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Needless medical tests not only cost $200 billion, they can do harm

It’s common knowledge in medicine: Doctors routinely order tests on hospital patients that are unnecessary and wasteful. Sutter Health, a giant hospital chain in Northern California, thought it found a simple solution.

The Sacramento-based health system deleted the button physicians used to order repetitive daily blood tests. “We took it out and couldn’t wait to see the data,” said Ann Marie Giusto, a Sutter Health executive.

Alas, the number of orders hardly changed. That’s because the hospital’s medical-records software “has this cool ability to let you save your favorites,” Giusto said at a recent presentation to other hospital executives and physicians. “It had become a habit.”

There are plenty of opportunities to trim waste in America’s $3.4 trillion health care system — but, as the Sutter example illustrates, it’s often not as simple as it seems.

At least $200 billion is wasted annually on excessive testing and treatment, according to an estimate by the Institute of Medicine, now called the National Academy of Medicine. This overly aggressive care also can harm patients, generating mistakes and injuries that are thought to cause 30,000 deaths each year.

“The changes that need to be made don’t appear unrealistic, yet they seem to take an awful lot of time,” said Dr. Jeff Rideout, chief executive of the Integrated Healthcare Association, an Oakland, California, nonprofit group that promotes quality improvement. “We’ve been patient for too long.”

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Progress may be slow — but there have been some encouraging signs. In San Diego, for instance, the Sharp Rees-Stealy Medical Group said it cut unnecessary lab tests by more than 10%.

A large public hospital, Los Angeles County-University of Southern California Medical Center, eliminated preoperative testing that was deemed superfluous before routine cataract surgery. As a result, patients got into surgery six months sooner, on average.

These efforts were sparked by the Choosing Wisely campaign, a national effort launched in 2012 by the American Board of Internal Medicine (ABIM) Foundation. The group asked medical societies to identify at least five common tests or procedures that often provide little benefit.

The campaign, also backed by Consumer Reports, encourages medical providers to hand out wallet-sized cards to patients with questions they should ask to ascertain whether they truly need a procedure.

Critics have knocked Choosing Wisely for playing it too safe and not going after some of the more lucrative procedures, such as certain spine operations and arthroscopic knee surgeries.

Daniel Wolfson, chief operating officer at the ABIM Foundation, said the Choosing Wisely campaign has been successful at starting a national conversation about unwarranted care. “I think we need massive change and that takes 15 years,” Wolfson said.

For patients, overtreatment can be more than a minor annoyance. Galen Gunther, a 59-year-old from Oakland, said that during treatment for colorectal cancer a decade ago, he was subjected needlessly to repeated blood draws, often because the doctors couldn’t get their hands on earlier results. Later, he said, he was overexposed to radiation, leaving him permanently scarred.

“Every doctor I saw wanted to run the same tests, over and over again,” Gunther said. “Nobody wanted to take responsibility for that.”

At Cedars-Sinai Medical Center in Los Angeles, officials said that economic incentives still drive hospitals to think more is better.

“We have excellent patient outcomes, but it’s at a very high cost,” said Dr. Harry Sax, executive vice chairman for surgery at Cedars-Sinai. “There is still a continued financial incentive to do that test, do that procedure and do something more.”

In addition to financial motives, Sax said, many physicians still practice defensive medicine out of fear of malpractice litigation. Also, some patients and their families expect antibiotics to be prescribed for a sore throat or a CT scan for a bump on the head.

To cut down on needless care, Cedars-Sinai arranged for doctors to be alerted electronically when they ordered tests or drugs that run contrary to 18 Choosing Wisely recommendations.

The hospital analyzed alerts from 26,424 patient encounters from 2013 to 2016. All of the guidelines were followed in 6% of those cases, or 1,591 encounters.

Cedars-Sinai studied the rate of complications, readmissions, length of stay and direct cost of care among the patients in whose cases the guidelines were followed, Sax said. It compared those outcomes with cases where adherence was less than 50%.

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In the noncompliant group, patients had a 14% higher incidence of readmission and 29% higher risk of complications. Those complications and longer stays increased the cost of care by 7%, according to the hospital.

Cedars-Sinai said it avoided $6 million in medical spending in 2013, the first year of implementation of Choosing Wisely guidelines.

In Northern California, Sutter has incorporated more than 130 Choosing Wisely recommendations as part of a broader effort to reduce variation in care. In all, Sutter said it has saved about $66 million since 2011.

