Posts Tagged ‘New England Journal’

California ends personal belief and religious exemptions for childhood vaccinations

October 7, 2015  |  General  |  No Comments

California has recently ended most exemptions from childhood vaccinations. Only exemptions for medical conditions remain, and such exemptions must be certified by a physician. The requirement applies to children attending elementary or secondary school, as well as day-care centers; home schooled children are not included. A recent editorial in the New England Journal of Medicine reviews the politics behind passage of the new law.

Clearly the recent outbreak of measles in the state played a large role in convincing the legislature to pass the law. That, plus the progressive fall in the percentage of children vaccinated. Epidemiological research has shown that when the percentage of the population that is vaccinated falls below a certain number, what is termed herd immunity no longer functions. That concept is that, if the great majority of the population is immune to a disease, the few who are not are protected by the overall rarity of the infection. The particular threshold for herd immunity varies with the disease, but it is usually in the neighborhood of 80-95%. The more infectious the disease, the higher the percentage of immune people needs to be to prevent spread. If sufficient herd immunity can be maintained for long enough, the disease can actually be eradicated. Thus far only smallpox and rinderpest (a disease of cattle) have been eliminated in this way. Perhaps the purest example of the importance of herd immunity is whooping cough, or pertussis. The people most prone to contract severe, even lethal infection are small infants. Yet they cannot begin to get the vaccine (it takes several doses) until they are several months old because it doesn’t work before that age. They are entirely dependent upon not encountering older persons who have the disease.

In my view, vaccine requirements are lawful applications of the state’s interest in public health. Adults have a right to do whatever they like to their bodies (although not their children’s) as long as their actions don’t affect others. In the case of vaccines, not participating in maintenance of herd immunity has significant and potentially serious effects on the health of others.

More here.

Pediatric Newsletter #15: Food Allergies, Gluten, and Pizza

March 29, 2015  |  General  |  No Comments

Welcome to the latest edition of my newsletter for parents about pediatric topics. In it I highlight and comment on new research, news stories, or anything else about children’s health I think will interest parents. In this particular issue I tell you about a couple of new findings about allergies in children, as well as some new information about gluten sensitivity. I have over 30 years of experience practicing pediatrics, pediatric critical care (intensive care), and pediatric emergency room care. So sometimes I’ll use examples from that experience to make a point I think is worth talking about. If you would like to subscribe, there is a sign-up form on the home page.

Big News About Peanut Allergies

This one made a big splash both in the medical news sites and in the general media. Peanut allergy is common. It has doubled in the past decade, now affecting between 1 and 3% of all children. And it can be a big deal for children who have it, even life-threatening. For years we recommended that children not be given peanut products early in life, especially if they are at risk (based on their other medical issues) for developing allergy. Unfortunately, avoiding peanuts in the first year of life doesn’t make a child less likely to develop the allergy. So what, if anything, can?

This recent, very well done study published in the prestigious New England Journal of Medicine is really ground-breaking. It took 4 to 11-month-old children at high risk for developing peanut allergy and divided them into 2 groups. One group got the “standard” approach — being told to avoid peanut exposure. The other group was fed peanuts 3 times per week. It was done in the form of either a peanut snack or peanut butter.

At age 5 years (the long follow-up time is a particularly strong feature of the study) the children who had been fed the peanuts had nearly a 90% reduction in the development of peanut allergy. This is a huge difference.

The study also was able to provide a scientific explanation for the difference. The children fed the peanuts developed protective antibodies that cancel out the ones that provoke the allergic response.

Washing Dishes by Hand May Reduce the Risk of Food Allergies

This report comes from Pediatrics, the journal of the American Academy of Pediatrics. There has been a long-standing theory about how allergies develop in children called the “hygiene hypothesis.”

The notion is that children, particularly in Western countries, are more prone to allergies (and asthma) because their exposure to microbes is delayed by our more sanitized environment.

In this study from Sweden, children in households that washed dishes by hand rather than using a dishwasher experienced a lower risk of subsequent allergies. The authors speculated that there was a causal association. They couldn’t prove that, but they also noted that early exposure to fermented foods and if the family bought food directly from farms also correlated with less allergies. I’m not totally convinced, but it is an interesting study worth thinking about. I expect to see more on the topic.

