Good Technology, Bad Technology

When I pick up the phone, the friendly woman's voice greets me in Russian. Or maybe it's Romanian? Or Polish? Then she begins a long discussion about an upcoming medical appointment in the mystery language. I know this because she mentions my name and a local medical center in English. She calls about once a month, a glitch in some health care provider's electronic appointment reminder system.

Ah, medical information technology. I still can't decide whether I like it or not. At my daughter's pediatrician's office, I wonder why they're still using a giant, scribbled-over paper appointment book and paper folders to hold medical records. Then I remember that a shift to appointment scheduling software and electronic medical records could mean technology glitches like my periodic Russian phone calls and the imposition of a laptop screen between the doctor and me when we talked. On the other hand, I reason, it's incredibly useful when a doctor I'm visiting can pull up electronic test results from another doctor I saw recently. Yet this easy access is also creepily Orwellian. How many people, exactly, do have access to my medical information? And what are they doing with it?

Sometimes, medical IT practices can cause real harm. A recent article in JAMA analyzed how radio frequency identification (RFID) devices, used to identify patients and equipment, can also interfere with medical equipment used to treat and manage medical problems. My daughter and I received RFID wristbands when she was born, in order to make sure that no unauthorized person took her from the hospital. Could the wristbands’ signals have interfered with the lifesaving equipment used on the infants in the neonatal ICU down the hall? Possibly, according to JAMA.

As I sort through my own opinions about information technology and medicine, the technology marches forward relentlessly. At the moment, the Markle Foundation, a public/private collaborative studying IT, health, and national security issues and endorsed by WebMD, the American Academy of Family Physicians, Microsoft Corporation, and others, is analyzing the public/private world of digital personal health information in an age of many grievous privacy breaches. The foundation has developed privacy guidelines for health information and services that consumers use online. With care, I think, health care IT will improve, but only in the way that medicine improves: by trial and error, educated guesses, and unanticipated consequences.

Infertility, Public Health, and Private Choices

Infertility is an increasingly common problem for many couples in the U.S, but infertility treatments are creating new problems, according to a report released last week by the CDC. In 2005, the most recent year with statistics available, assisted reproductive technologies (ARTs) such as in vitro fertilization had a 35% success rate (i.e., 35% of treatments resulted in a live birth). Forty-nine percent of these births were multiples (twins, triplets, or higher).

These ART-conceived multiple births may be a personal triumph but they are a public health disaster. Why? The chances of infant and maternal health problems increase with multiples, particularly those conceived with ARTs. Triplets and higher multiples conceived with ARTs, for example, have a 95% chance of having a low birthweight, according to the CDC. In 2005, although 13% of all infants were preterm, 42% of ART-conceived infants were preterm.

The public health cost of ART preterm births was approximately $1 billion in 2005, or an average of $51,600 per infant, the report stated. One percent of all U.S. infants born in 2005 were conceived with ARTs.

In the report “Assisted Reproductive Technology Surveillance – United States, 2005,” the CDC analyzed data from 89% of the 475 medical centers that treat fertility problems with assisted reproductive technologies.

The report stated that many ART medical centers are working to avoid multiple births in favor of singleton births by implanting fewer embryos at a time, but others are bowing to patient and marketing pressures to increase their success rate by implanting numerous embryos at once.

Successful fertility treatments themselves increase the number of children who are as genetically vulnerable as their parents were to infertility problems as adults. Successful treatments therefore create a new generation of customers for infertility clinics, and, barring medical advances in ARTs, fresh public health costs in the future.

There are alternatives. For a couple unable to conceive, adoption can help them build a family – a choice that helps both individuals and society. Considering the public health cost of ARTs and the dismal failures of the U.S. foster care system, it is in the government’s best interest to take two steps: regulate the use of multiple embryos in ART, and promote and streamline the domestic adoption process.

Addendum - July 17, 2008

Preterm birth can also have long-term consequences on an infant. Today, the New England Journal of Medicine published an article about the "Long-Term Medical and Social Consequences of Preterm Birth" among preterm infants followed to adulthood in Norway. Among this group, there was a significantly increased risk for cerebral palsy, mental retardation, and dependence upon disability payments as adults if they were born at 23 to 27 weeks. The abstract concluded that "the risks of medical and social disabilities in adulthood increased with decreasing gestational age at birth."

