Monday, March 10, 2008

Shocking news: incenting physicians towards one goal has negative impacts on other goals

I am so surprised by this shocking, impossible to predict, outcome:

AMNews: March 17, 2008. CMS metric may prompt excessive antibiotic use ... American Medical News

...A new study says physicians are 39% more likely to misdiagnose hospital patients as having community-acquired pneumonia due to the high-stakes environment fostered by mandatory public reporting of quality measures -- in this case, whether pneumonia patients got antibiotics within four hours of arriving at the hospital.

The results, published in the Feb. 25 Archives of Internal Medicine, are similar to those found in a Chest study published last year and echo many physicians' complaints about the measure of initial antibiotic timing, known as door-to-needle time. A February 2007 Infection Control and Hospital Epidemiology study tied excessive use of antibiotics encouraged by the performance metric to a severe outbreak of Clostridium difficile at a small rural hospital...

I trust my sarcasm is sufficiently dripping.

The CMS pay-for-performance programs will be eventually recognized as the most harmful health care innovation since Evaluation and Management coding killed primary care in the 1990s.

Alas, that recognition is still 18 months away -- and here I'm being atypically optimistic. E&M coding, for example, has now been a 13 year disaster.

There are many ways to improve health care quality that have been shown work and to be relatively free of perverse consequences. "Pay-for-performance", however, is an ideologically driven program that was reasonable to experiment with -- before the evidence of failure emerged. Now it needs to die -- but it won't until the Bush team leaves CMS.

How Homeland Security sets its priorities

Ever wonder how Homeland Security evaluates its security investments?

Maybe you imagine dozens of super-sharp analysts, veterans and geeks alike, weighing risk and assigning probabilities, preparing carefully reasoned analyses which their superiors review and confirm.

Oops. No, that a flash from the alternate reality where Gore became President, bin Laden and Zawahiri are dead, we're not in a recession, and we didn't commit ourselves to a 1.5 trillion dollar war in Iraq.

In the Bush administration it goes more like this ...

Airport passenger screenings to be reviewed - USATODAY.com

...Chertoff's department is about to issue requirements for crews and passengers of private jets to provide their names, birthdates and other information an hour before takeoff, so they can be checked against terrorist watch lists.

The next step could be requiring that private jets be scanned and passengers screened by U.S. Customs agents overseas, Chertoff said. The procedures might be "a little inconvenient," he said, but if a bomb got into the USA on a private jet, there would be calls to "shut all private aviation off."

Chertoff said he grew more concerned about the issue last year when a senior executive of a private-jet company told him, "I don't know who the heck gets on my planes, and it worries me."...

I'm imagining Chertoff is hitting up some GOP donor at one of those $2,000 a plate dinners, and somehow this comment lodges deep in his dormant brain. Maybe it was the fine Scotch. Who knows?

Fire.

Chertoff.

Now.

Please.

Then fire his boss.

Friday, March 07, 2008

iPhone developer response to Apple's 30% cut on iApp sales, and why I still won't order one.

iApp developers aren't too worried about Apple's 30% cute on all iPhone App sales -- "How about we make shitloads of money at 70% and ask questions later?"

Well said. The iPhones application distribution model is fantastic.

I almost ran out and bought an iPhone today. I had to tie myself to a chair and reread my August 2007 list of iPhone demands (rev Oct 2007). Of 9 non-negotiable demands, exactly 1 (a trivial one) was met in the past seven months.

Some of my demands will be met by iPhone developers - after June 2008. Some may be solved with the promised 2.0 firmware update. NONE of them have been met today. Gordon's third law of acquisition was written for this precise situation: "Don't buy on promises or potential. Acquire for real value now. Anything in the future is a plus (or, sometimes, a minus)."

So when the SDK is really available, and when I see the true state of the 2.0 firmware update, then I'll buy.

In the meantime, I've been abusing* the Aperture trial offer long enough. Instead of an iPhone I've ordered my copy of Aperture 2.01.

* If you delete the prefs you get another 30 days of trial. With 2.01 you have to swap a library in and out as well. It took me a long time to decide that Aperture's virtues outweigh its many flaws; I suspect Apple knows about the little quirk that extends the trial.