For her part, Giusto meets with Sutter doctors to present them with data on how many tests or prescriptions they order and how that compares to others. At one clinic, she shared slides showing that some doctors were ordering more than 70 opioid pills at a time when others prescribed fewer than 20. In response, Sutter set a goal of 28 tablets in hopes of reducing opioid abuse.

“Most of the physicians changed,” said Giusto, director of Sutter’s office of patient experience. “But there were still two who said, ‘Screw it. I’m going to keep doing it.'”

Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.

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Yearly Costs of Chronic Pain Exceed Those of Cancer, Heart Disease, and Diabetes

The annual cost of chronic pain is as high as $635 billion a year, which is more than the yearly costs for cancer, heart disease, and diabetes, say health economists from Johns Hopkins University in this month’s The Journal of Pain.

The researchers estimated the annual economic costs of chronic pain in the United States by assessing incremental costs of health care due to pain and the indirect costs of pain from lower productivity. They compared the costs of health care for people with chronic pain with those who do not report chronic pain. The authors defined people with pain as those who have pain that limits their ability to work, are diagnosed with joint pain or arthritis, or have a disability that limits capacity for work.

Data from the 2008 Medical Expenditure Panel Survey was used to gauge the economic burden of pain. The sample included 20,214 individuals 18 and older to represent 210.7 million US adults.

Results showed that mean health care expenditures for adults were $4,475. Prevalence estimates for pain conditions were 10% for moderate pain, 11% for severe pain, 33% for joint pain, 25% for arthritis, and 12% for functional disability. Persons with moderate pain had health care expenditures $4,516 higher than someone with no pain, and individuals with severe pain had costs $3,210 higher than those with moderate pain. Similar differences were found for other pain conditions: $4,048 higher for joint pain, $5,838 for arthritis, and $9,680 for functional disabilities.

Also, adults with pain reported missing more days from work than people without pain. Pain negatively impacted 3 components of productivity—work days missed, number of annual hours worked, and hourly wages.

Based on their analysis of the data, the authors determined that that the total cost for pain in the United States ranged from $560 to $635 billion. Total incremental costs of health care due to pain ranged from $261 to $300 billion, and the value of lost productivity ranged from $299 to $334 billion. Compared with other major disease conditions, the per-person cost of pain is lower but the total cost is higher.

The authors noted their conclusions are conservative because the analysis did not consider the costs of pain for institutionalized and noncivilian populations, for persons under 18, and for caregivers.

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Gut bacteria may affect how well your medicines work

To prescribe the best medicine, it might help if a doctor knows which bacteria live in a patient’s gut. That’s the finding of a new study.

Reports had shown that some gut microbes can alter the drugs that people swallow. That might affect how well those drugs work. But researchers weren’t sure how big a problem this was. Now, a study suggests that gut bacteria can modifymany drugs. And that means the genes in those microbes may predict how those drugs would work in that patient.

Maria Zimmermann-Kogadeeva is a computational biologist at Yale University in New Haven, Conn. She and her colleagues shared their new finding June 3 in Nature.

“Knowing how the gut microbes … affect a drug is hugely useful,” says Matthew Redinbo. He did not take part in the new research. But as a biochemist at the University of North Carolina at Chapel Hill, he understands that such effects could help drug companies develop more effective drugs. It could also help doctors choose the best treatment for a particular patient.

Researchers chose 76 types of bacteria that can live in the human gut. Then they tested if — and how — those bacteria changed the molecular structure of 271 drugs. From hormones to anti-virus drugs, each medicine had been designed to be taken by mouth.

The scientists put the bacteria into test tubes holding nutrients and drug solutions. After 12 hours, about two in every three of the drugs had been changed by at least one strain of bacteria. Each of these strains could modify between 11 and 95 different drugs.

“That is huge,” says Nichole Klatt. The microbiome is the sum of all of the microbes living in the body. Klatt is a microbiome researcher at the University of Miami in Florida. She, too, was not involved in the new study. Still, she notes, knowing which microbes affect which drugs isn’t enough. Future studies should look into exactly how bacteria make these changes, she says. Studies might also explore the impacts those altered drugs would have on the human body.

DNA detectives

Zimmermann-Kogadeeva and her colleagues wanted to know which part of a bacterium’s DNA lets it modify a particular drug. To find out, they first chopped up DNA from the germs of interest. Then they inserted individual snippets of that DNA into the cells of E. coli bacteria. Afterward, they watched to see which, if any, of these altered E. coli were now able to change the drugs. This told them which DNA fragments could mess with those drugs.