Does the Age at Which You Introduce Gluten Into Your Child’s Diet Affect Future Risk of Gluten Sensitivity?

Gluten sensitivity is in the news, with signs everywhere advertising “gluten free” as if this is always a good thing. I hear a lot of misconceptions about gluten sensitivity. Gluten is a protein found in grains such as wheat and barley. There is a condition, called celiac disease or sprue, in which a person can develop moderate or severe intestinal symptoms triggered by gluten. It is one of the eighty or so autoimmune diseases. The incidence of celiac disease in the US is about 0.7%. The risk of developing celiac disease is closely linked to a genetic predisposition to getting it. Importantly, if you don’t have the disorder, there is no benefit to eliminating gluten from your diet. In fact, the great majority of people who think they have sensitivity to gluten . . . don’t.

But for those children who do have a higher risk for developing celiac disease because of their genetic makeup it has long been a question if delaying gluten exposure will affect their chances of actually getting the disease. A good recent study gives an answer to that question, and the answer is no. There is no correlation.

If you think your child (or you) have problems with gluten there is a useful blood test that looks for a specific antibody. However, many people who have the antibody never get symptoms of celiac disease. The ultimate test is an intestinal biopsy.

My take-away conclusion is that all this gluten-free stuff you see in, for example, restaurants, is just the latest dietary fad. For over 99% of us there is no health benefit to avoiding gluten.

So How Much Pizza Do Teenagers Eat?

This is kind of a quirky item. If nothing else, it demonstrates how weird the medical literature can be sometimes. Every parent knows kids, teenagers in particular, mostly love pizza. A recent article in Pediatrics, a fairly respected journal, used food surveys to find how much pizza kids eat and the percentage of their daily calories they get on average from pizza.

The answer? The authors claim that in 2010 21% of kids ages 12-19 reported eating pizza sometime in the past 24 hours. That number is actually down from a similar survey in 2003. What about calories? For those kids who reported eating pizza, it accounted for about 25% of their daily calories, and that hasn’t changed. The authors primly suggest that we should make pizza more nutritious. I wish them luck with that. And I’m 63 years old and still like pizza.

The promises and pitfalls of healthcare quality performance measures

December 29, 2014  |  General  |  No Comments

The quality-measurement enterprise in U.S. health care is troubled. Physicians, hospitals, and health plans view measurement as burdensome, expensive, inaccurate, and indifferent to the complexity of care delivery. Patients and their caregivers believe that performance reporting misses what matters most to them and fails to deliver the information they need to make good decisions.

Thus begins a recent editorial in the New England Journal of Medicine. It was accompanied by another entitled “Getting More Performance from Performance Measurement.” These represent the rumblings of discontent with the status of current efforts to measure the quality of healthcare patients are getting.

Everyone wants high-quality healthcare. It’s obvious in the abstract. But how do we know what that is? It’s well known that healthcare delivery varies widely across the country. This was shown many years ago by the Dartmouth Atlas of Healthcare, which documented astonishing differences in how medicine was practiced, and of course therefore how much it cost, even between places right next door to each other. These variations persist today. Why? The diseases and disorders being treated don’t vary like that. It turns out, unsurprisingly, that local medical culture and traditions play a huge role. When a new physician comes to the area, he or she tends to fall in line with how things are done there. The obvious goal here should be to deliver the best and most effective healthcare — not skimping on useful care but not overdoing things and adding risk to the patient in the bargain. How can we do that? These days everybody is trying to figure that out, and our current efforts, as discussed in the above articles, aren’t doing as well as they could.

