The technology boom

Raise your hand if you’ve never undergone a CT or MRI scan, never taken a statin to lower your cholesterol or never had a joint replacement. If your hand is still in the air after reading this, you’re either in a healthy minority or just haven’t caught up yet with the odds.

American health care is very good – a world leader, in fact – at developing and using technology. Just how prevalent our technologic interventions have become is demonstrated in a report recently issued by the National Center for Health Statistics, which takes a look at this technology boom by the numbers.

The findings are rather eye-opening. Take, for instance, the report’s summary of the growth of medical imaging over the past couple of decades:

Despite the significant costs of acquiring advanced imaging capability, the availability and use of imaging technologies in the United States has substantially increased since their introduction in the early 1980s. In 2006, there were more than 7,000 sites offering MRI, with an estimated 27 million MRI procedures performed. In 2007, more than 10,000 CT units were in operation at more than 7,600 hospital and nonhospital sites, and the availability of PET and other imaging modalities has been steadily increasing. The site of imaging services has diffused from hospital inpatient and outpatient settings to nonhospital settings such as physician offices or radiology centers. During the past decade, the number of freestanding diagnostic imaging centers owned by radiologists, other specialists, private investors, or for-profit companies has more than doubled.

The report found that from 1996 to 2007, the number of advanced imaging scans ordered during outpatient office visits tripled in number. In emergency rooms, the use of advanced imaging grew fivefold between 1996 and 2007 for patients under the age of 65 and quadrupled for patients 65 and older.

The number of joint replacement surgeries has grown substantially. At least one analysis estimates the demand for total hip replacements could grow by 175 percent in the next 20 years, while the demand for knee replacements could increase sixfold.

The rate of kidney transplantation increased 31 percent between 1997 and 2006. Liver transplants increased 42 percent during this same period. The use of assisted reproductive technology has risen, especially among women younger than 35. From 1988-1994 to 2003-2006, the use of statins to treat high cholesterol rose almost 10-fold, while the use of antidiabetic medications as a replacement for insulin rose by 50 percent.

None of this is necessarily bad. As the report points out, it’s “almost inconceivable to think about providing health care in today’s world without medical devices, machinery, tests, computers, prosthetics or drugs.” Joint replacement surgery has enabled countless people to remain mobile, independent and pain-free. Angioplasties and organ transplants save lives. Drug therapies have staved off illnesses that might otherwise have been fatal and allowed patients to return to normal life.

The flip side to this is that it costs money. A lot of money. Even interventions that are less costly can add up as they become more widely used. From the report:

Technologies applied to new populations and conditions generally come at a cost to individuals and to society as a whole. Technologies can be very expensive (e.g. heart transplants, chemotherapy) or very inexpensive (e.g. the Band-Aid). Total expenditures for a given technology, however, are determined by both use and cost; consequently, widely used inexpensive technologies can often have higher aggregate expenditures than rarely used expensive ones. Some new technologies can be cost-saving – for example, annual influenza vaccinations in high-risk children. Many technologies, however, contribute to increases in overall health care expenditures because they increase utilization (e.g. more doctor visits may be needed to monitor new drug therapies); they may be used on a larger number of patients; they may be more expensive than technologies they replace; or they may increase life expectancy in populations and thus their lifetime health care costs.

In one of the most telling sentences in the entire report, the authors point out: ”In general, Americans – both providers and consumers – appear to be more willing and eager to adopt and use new technologies than people in other countries.”

This whole issue came to mind when I recently read a New York Times article about robotic surgery. It costs more per patient – $1,500 to $2,000 more. It’s not clear if the results are any better than more traditional surgery. But, as the article explains, hospitals and surgery centers are marketing it and patients are asking for “the robot,” in some cases walking away from surgeons who don’t do robotic surgery.

Readers chipped in with comments. Several said they’d had robotic surgery and couldn’t be happier with the results. Others were more skeptical. “Follow the money,” one person scoffed.

Last weekend my Sunday paper was accompanied by this article in Parade magazine: “Revealing the body’s deepest secrets.” It described several new forms of gee-whiz medical imaging technologies that are “transforming medicine.” One is the use of MRI for diagnosing heart attacks; another is a fiber-optic probe that can help detect oral cancer. To be fair, there could well be an appropriate niche for these technologies – but at what cost, not only in dollar terms but also in the ratcheting-up of people’s expectations? On some online message boards, I’ve seen people criticize their physician’s competence for not ordering a specialized test they felt they should have.

Finally, here’s yet another look at the issue, this time from Kaiser Health News, in an article titled “High-Tech Medicine Contributes to High-Cost Health Care”:

Just before Christmas, 41-year-old Michael Kelley decided he wanted a whole-body imaging exam, the heavily advertised service touted on television by celebrities like Oprah Winfrey. He didn’t smoke, wasn’t overweight, and didn’t have elevated cholesterol. “I’m pretty normal for a guy my age,” he said.

