses are increased three to six percent [pdf] by low health literacy; of that increase, 66 percent is public money, either Medicaid or Medicare.

Routine screening makes cervical cancer a highly preventable cancer in countries like the US, but American Latinas are nearly twice as likely to be diagnosed and to die of the disease.

Health literacy is also correlated to other types of literacy — almost one in four California adults cannot use written English at a basic level. That means more than nine million people and their children are at increased risk of missing out on important health screenings, and are more likely to wind up in the emergency room.

With such a pervasive problem, improvement will likely result from a mix of approaches rather than a single magic bullet. Several strategies have proven effective. For example, patient education is more successful when the essential information is presented first and with a minimum of distraction. Another successful strategy, called “teach back,” increases comprehension during appointments. Patients “teach back” by using their own words to explain what they just heard their doctor say. This gives the doctor a valuable opportunity to correct misunderstandings.

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Turning Health Data Into Information

Healthcare is not a science problem; it’s an information problem. Thomas Goetz,  TEDMED 2010

Todd Park speaks at the Commonwealth Club in SF. (Photo: gobemore.com)

Bank and airline customers rely on sophisticated systems that allow them to personalize and track complex data. But consumers of the services and products that comprise modern health care –  the patients — currently are offered much more rudimentary data handling. Faxed prescriptions, paper medical charts and X-rays on film — though not uncommon — are examples of outdated methods of recording and sharing data.

The forces needed to improve patient information systems are gaining momentum, said Todd Park, US Chief Technology Officer (CTO). Speaking June 18 at The Commonwealth Club in San Francisco, Park acknowledged the movement is in its infancy but said the nation’s healthcare information system is “light years ahead of where it was two years ago.”

Park’s trademark enthusiasm was also evident as he talked about the campaign to provide newly-authorized access to government data to software developers and entrepreneurs. The federal Health Data Initiative seeks to provide Health and Human Services (HHS) data to the public, free and with no strings attached, in effort to trigger the creation of health-related applications.

The campaign has precedent in other government bodies. For example, The Weather Channel exists because National Oceanic and Atmospheric Administration (NOAA) data was made public. Location-based services such as real-time driving directions rely on GPS, a system of satellites also owned by the government.

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New Health Care Jobs: How Healthy?

(US Navy: Flickr)

Hospital team moves patient from one bed to another. (U.S. Navy: Flickr)

California stands to reap tens of thousands of jobs because of the federal health care overhaul — according to a new report [PDF] by the Bay Area Council Economic Institute (BACEI).

Researchers compared the state’s 2010 workforce to what it might have been if the Affordable Care Act had been fully implemented in that year. They concluded that once the ACA is fully in place in 2014 almost 99,000 new jobs will be created as a result of the law, most of them in Southern California. The Sacramento Valley will see the largest increase rate: a 1.3 percent boost in job opportunities.

But ironically, health care jobs are not always healthy for the worker. Odd hours, ergonomics, and environmental factors contribute to specific risks for hospital and clinic workers.

By its nature health care is a 24-hour enterprise. Dr. Catherine Lau works nights almost exclusively as director of Nighttime Hospitalist Service at the UC San Francisco Medical Center. In an interview Lau said that while she appreciates the quiet, it can be “a little disorienting” to work at night in a windowless space. Shift-working nurses show higher rates of breast cancer, obesity and type 2 diabetes. Continue reading