A key distinction to understand is the difference between process measures and outcome measures. A process measure is something that keeps track of a particular activity that we know or assume will lead to better outcomes. A good example is washing our hands. Documenting that we did that is a process measure. We know, however, that it will decrease the number of hospital-acquired infections, an outcome measure. Marking the surgical site before surgery is a process measure; eliminating wrong-site surgeries is an outcome measure. Unfortunately, very quickly things get more complicated than these simple examples. One chronic complaint from physicians is that we are held responsible for outcomes over which we have no power to influence the results. Another complaint is that, as with medical credentialing (I wrote about that swamp here), there are a host of players involved in performance measures and many have their own metrics that differ from each other. From the second essay:

The current measurement paradigm, however, does not live up to its potential. Many observers fear that a proliferation of measures is leading to measurement fatigue without commensurate results. An analysis of 48 state and regional measure sets found that they included more than 500 different measures, only 20% of which were used by more than one program. Similarly, a study of 29 private health plans identified approximately 550 distinct measures, which overlapped little with the measures used by public programs.

A mess like that is a prescription for cynicism among hospitals and physicians — and failure. We need a much smaller, much more manageable set of measurements that everybody agrees are real indicators of good medical care. I think this means, among other things, that we can’t have every payer concocting their own scheme. That is asking for chaos.

We have had some successes in linking a process measure to an outcome measure. A good example is planned delivery of infants who were almost, but not quite, at term. Sometimes there is a good medical reason for doing this. But in the past this was often done for the convenience of the doctor or the parents. Sometimes that meant a baby was delivered too early and had to spend time in a neonatal intensive care unit. As a result of close monitoring of early deliveries, of making sure they were really medically necessary, the rate of early delivery has fallen to a quarter of what it was several years ago. That’s real progress, and it came from performance improvement projects. The author is optimistic:

The science and practice of performance measurement have advanced substantially in the past decade, and increased transparency regarding results means that we know more quickly what works and what doesn’t. Furthermore, all stakeholder groups are now invested in getting more performance out of measurement, which should ultimately drive the care improvement that patients need and deserve.

Maybe. I know this is all inevitable and good for patients in the long run. But I think we will have many more growing pains — false leads, useless measurements — before we get there.

 

The ultimate challenge in controlling healthcare costs: reducing needless care

October 8, 2014  |  General  |  No Comments

Efforts to reduce overuse of health care services run counter to the dominant financial incentives in our fee-for-service system, challenge the cultural assumption that more is better, and raise concerns about stinting on necessary care.

That quotation is from a recent editorial in the New England Journal of Medicine. It points out the often quoted estimate that 25-35% of all medical care either doesn’t do any good or is actually potentially harmful, what the editorialist calls low-value care. That is a huge problem, one that will prove very difficult to solve.

The fundamental issue as I see it is that, although founded on science, medicine is very imperfect as a science. It’s a mixture of science, near-science, intuition, guesswork, and blind luck. Depending upon the disease or condition, the more uncertain portions of medical practice figure much more prominently than the certain ones. Over the past several decades we have tried more and more to use evidence-based medicine, that is, doing only things and using only treatments that hard evidence has shown to be beneficial. Unfortunately, rigorous studies of what works and what doesn’t work are difficult and expensive to do. More than that, a great deal of what we do doesn’t even lend itself to that kind of research. We’re often stuck with what committees of experts recommend based upon weaker studies or just opinions.

The other huge problem is with how fee-for-service medical practice works: doctors are generally paid  much more for doing things than for not doing things. Low benefit or even useless treatments represent somebody’s revenue stream; limiting or even eliminating them takes money out of practitioners’ pockets, creating a strong impetus to keep going as we are. But the enormous cost may finally be convincing the public that something has to change:

Public acceptance of a role for policy in reducing the use of low-value care in the United States is tenuous but increasing with growing awareness of the burden that health care spending places on federal and state budgets and with patients’ increasing exposure to health care costs.

I have no doubt that ultimately physicians will be told what they can and cannot do, most likely through the mechanism of what insurance payers will pay for. We’ve been seeing various forms of that kind of limitation for years and the process will accelerate. The mechanism of high co-pays was hoped to help by giving patients a financial incentive to avoid needless medical care. But there is a problem with that, too.

Demand-side interventions — targeting patients — principally include financial incentives and education. Increasing patient cost sharing is a blunt instrument: research shows that it can reduce use of both low- and high-value care, which suggests that patients do not have the information or skill required to differentiate between the two.