No matter. The electrical engineer scheduled a full-body X-ray computed tomography or CT scan at Virtual Physical, a radiology clinic located in a glass-enclosed office building on a busy commercial strip not far from the headquarters of the National Institutes of Health. The clinic’s name, plastered in large red letters on the building’s exterior, served as a billboard aimed at cars exiting the high-end shopping mall across the street.

About an hour after checking in, Kelley left the clinic clutching a manila envelope with high-resolution 3-dimensional images of most of his major body systems, including the insides of the major coronary arteries pumping blood to and from his heart. “They said I was fine, no plaque,” he said. Kelley paid $1,400 for a CT scan to confirm what he and his doctor already knew – he was perfectly healthy.

The rest of the article delves into some of the difficult issues surrounding the use of medical technology. When does the technology genuinely benefit patients and when does it reach the point of diminishing returns? Is “better” always the best thing? How should we weigh the potential benefit to the patient vs. the risk of harm?

The article concludes that in the long run, technology will probably help save money, but we’re not there yet:

When robotic doctors are able to perform micro-surgeries; when arm and leg replacements function as well if not better than the original parts; when pharmacology replaces more expensive treatments and therapies, the U.S. may actually be able to use technology to bend the cost curve of health care downward. Until that time comes, we’re stuck with ever-increasing costs and left to wonder whether the investment is greater than the payoff.

What’s remarkable about this whole discussion is that it’s happening on a wider, more public stage. Ten years ago, maybe even five years ago, I’m not sure the average person was ready to contemplate the down side of technology. More and more, however, these questions are being asked and debated – not just within policy circles but among the public. We might not have the answers, but the sheer fact that we’re willing to acknowledge it and talk about it is surely a sign of progress.

West Central Tribune photo by Anne Polta

The cost of chronic disease

A timely new study confirms what many observers have seen all along: Medicare is now spending more on the outpatient management of chronic diseases than on acute hospital care.

The study appeared last week in the Health Affairs journal. The authors tracked Medicare spending trends across two decades, specifically looking at data from 1987, 1997 and 2006. They estimated the prevalence of chronic disease in each of those years and further analyzed how much was spent on the 10 most expensive chronic conditions, a category that included heart disease, diabetes, cancer, arthritis, high blood pressure and elevated cholesterol.

Among their conclusions: The 10 most expensive conditions accounted for about half of the inflation-adjusted increase in Medicare spending from 1987 to 2006. As chronic disease management shifts towards the outpatient setting, hospital inpatient care has fallen as a percentage of total Medicare spending, while spending on physician office visits and prescription drugs has grown.

To anyone who’s been paying attention, none of this should come as any surprise. What’s especially interesting about this particular study is what it reveals about trends in chronic disease and chronic disease management.

Twenty years ago, hospital care for heart disease was the largest and fastest growing area of Medicare expenditures. But by 2006, heart disease had fallen to the bottom of the list of the 10 most expensive chronic conditions among the Medicare-age population. The study’s authors found this wasn’t because heart disease is becoming less common; in fact the prevalence remained the same. What apparently changed is the management of heart disease, which has evolved away from hospital inpatient care to outpatient office care, prescription drugs and home health care. And although overall Medicare spending on heart disease is still rising, the increase isn’t nearly as steep and most of the growth is concentrated in physician care, prescription drugs and home health.

Where the spending really rose was for the management of other chronic conditions, such as hypertension, diabetes and cancer. Some of this, as in the case of high blood pressure and elevated cholesterol, wasn’t necessarily because the U.S. is having an epidemic of these chronic conditions. Instead, the study’s authors explain, the prevalence of hypertension and elevated cholesterol has increased because the threshold has been lowered for treating these two conditions, a move that automatically increases the number of patients eligible for treatment.

In the case of diabetes, however, there appears to be a true increase in the incidence of the disease – not just better identification and diagnosis of these patients, the authors wrote.

Why would these trends matter? Policymakers are focusing a great deal of attention right now on how to slow the growth in health care spending, but their efforts might be misguided if they only consider the big picture. From the study:

Many Medicare reform proposals designed to slow the growth in spending would redirect costs from the government to others, such as enrollees and participating providers. The slowdown would be accomplished by reducing provider payments, increasing the age of Medicare eligibility, implementing means testing for Medicare, restricting coverage as with the Part D “doughnut hole,” and increasing copays and deductibles. These approaches are unlikely to produce long-term reductions because they fail to address the key factors driving the rise in health care spending overall and in Medicare spending, particularly for chronic diseases. Understanding these facts is essential to reaching the right policy solutions.

Kenneth Thorpe, the lead author of the study published in Health Affairs, has made a rather distinguished name for himself as an advocate for new models of health care delivery that emphasize chronic disease prevention and management. Thorpe, who’s a professor and chairman of the Department of Health Policy and Management at Emory University, has frequently spoken on the need to find better, less expensive ways to deal with chronic disease.

