Tag Archives: Medicine

1/6 of US Deaths From Hospital Errors

I don’t post on medicine much lately, because my attention has been elsewhere. But this looks too important not to mention:

In 1999, the Institute of Medicine published the famous “To Err Is Human” report, … reporting that up to 98,000 people a year die because of mistakes in hospitals. The number was initially disputed, but is now widely accepted by doctors and hospital officials — and quoted ubiquitously in the media. In 2010, the Office of Inspector General for Health and Human Services said that bad hospital care contributed to the deaths of 180,000 patients in Medicare alone in a given year.

Now comes a study in the current issue of the Journal of Patient Safety that says the numbers may be much higher — between 210,000 and 440,000 patients each year who go to the hospital for care suffer some type of preventable harm that contributes to their death, the study says.

That would make medical errors the third-leading cause of death in America, behind heart disease, which is the first, and cancer, which is second. …

James based his estimates on the findings of four recent studies that identified preventable harm suffered by patients – known as “adverse events” in the medical vernacular – using use a screening method called the Global Trigger Tool, which guides reviewers through medical records, searching for signs of infection, injury or error. Medical records flagged during the initial screening are reviewed by a doctor, who determines the extent of the harm.

In the four studies, which examined records of more than 4,200 patients hospitalized between 2002 and 2008, researchers found serious adverse events in as many as 21 percent of cases reviewed and rates of lethal adverse events as high as 1.4 percent of cases.

By combining the findings and extrapolating across 34 million hospitalizations in 2007, James concluded that preventable errors contribute to the deaths of 210,000 hospital patients annually.

That is the baseline. The actual number more than doubles, James reasoned, because the trigger tool doesn’t catch errors in which treatment should have been provided but wasn’t, because it’s known that medical records are missing some evidence of harm, and because diagnostic errors aren’t captured.

An estimate of 440,000 deaths from care in hospitals “is roughly one-sixth of all deaths that occur in the United States each year.” (more; source)

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Diagnosis Futures

From ’97 to ’99 I was a RWJF Health Policy Scholar (at UC Berkeley), and my final project and presentation was on what I called “treatment futures”, i.e., the idea of using decision markets to forecast treatment-conditional health outcomes for individual patients. I proposed:

  1. At major treatment decision point, post sanitized medical record & options to web.
  2. Subsidize [betting] markets estimating treatment-conditional outcomes (e.g. lifespan).
  3. Anyone can trade or add treatment options.
  4. Market estimates inform treatment choice.
  5. Outcome determines market asset values.

I also posted on this in ’07. Yesterday I learned that a new startup, CrowdMed, is spending $1.1M to try a related idea. They will have ordinary people “bet” on particular patient diagnoses. I put “bet” in quotes because they only bet donations, and they don’t tell users how individual predictions, individual winnings, and consensus estimates on patients are related. That is apparently part of their patented secret sauce – you’ll just have to trust them.

A patient pays $200 to post their problem, and promises to eventually declare a “correct” diagnosis. Each player is given $5 to start, and can only spend winnings on donating to Watsi patients. So if after several years hard work, you do much better than average, and end up with $20, you might donate that much – woo hoo! Player incentives to diagnose correctly are diluted further by the fact that they only predict what the patient will say is their diagnosis, not the true diagnosis. And players don’t get to look at a full medical history, just a few paragraphs of description.

Patients mainly pay for possible diagnoses to suggest to their doctor to consider, diagnoses that players believe might find supporting evidence, if only the patient’s doctor would consider them. So patients have to believe that their doctor will believe that these volunteer amateur detectives have useful diagnosis suggestions to pursue, ones the doctor would not have otherwise considered. Seems a pretty high bar to me.