State of the universe: flat, 72% vacuum energy

CV provides the recipe for our universe from the most recent analysis of the echoes of the big bang:
WMAP 5-Year Results Released | Cosmic Variance:

...The WMAP folks have produced an elaborate cosmological parameters table that runs the numbers for different sets of assumptions (with and without spatial curvature, running spectral index, etc), and for different sets of data (not just WMAP but also supernovae, lensing, etc). Everything is basically consistent with a flat universe comprised of 72% vacuum energy, 23% dark matter, and 5% ordinary matter....
Of course the human brain is 70% water, so we shouldn't feel entirely bad that most of what we know is only 5% of the universe.

Here's what Wikipedia has on "vacuum energy":
... Two proposed forms for dark energy are the cosmological constant, a constant energy density filling space homogeneously,[2] and scalar fields such as quintessence or moduli, dynamic quantities whose energy density can vary in time and space. In fact, contributions from scalar fields, which are constant in space, are usually also included in the cosmological constant. The cosmological constant is thought to arise from the vacuum energy...
and
...Vacuum energy is an underlying background energy that exists in space even when devoid of matter ...
So the recipe is basically definitional. Take away dark and ordinary matter and you get, by definition vacuum energy. Vacuum energy may arise largely from "smooth tension" (aka "dark energy"), but perhaps that's an interpretation of the results, not a statement of the results.

PS. Please note I'm not physicist in any form, I just like learning this stuff.

Update 3/8/2008: A little more detail on bad astronomy. Age - 13.73 billion years (middle aged in terms of a universe in which we can live). The average temperature of the universe is 2.725 degrees Kelvin -- just a smidgin above nothing.

Unintended consequences and accidental death from polypharmacy

Patients are empowered, but lack knowledge.

Health care providers have knowledge, but are stressed, disintegrated, and "disintermediated". Primary care, in particular, is near death (or dead).

The pharmaceutical industry is in a lesser known crisis. Chinese generics drive ferocious price competition, the discovery pipeline is dry, patents are expiring, and the last cash cow, the US, is running out of money. So the advertisement is getting desperate.

The GOP has stripped regulatory agencies of mission and funding.

Add it all up, and you have a storm of unintended consequences brewing. Larry Zaroff tells the story very well (emphases mine)...

Heath Ledger death |By Larry Zaroff, M.D., Ph.D. | Salon Life

...According to the Centers for Disease Control and Prevention, motor-vehicle crashes rank first among unintentional deaths in America. But poisoning is second, most commonly from the abuse of prescription and illegal drugs. Unintentional deaths from accidental drug ingestion rose significantly from 1999 to 2004. This trend is primarily due to increasing use of prescription opioid analgesics, and not heroin, methamphetamines or other illegal drugs...

...After leaving the drugstore, the patient realizes the wise doctor has given her only 30 pills, not enough, since one pill no longer gives her what she requires: deep, worry-free sleep or relief of pain or anxiety. If she has all three problems, she will need more pills or other kinds. She goes to another doctor and gets a second supply. She is set for the moment. But her work requires travel, sometimes out of the country. She can locate other doctors in other places who will prescribe. Now she has a fine stash both in her medicine cabinet and in her suitcase.

She is young, smart, well regarded by her associates. She is the opposite of careless. But she has no understanding of physiology, how the body works, what controls vital functions -- breathing, heartbeat, circulation -- and how drugs can affect these functions. How drugs work, their rate of absorption, their peak level of activity, is of no interest to her. She only wants relief of her insomnia, her pain, her worries. She has no idea that drugs have an optimum dose, that combinations of drugs might be like taking too much of a single drug, that often dissimilar medicines can affect the same organs and stop their activities. Unknown to her, she may even have a genetic abnormality that makes her more susceptible to the synergistic effects of the drugs.

The patient is not an addict and suicide is the last thing she would consider. But she has a tough day ahead of her. She needs her sleep. She decides to take two sleeping pills since one did not work well enough the previous night. Because she strained her back yesterday and feared the pain might keep her awake, she takes a narcotic, a single dose. She feels edgy despite the sleeping pills and the narcotic, and so she takes a tranquilizer. The witches' brew works. She dozes off but awakes in two hours, her mind jumbled. She must sleep. She slips into the bathroom and repeats the doses. She lies down, sleeps soon, too deeply. An hour later she stops breathing. She is alone, no one to aid her...