Next, the researchers did a series of tests using different drugs. They started by sampling feces from 28 people. Then they tested whether the community of microbes in each person’s poop could modify any of the drugs. In each test, they exposed all the microbial communities to the same drug.

The researchers also scouted in each stool sample for the drug-altering DNA snippets they’d found in the E. coli test. They searched, too, for bits of DNA from other microbes that were at least 50 percent similar to these germs genetically. Their idea was that similar DNA segments likely would do similar jobs.

Feces with more of the drug-altering DNA pieces made more changes to drugs, the team found. That suggests doctors could genetically test a patients’ poop before prescribing them medicine. Such stool tests might tell them whether a patient’s gut microbes would likely alter a drug they could be prescribed.

Such tests might one day help doctors choose which medicine to prescribe. Or doctors might prescribe a treatment that makes a person’s gut microbes friendlier to a certain drug. Antibiotics or fecal transplants might even become ways to change a patient’s gut microbes, says study coauthor Michael Zimmermann. He’s a pharmaceutical scientist and systems biologist at Yale.

But it’s important to consider, too, that the way germs mess with drugs “actually can be beneficial,” Zimmermann-Kogadeeva says. Drug companies might want to make drugs that take advantage of the ability of germs to make a drug work better, she says. Those companies might also design pills to avoid bad reactions with bacteria in the first place.

Power Words

(more about Power Words)

antibiotic     A germ-killing substance, usually prescribed as a medicine (or sometimes as a feed additive to promote the growth of livestock). It does not work against viruses.

bacteria     (singular: bacterium) Single-celled organisms. These dwell nearly everywhere on Earth, from the bottom of the sea to inside other living organisms (such as plants and animals). Bacteria are one of the three domains of life on Earth.

biology     The study of living things. The scientists who study them are known as biologists.

cell     The smallest structural and functional unit of an organism. Typically too small to see with the unaided eye, it consists of a watery fluid surrounded by a membrane or wall. Depending on their size, animals are made of anywhere from thousands to trillions of cells. Most organisms, such as yeasts, molds, bacteria and some algae, are composed of only one cell.

coauthor     One of a group (two or more people) who together had prepared a written work, such as a book, report or research paper. Not all coauthors may have contributed equally.

colleague     Someone who works with another; a co-worker or team member.

computational     Adjective referring to some process that relies on a computer’s analyses.

develop     To emerge or come into being, either naturally or through human intervention, such as by manufacturing. (in biology) To grow as an organism from conception through adulthood, often undergoing changes in chemistry, size and sometimes even shape.

DNA     (short for deoxyribonucleic acid) A long, double-stranded and spiral-shaped molecule inside most living cells that carries genetic instructions. It is built on a backbone of phosphorus, oxygen, and carbon atoms. In all living things, from plants and animals to microbes, these instructions tell cells which molecules to make.

E. coli     (short for Escherichia coli) A common bacterium that researchers often harness to study genetics. Some naturally occurring strains of this microbe cause disease, but many others do not.

fecal transplant     A medical procedure that uses bacteria shed in feces (poop) from a healthy person to treat someone who is sick. The bacteria may be delivered down through the mouth and nose (via a tube) or up through the rectum. In some cases, the germs may even be delivered through a capsule that is swallowed. With luck, the new bacteria will colonize the sick patient’s gut — treating the targeted malady.

feces     A body’s solid waste, made up of undigested food, bacteria and water. The feces of larger animals are sometimes also called dung.

gene     (adj. genetic) A segment of DNA that codes, or holds instructions, for a cell’s production of a protein. Offspring inherit genes from their parents. Genes influence how an organism looks and behaves.

germ     Any one-celled microorganism, such as a bacterium or fungal species, or a virus particle. Some germs cause disease. Others can promote the health of more complex organisms, including birds and mammals. The health effects of most germs, however, remain unknown.

gut     An informal term for the gastrointestinal tract, especially the intestines.

hormone     (in zoology and medicine) A chemical produced in a gland and then carried in the bloodstream to another part of the body. Hormones control many important body activities, such as growth. Hormones act by triggering or regulating chemical reactions in the body.

microbe     Short for microorganism. A living thing that is too small to see with the unaided eye, including bacteria, some fungi and many other organisms such as amoebas. Most consist of a single cell.

microbiome     The scientific term for the entirety of the microorganisms — bacteria, viruses, fungi and more — that take up permanent residence within the body of a human or other animal.

nutrient     A vitamin, mineral, fat, carbohydrate or protein that a plant, animal or other organism requires as part of its food in order to survive.