My conditional forecasting concept could help patients even if patient doctors don’t believe in it, but it does require players to wait longer to find out if they win. And I think that players deserve a much higher fraction of the patient payments than this startup seems willing to give them — I expect CrowdMed incentives are way too weak. Many seem to have decided that the big idea in “crowd-sourcing” is getting amateurs to do for free what you’d otherwise have to pay professionals to do. Me, I think you usually need to pay good money to get good info, even when you do it right.

Added 3p: The CrowdMed founder replies in the comments; I respond also.

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Rah Second Opinions

What many people like about being religious is being part of a community built on the idea of being and doing good. They can meet and discuss how to be and do good, share practical tips and sometimes just do good together. That sure can feel great.

What many people dislike about other people being religious is their habit of presuming that if you aren’t religious in their way, you aren’t being or doing good; you are bad. Religious people often prefer similarly religious people to be their teachers, grocers, leaders, etc., because they can’t trust bad people in such roles and shouldn’t support bad people even if they can.

Many non- or otherly-religous folks say they have nothing against doing good, but say it is laughable to presume that people who are religious in your way are actually much better than others. Most religions do little to actually sort people by how much good they are or do; they mostly sort by loyalty, conformity, impressiveness, and local social status. Religions could sort people better if they spent lots of time together doing things most everyone agrees are clearly good, like healing the sick, but that is pretty rare.

My ex-co-blogger Eliezer Yudkowsy left this blog in 2009 to start the Less Wrong (LW) blog, which helped seed a growing community that sees itself self-consciously as “rationalists”. They meet online and in person and often discuss how to be more rational. Which is a fine goal. I’ve supported it by listing recent LW posts on the sidebar of this blog, and I’ve attended many LW-based social events. Some high status members of that community now offer (not-free) workshops where they teach you how to be more rational.

As with religion, the main problem comes when a self-described rationalist community starts to believe that they are in fact much more rational than outsiders, and thus should greatly prefer the beliefs of insiders. This happens today with academia, which generally refuses to consider non-academic beliefs as evidence of anything, and with political ideologies that consider themselves more “reality-based.”

Similarly, I’ve noticed a substantial tendency of folks in this rationalist community to prefer beliefs by insiders, even when those claims are quite contrarian to most outsiders. Some say that since most outsiders are quite irrational, one should mostly ignore their beliefs. They also sometimes refer to the fact that high status insiders tend to have high IQ and math skills. Now I happen to share some of their contrarian beliefs, but disagree with many others, so overall I think they are too willing to believe their insiders, at least for the goal of belief accuracy. For the more common goal of acceptance within a community, their beliefs can be more reasonable.

Some high status members of this rationalist community (Peter Thiel, Jaan Tallin, Zvi Mowshowitz, Michael Vassar) have a new medical startup, MetaMed, endorsed by other high status members (Eliezer Yudkowsky, Michael Anissimov). (See also this coverage.) You tell MetaMed your troubles, give them your data, and pay them $5000 or $200/hour for their time (I can’t find any prices at the MetaMed site, but those are numbers mentioned in other coverage). MetaMed will then do “personalized research,” summarize the literature, and give you “actionable options.” Presumably they somehow try to stop just short of the line of recommending treatments, as only doctors are legally allowed to do that. But I’d guess you’ll be able to read between the lines.

Of course that is usually what you pay doctors to do – study your charts and recommend treatment. And if you didn’t trust your main doctor, you could always get a second or third opinion. So why use MetaMed instead? The main evidence offered at the MetaMed site is data on high rates of misdiagnosis and mistreatment in medicine. Which of course means there is room for improvement via second and third opinions. But it doesn’t tell you that MetaMed is a relatively cost effective source of such opinions.

I wrote this post because I know several of the folks involved, and they asked me to write a post endorsing MetaMed. And I can certainly endorse the general idea of second opinions; the high rate and cost of errors justifies a lot more checking and caution. But on what basis could I recommend MetaMed in particular? Many in the rationalist community think you should trust MetaMed more because they are inside the community, and therefore should be presumed to be more rational.