I don't agree with Dr. Zaroff's recommended solutions (read the article). I think we need to go back to the list I started this post with, and work each one independently. I think we also need a national education program. The modern patient is going to "play doctor" anyway, so they might as well start in on medical skill. "Drugs Kill" might be a good ad slogan, though it might be confused with anti-cocaine ads.

Brad DeLong: Principles for enlightenment 2.0

DeLong responds to a post about the age of Milton Friedman with a statement of his own principles for our age.

Friedman's and his acolytes ascribed, perhaps unwittingly, wisdom and justice to the market itself. The religious right mixed this strange meme with their own traditions, creating a new golden calf that was one part Yahwism, one part Rand, one part Market, one part Calvin, one odd part Darwin, and one small part Christ.

DeLong's perspective is quite different, but it's very important to begin by recognizing that DeLong understands why the Market isn't the worst possible deity: (emphases mine)

Grasping Reality with Both Hands: Economist Brad DeLong's Fair, Balanced, and Reality-Based Semi-Daily Journal

...My principles would start from the observation that market economies and free and democratic societies are built on a very old foundation of human sociability, communication and interdependence. That foundation had a hard enough time functioning when human societies had 60 members -- eight orders of magnitude less than today's 6 billion.

So my principles would then be developed from Karl Polanyi's old observation that the logic of market exchange puts considerable pressure on that underlying foundation. The market for labor compels people to move to where they earn the most, at the price of potentially creating strangers in strange lands. The market for consumer goods makes human status rankings the result of market forces rather than social norms and views about justice.

This critique of the market is, of course, one-sided. After all, other arrangements for allocating labor appear to involve more domination and alienation than the labor market, which offers opportunities, not constraints.

Similarly, "social norms" and "views about distributive justice" usually turn out to favor whomever has the biggest spear or can convince others that obedience to the powerful is obedience to God. Market arrangements have a larger meritocratic component than the alternatives, and they encourage positive-sum entrepreneurship, making it easier to do well by doing good.

Nevertheless, the distribution of economic welfare produced by the market economy does not fit anyone's conception of the just or the best. Rightly or wrongly, we have more confidence in the correctness and appropriateness of political decisions made by democratically elected representatives than of decisions implicitly made as the unanticipated consequences of market processes.

We also believe that government should play a powerful role in managing the market to avoid large depressions, redistributing income to produce higher social welfare, and preventing pointless industrial structuring produced by the fads and fashions that sweep the minds of financiers.

Indeed, there is a conservative argument for social-democratic principles. Post-World War II social democracy produced the wealthiest and most just societies the world has ever seen. You can complain that redistribution and industrial policy were economically inefficient, but not that they were unpopular. It seems a safe bet that the stable politics of the post-war era owe a great deal to the coexistence of rapidly growing, dynamic market economies and social-democratic policies.

Friedman would say that, given the the world in 1975, a move in the direction of his principles was a big improvement. When I think of former US president Jimmy Carter's energy policy, Arthur Scargill at the head of the British mineworkers' union and Mao's Cultural Revolution, I have a hard time disagreeing with Friedman about the world in the mid-1970s.

But there I would draw the line: While movement in Friedman's direction was by and large positive over the past generation, the gains to be had from further movement in that direction are far less certain.

This is also what I believe. The Market is the best possible system we know of for "finding local minima" -- but it is not a Deity. Democracy is likewise imperfect. We seek a balance, something closer to Denmark and Canada than to old Hong Kong. Something that recognizes the problem of the weak, while admitting the limitations of human culture in 2008. This we can achieve, and this we must achieve.

Stories forgotten: Putin and the 1999 apartment bombings

Sometimes, when searching my blogs, I find fragments of stories even I've forgotten. I came across this one today:  Did the KGB blow up those Russian apartment buildings?.

In 2005 journalists at the Economists took seriously the possibility that Putin's KGB was involved in the "terrorist strike" that launched the Chechen war, and led, eventually, to Putin's current popular tyranny over all of Russia.

I wonder what would happen if evidence were to emerge that Putin was, in fact, involved.

If I were running the CIA, I'd be looking for that evidence. If I found it, I'd keep it for a rainy day ...

Thursday, March 06, 2008

A bad day for Gastroenterologists

The (very high) income of the Gastroenterologist just took a significant hit.

