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Friday, 30 August 2013

Health Care Spending - How Much is Enough?

DrPHealth welcomes guest items such as the following. Drphealth@gmail.com  

When it comes to health care spending, more money doesn’t equal better outcomes.

Bloomberg recently compiled a ranking comparing health care economics and life expectancy. Of the parameters, the strongest correlation is found between health care cost per capita and life expectancy. However, the association is far from linear.

Up until ~$3000, there is a logarithmic rise in life expectancy as the dollars spent increase. Then, a plateau. Canadians, which have life expectancies similar to the Greek and Portuguese, spend twice as much (or, get half the bang for their buck).

This plateau is even more pronounced when increasing the countries analyzed. Gapminder , an interactive indicator goldmine headed by statistical genius Hans Rosling, even provides a time-based visualization. In the last 15 years, small investments in developing nations have had large effects on outcomes (the logarithmic part of the curve).  All the while, Canada’s 280% increase in spending  resulted in marginal health benefit improvement.

When comparing health care costs as a percentage of GDP the correlation is weaker though affirming that economic vitality tends to be predictive of better health.   .

From a global perspective, much could be done to decrease inequities and improve lives by investing little.

At home, we seem stuck on the notion that more money will solve our woes. Provincial budgets are closing in on 50% devoted to health care, and continue to grow above inflation. These funds are all too often it’s siphoned from other provincial departmental pots such as environment, housing, social development, public safety, child & family development, agriculture, and advanced education. Those departments with the greatest influence on the determinants of health are losing out to  direct health care expenditures.

A different approach to spending is essential, and a gradual paradigm shift is in progress. Take the CMA’s recent summary of cross-country town halls addressing precisely this issue: “to improve health, tackle poverty.” While the CMA proudly pronounce that doctors have been sending this message for the last seven years, many public health doctors and other professionals have been strong advocates for the same message for decades.

We can all be vocal about our government fiscal direction and ensure investing in health care won’t be detrimental. 

Monday, 26 August 2013

Food poisoning - What the Cronuts outbreak should be bringing up about our food safety system

Cronuts (mega burger on a croissant-donut bun smothered in a sauce that looks like pure grease), you might be taking your life in your hands to eat one given the caloric content, but what the heck, isn’t gorging in unusual fatty foods part of the fun of the host of fairs, including the CNE.  That is assuming they are not also contaminated with food poisoning.  For over 150 people this past week, a couple of days of vigorous vomiting, stomach pains and feeling really bad appear to have been caused by cronut consumption.

Food poisoning is common.  Health Canada claims about 4 million cases per year in the country.

Food poisoning from food service establishment is not, but when it occurs two things are notable.  First, there are larger numbers exposed than in the typical family kitchen.  Second, it makes for great media headlines.

Canada’s food inspection system deserves kudos.  Multiple barriers through handler education, HACCP control programs (where facilities monitor their own critical control points), public health inspections, and surveillance for illness are reasonably well honed instruments.   Of course, we all eat, and in doing so put pressure on the food preparation system where plenty can go wrong.

And it does.

If Canada has one soft spot, it is not great and maintaining statistics nationally, in part a function that foodborne illness itself is not a nationally notifiable illness and CFIAs involvement is limited to widespread food production settings and interprovincial outbreaks.  It does have a better system for notification of certain illness which lead to a ill-informed Conference Board of Canada report that claimed more illness in Canada than the US which is likely not the case.  document protected site  Huffington Post synthesis

So, we turn south of the border to the US for good national surveillance, recently complied MMWR supplement June 2013.   Over a 1000 outbreaks a year.  Of these only a few dozen are multistate suggesting contaminated produce like a recent Cryptospordium outbreak DrPHealth.  Nearly 2/3 are associated with food preparation settings like restaurants, not quite 10% are associated with catered events.