The Price of Being a Patient

Whatever benefits modern medicine has for patients, I've experienced first-hand its power to undermine your ordinary life. In the spring, I switched primary care providers when I became frustrated with my long-time PCP's sluggish response to several urgent medical problems. When I gave my new PCP a sticky note listing a few medical concerns of mine at our first meeting, however, I inadvertently triggered an avalanche of medical appointments. She gave me a few referrals to specialists, including physical therapy to resolve some old injuries, and as I dutifully worked my way through the list I watched my time slip away. Add to that several medical checkups for my children, and the time drain was enormous.

Perhaps unwisely, I added it all up: six medical appointments in April (one of them for a child), and nine in May (one for a child). Some were mercifully clustered around a medical campus in the north part of city, some in the south part of the city, and two were east or west of the medical campus. Some providers collected co-pays on the spot, and others sent a big fat bill later on ("What's this?" my husband asked, waving an itemized list of co-pays in the air recently). To complicate things further, my insurance company periodically sent me bills for provider visits recommended by my PCP that they only covered partially.

My experience was typical, according to a poll of women's views of health care released today by the American Academy of Family Physicians (AAFP). The Harris Interactive poll of 1,270 women, commissioned by the AAFP, found that cost and time constraints were the top challenges women faced in obtaining health care for themselves and their families (in San Francisco, I would add "parking"). The AAFP used the poll's data to advocate for a medical home model, where all medical care is coordinated through a primary care physician and streamlined through technology such as electronic medical records, e-prescribing, and emails between patients and providers.

Considering the number of uninsured Americans, I'm supposed to write that I'm grateful to have decent medical insurance -- which I am, of course. I'm also grateful, however, for the new clients I gained in May, whose work, out of necessity, took up many nights and weekends this month as I juggled interesting new assignments with a relentless march of medical appointments. I'm equally grateful, as these appointments wind down at last, that I'm not coping with a chronic condition that requires frequent provider visits, and co-pays or bills for visits, prescriptions, or durable medical equipment.

At the end of May now, I have finished my assignments and met my target number of work hours, although I spent less time than I wanted to with my children. Luckily, I managed to squeeze in a weekday off to play hooky with my older daughter recently, who had a rough month at school. We both needed the break.

The VA and Soldier Suicides

Yes, here I am dipping my toe into health care policy once again. But I can’t help but react to the announcement this week from the National Institute of Mental Health that suicide rates among soldiers and veterans who fought in Iraq and Afghanistan might exceed combat deaths. As of May 7, 2008, the Department of Defense casualty statistics state that 4,071 soldiers have died in the Iraq conflict, and 492 have died in the Afghanistan conflict. Veterans Affairs secretary Dr. James Peake admitted to Congress this week that there are probably over 1,000 suicide attempts per month by patients within the VA system. In 2007, a VA official said that only 790 soldiers attempted suicide that year; the VA has been accused of under-reporting suicide rates.

Technical and medical advances have greatly improved survival rates for soldiers injured on the battlefield, but as a result there are more seriously injured veterans to treat within the VA system, according to Government Executive.com. A RAND Corporation study estimates that about 300,000 returning Iraq and Afghanistan soldiers have post-traumatic stress disorder (only half receive treatment for PTSD), and 320,000 have a traumatic brain injury.

I remember that in 2006, the VA was widely praised as a model health care system. In fact, I assigned a story on this very topic to a freelance writer I worked with. The VA boasted an efficient, timesaving electronic medical record (EMR) system, geographically widespread facilities, access to and support of new medical treatments and techniques, and lower prescription drug costs than many private health plans due to bulk drug purchases. The VA has been considered a possible model for a nationwide universal health care plan.

Its image has been tarnished more recently, with the mismanagement and neglect at Walter Reed Army Medical Center reported by the Washington Post in 2007, for example. There is currently a class-action lawsuit against the VA in San Francisco, contending that the VA provides inadequate mental health services. Furthermore, many middle-income veterans and their families are ineligible for VA coverage, due to enrollment restrictions imposed by the Bush administration in 2003, Physicians for a National Health Program told Forbes.com last year.