Many people outside the medical field think that applying simple market principles would help. If things cost so much, why not just increase the number of physicians and let them compete with each other on cost. Surely the result would be, as with other supply and demand commodities, that costs will come down. It doesn’t happen that way. In medical care, supply drives demand rather than the other way around. Adding more physicians who do things results in more things being done, something known for 50 years.

I don’t know what will happen with all this, but something will. But this will be the general direction:

To address overuse, we now need to work against the current of culture and payment models that still largely reward volume over value.

Procedure checklists: they can only work if you use them

June 11, 2014  |  General  |  No Comments

Complicated medical procedures can be dangerous, even when done by highly skilled and experienced people. Why? Because, irrespective of the procedural risk itself, all of us are human and we can overlook or forget things, no matter how many times we have done the procedure. This was recognized many years ago in the airline industry. Flying an airplane is a complicated and potentially dangerous activity and their are many steps to go through and check before takeoff. This is why, as you board an commercial airplane, you see the pilot and copilot going through a standardized list of things even though the pilot may have thirty years experience. Missing something can be fatal.

This process of formal checklists entered medical practice some years ago, first in the specialty of anesthesiology. It is one of the main reasons, along with new monitoring devices, that anesthesia is much, much safer than it was several decades ago. This approach then spread to other areas of medicine, in large part because of the work of patient safety guru Peter Pronovost. The idea is simple: for every procedure, rather than just tick things off in our mind like I was trained to do, we should go through a formal checklist process to make sure everything is correct and in place. Many of these are pretty simple things. Do we have the right patient? Are we doing the correct procedure on the correct body part? Do we have all the stuff we need ready to go for the procedure? This may sound sort of obvious, even silly, but there are many sad examples of physicians doing the wrong operation on the wrong patient.

The checklist concept really took off with Atul Gawande’s widely read book (it was a New York Times bestseller) The Checklist Manifesto: How To Get Things Right. The groundswell to establish checklists before and during procedures has now reached most hospitals. I know in my practice things have changed. In the past when I needed to do a procedure on a patient I just gathered up the personnel and equipment I needed and got started. Now we go through a checklist. An important part of the process is that any member of the team who has questions or issues is encouraged — mandated, really — to raise them. Now that I’m used to it, I like the new way better than the old one.

But the big question, of course, is if this increased role of formal checklists before procedures has done anything. Are rates of, say, wrong patient, wrong site, or other bad things improved? There are data showing that complications from at least one procedure, placement of central venous catheters, are reduced by checklists. But what else do we know? A recent article and accompanying editorial in the New England Journal of Medicine examined this question. The upshot is that things are murky.

The research study is from Canada. It looked at 3,733 consecutive patients at 8 hospitals that had implemented checklists for operative procedures. The bottom line was that there was no improvement in measurable outcomes. But hold on, observed the author of the editorial. As he saw it, the problem was that the checklists were foisted upon the operating room personnel without any preparation. There was apparently some resistance at the novelty of them, accompanied by gaming of the system — “dry-labbing the experiment,” as we used to say in the laboratory. The author’s point is that we really don’t know if the demonstrable success of checklists in some aspects of patient care can be generalized to other things. We hope so, but we don’t know for sure. The editorial author’s explanation for the findings of the research study is simple:

The likely reason for the failure of the surgical checklist in Ontario is that it was not actually used.

Meet the norovirus, now the most common cause of “stomach flu” in children

January 16, 2014  |  General  |  No Comments

Gastroenteritis, often called “stomach flu,” is common in children. It has nothing to do with influenza, the “true flu,” which is caused by a respiratory virus. Gastroenteritis is caused by a different set of viruses. These viruses are generally transmitted by what physicians call the fecal-oral route, which sounds kind of gross. What we mean by that term is that the bug is in our intestinal tract and gets on our fingers. When we touch things without washing our hands properly we can pass it on to other people who touch the same thing and then touch their mouths. Of course toddlers don’t wash their hands, so the illness is particularly common in them. Gastroenteritis can cause severe vomiting and diarrhea, which can lead to dehydration and a trip to the doctor, but usually it passes within a few days.