Here in lies the manipulation of statistics.  Of the restaurant outbreaks, the median number of ill persons was 5 (yes five).  That means of the estimated 48 Million cases of food poisoning annually in the US, only about 0.01% are associated with restaurants.  Well likely a bit more because of underreporting, but at less than 1% of food poisoning cases, we have a very elaborate system for protecting against foodborne illness that likely misses the main culprit – poor food hygiene in the home.

The classic description of foodborne illness, similar to the Cronut outbreak, is onset of vomiting hours after consumption of the food and readily attributed to the last meal.   The three commonest causes of foodborne illness have incubation periods over at least a day (Noroviru (39%)s, Salmonella(26%), E. Coli 6%)). Staphylococcus aureus toxin which has been implicated in the Cronuts is 6th on the list causing only 3% of outbreaks. 

For the 150 or more than became ill, the system failed them.   If you look at the burger, the natural assumption is that it was the meat – but for that to occur, the meat must have been mishandled and kept at room temperature for extended time, something that even the most naive of food handlers will not likely let happen, and given the speed at which they were being sold, meat did not sit around long.   Just as likely would be the sauce, prepared in advance and kept handy to slobber on at the time of serving.  Both culprits should be under investigation TPH on Cronut outbreak cause 

Thursday, 22 August 2013

Queue jumping – reaching to the heart of Canadian health equity.

Tired of waiting in line?  

How do you react when somebody butts into the line ahead? Anger, frustration, blame on the organization that put the line there anyway? 

Of course, if this was in some other countries, paying for privilege to jump lines is normal.   Fast tracking across borders, airport security express lanes, personalized banking service, have all become markers of class differential in Canada and while annoying, are integrated into our society.

Try to jump the line at Tim Horton’s and you might be assaulted.  Likewise, queue jumping in health services is almost a criminal offence.  Hence absolute outrage at the Alberta public inquiry final report findings.  Alberta Health Services Access Inquiry Calgary Herald coverage

Read the details though.  Individuals Albertans had little control over influencing their position in time.  The queue jumping problems were systems issues which saw certain service providers get greater access to resources.  It had little to do with the status of the recipient and more to do with the status of the provider.
Duh.  As if we as consumers didn’t know, if you want to get your hip done faster, choose the surgeon with the shortest wait list.  Want to spend less time in emergency, shop around for a shorter wait time facility – and that might mean driving an hour to save 3 hours of waiting. 

Waitlists are the culmination of numerous steps.

·         Identification by the patient of a need for something
·         Action by the patient to seek a health professional
·         Where it occurs, the time from visit to primary care provider to referral to specialist
·         All of the above can be prolonged by requests for lab tests or specialized diagnostic imaging
·         It is only at this point that the specialist may add someone to a waitlist for an intervention

When we measure a waitlist, we are only measuring the final step in a process that has many more opportunities to be manipulated by both the practitioners and the patient.  Its not surprising that we find rural residents, those from lower socioeconomic categories, marginalized patients etc that compared to other users of the system tend to have prolonged durations at every step of the way.

So why the outrage when only the last of the steps leads to a perceptions of inequity? Fixing it doesn't address the already well documented inequities of the earlier steps. 

And, who benefits the most from the measurement of the fifth step of waitlists? it is the specialists who can argue for more resources, more access, and even more money. In this respect the inquiry falls desperately short – it speaks to reducing wait times for medical procedures – but fails miserably in modifying a system that will provide equality in access.  Inquiry recommendations

Special note to public health folks of the mention in the report of pandemic vaccine access, but some will recall the Alberta boondoggle on handling vaccine when other provinces used clear priority methodology to attempt to address equity. It was an Alberta political decision to go with first come first served, and health care providers became opportunistic in misusing the scarce resource for their own purposes.    A sad footnote on equity and queue jumping.

Tuesday, 20 August 2013

Lyme disease – a serious public health issue, distracted by those that make it appear even worse.

