stimulus package

Stimulus package to include evidence-based medicine

palmd — Mon, 16 Feb 2009 08:17:45 +0000

Stimulus package to include evidence-based medicine

The New York Times is reporting that the economic stimulus bill will include over a billion dollars to fund research into medical evidence. This is a good thing, but it's bound to be controversial. I've mentioned before that we need to spend money to improve our medical infrastructure, and this could be a step in the right direction.

Much of what we do in medicine is science-based, and much of it has evidence to support it, but some does not. There are plenty of open questions about how we practice medicine, and in order to deliver safe, quality care, we need answers. For example, a recent study in the New England Journal of Medicine compared surgical and non-surgical therapy for arthritis of the knee. Surgery made logical, scientific sense, but it had never been carefully compared to non-surgical therapy. The study showed that conservative therapy, which is cheaper and less invasive, was just as effective as surgery. This doesn't mean that surgery will never help, but it is strong evidence that we should treat arthritis of the knee more conservatively. Studies like this aren't free, but if their results are reliable and repeatable, they may save us a lot of money and possible surgical complications.

So the idea of investing more money into comparing medical treatments makes sense, both scientifically and economically. Now there's a lot of predictable schreing about this, and since my L5 nerve root is still an issue, it's making me extra cranky.

As Congress translated the idea into legislation, it became a lightning rod for pharmaceutical and medical-device lobbyists, who fear the findings will be used by insurers or the government to deny coverage for more expensive treatments and, thus, to ration care.

In addition, Republican lawmakers and conservative commentators complained that the legislation would allow the federal government to intrude in a person's health care by enforcing clinical guidelines and treatment protocols.

I'm not sure that the legislation says anything about enforcing clinical guidelines, but to be fair, there is some implication along those lines.

And so what? Right now, my patients' insurance programs do exactly the same thing---if I prescribe an angiotensin receptor blocker for blood pressure control, I'm going to be asked to justify why I am giving this rather than the cheaper and as-effective ACE-inhibitor. The answer is usually that the ACE-I caused side-effects, but the question isn't stupid. Why should an insurer pay more when an equally effective, cheaper alternative is available?

If we have more evidence to work with, we can continue to make even better decisions regarding care. It may seem intrusive, but it's not very different from what we do already. And honestly, I'd like to know if I'm more likely to get relief of my radiculopathy from surgery or conservative therapy. I will not be offended in the least if my surgeon got a call from my insurer asking if surgery was really my best option, as long as the answer was supported by good evidence.

It rings rather hollow when people protest against gaining more knowledge. Libertarian types complain that this will inevitably lead to government interference (and it might, and maybe it should) but to ignore the need for evidence is absurd. We, as physicians and patients, need more knowledge, not less, and we shouldn't be afraid of where the data lead. It's a no-brainer. But then, some people are a little short on brains.

palmd Mon, 02/16/2009 - 03:17

Categories

Medicine

I hope that you are being disingenuous when you say there is no difference between an insurance company denying coverage for treatment A over treatment b and a government making it illegal to provide treatment A over treatment B. The former is a voluntary association between an individual and a private party. The latter is an involuntary association with the threat of force or jail for those who break the law.

I think you read into this more than was there, but I'll bite.

Remember, there is no talk of making anything illegal. That's just bullshit.

"Volutary" associations with insurance companies are illusory. You need insurance, you take whatever you can get. That, and the largest insurer in the US is...Medicare, a gov't agency.

I think you're gently strolling over to a big straw man.

most people get their insurance from work. They dont choose what insurance they have. If they are lucky they might have 2 plans but it is certainly not an instance of free choice and shopping around.

My co-blogger Merrill Goozner did a post on this. Sounds like you are basically on the same page.

http://www.gooznews.com/archives/001330.html

NIH has funded comparable effectiveness studies for years, in numerous fields. One example is NASCET, a randomized trial of surgical versus medical management for stroke prevention when carotid stenosis is present. NHLBI funded ALLHAT. So what's really new here? The new piece is the idea that this may be the first step towards constructing something like the UK's NICE. Conservatives have somehow hallucinated a link from "government funding comparativeness research" to "government regulating healthcare."

NICE doesn't actually fund clinical studies. It just evaluates available data. A proposal to gain more health care data on controversial topics seems to be very different than a proposal to create a NICE-like empire.

