Globalization and health care

A lengthy article in the most recent Economist takes a detailed look at medical tourism, predicting the number of medical tourist from the US alone could grow tenfold by 2012, creating an industry worth $21 billion (US) a year in just four years' time.

It attributes the growth to a development noted on this blog and in Toronto Star newspaper articles last May, the ability of the middle class to afford what was once the preserve of the wealthy: 

Some wealthy patients have always traveled for fancy medical care. Denis Cortese, head of the Mayo Clinic, in rural Minnesota, observes that “we have been global for a hundred years.” A few years ago Britons fed up with waiting for elective surgery started heading overseas to get joints replaced or cosmetic surgery—sometimes at government expense. Recently, shorter queues in the National Health Service and restrictions on reimbursements have undermined this trend.

However, globe-trotting patients only ever occupied a niche. What is getting people excited today is the promise of a boom in mass medical tourism, as a much bigger group of middle-class Americans prepares to take the plunge.

The Economist notes that much of the growth can be attributed to American companies changing their employees health plans to offer overseas surgery as an option, creating a larger customer base. Because getting major surgery can be performed in Asia for a fraction of the cost in the US -- including airfare -- insurance premiums can be slashed if foreign surgery is an option. Employees at Hannaford, a major grocery chain in New England, for example, can save up to $3,000 on their insurance co-payments by agreeing to go overseas if they need surgery.

In Canada, the big incentive to become a medical tourist is the chance to skip waiting lists for orthopedic or cardiac surgery. But like the US, the growth of the industry can be attributed to such options no longer being the preserve of the wealthy.

Today, a new hip or knee can be had in India for about the cost of a family vacation -- opening the industry up to a big new group of people.

Speedy organ harvesting

By taking a heart from a dying infant within 75 seconds of the heart stopping, the chances of a successful transplant to another baby are greatly increased, according to a study in today's New England Journal of Medicine that is raising ethical questions about the definition of death.

The study examined the cases of three dying newborns whose hearts were taken within 75 seconds of cardiac death and given to three other infants.

"As a result of their investigational protocol, three babies are now alive; had the procedures not been performed, it is virtually certain that all six babies would be dead," the journal's executive editor Dr. Gregory Curfman and others wrote in one of several commentaries accompanying the study.

Organ harvesting after cardiac death -- rather than waiting for brain death -- is much more common in the US than in Canada. The standard until now, however, has been to wait until five minutes after cardiac death before removing organs.

The journal notes, however, that the longer a heart remains in the body, deprived of oxygen, the lower the chances of a successful transplant.

Dr. Kerry Bowman of the University of Toronto's Joint Centre for Bioethics told the CBC the study raises issues about the definition of death and how soon is too soon for doctors to start harvesting organs.

"I think the pull and the need for organs is so strong that it could easily encourage critical care physicians to consider the declaration of death potentially sooner than they normally would," said Bowman, who is not opposed to donating after cardiac death.

Robert Truog, professor of medical ethics at Harvard University and author of one of the commentaries, told Bloomberg, "The worrisome thing that people might take away from the study is that doctors are doing something unethical in order to increase the number of organs for transplantation. That would be the wrong conclusion.''

Medical ethics award winner

Toronto's Dr. Philip Hebert has been awarded the Canadian Medical Association's annual Dr. William Marsden Award in Medical Ethics in recognition of his work to promote ethics within the profession.

"Medical ethics can remind us of our primary commitment to the welfare of our patients," Hebert said in a CMA press release last night.

A family doctor at Sunnybrook Health Sciences Centre, Hebert set up the University of Toronto's medical ethics program for medical students, and wrote a popular textbook on the subject, Doing Right: A Practical Guide to Ethics for Medical Trainees and Physicians in 1996, with a second edition coming out next year. He is also chair of the Research Ethics Board at Sunnybrook and a clinical ethicist at the Joint Centre for Bioethics.

He will receive the award next week at the CMA's annual meeting in Montreal.

Too costly for care

The British National Institute for Clinical Excellence has decided that some patients are just too expensive for care — so shouldn't get treatment, according to a story in The Independent newpaper.

The UK's medicines watchdog, know by its acronym of NICE, says the strong human impulse to expend vast resources to save someone — refered to as the rule of rescue — cannot apply to medicine. The decision comes on the heels of a controversial NICE decision last week to reject four new drugs for kidney cancer even though they have been shown to extend life by five to six months. NICE's own citizen's council recommended six months ago that it adopt the rule of rescue as a mark of a humane society.

NICE, however, rejected the idea, saying there just isn't the money and that applying the rule of rescue would deny care to others. "When there are limited resources, applying the 'rule of rescue' may mean other people will not have the care or treatment they need," the NICE report says.

Treatment may also be refused to elderly patients if the benefits are deemed too low or the risks too high.

