Los Angeles Fast Food Moratorium

From Reuters: LA City Council passes a 1-year moratorium on fast food in several poor neighborhoods following a study that childhood obesity rates were 30% in South Los Angeles, West Adams, Baldwin Hills and Leimert Park compared to 21% in the rest of the city.

Although no existing restaurants are being closed down because of this law, and no provisions to promote the availability of low-cost healthy foods in these areas, this will make for a good case study of an interesting policy option. I'm interested to learn how the impacts of this will be evaluated.

We stink at estimating the caloric content of food...

...so why not require caloric content be labeled on restaurant menus, asks a pair from RWJ.

Opponents to menu labels argue that the info is already provided on websites and pamphlets (but how much would that influence consumer choices?), that the information would not be intelligible/useful to the average consumer (but couldn't it be useful with a little education?), and above all costly to the restaurants--not so much for the nutritional analysis which they already do, but for decreased sales. But that's the whole idea. We need to eat less.

Anyway, this is just an editorial with no new data, but they do cite prior studies including one indicating that providing point-of-purchase calorie info for items for which consumers tend to underestimate caloric content reduces the likelihood of purchasing the item from 37% to 24%.

Integrating Patient Preferences with Clinical Guidelines generation

An editorial by Krahn and Naglie (2008) in JAMA makes a case for incorporating patient preferences into clinical practice guidelines (CPGs). Our work in tailored interventions and subgroup analysis may inform this discussion.

The authors makes some suggestions, here in brief:

1. Find Preference-Related Evidence, 2 Integrate Preference-Related Evidence Into Recommendations, 3. Use Guidelines in Individual Decision Making, 4. Include Patients in the Guideline Development Process, 5. Evaluate Guidelines With Preferences in Mind.

Atkins wins...or does it...

NEJM published a new study comparing low carb to low fat to Mediterranean diets in their effectiveness in promoting weight-loss and improved lipid regulation. In short, those assigned to the low carb diet lost more weight and saw better lipid numbers than the others. The study is here:

http://content.nejm.org/cgi/content/short/359/3/229


Dean Ornish, the king advocate of low-fat diets, argues that the "low-fat diet" in the study was hardly low fat at all, and that the "low carb" diet encouraged more non-meat choices than the traditional Atkins-type low carb diet. In other words, the source of the group differences reported in NEJM may be factors that aren't reflected in the labels that the groups were given. Ornish's comments are here:

http://www.newsweek.com/id/146641

Higher Gas Prices, fewer motor vehicle fatalities

Higher gas prices amounts to people driving less often, less fast, and in less gigantic cars. It's not too surprising, then, that motor vehicle fatalities also decline when prices rise.

In an analysis of fuel prices and motor vehicle fatality data from the National Highway Traffic Safety Administration from 1985 to 2006, Michael Morrisey of the University of Alabama at Birmingham and David Grabowski of Harvard Medical School found that a 10% increase in gas prices was associated with a 2.3% decline in auto deaths for all drivers, a 6% decline for drivers ages 15 to 17, and a 3.2% drop for drivers ages 18 to 21.

If the results of the study (presented at the meeting of the American Society of Health Economists) do not assuage some of the grumbling about rising prices (they won't), they at least lend credence to arguements that the costs to society of automobile use and gasoline consumption were not fully captured in the prices paid at the pump, especially when prices are low. Now gasoline may in fact be priced more closely to the actual costs to society, but the revenues from its sale, of course, do not go directly to remedying the problems that's its use creates.

On end-of-life care

To respond to some of Jay's thoughts on this matter: In the same way that preventive care and lifestyle change are undervalued (in terms of their health bang for buck reimbursed), end of life care is overvalued--or more correctly, consumers are willing to pay a steep premium for immediacy. In other words, from a purely rational standpoint, an additional year of healthy life (sometimes measured in a unit called quality-adjusted life years (QALY)) should be worth the same number of dollars whether it was "bought" using services applied in the 30th year of life or the 80th year, but in practice, we pay much, much more to extend life in the later years than we do in the earlier years.

This fact is not necessarily due to an evil empire, or even an irrational market. In fact, couldn't you argue that aggressive, expensive end-of-life care does not only serve the needs of those who benefit financially, but also serves the preferences of consumers who pay healthcare premiums? This is just a very rough idea, but what if the healthcare system was designed to take advantage of the loose purse strings we see at end of life to pay for better prevention? Perhaps rather than cutting back on end-of-life health care service utilization, payers (or policymakers through taxation) could skim a percentage of the profit margin realized for end-of-life care to pay for better preventive services or even directly compensate (or subsidize) individuals for healthy lifestyle choices. Not only might this help delay the onset of end-of-life care, it could keep healthy people productive in the workforce (and paying into the system) longer.

As strange as this sounds in a country where Social Security benefits for retirees are paid out of the payroll taxes of the current workforce, the premium we pay on end-of-life care could be harnessed to support better prevention in the current workforce. There are countless practical considerations that would go into this, but in the same way that individual IPAs and HMOs subsidize necessary but poorly reimbursed services with revenues from high margin procedures, a rational system could take revenues from potentially higher-margin (and "irrationally" over-reimbursed) end-of-life care to pay for valuable, but under-reimbursed prevention.

The end marks the beginning: how hospice helps me think about health policy

Why blog about health policy? Well, by way of explanation, let me tell you about my morning…

Before heading into the office, I visited a patient at home. I know that sounds old-fashioned and maybe even unsafe these days depending on the neighborhood. However, weakened by metastatic cancer, my patient would not reasonably have made it to see me in my office before his demise. I therefore decided that our best option was a home visit. We spent the first part of our visit discussing his physical health (controlling pain, managing shortness of breath and addressing nutritional issues) then transitioned later to his emotional and spiritual health (acknowledging fear and anger and achieving peace). He grasped that the cancer was inevitably going to overcome him physically and yet, he continued to fight for every last moment to be with his family, several of whom had traveled large distances to be with him. After talking some time thereafter with his children and wife and answering questions, I left for my office.

For the uninitiated, hospice is medical care that is provided at the end of life. I am not referring to chest compressions, being put on a respirator, or epinephrine (stat!); I am referring to making an informed decision to be comfortable and amongst loved ones at home when the moment of death comes. For some, hospice may seem antithetical to our modern-day technology-driven success-at-all-cost sentiments. These very sentiments are partly to blame for the crisis in healthcare spending (projected to surpass 20% of our GDP in the next quarter century!) that our nation faces today. The bottom line = we spend too much on dramatic end-of-life care that is high cost-low impact. Why not spend your dying moments at home with your family and friends in peace? Why suffer an unnecessarily “violent” death in the hospital? It seems clear, doesn’t it?

Somewhere between “duh” and “no duh” lies our ability to approach healthcare reform in a rationale way. Things seem so obviously fractured yet we, as the general public, continue to accept things as they are. To borrow quotes from a friend and a mentor, silence = consent and if we’re not at the table, then we’re on the menu. Now is the time to use our voices together and to sit at the table. Look forward to continuing this dialogue with you and “imagineering” real solutions that serve everyone’s needs, not just those who are (financially) benefiting from the way healthcare in the U.S. is delivered.

Cheers, Jaywon