It would be hard for anyone to argue that Medicare spending isn’t growing at a pace that’s becoming unsustainable. The real implications of this latest study, it seems, lie not within the dollars and cents but in where the money is actually going and what it means for cost containment.

Close encounters of the awkward kind

You’re out running errands, shopping for groceries or walking the dog when you run into, of all people, your therapist. What should you do? Hide? Ignore each other? Politely say hello? Launch into a lengthy conversation?

It’s one of those etiquette questions that bedevil the doctor-patient relationship – not only for therapists but for physicians as well.

Dr. Elvira G. Aletta recently explored this issue at PsychCentral, asking the question: ”What if I run into my therapist in public?” Then it was taken up at the New York Times Well blog with some interesting discussion and personal stories.

Dr. Aletta writes:

In my dad’s day, there would have been no question. Psychoanalytic thinking was very clear back then. Both patient and therapist should pretend they don’t see one another, even if it is obvious to both that they have.

There are reasons many therapists still feel that way. One is that it could be seen as inappropriate, even harmful, to acknowledge the working relationship outside of the “therapeutic frame,” meaning the clear boundaries of the time and day of the session and the four walls of the office.

Plus there are issues of confidentiality. Saying hi to my patient in public might put them in the uncomfortable position of explaining who I am and why they know me.

Depending on where the encounter takes place, the patient’s level of discomfort might be even higher. One reader at the Well blog shared this experience: “About a year after I completed outpatient therapy for alcoholism (and still sober, then as now) I ran into one of the counselors at the supermarket while shopping for a dinner party – on my way to the wine aisle.” Someone with bulimia recounted hiding after she spotted her psychiatrist while loading up a shopping basket with junk food.

OK, so it’s awkward. But although social encounters outside the professional therapist-client or doctor-patient relationship should be handled with some sensitivity, “I don’t believe we need to be all rigid about it,” Dr. Aletta declares.

Among the guidelines she offers: The first move belongs to the patient. If you do greet each other, it’s up to the therapist to put the patient at ease. The conversation should be kept short and pleasant. References to the therapeutic relationship are off limits.

I’m not sure it should matter who makes the first move, especially if the therapist and client or physician and patient already have a solid relationship. The point, after all, is to be respectful, not to snub each other.

The main question seems to be one of boundaries, which aren’t always easy to negotiate – and let’s not forget the boundaries go both ways. Therapists and physicians need some personal space too. When Dr. Theresa Chan, a hospitalist in rural California, penned an open letter to the patient who accosted her at the supermarket, it struck a nerve with many of her readers. She wrote:

Dear Neighbor/Patient,

It was very kind of you to inquire after the state of my garden when we bumped into each other at Safeway this morning. We haven’t seen much of each other lately and I was pleased to hear your early peas are flowering. We waved good-bye to each other and went about our business. Or so I thought.

Moments later, you cornered me as my food items were being scanned and asked me, “What do you think about all this stuff they’re saying about Fosamax? Should I stop taking it?” I was unprepared for such a question, because my navel oranges were bumping into the large globe artichokes and threatened to clog the upstream progress of the red seedless grapes onto the rubber rolling mat that conveys the groceries inexorably towards the bagging platform.

In short, she writes, “I do not like to be asked medical questions when I am conducting my everyday errands.”

Readers quickly chimed in with stories of their own. “I’m a family doc in the small town I grew up in and there is no quick trip to the store,” one person wrote. Another commenter confessed to switching barbers six times in 10 years. “That’s the worst predicament; trapped in the chair providing free medical consultation while someone with sharp objects buzzes around your head,” he wrote.

When it comes right down to it, much of this is just Civility 101: being courteous and acknowledging the other person while refraining from being overly familiar or demanding. ”The common social contract that most people subscribe to is that you say ‘hello’ to people that you know,” one of the commenters wrote in response to Dr. Aletta’s essay.

There are even times when out-of-the-office social encounters, when they’re handled well, might help reinforce the relationship between professional and client/patient or be therapeutic in and of themselves. “I find that it comforts a lot of clients to know their therapist is ‘human’ and does the same things or goes to the same places,” one person commented. A therapist who attended a wake for the deceased son of a client and visited another client’s daughter in the hospital wrote that this “seemed like the human thing to do. In both cases, my patients expressed their appreciation and I believe that the therapeutic process was enhanced, rather than threatened.”

Really, can’t we all just get along?

Best of the medblogs

There’s a lot of compelling and interesting content out there in the medblogosphere. Just ask the readers who voted in the annual Medical Weblog Awards this past month to select the outstanding entries from 2009.

There were a ton of nominees for the awards, demonstrating how active the medical blogging community has become. Finalists were selected by the editors of Medgadget; readers were allowed to vote online for their favorites. The polls closed last week.

So who won? The winners for 2009 are announced here. There are seven of them:

- Best Medical Weblog of 2009.

- Best New Medical Weblog.

- Best Literary Medical Weblog.

- Best Clinical Weblog.