But any effect of this sort is likely to be pretty weak, I think. Whatever are the social pressures than tend to corrupt the usual medical authorities, I expect them to eventually corrupt successful new medical firms as well. I can’t see that being self-avowed rationalists offers much protection there. Even so, I would very much like to see a much stronger habit of getting second opinions, and a much larger industry to support that habit. I thus hope that MetaMed succeeds.

Added 8:45p 23Mar: Sarah Constantin, MetaMed VP of research, replies to this post at Marginal Revolution (!):

Investigating your condition in depth, in the context of your entire medical history, genetic data, and personal priorities, may well turn up opportunities to do better than the standardized medical guidelines which at best maximize average health outcomes. That’s basically MetaMed’s raison d’etre. … Fundamentally the thing we claim to be able to do is give you finer-grained information than your doctor will. …

Robin Hanson seems to be implying that MetaMed is claiming to be useful only because we’re members of the “rationalist community.” This isn’t true. We think we’re useful because we give our clients personalized attention, because we’re more statistically literate than most doctors, because we don’t have some of the misaligned incentives that the medical profession does (e.g. we don’t have an incentive to talk up the benefits of procedures/drugs that are reimbursable by insurance), because we have a variety of experts and specialists on our team, etc. (more)

I was asking why pick MetaMed over ordinary medical specialists. I expect most doctors will disagree strongly with the claims that they don’t give patients personalized attention, only improve average health outcomes, and don’t offer the finest-grain advice available. But they could be wrong, and it would be great if MetaMed could show that somehow. On misaligned incentives, a reason to ask a different ordinary doctor for a second opinion is exactly that they can know they won’t get paid for any treatments they recommend.

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Bike Helmet Laws Fail

Two years ago I posted on evidence that called into question the effectiveness of bike helmet laws. A new NBER paper confirms this skepticism:

Using hospital-level panel data and triple difference models. … We consider the effects of the [US bike helmet] laws directly on ['91-'08 US] bicycle related head injuries, bicycle related non-head injuries, and injuries as a result of participating in other wheeled sports (primarily skateboarding, roller skates and scooters). For 5-19 year olds, we find the helmet laws are associated with a 13 percent reduction in bicycle head injuries, but the laws are also associated with a 9 percent reduction in non-head bicycle related injuries and an 11 percent increase in all types of injuries from the wheeled sports. ..

The estimated reduction in head injuries resulting from helmet laws is robust to changes in the definition of the control group, to changes in the type of fixed effects included (state versus hospital), and to changes in the samples of states and hospitals evaluated. … Considering the different offsetting results, we run our preferred specification on injury counts for 1) all head injuries and 2) total (all head and body) injuries arising from cycling and wheeled sports. The net effects of the helmet laws are small and are not statistically different from zero. (more)

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Respectable Resentment

Assume for the purpose of this post that used car sales folks are exploitive and socially unproductive – they mainly trick buyers into spending more than they need. I don’t actually believe this, but I don’t want this post to be distracted by the issue of which professions are or are not socially productive.

So, imagine that you are competing to be a successful used car salesperson. But you find that you face real biases. Buyers are unfairly less willing to buy from you because you are female, or young, or the wrong ethnicity, or the wrong personality type. Or perhaps it is managers at used car sales firms who are biased against hiring your people. In any case, you have a legitimate complaint of bias, and you can legitimately resent that bias.

Even so, I don’t feel very sympathetic to your cause. Oh, on the margin I’d prefer that you win your battle against such biases. Its just that I don’t see it is as a high priority. Why? Because your cause is mostly selfish. Oh sure, the used car sales industry might be slightly more efficient if they weren’t unfairly biased against your sort. But by assumption what they’d get more efficient at is mostly exploiting ignorant buyers. Not a cause I can get behind.