The cause? We've now learned that half of all colon cancers arise from hard-to-see "flat lesions" in the colon:

Easily Overlooked Lesions Tied to Colon Cancer - New York Times

Japanese researchers became concerned about these flat lesions in the 1980s and ’90s, but studies here had mixed results and American doctors tended to think that flat growths were less common and less dangerous in the United States.

The new study, to be published Wednesday in the Journal of the American Medical Association, suggests otherwise.

Some doctors in this country were already alert to flat lesions, but the findings will pose a challenge to others, because it takes a trained and vigilant eye to see the growths and special techniques to remove them...

...The study, of 1,819 military veterans, mostly men, found that 9.35 percent had flat lesions, and those lesions were five times as likely as polyps to contain cancerous or precancerous tissue. Depressed or indented lesions were the least common but the most risky. Together, the flat or depressed lesions accounted for only 15 percent of the potentially cancerous growths found in the study, but were involved in half of the cancers. Once the doctors spotted the flat lesions, they sprayed a bluish dye on them to see their outlines better and remove them completely...

These suckers are hard to see. Looking for them may double the duration of a colonoscopy.

Problem is, Gastroenterologists are paid by the procedure, not by the minute. If a colonoscopy takes twice as long, then colonoscopy earnings fall by 50%. That probably translates to at least a 10-15% overall income cut.

Or, they could do what studies have shown many already do -- believe they're so incredibly skilled they can go really fast and still do a good job. Not true of course, but wishful thinking is strong when the money is right.

Either way, not a good day.

iPhone announcement - Fake Steve Jobs says it all

Love the Iron Man graphic ...

The Secret Diary of Steve Jobs: Happy now, bitches?

...29 June 2007 might be the day the world changed, but today it just changed again. BlackBerry is dead. Microsoft is dead. Windows Mobile is dead. Amazon is dead. Kindle is dead. Nokia is dead. Motorola was already dead but now they are even more dead...

... Seriously, folks, it's game over.... In Canada they declared a national day of mourning for RIM. It's that huge. Today, frankly, is a day that will live in the history of our industry...

Read the whole thing. It's funny, but might be true. I'm still waiting for the catch, but this announcement is way on the high end of what I'd expected.

One caveat: the June (31st*) SDK release is likely to come with iPhone 2.0, and my past experience with Apple is that new software releases never quite fly on hold hardware. So those of us considering buying an iPhone today have to recognize that we might be selling it four months from now.

* see comments

iPhone surprise: Microsoft is on board. Why?

About one week ago Michael Mace declared the mobile application marketplace dead.

Today Apple's developer web site was knocked off the net, completely obliterated, by people downloading the beta version of the iPhone SDK.

Sorry Michael.

Of course my critique of Mace's thesis wasn't perfect. I wrote:

... So now we have the iPhone. The browser experience leads people like Mace to predict that the browser is the new platform.

Maybe.

On the other hand, there are a lot of very, very smart developers who want to create the best possible native experiences for millions of iPhone users. Experiences that work on airplanes, cars, trains and lots of other places where the wireless experience sucks. Sure, you'll be able to create disconnected apps using Google Gears 2009 and Adobe AIR 2009, but they won't have the smooth elegance of native apps.

If Apple can prosper while staying clear of Microsoft's Exchange turf (don't go there Apple, it's a death trap) Mace may discover that he's declared the mobile platform dead at exactly the wrong time ...

Well, Apple didn't exactly steer clear of Exchange. They've embraced it, even licensing Microsoft's ActiveSync technology (current version supports sync with Exchange AND Outlook, but I didn't see the latter mentioned.)

Microsoft is playing along, helping Apple far more than they've helped RIM. Not to mention Microsoft's past use of Exchange to eviscerate Palm almost a decade ago.

So why is Microsoft playing nice? Are they just luring Apple into a pit of doom? Is this a clever way to bury RIM/BlackBerry without getting into antitrust problems? How the heck does Microsoft intend to protect their crappy corporate Mobile platform if the iPhone can sync with Exchange?

Those billion dollar EU fines have to be a part of the reason. Microsoft's (mis)use of Exchange protocols is cost money even they notice.

Even so, ActiveSync licensing?

I really don't think Microsoft is going to drop Windows Mobile and embrace the iPhone, but this is weird.