The British Medical Association has criticized the report, saying doctors have a responsibility to do everything they can for a patient. Says Tony Calland, the BMA's ethics committee chairman: "We would be opposed to ignoring a rule of rescue when it introduces a degree of flexibility around extreme cases. So what if you waste a few pounds if you are doing your best for humanity?"

Access to care stands to become a growing issue in healthcare as drug companies come up with expensive new treatments and governments must decide which they pay they will pay for. Canadian Medical Association president Brian Day has long warned about this looming problem, made worse by the aging baby boom generation.

Health and size

The Associated Press had an interesting story overnight (it appears in this morning's Toronto Star) that shakes up a few medical assumptions.

It seems being overweight is not necessarily an automatic indicator of poor heart health. In fact, the chances of weight being an issue are only about 50-50.

In the study, about 51 per cent of overweight adults, or roughly 36 million people nationwide, had mostly normal levels of blood pressure, cholesterol, blood fats called triglycerides and blood sugar. Almost one-third of obese adults, or nearly 20 million people, also were in this healthy range, meaning that none or only one of those measures was abnormal. Yet about a fourth of adults in the recommended-weight range had unhealthy levels of at least two of these measures. That means some 16 million of them are at risk for heart problems.

I would expect this study to generate some controversy. Already one Star reader has posted a comment online pointing out that the risk factors for health problems are higher than for people in the recommended weight range.

But the point of the study is that being oversized might not be as automatic an indicator of problems as previously thought.

What makes that interesting is the growing number of doctors refusing to see patients who smoke or are overweight — saying that if the patients won't help themselves, there's not much they can do for them.

In a recent posting to this blog, a nursing student asked, "Do you think its fair that people who take care of themselves pay the same taxes as people who don't?" Adding: "There has to come a time where people stop relying on our `great healthcare system' and start relying on themselves."

If this study is to be believed, however, such judgements might be premature.

Medical ethics growing

Two stories from opposite sides of the world show how fast the medical ethics field is growing.

The Age newspaper in Melbourne, Australia reports that the Royal Children's Hospital in in that city is spending $900,000 (Australian) to open a Children's Bioethics Centre, billed as only the second such centre in the world. The centre opens today, and will tackle some of the central issues of modern medical ethics:

Paediatrician Dr Hugo Gold, who will chair the new centre, said it was the result of two major trends: technological advances that have created new treatments, and a move to give patients more choice. "In the good old days it was 'doctor knows best, no questions asked,'" he said. "The world has changed a lot. Medicine is now much more inclusive."

Meanwhile, the Associated Press reports that the University of Minnesota's Center for Bioethics is about to become one of the few institutions in the United States offering a master's degree in bioethics.

The school, which already offers an undergraduate bioethics degree, expects about 10 students a year to enroll in the new program. Jeffrey Kahn, director of the school's bioethics center, said the degree will be for students in with a degree in another field, such as law or medicine, who want to add bioethics to their expertise.

Stem Cells research, post-Bush

With US president George Bush about to leave the White House, researchers in that country who have chafed under White House restrictions on stem cell research and their supporters are beginning to push for the restrictions to be lifted by the next administration.

In a column in Sunday's San Francisco Chronicle, two Washington pundits with the liberal Center for American Progress called Bush's ban on federal funding for embryonic stem cell research morally hollow and said they are hampering American scientists.

Recent revelations that many of the Bush-approved stem cell colonies were obtained in clear violation of widely recognized ethics rules have now laid bare the moral hollowness of Bush's approach. At least five of the 21 cell colonies approved for federal funding by virtue of their having been derived before Bush's 2001 address came from embryos that were "donated" by women who were either not told anything about what they were agreeing to or were expressly told that their cells would not be preserved as regenerating cell cultures. Other colonies were obtained with lesser but still troubling ethics lapses. Having learned of those failures of informed consent, at least six of the nation's leading academic stem cell centers - four of them in California - are now reconsidering whether to allow those cells in their research protocols.

The two column writers, Rick Weiss and Jonathon Moreno want not only for the Bush funding ban to be lifted, but for there to be a congressional probe into the impact of the ban. "It is time to move beyond the Bush era of stem cell research, with its faux moral high ground and simplistic reliance on a TV broadcast date," the two write.

Seven years ago last Friday, Bush used his first televised national address to announce that from that day forward, the American government would not fund embryonic stem cell research on ethical grounds. Conservative religious ground applauded the move. Stem cells lines collected before the TV address were exempted.

Embryonic stem cells are considered the best by stem cell researchers, who hope to use them to reverse degenerative diseases such as Alzheimers or Parkinson's.

I attended the annual meeting of the International Society for Stem Cell Research in Toronto a couple of years ago, at which several US researchers commented that Bush's ban did not stop the research it was targeting, but did make it much less efficient. The research was able to continue with state government funding, but because of Bush's ban no equipment bought with state money -- from microscopes to paper clips -- could be used for federally funded research. That, they said, meant duplicating efforts and endless paperwork to prove no cross-over of funding -- making their work much less efficient and giving an advantage to researchers in countries, such as Canada, without the same restrictions.