Now imagine that you run a charity, and that while your charity is especially effective at its cause, e.g., reducing African poverty, it suffers from the bias that donors care more about using their donations to seem to help, than to actually help. You resent the fact that your charity doesn’t do so well because it isn’t as good at helping donors look caring. This time, I’m a huge supporter of your cause. Why? Because the bias you oppose is hurting us all, a lot.

So if you face gender bias getting hired as a cancer doctor, but for a type of cancer where doctors actually do little to help patients live longer, then I’m only mildly sympathetic. But If you suffer as a doctor because patients are biased to “do something,” and dislike your correctly telling them they are better off doing nothing, then I’m a huge fan and supporter.

If you suffer bias in academia because you are religious, but your chosen research area is mostly a pointless exercise in showing off math skills, I’m not going to get too worked up for you. But if your academic career suffers because your research is focused on a way to actually making important intellectual progress, which doesn’t happen to be a good way to show off math skills, I’ll shout your cause from the rooftops.

If you suffer from a bias based on the kind of person you are, you have a legitimate complaint. But it may not be an especially noble cause. However, if you suffer because of a common bias against doing a sort of thing that is especially useful, you may have a very noble cause. I can much more respect your resentment of a bias against doing good, than a bias against who you are.

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US Politics Of Medicine

After presiding over an economy with a record disappointing performance, which usually gets incumbent presidents fired, Intrade puts Obama’s chance of re-election at 79%! I attribute an important part of this to the politics of medicine. Here’s recent US medical politics in a nutshell:

Seniors vote a lot more, and they love their free medicine, so US politicians have long written them a blank check, leading to rapid cost increases. Wonks have long said “something must be done” about costs, and the left has long wanted to expand the number with health insurance. So Obama pushed through a law requiring such an expansion, and declaring an intention to do something about costs. Later. But something, they swear.

This created a vague unease among seniors that their free medicine might get cut. Vague because seniors don’t really get how exactly costs might be cut. But still, cuts! Which created an opening for a Republican to get elected president by promising to never cut senior medicine. Except that the frontrunner Republican candidate was someone who had implemented a similar program when he was governor. And then he made a “bold” move to pick a running mate with a bold plan to turn Medicare into a voucher system. Which Romney thought would give him credit for taking problems “seriously.”

Bad move. Voters don’t really like “bold” politicians. Since seniors have a better idea of what “vouchers” mean, and how exactly they lead to cuts, that let Obama more effectively attack Romney as planning to cut seniors’ free medicine. Which is sticking, because although everyone says “something must be done”, seniors don’t actually believe that their free medicine needs to be cut. So seniors in key swing states move toward Obama, and he gets re-elected.

And after the election, there’s pretty much no chance Obama will let senior medicine get cut, at least in any way they could trace back to him. Nor will the next president after him. Maybe we’ll go into more debt, or raise taxes, or cut military spending. But no way will they stop writing medical blank checks to seniors, and letting costs rise as they will.

Here’s the recent data fleshing out this public opinion story: Continue reading "US Politics Of Medicine" »

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Placebos Show Care

Something similar to the placebo effect occurs in many animals. … Siberian hamsters do little to fight an infection if the lights above their lab cage mimic the short days and long nights of winter. But changing the lighting pattern to give the impression of summer causes them to mount a full immune response.

Likewise, those people who think they are taking a drug but are really receiving a placebo can have a response which is twice that of those who receive no pills. In Siberian hamsters and people, intervention creates a mental cue that kick-starts the immune response. …

The Siberian hamster subconsciously acts on a cue that it is summer because food supplies to sustain an immune response are plentiful at that time of year. We subconsciously respond to treatment – even a sham one – because it comes with assurances that it will weaken the infection, allowing our immune response to succeed rapidly without straining the body’s resources. … Farming and other innovations in the past 10,000 years mean that many people have a stable food supply and can safely mount a full immune response at any time – but our subconscious switch has not yet adapted to this. (more)

OK, but the key question is: why would getting a placebo pill ever have been a credible signal that you could safely turn on your immune system? If for our ancestors treatments like pills tended to be very effective at improving health, you might think that a pill would give you so much extra energy that you could afford to spend some of that extra on your immune system. But pills are rarely that effective, and your body would quickly notice that fact.

