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The Health Wrap: #Midterms2018, hip fractures, loneliness and the placebo effect

In this US midterms edition of The Health Wrap, Lesley Russell takes a look at what the results mean for health, science and the environment.

Also featuring the latest on hip fractures, loneliness, the economics of equity, e-health and the placebo effect, this is a bulletin you don’t want to miss.


Lesley Russell writes:

Maybe it wasn’t a tsunami but the US midterms saw a reasonably large blue wave hit the Congress and – just as importantly – many of the states and gubernatorial races.  You can read my assessment (now a little out of date) here on Inside Story and there’s a more up-to-date assessment from FiveThirtyEight here.

The influx of new democrats to the House of Representatives looks much more like the America they represent – younger, more female, more diverse in terms of race, religion and sexual orientation.

They are not necessarily all more progressive, but issues like healthcare, gun control, women’s reproductive rights, immigration and environmental protections will garner much more support. We can expect the House leadership to work hard to pass bills that reflect the Democrats’ position on these issues.

With the Republicans in  control in the Senate and Trump in the White House, they will not become law, but will serve to signal what could be delivered if Democrats win big in 2020.

Healthcare

The elections have big implications for healthcare and not just because a Democrat-controlled House will protect against legislative attacks on Obamacare.

Exit polls confirmed that healthcare was a key issue for voters. This was reflected in the level of support for a number of state ballot initiatives, sending a warning message to Trump and Republicans about continuing attacks on Obamacare.

Voters in Idaho, Nebraska and Utah (traditionally red states) overwhelmingly endorsed ballot initiatives to approve Medicaid expansion, and Kansas, Maine and Wisconsin all elected Democrat governors who are proponents of Medicaid expansion. This could take to 39 the number of states that use Medicaid expansion to provide free health cover to low income residents.

Given the growing popular support for Obamacare and the fact that the Republicans’ resolve to destroy it may have cost them the House, in my more optimistic moments I speculate whether reforms to this law could become the meeting point for bipartisanship in the new Congress (though I don’t dwell long on such flights of fancy).

(There is a good summary of health wins here at Axios. You can read a Commonwealth Fund report in the implications here and an article in the US version of The Conversation here)

As a sign of where many Americans stand on issues of “the public good”, in my home state of Colorado, voters in the Denver area voted for increases in local sales and property taxes to raise funds for parks, mental health and food programs.

When Medicaid expands, more people vote

In a wonderful corollary (which surely the Republicans hate) there’s growing evidence that giving people healthcare cover through expansions of the Medicaid program increases their likelihood of participating in the next election.

Medicaid expansions seem to raise both voter registration and voter participation, at least temporarily.

It’s not clear how. One theory is that Medicaid, which has been shown to increase treatment for depression and improve financial stability, makes it easier for people to participate in the political process.

Perhaps enrolment in the program simply connects people to information about registration and voting. Or Medicaid might also boost civic engagement by making people more grateful to the government and more interested in public policy.

You can read more, with some further references, here.

Science

This year, more candidates with degrees in science, medicine and engineering ran for Congress than ever before. Seven scientists are among the new members of Congress, five of them are women and all are Democrats.

Democrat Eddie Bernice Johnson will take control of the House Committee on Science, Space and Technology. She was the first registered nurse elected to Congress, and will be the first chair of the committee with a STEM background since the 1990s.

This will be a refreshing change from the former Republican chair of the committee, Lamar Smith, who vehemently denies man-made climate change and fought to curb federal research in this area, frequently questioned National Science Foundation grants, and used subpoena power to demand scientists’ data and correspondence.

Climate change and energy

Climate-science deniers were ousted from the House of Representatives and replaced across the country by Democrats calling for investment in clean energy. Nearly every House race prioritised by the Vote Climate U.S. PAC was won by a candidate who wants to see action on climate change.

This will make it harder for Trump to bail out uneconomic coal and nuclear plants, and the Democrats will use congressional oversight — including subpoena power — to expose and oppose the Trump Administration’s environmental harms. You can read more here.