For many years rotavirus was a very common cause of gastroenteritis in small children, but now a vaccine has reduced its incidence. Nature being nature, a new virus is taking its place and is emerging as the most common cause for gastroenteritis, accounting for 20% of cases. It’s called norovirus, and it’s a pretty amazing beast. In particular, it’s astonishingly infectious, making transmission quick and easy for it to accomplish. A recent report in the New England Journal of Medicine gives us some information about how it behaves.

The most amazing thing is how few viruses a child (or you) needs to get into their system in order to cause illness. Most micro-organisms need thousands of individual bugs to cause disease. Norovirus needs just 10 to 100. Considering how small a virus is that is quite astonishing, making norovirus one of the most efficient pathogens I’ve ever heard of. It is possible to contract the infection just by walking by someone with it because, unlike rotavirus, norovirus can also spread through the air. In one outbreak, 300 people were infected in a concert hall when they walked through a lobby where an ill person had vomited on the floor. It’s a huge problem in the food industry: in one outbreak a single infected food worker contaminated 76 liters of icing that went on baked products, causing disease in 3,000 people over the course of 4 days. Norovirus is responsible for about half of all cases of food-borne illness in the US.

To put some perspective on how common it is, by the age of 5 years, the authors of the New England Journal article calculate that norovirus will have caused 1 in 6 children to see a doctor in the office and 1 in 14 children will have visited the emergency room because of it. One in 278 will have been hospitalized, usually for dehydration. That’s pretty common. The peak incidence is 6 to 18 months of age.

For a parent, the key to taking care of your child with gastroenteritis is to keep them from becoming dehydrated. Here are some details about how to do that. At this point there is no simple test for norovirus. Knowing it’s there doesn’t affect therapy. But my recent reading about it has given me new respect for it.

Should we shorten medical school?

September 24, 2013  |  General  |  No Comments

We have been training physicians the same way for a century, ever since the famous Flexner Report of 1910. That report was commissioned by the Carnegie Foundation in an attempt to improve medical education. Up until then many medical schools were simply terrible. Many were proprietary schools, owned by doctors and run for profit rather than education. Many doctors met their first actual patient after they graduated.

During the decade following Flexner report these proprietary schools either closed or merged with universities, becoming the institution’s medical school. Within a fairly short time the model of medical school as a four year course divided into two preclinical years (studying basic medical science) and two clinical years (learning to treat patients) was the standard. We’ve been doing it that way ever since.

There have long been calls to change this. Various schemes have shortened the usual eight year process of four years of college followed by four years of medical school, usually by shortening the college part. A recent op-ed in the New England Journal of Medicine renews the call for shortening the process, this time by making medical school three years instead of four. A counter-point essay follows, arguing to keep medical school at four years.

What do I think? I think the arguments for shortening medical school are beside the point. Two of the main reasons the advocates give are to reduce student debt and lengthen the useful practice careers (by one year!) of doctors. The latter, they write, would improve the doctor shortage. But really, if the problem is student debt, there are many direct ways to address that. Likewise, if one thinks we need more doctors, then train more.

I think we should keep medical school at four years. There is already far more to learn than can be learned in that period, so shortening things would only make it worse. There is also the maturation factor; to function as a doctor you need how to think like one and act like one. That takes time — I’m still learning at age 61. Lopping a crucial year of the process is not the answer.

Should families be allowed, or even encouraged, to watch CPR?

Should families be allowed, or even encouraged, to watch CPR?

May 11, 2013  |  General  |  1 Comment


This is a topic that comes up from time to time for often spirited discussion. The most recent example comes in a a couple of articles in the New England Journal of Medicine. One was a research paper; the other was a pro and con discussion.

The research paper studied cardiac arrests that happened outside the hospital. The authors tested the premise that allowing families to watch the efforts of the medical team reduce their psychic distress later. One group of patients received usual care, which meant keeping the families away from what was going on. Families of patients in the other group were asked if they would like to observe the resuscitation up close: 79% chose to watch. A medical team member was assigned to be with them and explain everything that was going on. The researchers then followed up with the families 90 days later to determine how many had symptoms of anxiety, depression, or actual post-traumatic stress disorder.

The investigators found a significant reduction in psychological symptoms among family members who had watched the CPR. Also important is that there was no problem with family members interfering with the medical team.