My showing that you care theory, that the main function of medicine is to signal concern, fits well here. The idea is that we are reassured by the fact that people take the trouble to take care of us.

The most severe part of our ancestors’ environment wasn’t the weather, it was other humans. When people were sick, they worried that their rivals and enemies would use that opportunity to hurt them. If such harms were coming, they had to be attentive, wary, and ready to act — they couldn’t afford to turn on their immune system, which would make them lethargic.

But if someone had caretakers, who spent time and other resources to take care of them when they were sick, why then such caretakers would probably also protect them from rivals. So they could afford to turn on their immune system. If your associates spend resources to buy you pills, and then take time to make sure you take certain pills at certain times, they probably care enough to protect you from rivals.

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Dirty Air Kills

I’ve long been struck by how consistently different methods find large health harms from air pollution. Most people seem to think we no longer have an air pollution problem, because we mostly don’t see much air pollution. But the particles that are too small to see continue to cause great harm.

The US Federal EPA standard for air pollution in the form of particles of size 2.5 microns or smaller is an annual average of 15, and a 24 hour average of 35, micrograms per cubic centimeter. Many places are not in compliance with these standards (check your area here and here).

A 2009 paper in the New England Journal of Medicine estimated that decreasing this pollution number by 10 units on average increases lifespan by 0.61±0.20 years. A 2006 paper in the American Journal of Respiratory and Critical Care Medicine estimated that such a change would decrease mortality by about 15%, adding about two years of lifespan. (Quotes below.)

These are huge gains, which could be achieved at a modest expense, especially compared to the vast costs we pay for tiny health gains via medicine. More should be done.

Those promised quotes: Continue reading "Dirty Air Kills" »

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Brain Prize Eval Fund Near Enough

Great news: The cryonics organization Alcor is adding $10,000 to the Brain Preservation Technology Prize Evaluation Fund. With the other donations counted here (including my $5000), that should bring the prize evaluation fund to near $30,000, which might be near enough (so please donate more):

We [Alcor] are committing $10,000 towards the Evaluation Fund. … Although the Prize itself is fully funded, funds are needed to conduct the evaluation. Alcor’s contribution will make a big difference, since the tests are estimated to cost $25,000 to $50,000.

Alcor does not directly have a horse in this race. The cryopreservation approach is represented by a team from 21st Century Medicine. 21CM aims to demonstrate the quality of ultrastructure preservation that their low temperature vitrification technique can achieve when applied to whole rabbit brains.

We will follow up this announcement of Alcor’s contribution with a longer piece. That article will address claims (currently untested) for the advantages of chemopreservation over cryopreservation. We will critically examine the claim that chemopreservation or plastic embedding would be much cheaper (for individuals not committed to whole body preservation), look at some reasons to expect significant damage caused by chemopreservation of whole brains, identify problems for chemopreservation under less-than-ideal circumstances, explain why the Prize handicaps the cryopreservation option because of the way the test is to be carried out, and will argue why brain preservation technologies should be evaluated by viability criteria as well. (more)

While I look forward to reading their critique, I’ll note no one has accepted my bet offer:

I offer to bet up to $5K that plastination is more likely to win this full prize than cryonics. (more)

My thinking has evolved a bit over the last month. In chemopreservation [= plastination], one fills a brain with plastic-like chemicals, which make strong cross-links bonds between most everything they touch. So there are two times when brain info can be lost: before it is filled with plastic, and after.