species     A group of similar organisms capable of producing offspring that can survive and reproduce.

stool     (in medicine) Another name for feces.

strain     (in biology) Organisms that belong to the same species that share some small but definable characteristics. For example, biologists breed certain strains of mice that may have a particular susceptibility to disease. Certain bacteria or viruses may develop one or more mutations that turn them into a strain that is immune to the ordinarily lethal effect of one or more drugs.

transplant     (in medicine) The replacement of a tissue or an organ with that from another organism. It is also a term for the material that will be transplanted.

virus     Tiny infectious particles consisting of RNA or DNA surrounded by protein. Viruses can reproduce only by injecting their genetic material into the cells of living creatures. Although scientists frequently refer to viruses as live or dead, in fact no virus is truly alive. It doesn’t eat like animals do, or make its own food the way plants do. It must hijack the cellular machinery of a living cell in order to survive.

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How neuroscience equip us to become better creators

We are in the midst of a shift in the perception about neuroscience. No longer do we regard it as just an interesting topic; we are now talking about neuroscience as a proven and useful tool. The conversation tends to focus either on the different technologies and their use in research and evaluation; or on learnings from behavioral science, such as framing, anchoring and loss aversion, that can help nudge people towards taking actions.

But, as designers, we see other opportunities for neuroscience.

According to research, it takes the human brain just 13 milliseconds to begin to process an image, whereas typically it takes up to 400 milliseconds to read a word and understand what it means. In fact, so heavily weighted are our brains towards what we see, that the interpretation of visuals can override both rational consideration—such as when vanilla puddings are colored brown and miraculously reported as tasting of chocolate—and even senses like hearing.

The human brain uses two markedly different systems for processing information and making decisions. The first is an automatic, fast and often subconscious way of thinking, which requires little attention or effort but is prone to biases and errors. This is called System 1.

The second is a much slower and more controlled process, which requires energy and attention but, once engaged, it has the ability to filter those instinctive biases and errors. This is known as System 2.

Marketers can benefit greatly from understanding more about how System 1 decodes the visual world, particularly with an ever-increasing number of stimuli competing for our finite attention.

Of these, visual stimuli are by far the most dominant, with around 90% of our System 1 being concerned with making sense of what we see. As such, it can be argued that many of our conventional approaches to persuasion through communication—headlines, copy and voiceover—appeal to our rational decision-making and, therefore, may be far less influential than the visual cues people decode subconsciously.

System 1 learns by association, connecting stimuli and concepts, so that one triggers the other. For example, one study found that participants who completed a word search featuring terms associated with the elderly, such as “Florida”, “forgetful” and “wrinkle”, walked significantly more slowly when leaving the room than those with more neutral words.

This effect enables marketers to code design with visual cues that connect a brand intuitively with a concept borrowed from culture or other categories to evoke a similar concept. For example, the Adidas flagship store in New York borrows heavily from the world of stadiums, featuring concrete entrance tunnels, locker-room-style changing rooms and ticket-booth cash desks, all of which cement the brand’s link to sport.

And while we are all aware of the power of humanity in connecting audiences to brands—like a cute baby to engage us or a directional gaze to shift our attention—we can go beyond many of the more obvious uses towards subtler but nonetheless powerful ways to infer human characteristics and connections, through the use of personality, individuality, human touches, imperfections and names.

Such ideas are not new, of course. Back in 1944, a psychological experiment found that subjects who had watched a short, animated film showing the basic movement of simple shapes were quick to make sense of what they had seen, creating characters and storylines by association with these seemingly ambiguous visuals. Today, many brands are finding success from building visual cues and strong associations into their design: like Bonne Maman, whose jars, lids and labels epitomize the feeling of “homemade” (which they most certainly are not); and bad-ass coffee brand Bandido, whose ‘B’ has been cleverly rotated to form a Zorro-style mask.

The overall look is important, too. System 1 interprets beauty as something which has been invested in, cared about and has self-belief. This means we will instantly decide that we would be prepared to pay more for an aesthetically pleasing brand because we believe it is worth it. The same process also skews our judgment on things like web content. People decide whether they like a web page within 0.05 seconds of seeing it by reacting to the overall aesthetic, rather than to the content itself. So, while sweating the content is important, even the most substantive message will be poorly received and interpreted if we don’t pay attention to the overall design.

By understanding some of these principles, we can use neuroscience not only to measure more precisely but to create more effectively in the first place.


Written by:  John Clark

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Note: Most seniors do not want to be called seniors but older adult.