Everyone would agree that in its worst manifestation (late disseminated infection), it rivals the most complex of chronic infectious diseases like syphilis.   When caught with early disseminated infection secondary to hematogenous spread its symptoms are significant and sometimes devastating.   Caught early as localized infection (about the first month), the classic erythema migrans present in three-quarters of cases can be readily treated.   Those without the classic skin rash are more likely to proceed to the disseminated forms of illness.

The culprit is a bacteria transmitted in a tick bite.  Ticks have to go through a complex life cycle during which they are exposed to the bacteria in deer mice, and subsequently attach to a human (deer are the preferred mammalian feed) for feeding during which the bacteria is injected.  It is the Ioxides tick species follow this particular life cycle, which is a relatively small tick and less likely to be noted than some larger tick species that cause many fearful reactions.  Its relative size may facilitate it not being detected, as transmission generally requires at least 24 hours of attachment before infection with the spirochetal bacteria has occurred.

Treatment requires prolonged antibiotics, and is most effective when prescribed earlier.  Those with disseminated illness often developed persistent symptoms not associated with persistent infection. 

On this later point hinges the controversy.   The long term symptoms of Lyme disease are often associated with fatigue, achiness, and weakness.   Very non-specific symptoms that can be associated with a wide range of diagnosis, including chronic fatigue syndrome, fibromyalgia, and depression.   Distingushing between different clinical syndromes can be challenging, and most of us would prefer to have a clearly identified culprit to blame for our non-wellbeing.   Ticks, bacteria and Lyme disease make for an excellent target for such externalization of blame.  

Those with similar symptoms can be the victims of unscrupulous entrepreneurs or even just misguided health professionals with personal biases.   These victims are fuelled by those with real chronic Lyme illnesses.  The symptoms and diagnosis being accepted frequently for long term disability and other forms of support.   A notorious inaccurate laboratory test likely labelled thousands of people erroneously as long term “carriers” of Lyme infection.  Other health practitioners that have blamed symptoms on a post-Lyme condition even where definitive Lyme illness has not been identified.

CDC has recently reported that as many as 300,000 cases of Lyme disease are diagnosed in the US each year.  The estimate based on multiple methodologies including serosurveys,  medical claims, and self-reported disease.   CDC report

While Lyme disease is less common in Canada, the incidence is likely increasing.    PHAC’s carefully worded site contains excellent information PHAC Lyme Q and A   for general questions, and health professionals and others can view more detailed information at PHAC Lyme for health professionals .  Notable are the maps that document the risk areas for transmission, with moderate to high risk limited to southern Ontario and Quebec, and areas in New Brunswick and Nova Scotia.  Low risk areas exist in PEI, Manitoba and BC.  Almost all reports acknowledge the risk is changing and that climate change will likely increase Lyme disease and tick prevalence in Canada. 

While groups like the Canadian Lyme Foundation have advocated long and hard for increasing the profile of Lyme illness, they have done so by depending on less rigorous science.   In doing so, they have diluted what is otherwise a serious illness and real threat for well over half of Canada’s population who live in risk areas.   

Monday, 19 August 2013

West Nile Virus - a reminder of the annual threat

West Nile Virus season is hitting full speed now.  Mid-August is the time the mosquitoes may be into their fourth generation and have had sufficient previous feeds to have potentially contracted WNv from its natural host in birds and now competing for a blood feed, some species get less picky on their preferred blood source and may accept the less desirable blood of a human.  Moreover, early sunsets mean that dusk activity for humans increases, and that is the preferred feeding time for vector species of mosquitoes. 

If you look at most messaging however, you would think that the greatest risk for West Nile comes with the hoards of spring mosquitoes (mostly Aedes sp. and Coquilletidia perturbans) and by now the messaging has petered out, when the risk of transmission is at its greatest.