Assuming you can keep them safe from melting, burning, etc., plastic brains should last for a very long time:

Brain researchers have looked at samples preserved many decades ago, and see almost no change. Tissues preserved in amber seem to have remain unchanged for forty million years. (more)

So the main issue is how much info is lost before filling with plastic. Now it is obvious that non-fresh brains with collapsed blood vessels pose a serious problem – the plastic might just not get to some places. But for brains filled with plastic within a few minutes of live blood flow, I just can’t see the problem.

For example, imagine that key brain info is encoded in certain key protein densities at tiny synapse pores, with different nearby pores having different key proteins. As long as there are thousands of copies of each key protein in each pore area, the plastic will almost surely usually preserve the info of which kind of proteins were in which areas. Even if some key proteins move away from their pores, most will stay near, and the amino acid sequences that define the proteins will mostly be preserved by the cross-link bonds the plastic makes.

And even if this isn’t true for twenty percent of the key proteins, there is almost surely enough brain system redundancy for this to not matter. Yes, you’d need a finer scan than the Brain Preservation Prize will use to read it, but the info is still there.

So as far as I can tell, the main issue with plastination [= chemopreservation] is how quickly brains can fill with plastic after ordinary blood flow has stopped. If we can find ways to do that well, plastination just wins, I think, at least for the goal of saving the info that is you.

Added 19July: Sad news:

The [Brain Preservation] Foundation has declined [Alcor's] donation because of concerns that it might be perceived as influencing the judges’ decisions.

Added 13Jan’13: They reached their $25K goal!

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Frozen Or Plastic Brain?

My post Monday on donating $5K to a Brain Preservation Prize testing fund has induced commentary (here, here, here, see also here). They’ve raised many issues on the choice between freezing brains or fixing them with chemicals.

Some prefer the term “chemopreservation” over “plastination”, which some artists have used to describe approaches that don’t try to preserve fine spatial detail. But I don’t like to replace clearer short terms with long vague awkward ones, just to avoid a weak association. If needed, I’d clarify by saying “ultra plastination”.

Some worry that we can’t prove plastic brains will last a long time. But brain researchers have looked at samples preserved many decades ago, and see almost no change. Tissues preserved in amber seem to have remain unchanged for forty million years. We have pretty good chemistry reasons to expect these plastics to last a long long time.

Some worry that plastic forgoes the prospect of reviving brain tissue directly after thawing, and relies instead on transferring its info to a new substrate, as with emulation. But direct revival seems extremely difficult given freezing and anti-freeze damage, and I think brain emulation is the future anyway.

Some worry that tests on fresh brains won’t show how well the techniques preserve less that fresh brains. But we could cheaply do tests now on not so fresh brains, after we test fresh ones.

The big issue, I think, is that plastination probably merges and diffuses some relevant chemical densities. If we knew about the minimal sufficient sets of chemicals to track, we could probably design dyes to mark such a set before we sent in the plastic. But since we aren’t sure which chemicals to track, we’ll have to make educated guesses, guesses that could be wrong.

Now many of us expect an awful lot of redundancy in brain cell spatial shape and various chemical densities, such that it will probably be enough to know the cell shapes, connection strengths, and the chemical densities that happen to be preserved in the first otherwise good plastination approach. If we go out of our way to tag a few more chemical densities, this can increase our odds. This is hardly a guaranteed approach though, so you might think freezing is safer, at least if anti-freeze can be shown to preserve more chemical densities.

But the much bigger risk, however, is that cryonics organizations won’t last long enough to keep brains frozen long enough. Most cryonics customers signed up a while ago, and their age distribution is slowly aging. If they can’t restart exponential growth, they’ll have more and more old dying customers relative to young paying supporters, and then may have a declining customer base. In addition, a great many managerial, political, social, etc. surprises could result in patient thaws even in a growing healthy organization.

Thus we unfortunately must choose between two unwanted risks – we must either suffer a plastination risk of not saving enough chemical densities, or suffer a cryonics risk of thaw by organizations with limited long term reliability. Since I judge the info saving risk to be mild, and the organization reliability risk to be severe, I’d choose the former.

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