On the other hand, NCCAM supposedly funds studies of alternative medicine, and their findings haven't resulted in the elimination of sham practices.

I should perhaps make it more clear that I am much in favor of the idea of funding effectiveness studies. I'm also in favor of making clinical, evidence-based guidelines easily available.

I'm not all that keen on gov't control of the physician-patient relationship. That being said, there's a lot of bad doctors out there who practice crappy medicine without regard to evidence? How do we fix that? I don't know.

I think part of this argument beyond insurance is also about the costs of new drugs, new devices and physician involvement in these enterprises which has led to incredibly complicated negotiations and uses of pharma and devices which do not have evidence of their effectiveness, are incredibly expensive and therefore jack up the rates of healthcare and insurance. Not to mention the legal liabilities for everyone concerned. So in some ways, I think the questions of evidence and effectiveness need to be asked and should be funded, because hopefully we might begin to tackle the waste and expense of a non-performing system of healthcare.

I don't think I've been against gaining knowledge and evidence or figuring out what works best overall. I am suspicious of large databases (that I know from experience contain errors) and feel a need to know who is using them for what.

For the obligatory anecdotal evidence: my son is insured by Medicare (stemming from a childhood disability) and has just been denied any coverage of a drug that he's been using for 3 months (samples from his doc) with very good results - it treats what he's taking it for without interfering with other drugs or worsening other health problems.

However, his denial states that he must FAIL for 90 days on an alternative treatment before he's approved for this drug. He has failed on this exact alternative treatment but it was more than 3 months ago, so it doesn't count. He must fail again. Failure means hospitalization, which is much more expensive than the drug.

How does this make medical or money sense?

I haven't read the final version of the stimulus bill (has anyone?) but I read substantial portions of several of the preliminary versions and provisions appeared and disappeared like monsters on the sides of the highway in kudzu covered Mississippi late at night when sleep-deprived.

(hey, I think that last paragraph could be a Bulwer-Lytton entry.)

Science Funding In Jeopardy

gregladen — Fri, 06 Feb 2009 09:16:05 +0000

Science Funding In Jeopardy

UPDATE HERE

I just received this note from Sean Otto of ScienceDebate 2008:

I am writing to alert you to efforts underway this morning to zero out a large portion of the science funding from the Senate American Reinvestment and Recovery Act as a part of a $77.9B reduction effort led by Senators Ben Nelson (D-NE) and Susan Collins (R-ME).

As you know better than most, science and technology are responsible for half of the economic development of the United States since WWII and yet, if current trends hold, some, such as the Business Roundtable, have predicted that 90% of all scientists and engineers will live in Asia within 5 years.

The United States simply MUST renew our investment in the single greatest economic engine this country has ever known. Small federal investments in scientific research have helped produce things like the internet and the transistor that have consistently delivered multi-trillion dollar economies.

The United States is at a critical juncture, and if this concerns you we suggest now would be a time to contact your Senators and urge them to support science funding. Here is what is being proposed to be cut from the bill, according to TPM:

NASA exploration $750,000,000 = 50%
NSF $1,402,000,000 = 100%
NOAA $427,000,000 = 34.94%
NIST $218,000,000 = 37.91%
DOE energy efficiency & renewable energy $1,000,000,000 = 38%
DOE office of science $100,000,000 = 100%

More details here.

Every state (except mine) has two senators. You need to contact them immediately in order to fix this. Find your senator here

gregladen Fri, 02/06/2009 - 04:16

Tags

Politics

stimulus package

Last time I contacted my senator it took him 3 months to get back to me and by that time what I had to say didn't mean much. He's a busy guy (Tom Cobourn, I will NOT speak to Inhoffe) but I didn't need a big long letter that turned into a campaign ad. Just want him to read it. Hopefully, he just reads this letter.

Meanwhile, what do they propose cutting from the DoD budget in the same bill? $100,000,000 marked for "Alternative Vehicle Tech. Procurement". Less than 1/40 of a percent.

Unbelievable.

And all this stuff needs to be in an "economic stimulus" bill why, exactly?

This "stimulus" bill is a big stinking pile of democrat garbage, every wet dream they ever had all piled up in one rotting package. The whole rotten thing needs to be zeroed out.