- Best Health Policies/Ethics Weblog.

- Best Medical Technologies/Informatics Weblog.

- Best Patient’s Blog.

I was already familiar with many of the entrants but I discovered several newer blogs as well that I want to bookmark and continue to follow. Take some time to follow the links and check out all the blogs; perhaps you’ll find some that become your favorites.

The editors at Medgadget note, "We feel that during the last year, the medical blogosphere has matured, and it now displays the level of writing, reporting, and commentary that challenges traditional media." I prefer to think of it as widening the perspective of medical writing, reporting and commentary in ways that weren’t previously possible. These bloggers bring a unique voice to the discussion, and it’s good to see them recognized. Congrats to all the winners.

Health and geography

Does where you live make a difference in your health? There’s plenty of research to suggest it does, the latest being a new set of county-by-county health rankings issued this week by the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute.

It’s the first time anyone has attempted to show how each of the 3,000-some counties in the United States stacks up on a variety of health measures. A wealth of data, ranging from the U.S. Census to poverty and unemployment statistics, was used to come up with the rankings.

You can see here how Minnesota counties fared. All but two of the state’s 87 counties are included on the list. It’s clear from the map that many of the so-called healthiest counties are clustered around the Twin Cities and in southeast-central Minnesota, while those that fare worse are in rural central and northern Minnesota.

Some caution is warranted in interpreting the rankings. They were compiled with information that came from a wide variety of sources and may not have been measured in exactly the same way. Some of the statistics go back to 2000, making them a decade old. Information on premature death rates was collected from the National Center for Health Statistics for only two years, 2004 to 2006. Unemployment information came from the U.S. Bureau of Labor Statistics and only covered 2008, when the recession was just beginning to deepen in Minnesota. The Behavioral Risk Factor Surveillance System, which tracks health-related behavior such as physical activity, tends to rely on self-reported data from the public that might not be 100 percent reliable.

Without seeing the raw scores for each county, it’s also hard to know what separated the good from the not-so-good. Was it a difference of 10 or 20 points, or was it a difference of tenths of a point?

That said, this new report provides some interesting insight into the many contributing factors to what we think of as healthiness. Although we often view behavioral factors – for instance, eating fresh fruit and vegetables and avoiding tobacco use – as the most critical determinants in overall health, in reality they’re only part of the picture. Environment can make a difference; so can local culture and ready access to quality health care.

Many of the counties that ranked in the bottom tier also had higher rates of poverty and unemployment. This is no accident; two of the most important predictors for overall health status are income and education level. Income and education appear to have a significant influence on health-related behaviors, although it’s not totally clear why this is so. Smoking rates, for instance, generally are lower in the higher income brackets and among the college-educated. And across the board, the poor tend to be more vulnerable to being uninsured, having less access to health care services and suffering worse outcomes than those who are better off.

Geography matters in other ways as well. In highly rural counties and in inner cities, for example, it can be more challenging for people to consume fresh fruit and vegetables each day because there might not be a nearby grocery store that sells fresh produce. Access to medical care is more of an issue, especially in isolated rural areas where resources are thinly spread.

Barriers like these can be overcome, however, suggesting that local decision-making and priorities also have an important role. You’d expect Olmsted County, home of Rochester and the Mayo Clinic, to be one of the top performers on measures of clinical care provided by doctors and hospitals. But look who else scored well in this category: Kandiyohi County at No. 8 and Redwood County at No. 11. On measures of morbidity, or quality of life, the list was topped by small, rural Lac qui Parle County at No. 1, Swift County at No. 2 and Kandiyohi County at No. 9.

So now we know how we stack up, what do we do with the information? The authors of the county-by-county rankings view them as a call to action by health care and community leaders. It’s hoped that counties will be spurred to improve in the areas where they’re not doing well and reinforce their commitment in areas where they’ve been successful.

These kinds of initiatives are not a quick fix. It may take years to see improvements that are not only measurable but sustained. It’s probably going to take the involvement of community and business leaders and local government; after all, these aren’t issues that can be handed off to health care folks to solve themselves. Future report cards will tell the tale of who has responded to the call for action and who has not.

A time for fasting

After the revelry of Mardi Gras yesterday comes Ash Wednesday and the start of Lent, a time when Christians have traditionally fasted so they could better concentrate on matters of the spirit.

Among the world’s religions there’s a long history of combining fasting and prayer. During the month of Ramadan, observant Muslims fast each day, neither eating nor drinking from sunrise to sunset in order to focus more fully on worship, the mastery of desire and service to Allah. Devout Jews fast on Yom Kippur, the Day of Atonement, to signify repentence. Among Hindus, fasting is observed not only on certain days of the week but during numerous festivals and on other occasions as well, such as the anniversary of the death of one’s parents.

Fasting can take various forms. People who fast might limit themselves to one or two small meals a day, or consume only liquids. Or they might abstain from all food and drink for 24 full hours.