Physicians to go iPhone crazy

This is only the beginning, though it was neat to see Epocrates get Steve (Jobs) Note attention:

Epocrates Search Portal

...it was recently announced that Epocrates is one of a limited number of developers who have been working directly with the Apple team to make our applications available on the iPhone/iTouch.  We look forward to making the product available in the near future...

The iPhone SDK isn't officially out until June, so I don't necessarily expect Epocrates before then. On the other hand, they did demo it.

So much for Emily's BlackBerry Pearl -- ePocrates barely works on it and there's some memory leak besides. Anyone want a cheap Pearl?

Physicians loved the Palm when it worked, and the Newton before that. There are a surprising number of physicians who are perfectly happen to program (some did it professionally in prior lives), they'll be cranking out free iPhone and commercial iPhone apps at an amazing rate.

Wednesday, March 05, 2008

Toxic heparin was fraud, not accident

I realize I'm repeating myself, but this really would be a good time to panic.

A major medication, Heparin, was manufactured in very substandard conditions. The final product contained counterfeit chemicals designed to fool quality tests. It was then distributed widely in the US healthcare systems.

Up to 10% of the entire US supply of Heparin may consist of a counterfeit drug:
FDA says recalled heparin contained contaminant - USATODAY.com

In a finding eerily similar to the contamination of pet food last year, the Food and Drug Administration said Wednesday that a counterfeit chemical has been detected in recalled supplies of the blood thinner heparin.

From 5% to 20% of the active pharmaceutical ingredients in some heparin supplied by Chinese companies to Baxter (BAX) Healthcare is a similar, but different, chemical that mimics the blood thinner in commonly used tests.

Nineteen people have died since Jan. 1, 2007, from allergic reactions that appear to be associated with contaminated heparin, says Janet Woodcock, acting director of the FDA's Center for Drug Evaluation and Research. The death toll had been four.

Last year, thousands of pets fell ill after eating food made with adulterated wheat flour from China. The flour contained two industrial chemicals, melamine and cyanuric acid, added to make it appear to be the more expensive wheat gluten.

Baxter, which supplied half of the heparin used in U.S. clinical settings, first recalled some of its heparin products on Jan. 17. The company expanded the recall on Feb. 27 to include all of its multidose, single-dose and Hep-Lock products, used to flush intravenous lines to ensure that they aren't blocked by blood clots.

The USA's main other supplier of heparin, APP Pharmaceuticals, (APPX) has not had any reported allergic reactions associated with its products. It increased production after the Baxter recall.

Heparin is commonly used in many medical and surgical procedures. Initial analyses could find nothing wrong with the recalled product, says Woodcock.

"It reacts like heparin in some of the conventional tests used for heparin, which is why conventional acceptance tests of this ingredient might not detect this contaminant," she said.

But sophisticated tests by Baxter and the FDA, including nuclear magnetic resonance spectroscopy and capillary electrophoresis, showed slight differences. The counterfeit chemical is very like heparin in its molecular makeup and is also from an organic source, says Baxter's Peter Arduini. The raw ingredient in heparin comes from the lining of pig intestines.

Baxter Healthcare is based in Deerfield, Ill. Wisconsin-based Scientific Protein Laboratories (SPL) supplies Baxter's heparin from sources in China.

SPL has been a successful supplier of the active pharmaceutical ingredient in Baxter's heparin for almost 30 years with no problems, says Arduini.

Both the FDA and Baxter said they can't yet confirm that the heparin-like compound was the cause of the allergic reactions, but they are centering their investigation on them. They also don't know if it was introduced intentionally.

The news is good for Baxter as a company, says Aaron Vaughn at investment firm Edward Jones.

"Originally, it was a Baxter story. Now, it's become China supplying the U.S. market with goods that are not up to international standards," he says,

Good for Baxter? Maybe under current law.

We need to change the law.

Let me say that again.

We need to change the law.

Distributors must be held responsible -- only then will they be incented to move their supply chain away from unreliable sources. Congress should be considering vary large tariffs on medications coming from countries with known production and quality issues. The tariffs can help pay for the compensation claims that should be paid to injured persons.

This is why we need trial lawyers like John Edwards. It's also why we need to get the GOP out of the executive office, and resurrect America's regulatory infrastructure.

Update 3/20/2008: Yep, it sure looks like fraud.