Moreover, while not exclusive to Culex sp. , Culex is the mosquito most likely to feed on birds and mammals – and our western provinces are at greater risk because of a particular species C. Tarsalis which is even less finicky than the more common eastern variety C. Pipiens

Those that are interested in more on West Nile Virus and appropriate messages are referred to DrPHealth posting from August 2012

Surveillance for West Nile ramps up considerably after the initial summer anxiety in the media.   Kudos to PHAC for actually trying to message appropriately at this time of the year.   However, data reporting in the busiest time period is still biweekly, and often weeks out of date.   August 3rd reporting only identified two Canadian human cases, with positive mosquitos from Quebec  through Saskatchewan.  Alberta surveillance is far from up to date and must be suspect. BC reported a positive mosquito pool in an August 15th update.   The BC report alludes to five Canadian human cases, 97 mosquito pool positives and positive birds from Ontario through to Saskatchewan.

The US is reporting nearly 200 human cases predominately in states other than the Eastern Seaboard. 

While it may overall be a cooler and wetter year for most of Canada, conditions that do not favour Culex species, it is a healthful reminder that now is the time to be most cautious on avoiding mosquito bites. 

Thursday, 15 August 2013

National Household Survey - the National embarrassment gets worse.

As an anti-government libertarian mentality sweeps across the nation, the changing face of Canadian society incrementally edges towards some cataclysmal edge. Well perhaps, perhaps not, but at least on the journey through change,  those that have promoted collectivism and common good seem to be less likely the survivors while the fiscal gaps between highest and lowest earners increase, and the proportion of wealth assumed by the top 10% continues to grow substantively.  

One victim of the libertarian shift was the mandated long form census, replaced by the voluntary National Household survey.  The global non-response rate nationally was 26.1%, varying from a provincial low in Quebec of 22.4% to a high in PEI of 33.4%.  The best performer was actually the NWT at 16.1%.  

Making adjustments for non-response and data quality problems must be a nightmare for the statisticians used to completion rates in the low 90’s in previous censi.  The methodological issues are detailed at NHS data users guide  

So, what a shock when Stats Can puts a halt to the release of the third of the final three detail summaries.   Critical information on income distribution and housing, likely the most embarrassing data for the government, has been delayed by at least a month.  On the surface, the explanations appear to be legitimately operational with an error in data processing that will require reruns and reanalysis, and any researcher will sympathize.  However, delaying the release only 48 hours before its announced date has got to raise more eyebrows than the attention it appears to have garnered.   It is surprising the conspirists are not yet filling the airwaves with speculation on the data contents.  Globe and Mail August 14

We will need to wait about a month to figure out what bombshells will be dropped, by then the quieter summer news channels will be filled with items as schools, governments, universities are back into full swing and data releases from Stats Can might just not be a high priority.
Reading the Globe and Mail article also leads one to think that the cost of protecting the right to choose for the additional 20% of the population  exceeded $100 Million.  Not a trivial amount for a government that is honing its machete once again and preparing to swing hard and deep into its civil servant ranks. 

Wednesday, 14 August 2013

Texting and Driving: The dangers of distraction. The latest public health problem.

Passionate about a public health topic?, DrPHealth welcomes contributions such as follows.  Email DrPHealth@gmail.com

The unusual pairing of an telecommunications giant, and an acclaimed German  art house director has resulted in the creation of a compelling film on the dangers of texting and driving. In “From One Second to the Next,” Werner Herzog, commissioned by AT&T, avoids gruesome collision scenes and relies on images of benign looking roads (long after the crash has been cleaned up) and the stories of survivors, both victims and perpetrators, to drive home the point that horrifying crashes occur to regular people on regular roads, doing regular tasks, while driving.

This is not the first video to warn about the dangers of texting and driving. A Welsh public service announcement made headlines in 2009 for its far more graphic portrayal of the consequences of texting behind the wheel. I was unable to find an evaluation of the video’s impact, though in a recent comparison of the US and seven European countries, the UK fared better with only 20% of adults admitting to using sending texts or email while driving compared to 68% in the US. Canadian surveys put self-reported use at 36%.