Fasting can be rigorous, and it’s not without health implications. Experts warn it isn’t a good way to lose 10 or 15 extra pounds, especially if your goal is to keep the weight off. According to WebMD, people who are generally healthy can fast for a day or two without ill effects, as long as they get enough fluids. Fasting for long periods of time, however, “can be harmful,” says WebMD.

Your body needs a variety of vitamins, minerals, and other nutrients from food to stay healthy. Not getting enough of these nutrients during fasting diets can lead to symptoms such as fatigue, dizziness, constipation, dehydration, gallstones, and cold intolerance. It is possible to die if you fast too long.

Even short-term fasting is not recommended for people with diabetes, because it can lead to dangerous dips and spikes in blood sugar. Women who are pregnant or breastfeeding, or anyone with a chronic disease, should not fast.

If you’re healthy enough and you decide to fast during Lent or other religious observances, don’t expect it to be easy, advise the folks at HowToFast.net. They explain:

Feeling hungry and not eating does a lot to your mind, body and spirit. It may be physically uncomfortable. Headaches, dizziness and other ailments may arise as a result of detoxification. Hunger pangs can also manifest themselves in a physical way (if you develop any strong physical symptoms or problems you may need to break your fast and possibly go see a doctor).

There has been considerable study on the health effects of fasting. Fasting-related headaches, for instance, are so well documented that they’re often referred to as “Yom Kippur headache” or “First-of-Ramadan headache.” There’s also a fair amount of research on how the body adapts to semi-starvation. It’s generally agreed that a Biblical fast for the Lenten period of 40 days and 40 nights is, according to this article that appeared a couple of years ago in an obesity journal, “well within the overall physiological capabilities of a healthy adult” (emphasis added). Muslim athletes who fast during Ramadan have been shown to experience little, if any, decline in physical fitness or performance.

A study of a group of members of the Church of Jesus Christ of Latter-day Saints in Utah found a lower incidence of heart disease among those who routinely fasted – although it should be pointed out that it’s not clear if fasting made the difference or if abstinence from tobacco and alcohol also played a role. It’s also thought that caloric restriction might contribute to longer life spans, although again, it’s unclear whether additional factors are involved or whether it’s truly a safe practice for certain groups such as children, pregnant women or people with chronic illness.

In the 21st-century United States, with its surfeit of food, fasting for any reason other than weight loss might seem unbelievably quaint. There’s no question it takes discipline. A few years ago I gave up all sweets for Lent. The first couple of weeks were easy. Then it got much harder, not because I craved the sugar but because of the constant mindfulness required to stay on track. I recall attending a meeting during which a plateful of cookies was passed around the table, not just once but two or three times. I had to keep repeating, “No, thank you” and pass the cookies to the person next to me.

Does fasting make us better people? Many Americans seem to have difficult relationships with food. Perhaps by denying ourselves food for a short time, we can discover something about our feelings about food and eating, suggests HowToFast.net. From the Web site:

You can use this as an opportunity to think about how and why you eat. This knowledge can teach you how to eat better during times that you are not fasting. From a spiritual perspective many people use fasting to focus on their beliefs, to enter into periods of prayer, and grow their faith.

Whether we benefit from fasting ultimately depends, I guess, on why we’re doing it and what we hope to get out of it.

Image: Sinai desert. Photo courtesy of Wikimedia Commons

Hoarders: Behind closed doors

Gail’s house has no heat. The support beams, damaged in a fire several years earlier, are threatening to give way. But until Gail cleans up the mountains of clutter she has collected over the years, repair crews can’t get into the house.

Warren accumulates stuff too – tools, refrigeration units, even the old van in which his father died. His wife, Leanne, is worried about how Warren’s hoarding is affecting their 3-year-old son. She has given him an ultimatum: Clean up or get out. Unfortunately the problem isn’t that easy to solve, because it turns out Leanne is a hoarder too.

Watching an episode of “Hoarders” on A&E is a little like watching a train wreck: It’s appalling but you can’t stop looking. And ultimately you have to wonder if it isn’t exploitive to bring TV cameras into these people’s homes and display their dysfunction for everyone to see, even if the purpose of the show is supposed to be educational.

Hoarding is thought to affect somewhere between 2 million and 3 million Americans. While this sounds like – and is – an enormous number of people, it’s still only about 1 percent of the population. Since many hoarders operate under the radar, so to speak, it’s hard to get a handle on the true extent of this behavior.

It’s not even clear whether hoarding should be classified as a mental disorder. It is being considered for inclusion in the next edition of the Diagnostic and Statistical Manual of Mental Disorders, but a task force hasn’t decided yet whether to list it in the manual itself or in the appendix. The DSM-V’s working definition of hoarding disorder:

A. Persistent difficulty discarding or parting with personal possessions, even those of apparently useless or limited value, due to strong urges to save items, distress, and/or indecision associated with discarding.