It will be interesting to watch what happens after the next election. The candidates, however, have shown little interest in talking about the issue so far.

Drug marketing

There was an interesting Canadian Press story in the Toronto Star this morning about a recent study that found more than half the press releases and news stories about new medications were based on preliminary research, and almost a third contained no caveats about the limitations of the results.

"They didn't talk about the study limitations and the idea that this is preliminary studies or preliminary data. Almost universally this was not discussed." Dr. Chaim Bell, the study's senior author and an assistant professor of medicine and health policy, management and evaluation at the University of Toronto, told CP.

The study appeared in the the journal Public Library of Science One.

Russell Williams, president of Canada's Research-Based Pharmaceutical Companies, said in a statement that the group hasn't fully reviewed the findings, but noted there are "space limitations" in press releases and pointed out that reporters have other sources for checking for further information or contacts.

On a positive note, the study found that 20 per cent of the news releases described studies published in peer-reviewed journals and 76 per cent talked about adverse effects of the drugs.

Blogs, privacy and professionalism

Blogs written by medical professionals may pose a risk to patient privacy, according to an online study in the Journal of General Internal Medicine. Many also contain product endorsements and "unprofessional" comments about co-workers and patients.

This blog is not written by a medical professional.

The study's authors looked at 271 blogs written by doctors or nurses over the course of a year, and found that 16.6 per cent provided enough information to reveal the identity of the patients being discussed. Three even published photos of the patients. "When these authors discuss their interactions with individual patients, they compromise their patients’ privacy," the study found.

It can also come back to bite the doctor, according to the study:

For example, the anonymous blog author “Flea” revealed details of a patient’s death after a malpractice case was brought against him. The lawyer for the plaintiffs recognized the description of the case, and shortly thereafter, the case was settled out of court and the author removed his blog from the Internet.

Although most of the blogs attempted to be anonymous, more than half (56.8 per cent) provided enough information to identify the bloggers.

Many of the bloggers appear to use their online forums as a way to vent their frustrations about work, and in 17.7 per cent of the blogs to make critical comments about their patients:

“The unwritten definition of proper patient: attached to a breathing machine, a lot of wires and completely sedated or even paralyzed.” Adrenalin Rush

“She was a stupid, lazy, selfish woman all of which characteristics are personal problems, not medical issues or barriers to care” Panda Bear MD

“When you come into the ER yelling, moaning, and twisting in agony because you have a sprained ankle - I will hate you. Why will I hate you? I will hate you because the man in the next stretcher is dying of an excruciatingly painful form of cancer, yet he is silent.” ER RN

Colleagues, and the medical profession in general, are discussed on 50.6 per cent of the blogs. Forty per cent contained positive comments, and 30 per cent had negative comments complaining about poor management or lazy co-workers.

"Some blogs include unprofessional tone or content, such as negative comments about patients or the profession, violations of patient privacy, or promotion of special interests," the study found.

In fact, 11.4 per cent contained postings endorsing a health care product. An earlier study by another group found that 29 per cent of blog authors had been approached to endorse such products, and that 52 per cent of them had done so.

The authors also found many well written and respectful blogs that give them hope that such problems can be overcome. The study recommends that medical students get some training on their online behaviour, and that profession groups tackle the issue with guidelines.

"Medical blogs have the opportunity to be such a benefit to patients," one of the authors, Dr. Tara Lagu, an internal medicine specialist, told the Los Angeles Times.

"By revealing the struggles we have, they can really open patients' eyes to how to interact with doctors, they can connect patients and nurses who can be isolated from each other and they can be an important source of information for doctors as well as patients."

A sale on heart valves

For a limited time, Thailand has a deal on heart valve replacements.

At the (relatively) low price of 590,000 Thailand Baht, or about $18,000 Canadian, the Bangkok Hospital Medical Center will replace your damaged heart valves — a procedure that sometimes become necessary in middle aged patients for reasons ranging from infection to rheumatic heart disease to congenital heart defect to valve disease or even just normal aging and wear.

The $18,000 gets you use of the operating room, critical care unit accommodation for two nights, a standard single room for five nights (including nurses, meals and room service), treatment by a team of cardiologists, surgeons, anesthesiologists and rehabilitators, medications, laboratory and diagnostic services and blood transfusions. The valves themselves are not included.

The price is billed as about 20 per cent of the cost of having the procedure done in the U.S., the target market for the offer. It's not immediately clear, however, how much of a savings the price is from the hospital's regular charge. But a chart in a recent edition of US News and World Report would place the rate somewhere between what a patient could expect to pay in Singapore (considered the high-end destination for medical tourists) and notoriously value-priced India.

But act soon, the offer ends Sept. 30.