Friday, August 28, 2009

It's so danged complicated!

My Health Economics lectures are still pretty interesting, although my friend, Polly, is not exactly enthralled. What I've noticed is how terribly complicated the picture is becoming surrounding the allocation of resources fairly within the health system!
We've been looking at how Australian public hospitals "never say NO" to performing surgical procedures or somehow treating a person's problem regardless of age or disability. I already figured there must be a bit of "NO" going on, or the hospitals would be bulging with 95 year-olds having heart transplants! Yes indeed, there are some "NO"s emerging, much to the disgust of several students in the class. For instance- an Intensive Care Unit that does not admit anyone aged 90 plus. I had been mildly surprised when my friend E told me her 92 year old MIL was in a high-dependency ward but not ICU after she had a stroke which made her quite delusional and unable to talk coherently- obviously her age was excluding her from the top treatment category. I had already been privy to the fact that certain physicians at unnamed hospitals "pull the plug" on young male accident victims whose brain injuries appear irremediable after some days in ICU, but hadn't heard about anything else. The over-90 rule seems perfectly sensible to me, given the expense of ICU, the pressure on the beds from younger people with more prospect of recovery and the average lifespan being 79 (men) and 80 (women) in Australia. In my world-view, the 92 year old has indeed had a "fair innings" as the noted health economist, Alan Williams, might have said.
However, the question facing everyone in the health care profession (and facing us as students during a tutorial!) is: How mindful of public dollars should the bedside doctor or nurse really be?
Obviously there are views ranging from "Of course they should be- who pays them anyway!?" to "It is not ethical for doctors to consider costs when saving lives".
I am inclined to think that having regard for the probability of a good outcome given the investment of public dollars should be a routine consideration- something "trained for" in a medical education, not something that comes as a big surprise when doctors are questioned later about particular decisions. It would be good to see that consideration of the general cost to society built into the contracts or agreements that medical personnel work with. Just because lives are involved doesn't mean people should abandon the principle of general utility- as a public servant I couldn't order an antique oak desk for my office even if I was allergic to the laminate in the generally supplied ones!
Now the outlook has shifted along to the issue of how we rate someone's prospects of a good life following a medical treatment, vs. how much it is going to cost the public purse, and ultimately, the taxpayer. For this some fancy measurements have been invented such as the Quality Adjusted Life Year or QALY. Be ready for a rollercoaster ride when I get stuck into this little monster!

Saturday, August 22, 2009

Germs- eerrgghh!!

I was inspired by Mike Mad Biologist (, to have a (-nother) rant about spreading germs.

I truly hate it when people:

a) sneeze, cough, spit or snort without attempting to cover it up or face away from others. If only the training most of us receive in childhood about these courtesies would stick!

b) laugh at me when I ask them to keep their germs to themselves.

I'm quite phobic (in a mild sort of way) about catching seasonal viruses and things as I'm an asthmatic. My body is notorious for catching a virus, going all breathless on me and making fertile ground for a friendly bacteria to jump on board and lay me low for days or weeks. I've improved with age and learning to look after myself, but I still get horribly wheezy when I get a cold or whatever. I absolutely HATE IT! It feels like I am sidelined from real life for a while and I just have to sit here and take it, while life goes on as usual for everyone else. I don't seem to be able to carry on as usual like most people- I need rest, I can't breathe well enough to hold a decent conversation and I'm useless going out for a meal. The housework piles up, the cats get hungry, we run out of clean clothes and I scowl at the sheets that need changing while I'm stuck in bed gasping and snorting.