There was also action in the state elections. One news article header read “Climate and energy score brilliant wins and stunning losses in the states”.

In summary: advocates for clean energy and climate action won positions as governors, attorneys-general, and commissioners, although some climate hawks failed to get elected.

An offshore drilling ban passed, an onshore ban failed, and America will not be trying out its first climate tax.


Hip fractures in the elderly: too often a death sentence

The recent release of the Australian and New Zealand Hip Fracture Registry‘s 2018 report prompted me to take a closer look at this growing public health problem.

Every day more than fifty Australians break their hip. Most of these people are aged 65 and over, and more than half are older than 85.

These people face pain, loss of physical function, decreased social engagement, increased dependence – and death. Virtually all will be admitted to hospital, most will require surgery, two will die while in hospital and another seven will die within the next year.

Four patients will not be able to return home but will be discharged to residential aged care, and fewer than half of those remaining will be able to walk as well as before their fall.

Australian Institute of Health and Welfare data from 2015-16 shows that 87 percent of hip fractures are the result of low impact falls, generally at home (48 percent) or in an aged care facility (27 percent).

The incidence of hip fracture is three times higher in women than men, and five percent higher for Indigenous Australians.

In 2015-16 hip fractures accounted for 50,900 episodes of hospital care and a total of 579,000 bed days, of which 59 percent were in acute care and 41 percent in subacute, rehabilitation, palliative or geriatric evaluation and management (GEM) care.

The main risk factors for falls are age and frailty, poor vision, osteoporosis, physical trip hazards and the effects of medications. The main causes of death following a hip fracture are infections, internal bleeding, stroke and heart failure.

Many older patients have multiple chronic conditions – diabetes, cardiovascular disease, musculoskeletal conditions – and these people face increased morbidity from hip fractures.

There is evidence to suggest that prevention efforts are working. The rate of hip fractures per 100,000 people is declining, even though the number of fractures is increasing as the number of older people increases.

However, there is considerable variation in the rate (as indicated by the number of hip fracture admissions to hospital) around the nation: ranging from 484 to 787 per 100,000 people aged 65 years and over across different local areas. By state and territory, figures range from 533 per 100,000 people aged 65 years and over in Tasmania, to 727 in the Northern Territory.

Socio-economic and demographic factors probably contribute to this variation, but more research for explanations is needed.

More also needs to be done around primary prevention, while research shows that effective secondary preventive care (rehabilitation, treatment for osteoporosis, improved nutrition) after fracture is also not routinely delivered.

This care gap leaves hip fracture survivors with an increased risk of subsequent falls and fractures that greatly increase mortality and disability, and contribute to avoidable  healthcare costs.

The 2018-19 Budget provided additional funding of $0.3 million from 2018-19 to 2019-20 to build the capacity of the Australian and New Zealand Hip Fracture Registry (ANZHFR) to improve data collection, support data provision to hospitals and clinicians, and monitor standards to reduce deaths and complications for older people recovering from a hip fracture.

ANZHFR findings

This report has information from all 116 public hospitals around Australia and New Zealand that operate on people with a hip fracture. Sadly, just two private hospitals are included.

It is great to see that 83 percent of these hospitals are identified, and 56 percent have provided patient level data.  One might ask – where are the rest of the private hospitals, and will we eventually get patient data from all the hospitals which are all identified?

The Australian data show that 25 percent of hip fracture patients are aged 90 years and over, and 39 percent have impaired cognition or dementia at presentation.

The key findings show that there is a long way to go before compliance is reached with the recommended guidelines and standards for treatment of patients with a hip fracture:

  • Only 54 percent of patients had a documented assessment of pain within 30 minutes of presentation to the Emergency Department
  • Only 56 percent of hospitals reported having a pain management protocol for hip fracture patients.
  • Only 36 percent of patients had a documented assessment of cognition prior to surgery, although 63 percent of patients were assessed by a geriatrician prior to surgery and 55 percent of hospitals had an orthogeriatric service for older patients with hip fractures
  • The average wait time to surgery was 30 hours, extending to 54 hours if the patient was transferred from another hospital
  • Only 24 percent of hospitals routinely provided individualised, written information on prevention of future falls and fractures at discharge

The report concludes: “What remains apparent is the marked variation in a number of process measures … which have a real impact for the patient: assessment and management of pain; time to surgery; secondary fracture prevention.”