Distracted driving has emerged as the new collision risk of note, overtaking drunk driving in 2010 as the number one road safety concern reported by Canadians. All provinces and territories with the exception of Nunavut currently have laws forbidding the use of cell phones (including texting) while driving with varying penalties. Though the public discourse, research and policy reaction has been dominated by cell phones, distracted driving encompasses a wide range of activities including, adjusting the radio, eating, reaching for fallen objects, and grooming. Determining which ones play significant roles in motor vehicle related injuries remains challenging.

There is little doubt that texting while driving increases the risk a crash and the consistent reports of frequent use by drivers, and young drivers in particular, is a distressing trend. However, in our zeal to stamp out an obvious, preventable risk, the dangers of texting and driving can distract us from also keeping focus on other significant hazards (from Transport Canada’s 2011 Report on Road Safety):

·         In 2009, 38% of motor vehicle fatalities involved alcohol. In fact, between 1998 and 2009 there has been no significant decrease in this proportion for any age group.

·         An estimated 20% of fatalities are related to fatigue; 60% of drivers reported driving while fatigued and 15% admitted to falling asleep at the wheel.
·         Speeding played a role in 27% of fatalities and 19% of serious injuries; 40% of fatally injured drivers were between 16 and 24.

Perhaps Mr. Herzog can help humanize these numbers.

(Let’s save the challenge of distracted walking for another day.)

Monday, 12 August 2013

DrPHealth – 2 years old, (hopefully) providing a Canadian public health service.

It started in July 2011 as an experiment and has now grown to over 300 posts and an equivalent number of Tweets. 

The audience appears to change in response to specific issues, or certain followers.   This month there is a surge in Latvian readers.  Overall there have been some 16,500 views – an average of just over 50 views per posting, a rate that has only marginally changed over the two years.   Enough to keep prying time to support the ongoing postings. 

The prime audience of Canadian Public health workers has slowly eroded to a good following, and occasional episodic bursts of international interest in particular topics.  Some postings keep being accessed over time, lately it is a February 2012 posting on adult pertussisFracking October 2012 is the all-time high viewed site, albeit the largest proportion of viewers were within the first weeks.  The comments on the new Minister of Health July 2013 struck a chord with Canada’s public health journalist Andre Picard and drove numerous people to the site and the Twitter account, and similar comments seemed to become engrained in other health commentators subsequently.   

Imitation is the kindest form of flattery.  Several resident groups are dedicated followers to the commentaries and material.  There is a gold mine of information for those preparing for Royal College exams in public health and preventive medicine. 

On the downside, only a handful of individuals post comments, and even fewer email to DrPHealth@gmail.com . The number of comments only averages about one in four postings.   Only a handful of followers are noted, and in a quirk of blogspot it is not known how many people receive the postings directly through email although we hear anecdotal evidence that is the preferred method for some (and are not included in page view statistics).  Twitter-wise the number of followers has grown to 90, mostly Canadian public health folks suggesting it is reaching the intended audience.   A sporadic stream of mentions and retweets invariably is followed by a spike in views to the blog site – so Twitterers, please help drive readers to the blog, it is the most highly effective method of advertising.

International followers are more than welcomed to catch a glimpse of some of the inner workings of the Canadian machine.    One-fifth of viewers are neighbours from just south of the border and clear when certain topics strum the right chords.  Ten per cent are from Russia, with Germany and the United Kingdom rounding out the top five.

The Twitter feed is the top referring site followed by Google.  The most common search is on DrPHealth itself with a smattering of topic specific items that might otherwise be consider “esoteric”.   To come depending on time, is a table of contents that might be easier to search for relevant topics.  Blogspot does not have useful search capacity. 

The past two years has seen the expansion of the number of other relevant public health sites, so for the dedicated readers, a heartfelt thanks.   It is only through your dissemination of the blog that readership is sustainable.  

Thank you. 


Thursday, 8 August 2013

Bicycling - a public health intervention in active transportation and the need to balance safety.

There was a great Tweet the other day - One way to increase bike safety? Increase the number of bikers.   With a link to a NYTimes article on bike sharing.  Seems that the more people biking on the road, the safer it is for all cyclists.  