B. The symptoms result in the accumulation of a large number of possessions that fill up and clutter the active living areas of the home, workplace or other personal surroundings (e.g. office, vehicle, yard) and prevent normal use of the space. If all living areas are uncluttered, it is only because of others’ efforts (e.g. family members, authorities) to keep these areas free of possessions.

C. The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning (including maintaining a safe environment for self and others).

If you’ve never seen the effects of hoarding, an episode of “Hoarders” is jolting. Some of the things that can be learned from this series:

- The clutter and the accumulation of items can be extreme. At some level, many of us probably fear our own personal clutter – the stack of unread magazines, the children’s toys and clothing we no longer use or need – will eventually take over the house. Genuine hoarding, however, goes far beyond the typical clutter of the average household. Hoarders often stop using a kitchen or dining room or bedroom because it’s simply too full of stuff. When we meet Gail, for instance, she’s living out of a bedroom and heating all her meals in a microwave oven in an upstairs hall.

- Health and safety can be at risk, and it’s not unusual for living conditions to become downright squalid. A hoarder’s cupboards might be filled with moldy food. In some episodes of “Hoarders,” mice have been found under the silted layers of accumulation. Necessary repairs often don’t get done because the house is inaccessible to repair crews. A surprising number of the individuals featured on the show were living without heat or running water, in some cases for months. In the worst-case scenario, a house can sustain structural damage that’s too extensive to fix.

- Hoarding can escalate into a crisis when people are threatened with eviction or the loss of their children to child protective services, or if the hoarder becomes sick or injured and needs to be rescued from among their mountains of clutter.

- Hoarding affects entire families. Spouses of hoarders feel frustrated and powerless. Children of hoarders can’t invite their friends over. Efforts to help are often met with resistance or resentment, which can further break down family relationships.

- Although hoarding tends to be associated with older people, perhaps because they’ve had a longer lifetime to collect things, it also affects younger people. The syndrome is thought to have a genetic component. (Actress Lindsay Lohan revealed a couple of weeks ago that she “has a lot of stuff” and needs to clean out her home, although it’s not clear if this means she truly is a hoarder or if she’s just disorganized.)

- The emotional attachment that hoarders have to their possessions is very real and not necessarily rational. Gail got increasingly testy when her family and a professional cleanup crew tried to pry away some of her accumulated belongings. Warren was unable to part with his father’s old van, and at the end of the episode, the van was still sitting in the back yard.

There’s a lot, however, that this show simply doesn’t tell you. Are the individual stories typical of hoarders, or do they represent the extreme end of the spectrum? How these people got this way is never really explored, although there are hints that among many of them, the hoarding escalated after a loss or death in the family.

Nor is there much exploration of hoarding itself. Even the experts can’t completely agree on how to classify the psychopathology. Is it a variant of obsessive-compulsive disorder, or is compulsive hoarding syndome an entirely separate entity? Research suggests there is indeed a difference between compulsive hoarding and hoarding associated with OCD, with implications for how each should be treated. Elements of social phobia, anxiety disorder and ADHD might be intertwined as well. And exactly where animal hoarding fits into the overall spectrum is not clear.

Where “Hoarders” perhaps commits the greatest disservice, however, is in its portrayal of intervention. A convoy of trucks rolls up to the hoarder’s doorstep and the race is on to clear out the home in two days, three days or whatever deadline has been set by the family’s circumstances. As the cleanup progresses, viewers get to see the couch chewed up by mice, the discarded food packages, the dirty and soggy detritus being carted out to the trucks. We get to witness the tears and anxiety as the hoarder attempts to part with his or her possessions, with a few family squabbles thrown in for good measure. By the end of the episode, the house is restored to reasonable order and the family is receiving aftercare and/or ongoing therapy.

To be fair, the show’s producers bring in therapists and professional organizers to help work with their subjects. They’re up front about the fact that not every intervention is successful. But viewers would do well to ask themselves: Is it really fair to deliberately put hoarders into a situation guaranteed to be stressful, anxiety-producing and probably embarrassing, all for the sake of a TV show?

More to the point, is a one-time, aggressive intervention truly effective? It might help temporarily, but most experts agree hoarding is usually a chronic condition. Once the hoarder’s home has been cleaned, he or she often will start accumulating things again. A combination of cognitive therapy and drug therapy shows some promise, but the psychiatric community still has a long way to go in finding effective ways to treat compulsive hoarding and helping prevent relapses. Among animal hoarders, the relapse rate is thought to be nearly 100 percent without intervention, nor is there any standard treatment yet for animal hoarding.

To the extent that “Hoarders” brings the issue of hoarding out into the open, the show is providing a benefit. It’s beneficial too for people who’ve struggled with this disorder, or watched someone in their family struggle with it, to know that some help is available. We can’t forget, however, that the stories on “Hoarders” are about real people with a real disorder. Long after the TV cameras have disappeared, these people will more than likely continue to struggle with their hoarding and some of them will probably relapse. Although the drama of intervention might make for a compelling TV show, in reality there are few easy or long-lasting solutions to the issue of hoarding.