The report also showed that there is very little Australian follow-up data for patients – only 54 percent of hospital records had 30-day follow-up data, and 43 percent had data for 120 days.

In New Zealand hospitals these records were available for 80 percent of cases.

Clearly efforts must be made to do better for this very frail, vulnerable population.


Loneliness and health

The first comprehensive measure of loneliness in Australia, the Australian Loneliness Study, was released last week by the Australian Psychological Society and Swinburne University.

It found that one in four Australians report being lonely. People in relationships are less likely to be lonely (not surprising) and people over 65 are considerably less likely to describe themselves as lonely than any other age group (somewhat surprising).

Loneliness is a health issue. It has significant physical effects: lonely people report trouble sleeping, headaches, stomach complaints, nausea, colds and infections.

Chronic social isolation has been shown to have the same implications for heart disease and stroke as smoking fifteen cigarettes a day. And there are also effects on mental health and wellbeing: lonely people report higher levels of depression and anxiety, and loss of confidence.


The Australian study’s authors think that loneliness, which triggers similar neural pathways to physical discomfort, should be regarded as a “social pain”.

Loneliness becomes a sort of self-fulfilling prophecy, in that higher levels of loneliness are associated with higher levels of social anxiety, less social interaction, poorer psychological wellbeing and poorer quality of life.

Researchers are just beginning to understand the detrimental effects of loneliness on health, social lives and communities.

But many health professionals are unaware of these impacts and they are not taught to ask or look for signs. Their lack of training means that too often the needs of lonely people who present in general practice and emergency departments are not recognised, or are trivialised.

Loneliness is increasingly being recognised around the world as a significant health and social issue.

Earlier this year England appointed a Minister for Loneliness, implementing a  recommendation from assassinated Member of Parliament Jo Cox. In Australia, Victorian MP Fiona Patten has proposed a similar ministerial position to reduce stigma and address growing social isolation.

I wrote about loneliness and some ways to address it in the July 19 edition of The Health Wrap.


The economics of health inequality

A recent Policy and Research Briefing Paper from the UK looks at how to include health inequality impacts in the economic analysis of policy options.

It provides a mechanism for measuring the extent to which health spending not only improves health and is cost effective but also reduces unfair health inequalities.

The equity impact plane puts into practice the idea of “proportionate universalism” – providing universal services in proportion to what is needed for a healthy life.  This is a concept put forward in the 2010 Marmot Review.

This briefing paper looks at the various combinations of cost-effectiveness and reductions in health inequalities in terms of wins and losses.

Some examples follow (note – these are UK examples and might not apply in the same way in Australia):

  • Public funding of nicotine replacement therapy (NRT) to help people quit smoking is a “win-win” compared to no NRT. It is a bigger ‘win-win’ if the NRT is targeted at more deprived areas where smoking rates are higher (this is “proportionate universalism”).
  • Some cost-effective interventions like bowel cancer screening are “win-lose”. They increase total health but increase health inequalities, because socially disadvantaged people do not participate to the same extent.
  • Treatment for mesothelioma, which is very costly, is a “lose-win” situation. The health opportunity cost exceeds the health benefits, but treating mesothelioma reduces health inequality through improving the health of disadvantaged people who worked in traditional industries with asbestos.

I particularly like the worked example looking at health checks (many will know that I have a ‘thing’ about the value of health checks).

This study found that the current NHS policy on health checks has a negative health benefit and a negative equity benefit – it is a “lose-lose”. It can become “win-win” only if effectively targeted to the most deprived population group.

Clearly such work is not without an ethical component (acknowledged in the briefing paper), and will generate some controversy.