The Times article is a nice little review of what we are learning about making biking safer.  With cities like Toronto, Montreal and Vancouver beginning to invest considerably in bike infrastructure with separated lanes, bike sharing programs and traffic reduction activities that increase the affability of biking, Canada is on its way to at least finally making the bike a viable form of active transportation.

According to the CAA, some 7500 bikers are seriously injured each year in Canada. There were about 50 deaths each year in the mid-2000s.

Back in the 80’s the focus was on what should the cyclist do to be safer, and in typical fashion we mandated helmets since 2/3rds of deaths were secondary to head injuries.  Talk about victim blaming by public health.  Now, this writer would not give up their helmet, having been run off the road by a cement mixer and crashing into post.  But only now are we asking why would cement mixers and bikes be sharing the same road space?  A 2004 Canadian study looking at comparative rates of pedestrian and cyclists deaths concluded that helmet use had no protective effect Vehicular cyclist a group opposing helmet legislation , a finding apparently mirrored in US and Australia.  More recently a case-control study looking at cycling fatalities and severe accidents found a protective effect however the study while referenced in Globe and Mail is not accessible on-line. 

While one can debate the relative merits or not of helmets, the effect is limited.  The solution is to prevent cyclist and motorists from colliding, and just as with vehicles, the solution is often in the engineering.   In this case the engineering is in road design.   Sociological engineering in making motorists more aware of cyclists, in increasing numbers of cyclists travelling together in volume, and in imbedding the needs of safer cycling into road designers will have the longer lasting sustainable changes that are starting to show in the major cycling areas like Victoria (5.6% of workers, Saskatoon at 2.8% and Ottawa 2.2%).  

One final aside on cyclists, in cities with poor air quality, it is still unclear what the added health risk is for cyclists that are inhaling the worst air which is immediately adjacent to roadways, while exerting their bodies.  

Kudos to the dedicated cyclists that are literally clearing the roads to make for safer active transport.  

Friday, 2 August 2013

Summertime hot topics in public health

Who says that things slow down in the summer?  

Great new materials worth looking at.

The CMA released its report on Health Care in Canada – What makes us sick? The major focus of the document being the need to alleviate poverty and its manifestations as the main method of preventing illness and that true health care reform needs to take aim at the determinants of health.  For readers it is perhaps a very basic document.  For medical health officers and public health and preventive medicine specialist the comment that doctors have only been advocating on patient needs is clearly a slap in the face, those physicians have been advocating for decades.  The best way to institutionalize change is to have your target group believe they are the owners of the issue, clearly the CMA has taken this task to on.  CMA What makes us sick

Getting to tomorrow a Report on Canadian Drug Policy is a comprehensive look at current drug policy initiatives and well worth reading for its overview, background and insights.  Drug Policy in Canada  .  There is a bias towards changing current get tough on drugs policy, but consistent with a thematic in the health sector for the last few years.  The document will have the reader questioning the status quo as anything other than just plain useless.

 From HealthEvidence.ca some good reviews of important information

·         The minor benefit of food supplementation programs http://www.healthevidence.org/view-article.aspx?a=24439

·         The lack of benefit of general health checks http://www.healthevidence.org/view-article.aspx?a=24502, and,

·         The benefit in treatment but not prevention of education in childhood obesity http://www.healthevidence.org/view-article.aspx?a=24415

The final item to digest is a 2013 report on food insecurity in Canada.  The report details the challenges faced by the 1.6 Million Canadians with food insecurity issues.  The list of indicators in the document is itself is very helpful in measuring the continuum of insecurity challenges.  Year to year rates by province/territory are provided to show improving trends in some areas especially in Newfoundland and Labrador, and remaining flat in others. Some upward trending in Saskatchewan and Alberta are potential heralds of disconcerting changes.  Canadian Food Insecurity

Stay safe and comfortable over what has become one of the most dangerous weekends of the year.