Photo courtesy of Wikimedia Commons

The Olympian elite

For the next two weeks, many of us will be glued to the TV, watching the Olympic athletes as they race downhill on their skis and snowboards, compete on the hockey rink and perform feats of strength and grace in ice dancing.

How do they do it? Are they simply more physically gifted than everyone else? Or are they just more determined and hard-working?

To be sure, training is everything when you aspire to compete at the Olympic level. Spend some time at the official Web site of the 2010 Winter Olympics and you can find out exactly what it takes. A high-performance downhill skier, for instance, typically practices up to twice a day for two to four hours each time. In the weight room, 75 percent of the training is focused on building lower-body strength. Flexibility exercises are aimed at reducing the risk of hip and knee injuries.

For speed skaters, the drill involves many hours of skating in circles on a 400-meter track. From the Olympics site:

Ice practice sessions can last up to two hours depending on the volume and intensity required for a particular athlete. Sprinters have shorter ice sessions than distance skaters but their training intensity is extremely high and includes short bursts of speed. Distance, middle distance and all-around speed skaters have long ice sessions focusing working on balance, cornering and positioning.

In some winter sports, such as curling, it’s the mental game that really counts. Figure skaters need to be not only skilled but artistic and confident as well.

But it’s hard to overlook the importance of the genetic component. Ross Tucker and Jonathan Dugas, two scholars who study and blog about the science of sport, analyzed this issue during the 2008 Summer Olympics in Beijing and conclude, "Choose your parents wisely!" They write: "While we will be the first to admit that a myriad of factors and variables must converge to produce superior athletic performance, it is perhaps the genetic component that plays the biggest role."

Body type makes a difference, they explain. The best endurance runners, for instance, are generally either small or are tall and lanky – two physiques that are the most efficient for accommodating the energy demands of the body.

One of the first genes to be associated with athletic performance is the ACE, or angiotensin converting enzyme gene, they write. "It is an enzyme involved in fluid balance and has an association with performance. In other words, some people who have specific variations of this gene do better in endurance events or respond better to endurance training."

Environment also is critical, Tucker and Dugas explain:

… To succeed at the highest levels of sport one must clearly have the genes. However at the same time you must be exposed to the appropriate environmental stimuli that will permit you to exploit your superior genes. We guarantee that for every Bo, Deion and Sheila, there are countless others who do in fact possess the genes for superior athletic performance, but instead of training six days a week, they are working a desk job six days a week – and that is simply because they were not exposed to the "right" environment for them to end up as an athlete.

Dr. David Geier, director of the sports medicine program at Medical University of South Carolina, can be found here on YouTube discussing the physical commitment it takes to be an Olympic-caliber athlete.

The death of a luger who crashed during a training run last week underscores another important and sometimes overlooked element: the risk-taking that’s often required to excel in the winter Olympic sports, and the capacity to ignore your own fear.

Whether we’re a weekend athlete or a couch potato, we all admire the Olympic athletes. But they’re truly a breed apart – an elite that only a few of us can genuinely aspire to.

Photo: Associated Press

Copayments, cost-cutting and contradictions

It’s long been the common belief that when consumers have to pay more out of pocket for their health care, they’ll make wiser, better decisions and money will be saved.

An interesting new study calls this into question, suggesting that when elderly patients have a higher copayment for outpatient care, they might be more likely to skip doctor visits and wind up needing hospital care that’s ultimately more expensive. The study appeared a couple of weeks ago in the New England Journal of Medicine.

It was a good-sized study, involving nearly 900,000 Medicare enrollees who were tracked from 2001 through 2006. Those who had their copayment raised for ambulatory care were matched against a control group whose copayment for outpatient care stayed the same. What the authors found was a little surprising: Medicare enrollees who saw their out-of-pocket costs for office visits go up were more likely to be hospitalized.

They wrote:

Over time, there was an increase in ambulatory visits in both the case and control plans. However, the increase was smaller in case plans than in control plans. In contrast, case plans had significant increases in annual inpatient days, annual inpatient admissions, and the probability of any use of inpatient care, as compared with control plans. Of the 18 case plans, 13 had declines in annual outpatient visits and 15 had increases in annual inpatient admissions, as compared with the concurrent trends in the matched control plans.

The authors also found this trend was magnified among Medicare enrollees who lived in areas with low income and low educational levels, enrollees who were black, and enrollees with high blood pressure, diabetes or a previous history of heart attack.

What’s going on here?

The copayment increases weren’t particularly large. They ranged from $5 to $10 more for a primary care visit and $5 to $15 more for an office visit to a specialist. The actual copayment for a primary care visit was $7.38 before the increase and $14.38 after the increase. For specialty care office visits, the mean co-payment rose from $12.66 to $22.05.