The fundamental problem is limited funding, which threatens the VA every year. This problem will only get worse as soldiers continue to return home with complex and expensive mental and physical health problems. The suicide rate is a stark reminder that the VA has failed to help these people.

Gender and Cancer Vaccines

A number of cancer vaccines are on the market or under investigation right now, many targeted to gender-specific cancers. Along with the FDA-approved Gardasil(TM) HPV vaccine, which can prevent certain types of cervical cancer, trials are underway on the prostate cancer vaccine GVAX(R), a breast cancer vaccine, and another cervical cancer vaccine.

One important difference between all these vaccines is that Gardasil is given before any cancer diagnosis, and the other vaccines under trial that I mentioned are given after a cancer diagnosis in addition to standard cancer treatment. These post-diagnosis vaccines seem to be the trend with cancer vaccines, despite the heavy marketing of Gardasil. These vaccines are designed to "retrain" the patient's immune system to respond more effectively to proteins associated with cancer cells. Some of these vaccines are developed using the patient's own cells, and other are not.

Two promising post-diagnosis vaccines under investigation that are not gender-specific target lung cancer (the most deadly cancer among both men and women) and cutaneous melanoma (which is more deadly among men than among women).

I'm curious about the gender differences between cancer vaccines. Do women respond more favorably than men to cancer vaccines, or vice versa? Are vaccines that use the patient's own cells more or less effective than those that don't? Are vaccines for gender-specific cancers, such as prostate and cervical cancer, more or less effective than vaccines for cancers that can strike both genders? There might be no patterns here, but if there are, it would be interesting to see how physiology, sociology, and other factors impact the effectiveness of these vaccines.

BPA and Baby Bottles

A chemical often used to manufacture infant bottles, water bottles, and food packaging might be harmful to humans, according to a draft brief released this week by the NIH-funded National Toxicology Program's (NTP) Center for the Evaluation of Risks to Human Reproduction (CERHR). The NTP reviewed a number of mostly animal studies that indicated that Bisphenol A (BPA), used in resins and polycarbonate plastics, might cause neural changes, precancerous prostate and breast lesions, and early puberty, among other problems, at fairly low doses. At significantly higher doses than humans are likely to encounter, BPA has been proven to slow puberty and growth, and decrease survival rates in animal studies.

Although BPA is also sometimes found in tableware, medical devices, dental sealants, and automobiles, among other places, the draft brief stated that humans primarily absorb BPA though food and drink. The U.S. produces 2.3 billion pounds of BPA yearly, and infants and children have the greatest exposure to the chemical "because they eat, drink and breathe more than adults on a pound for pound basis," the report stated.

The draft brief points out that most ingested BPA is metabolized and eliminated in the urine. The remaining ("free") BPA in the body is probably harmful. Based on evidence from animal studies, infants and young children are thought to be less efficient at metabolizing and excreting BPA than adults, the draft brief states, so they retain higher levels of free BPA in their bodies. The draft brief also says that BPA seems to leach more easily from plastic into foods when the food is heated. As such, baby bottles (often heated up, of course, before given to the baby) seem like an especially potent source of exposure in infants.

Formula-fed infants aged 0 to 6 months, who are exposed to BPA primarily though baby bottles but also through the packaging of formula containers, might absorb about ten times the amount of BPA as a breast-fed infant, according to the draft brief.

I find this information, and the pervasiveness of BPA in the environment, disturbing news. I first read about the NTP draft brief in a story on the Washington Post online, and the writer considered the report's findings worrisome. A number of other online news outlets, such as Fox Business, on the other hand, chose to run the press release on BPA from the American Chemistry Council as an article. The American Chemistry Council press release, not surprisingly, states that the NTP draft brief proves that there are no serious human reproduction concerns about BPA.

Yes, the data is based primarily on animal rather than human studies, and the authors of the NTP draft brief pointed out a number of limitations to the studies they looked at, such the reproducibility and structure of some studies. I still think that the information in the NTP draft brief is too important to be dismissed – especially for parents, who have been concerned about the plastics in baby bottles for years.