The Democratic primaries vs. the general election: an enlightening comparison

This is funny, but so true.

Shtetl-Optimized » Blog Archive » Long-dreaded politics post

... The general election is so damn easy by comparison. There, the only questions I need to ask myself are, “do I prefer the Enlightenment or the Dark Ages that preceded it? Is the Earth 4.6 billion years old or 10,000? Do anti-gay laws spring from a less repugnant part of human nature than Jim Crow laws?” While I look forward to the day when my answers to such questions won’t determine my vote, so far they unfailingly have — thereby eliminating the need for me to adjudicate more complicated social and economic issues that I don’t really understand...

Everything is simple once the Democratic Primary is over. We ex-Edwardians slightly favor Obama, but if Hilary wins the same check is will be in the mail. We've not spent a cent on the primary battle, it's all for McCain. So to speak.

The iPhone software advantage: strong Digital Rights Management

This is sad.

But it must be said.

I am no friend of Digital Rights Management. I don't buy FairPlay'd music -- because I can't play DRMd music on my car stereo [1].

On the other hand, I remember when there was a large selection of games and children's software for the Apple II and the original Macintosh. There's almost nothing left like that today - on XP or OS X. The CDs we bought 5-8 years ago were the last of that wave, and they no longer work on XP or 10.4 Classic [2].

There are such games today of course. They're on the Nintendo platform [3].

Why is this software on Nintendo, and yet not on OS X?

It's the Digital Rights Management. You can't give a copy of your favorite Wii game to a friend. You can't even move the games you bought at work to your home. This 21st century version of "copy protection" cannot be broken as easily as as the 1980s version.

The iPhone, like the Nintendo Wii, has very robust DRM. It will not be possible to download an iPhone app via iTunes and install it on your wife and children's iPhones and iTouchs [4].

Unlike the Palm, the iPhone and iTouch will combine robust DRM with a single contact built-in delivery mechanism for software developers willing to push through the distribution hurdles.

Guaranteed distribution. Guaranteed copy protection/DRM.

The iPhone will have a very large software advantage over the Mac version of OS X, and over the Palm and Microsoft mobile devices that have preceded it.

Ringtones were once a billion dollar industry, though that's dying now. The iPhone software advantage will be bigger.

We'll have to pay for the apps though.

I'm happy to do that. It's just too bad we need the DRM to make this work.

--

[1] Most know this, but it's worth mentioning that AAC is a format and not a DRM mechanism. AAC encoded music plays on our SONY car stereo and our Nokia and Blackberry phones).

[2] 10.5, of course, doesn't support Classic on any platform, so when our G5 iMac dies so will all our old favorite children's apps. My son collects the old CDs in his desk drawer, hoping, perhaps, that they'll one day come to life again.

[3] It is odd that no other game platform seems to have realized that teen players come from children players, and yet they don't provide entry level game software. Maybe the execs don't have children?

[4] On OS X and Vista there is a strong tie between a hardware device and a user identity. Each device must sync to a single account on a single machine, though Apple has screwed up the software/hardware/multi-user integration (See also). Once you start going down the iPhone/iTouch route, you will discover a very interesting set of problems with sharing your music library.

PS. An exercise for the Reader: Consider an alternative path that Google's Android might take, and how that path resembles a future funding mechanism for the New York Times.

Wanted: an identity management service. Business model included.

I have many digital identities. Some are loosely connected (facets?), others are distinct personae. The varied identities each have their own managed reputations, with the facets sometimes sharing the same emergent Google-derived reputation. Even I have trouble keeping track of them. Personae are also susceptible to cloning; requiring either identity recovery or identity termination.

I'm not alone in this swamp.

We need more identity management tools that let us rapidly switch our personae (visible identities) and facets, while tracking our associated reputations and providing a visual cue as to our current identity. These tools can also remind us what each identity is designed for; it's not hard to forget the purpose or a persona, and thus to misuse it.

Obviously such a tool should have a biometric component, though it would need to be optional at first. One way to generate a revenue for such a service would be to provide the service free, but charge for the associated token*, biometric authentication component, or personal VPN add-on.

Needless to say, the service could not be hosted in the United States.

Denmark perhaps?

* Personally I'd like a token embedded in the well recognized geek watch.

PS. If you do create this business, I'd love a one-year free subscription :-).