But if the intention was to reduce costs by having these elderly patients pay a larger out-of-pocket share, it may have backfired. The analysis found that among the plans that increased the copayment for ambulatory care, inpatient hospital expenses actually went up. There were 2.2 additional hospital admissions per 100 enrollees per year and 13.4 more inpatient days per 100 enrollees per year compared to the plans that didn’t increase their outpatient copayment. In fact, the savings from higher copayments for office visits were wiped out by increased hospital inpatient costs by a factor of 2 to 1, the study found.

The authors of the study speculated the higher amounts may have been enough of a barrier to discourage many of these enrollees, all of whom were over age 65, from seeing a doctor. Their conclusion: “Increasing copayments for ambulatory care among elderly Medicare beneficiaries may be a particularly ill-advised cost-containment strategy.”

It’s not clear if these same findings would apply to a younger, working-age population. The study noted elderly patients might be more sensitive to increased copayments because their incomes tend to be lower and they’re more likely to have chronic or multiple health problems. They could also be more likely to have additional copayments for prescription drugs, medical equipment and so on, leading to higher overall out-of-pocket health care expenses. The study also was unable to definitively connect the dots between fewer doctor visits and increased likelihood of hospitalization.

Nevertheless, this isn’t the first time concerns have been expressed about the unintended consequences of giving health care consumers more responsibility for the money they spend. In a paper issued for health insurance purchasers, the U.S. Agency for Healthcare Research and Quality cited the existing research and warned, “Patients who had to pay used care less often, but they tended to forego appropriate care as well as inappropriate care.”

Similar findings have been reported with HSAs, or health savings accounts. Although these have been touted for saving money and giving consumers more power, the large deductibles – often $3,000 or $5,000 per year – can cause some people to delay or skip necessary care, especially if they don’t have a lot of money banked in their account.

This study, conducted a few years ago for the Center on Budget and Policy Priorities, found that while HSAs helped lower health care costs for people who were more affluent, those who were less well off incurred higher costs and were more likely to delay primary care.

A few conclusions come to mind. First, asking consumers to pay more for their own health care doesn’t necessarily lead to lower overall costs. Second, giving consumers more responsibility for their health care spending is not a guarantee they’ll make wise choices or that they’ll even know what the right choice is supposed to be. Third, some segments of the population – namely those who are elderly and/or have lower incomes – seem to be more vulnerable to the effect of increased out-of-pocket expenses. And finally, what seems intuitively correct – in this case, the belief that it saves money to give people more financial skin in the game - is not always borne out by the facts.

Cabin fever

Tired of shoveling snow? Feeling cooped up by the winter weather? More than a few of us are probably beginning to develop cabin fever, that feeling of crankiness, restlessness and boredom that often sets in among people who are confined indoors too long.

The term “cabin fever” originated in the American West in the early 1900s and was first used to describe the negative effects of being pent up in an isolated cabin. Being shut in, especially in winter, can have a definite impact on mental health, the Midwest Center for Stress and Anxiety explains:

While not an actual disease foreshadowing insanity, cabin fever can be a very real claustrophobic reaction which occurs when a person is isolated for long periods of time. A lack of environmental stimulation, lack of physical exercise and the shortened daylight hours of winter can have a detrimental effect on the healthiest of psyches.

Symptoms often include lethargy, grouchiness, a lack of motivation, cravings for high-carb foods and weight gain. Most of the time, cabin fever isn’t serious. Among some people, though, it can be a sign of seasonal affective disorder or depression and may require some kind of intervention.

How can you tell when cabin fever has crossed the line into something more pervasive? If winter blues are affecting your work, your relationships and your quality of life, you probably have something more than cabin fever, mental health experts advise. Light therapy, psychotherapy or antidepressant medication might be indicated. For some reason, younger people and women seem to be more vulnerable to the winter blahs; SAD also is more prevalent in northern latitudes where winter daylight hours are significantly shorter.

But if what you have is garden-variety cabin fever, a simple change of pace and an effort to be more social and active is usually enough to restore your normal frame of mind. From the U.S. Air Force base in Minot, N.D., (where they really know something about cabin fever) comes this good advice:

One key to a speedy recovery is being able to recognize the symptoms of cabin fever which include but are not limited to: crankiness, loss of sleep, overeating and feeling down due to the inactivity. The idea is not to subject yourself to depression and added stress because of the cold weather. A change in scenery is simple but a tremendous help in overcoming winter blues.

When the Post-Gazette of Pittsburgh, Pa., queried people about how they coped with cabin fever, they got a variety of responses. A long-distance truck driver said he listened to loud country music on the radio. One woman walks her dog outdoors four to five times a day. Others said they volunteer or, when the weather is bad, they stay indoors, read, do crossword puzzles and clean the house.

My personal remedy usually involves an expedition to the Willmar Public Library for a few good books, or a leisurely weekend fortified with homemade soup and quality time with my kitty and canary. It works like a charm, every single time. And when all else fails, well, the first day of spring is only five and a half weeks away.

West Central Tribune file photo by Carolyn Lange