I'm rooting for science to embrace the belt-tightening that regular American citizens are having to endure right now. Rather than whining about stimulus cuts in a general way, why not put our energy toward defining national science priorities? Let's take a hard look at which science really benefits humanity (and, topping out my own priority list: the planet), and funnel our country's great expertise and funds toward those things. I'm feeling the economic crisis personally, and so are people close to me. But in all cases, science included, I see an opportunity to come out leaner, stronger and more focused.

I don't think there's ever been an effort to target science funding with the intention of getting results more efficiently or effectively that has actually worked.

Example: Infectious disease research targeted towards bacterial disease topped out the effectiveness of its results in the 1970s or 80s. When HIV came along (for all practical purposes in the 1980s) it was a huge problem that targeting has overlooked viral diseases because it was thought to be a waste of money ... viral diseases were not that big of a deal.

A larger percentage of the people who have died of HIV/AIDS would not have, most likely, if there was aggressive "research for research sake" in viruses through the 1960s and 1970s.

This morning at Politico.com Glenn Thrush has a list of changes in the bill that includes -200 million NSF, -150 total million NASA -100 million each NIST and NOAA, -100 million to "Science" which could be the DOE office of science (I hope not). The 3.5 billion for Higher Ed Construction was zeroed out, but most Universities don't want to have to pay to clean and light new building anyway right now anyway.
If the report is correct, NSF is in line to get an increase of 1.2 billion, and its about time. Usual hugh increase in NIH on a voice vote (I think) given Spector's history. So overall, even before the House-Senate conference its looking up.

Science research funding is critical to economic stimulus: it funds jobs for students (research assistants) and degreed professionals; indirect costs from federal granting agencies (58% of total award at my U) are vital to the operating budgets of universities, allowing them to not raise tuition as much as they otherwise would, thus subsidizing the educations of all college students and the future workforce; science research ends up saving money on healthcare, defense, public policy, etc., etc.; without trained scientists in ALL fields (not just applied sciences or someone's pet projects), our nation is at risk of pandemics, attack, energy shortages, epidemics in everything from dementia to obesity to cancer to HIV/AIDS, etc., etc., all of which will cost a lot more money to deal with later rather than sooner. People who acti like basic scientific research has nothign to do with their lives are fools.

I'll take Science Funding for 20 billion, Alex.

I am with you 100% and have gone so far as to suggest that we spend more of our budget on research and less of it on stupid wars.

The Stimulus - How much is marked for science funding?

apalazzo — Thu, 29 Jan 2009 08:10:53 +0000

The Stimulus - How much is marked for science funding?

From the AAAS:

The three agencies highlighted in the America COMPETES Act of 2007 and President Bush's American Competitiveness Initiative (ACI) would do extremely well in the stimulus appropriations bill. The National Science Foundation (NSF) would receive $3.0 billion; the Department of Energy's Office of Science (DOE OS) would receive $2.0 billion; and Commerce's National Institute of Standards and Technology (NIST) would receive $520 million; nearly all of these supplementals are for R&D activities. The $5.5 billion allocated to these three agencies would finally put all three budgets on track to double over the next 7 to 10 years as envisioned in the ACI, America COMPETES, and Obama campaign promises.

The National Institutes of Health (NIH) would receive $3.9 billion in the stimulus appropriations bill, divided roughly evenly between research and infrastructure (construction and maintenance of facilities). The stimulus funding would turn around a NIH budget that has been in decline since 2004. The Department of Energy's (DOE) energy programs would also be a winner with $2.0 billion for R&D and related activities in renewable energy and energy conservation, with billions more for DOE in weatherization, loan guarantee, and clean energy demonstration funds. And the National Aeronautics and Space Administration (NASA) would receive $600 million, mostly for R&D.

Let's not mess things up this time! The last major increase to the NIH caused major problems years later. Money was simply pumped into new and existing grants, PIs hired many new grad students and postdocs, and the pyramid scheme got a major influx bloating the bottom of the academic edifice. As the bottom rose, many chunks fell of and as one Nobel Lauriate stated, we sacrificed a generation of scientists.

So what to do? President Obama has stated that we should "triple the number of fellowships in science to help spur the next generation of innovation". But as I pointed out yesterday, NIH funded labs must also change the way postdocs are treated. This can be done quite simply by

Increasing the wage guidlines issued by the NIH
Increasing funding for career postdocs

Let's see what happens.

(ht: Andrea D'Ambrogio)

apalazzo Thu, 01/29/2009 - 03:10