After reading this, here’s an interesting challenge for readers to think through: what do you make of the announcement from the US that the Brain Tumor Foundation’s mobile MRI unit is offering  free brain tumour screening ?

There’s more information to help you apply the equity impact plane to this initiative here.  I’m pretty certain it’s a “lose-lose”, but am interested to hear what you think.

The Marmot Review ‘Fair Society, Healthy Lives’

I referred to this review above. If you haven’t read it, it’s worth the effort. If you have, it’s worth a revisit.

Here are the most important of the key messages in the report (nos 4 – 7):

4. Focusing solely on the most disadvantaged will not reduce health inequalities sufficiently. To reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage. We call this proportionate universalism.

5. Action taken to reduce health inequalities will benefit society in many ways. It will have economic benefits in reducing losses from illness associated with health inequalities. These currently account for productivity losses, reduced tax revenue, higher welfare payments and increased treatment costs.

6. Economic growth is not the most important measure of our country’s success. The fair distribution of health, well-being and sustainability are important social goals. Tackling social inequalities in health and tackling climate change must go together.

7. Reducing health inequalities will require action on six policy objectives:

  • Give every child the best start in life
  • Enable all children young people and adults to maximise their capabilities and have control over their lives
  • Create fair employment and good work for all
  • Ensure healthy standard of living for all
  • Create and develop healthy and sustainable places and communities
  • Strengthen the role and impact of ill health prevention

Note the reference to climate change in message 6, and realise that this was written in 2010.


The Pandora’s box of the placebo effect

A recent piece on the placebo effect in the New York Times caught my eye. It highlights how research is zeroing in on the biochemical basis for the placebo effect – possibly opening a Pandora’s box for western medicine.

There’s a growing list of conditions including depression, back pain, chemotherapy-related malaise, migraine, and post-traumatic stress disorder, that respond to placebos as well as they do to drugs in some patients — even when patients know they are getting a placebo.

I find this quite fascinating and I wrote about it in a piece for Inside Story in 2017.

The idea of the placebo effect in surgery is particularly interesting, not least because of the ethical questions that sham surgery raises.

Here are some publications on the topic for your further reading:

Surgery’s placebo effect. American Council on Science and Health, 2017.

Placebo controlled trials in surgery. Medicine, 2016.

Surgery, the ultimate placebo.  Sydney Morning Herald, 2016

Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled clinical trial. BMJ, 2018

I include this last one because I have had this surgery with great success – it put an end to 18 months of pain that nothing else fixed.

An expensive placebo, if that’s what it was, but very effective and long-lasting.


Why Doctors Hate Their Computers

It’s no secret that I’m a big fan of Atul Gawande’s writing.

Last week the New Yorker published a piece he said he has worked on for several years. It’s entitled Why Doctors Hate Their Computers, and it explores the failed promises of e-health from the doctor’s perspective.

His conclusion: “I’ve come to feel that a system that promised to increase my mastery over my work has, instead, increased my work’s mastery over me.” (FWIW: Gawande is relatively young, innovative, and definitely not a Luddite)

He explores the problems and offers some solutions. It’s a very worthwhile read.

The promise of e-health is comprehensive and compelling: better quality of care; more effective and efficient care; better service to the patient; shared decision-making; support for patient self-management; increased availability of high quality data for quality assurance, education and research.

But to date the returns on the considerable investments that have been made are miniscule in the US, in Australia, and elsewhere. The continuing issues in Australia over My Health Record, which has turned into something of a political football, just go to support this case – so much expected, so little delivered.

This article on “The promise of e-health for primary care” gives the Dutch perspective.

Off the topic of e-health but still on the topic of good reads from Gawande, here is a link to another piece of his – a commencement address given earlier this year.

It’s a fearless exploration of what he calls “the foundational principle of medicine” – that all lives are of equal worth. And he asks what this means for those who practice medicine, especially given that hospitals are one of the very few places left where you encounter the whole span of society.

Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. You can follow Lesley on Twitter at @LRussellWolpe

Previous editions of The Health Wrap can be read here

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