What's more, every time I get something serious, I'm reminded that both my grandfathers died in the 1918 Spanish flu epidemic- neither one having left their home towns for the First World War. Sure, one of them probably suffered from asthma as well and worked in a hospital; but the other grandfather was a pretty healthy bloke until then. They both left large families to be brought up by their wives and the eldest kids, which must have been a struggle in those days. Luckily both grandmas had small businesses, which is pretty unusual- one had a sandwich shop in Elizabeth St in Sydney and the other was a well qualified Tailor (-ess) in Wellington, New Zealand. It's not like many younger people die from colds or flu these days- it's mainly older people and those with pre-existing conditions (like asthma, which killed my education tutor at uni when she was only 29). However, so many days of work and useful life are lost from seasonal viruses that I think it's worth defending yourself and others the best way you can.
First line prevention is just what Mike the Biologist says: Wash your hands! and Cover those sneezes!

I'd certainly wear a mask if the flu really took hold- I think the Japanese are quite good with this measure, even though we have been laughing at them on their highspeed trains with their face masks all these years.

Let's get with it- protect ourselves and our mates and cost the country a lot less!

PS. I've been intrigued for some time with the notion that some schizophrenia might be precipitated by prenatal effects of viruses such as the flu or common cold on the developing brain. This article is a broad account of such ideas.

Sunday, August 9, 2009

Fighting for health dollars!

I was having some ideas while listening to the first two lectures in Health Economics. I guess what I think now will change over the course, so I should write down what I believe at different stages. At the moment I think the whole government health budget should be divided in a different way (of course, they couldn't SUDDENLY change the proportions of various segments, but could work towards it, in my ideal universe!).

Firstly I think we should look at the people in the population and see how many are in various age segments, and what these segments will average out being over the next 5 to ten years.

Then we should look at what services were used by the age groups, divided initially into medical/pharmaceutical vs. surgical vs community health and public health/health promotion. Obviously we'd find that not many dollars are spent in community, public health or health promotion. There seem to be stacks of dollars spent on pharmaceuticals and I noticed that dental costs take 6.6% of the nation's health $$- strange since we don't tend to think of our mouths as using a lot of our general health resources or time.
Dept of Foreign Affairs and Trade describes the health system for lay persons and outsiders:

How they work out costings at the moment:
And here is the expenditure in public and private sectors:

I don't like DRGs (Diagnostic Related Groups) as they stand- although I may not understand them fully and therefore agree with them more than I think! However, I think that looking at the most prevalent illnesses for each age group and looking at the medical vs. surgical dollars spent on various procedures, rather than all admission costs, might result in a better idea of how to allocate funds in the future.
As well, I think that costs should be normalised/standardised for each age group and for the procedures and treatment packages most used so we can easily compare subgroups on a proportional rather than absolute cost basis.

Perhaps we look at the 50- 65 year old age group and find that there are a lot of cardiac-related surgical procedures and cardiac-related medications and GP consultations. We should look at what could possibly be "saved" by doing alternative things with the dollars at earlier ages and at how we might gradually reallocate the surgical dollars to prevention dollars. eg. we might see a lot of coronary artery bypass grafts (CABGs) and note that these cost a lot, whereas doing one or two stents on a younger person might achieve the same ends and give a longer average life after the procedure.
Giving a potential 25 years extra life to someone with a procedure at age 55 should be better than giving an extra 15 years at age 60 and each procedure and hospital stay ought to be cheaper on average, plus people are happier and have better mental health, saving some mental health dollars as well!

Therefore we need to use the Burden of Disease Statistics, look at getting the average number of years of life gained from various procedures/medical treatments, projecting the likely number of cases for the forward budget period and applying normed corrections for the proportions of the health budget to go to various health problem clusters. I noted that musculo-skeletal and respiratory diseases are priorities for the near future and that reducing cardiac disease and spending is also a continuing priority. There also looks to be a need to prevent acceleration in the obesity rate in order to avoid flow on costs to diabetes incidence/prevalence, cardiac disease strokes and falls. The community doesn't seem to have got the message about weight gain, especially in children and there don't seem to be huge innovative programs being introduced to remedy the situation- so this needs a lot of factoring in.

Anyway- rave rave. I'm just jotting here- will get down to specifics later.