Now comes the controversy. Family observation of CPR is a hot topic among critical care and emergency physicians, and opinions are strong both for and against. This is shown in the next article. It is short — a case scenario of a cardiac arrest, and is well worth reading if you don’t know what we actually do in those situations. Two experts then wrote brief pro and con statements about allowing families to watch. But it is in the comments where things really heated up. Here are some examples:

Being present is more harm to the family

A genie that should not have been let out of the bottle

No family presence for me!

Absolutely no — apart from the chaotic scenes of CPR, I don’t want to be accused by the family bystander that I killed their loved one, do you?

Don’t deny families who choose to be present –support them

Being present far more important for all.

Yes, I support family presence at the bedside during a code situation

And so on, for nearly a hundred comments. Scanning them over, they seem pretty equally divided. I assume the commenters were talking about adults, but this issue always comes up when we have a CPR event in the PICU. For pediatric intensivists, the question of parents observing is I think less devisive. I always ask families if they wish to leave or would like to stay with their child. Nearly all choose to stay. I have heard many times afterwards that they were glad they had the opportunity to participate in some small way. Nearly all the pediatric intensivists I know feel the same way.

I have never had a problem with parents interfering with care in any way. But the demeanor of the team members, especially the physician directing the resuscitation, is key. Resuscitations are stressful — and messy, too. But shouting never helps anything. A calm, firm demeanor is what parents need to see, especially in the doctor. So do the other team members. I’ve been doing this for 30 years and have seen my share of chaos. The way to control that is practice, practice, practice: mock codes keep everybody sharp.

It is crucial, however, that someone be delegated to stay right by the parents and explain what is happening. Usually I designate an experienced PICU nurse, who needs to be ready to support the parents emotionally — physically, too, which means finding chairs or stools as needed. Every parent I have ever dealt with in this way has been grateful afterwards for being allowed to stay.

Maybe adult patients are different; I have no experience with that. But I think parents of a child should always be given the option. It the resuscitation is unsuccessful, it is a good way to assure them that everything possible was done to save their child.

If you’re interested in this issue at all, I highly recommend you read the pro and con piece linked above, especially the comments.

Stopping the spread of bacteria resistant to most (or all) antibiotics

December 15, 2012  |  General  |  2 Comments

This little cartoon, courtesy of xkcd, highlights a problem we have had for some time, but which is getting worse–highly antibiotic-resistant bacteria. Soon after the first antibiotics appeared, especially penicillin, doctors noticed the phenomenon of developing bacterial resistance to them. The cause is evolution in action. The replication time for bacteria is extremely fast, as short as twenty minutes in some cases. So the process of evolution, of random mutation and passing new traits on to offspring, happens in minutes rather than years.

Say a population of bacteria is 99.99% susceptible to being killed by an antibiotic, or sensitive. When the antibiotic has done its work there are 0.01% of the bacteria left. If their resistance to the antibiotic is heritable, they will pass that on to their offspring. Before too long, if the antibiotic is still present in the system and nothing else intervenes, all of the bacteria will be resistant. An important thing that can intervene is that the body has its own ways of killing bacteria on its own without the help of antibiotics. If the burden of infection is low, as when antibiotics kill nearly all the bacteria, our natural infection-fighting system can do the rest.

It’s been known for a long time how to at least slow down the process of bacteria acquiring antibiotic resistance — limit the use of antibiotics to when they are really needed, and use the ordinary, simple antibiotics whenever possible. So if a germ is sensitive to many antibiotics, which is often the case, use the simple one. This reserves our newest, most powerful drugs for when we really need them, which is when they are the only ones to which the germ is sensitive. In addition, don’t use antibiotics when they don’t do any good, such as with viral infection.

A recent article in the New England Journal of Medicine, “Preventing lethal hospital outbreaks of antibiotic-resistant bacteria,” describes how we are doing. It is a vital question, because bacteria resistant to many, and sometimes all, antibiotics are killers. It’s a particular problem in hospitals, which you can think of as gathering together many sick and vulnerable people in one spot. It’s a set-up for disaster if a highly resistant bacterial strain gets loose, and is why hospitals themselves can be dangerous places — you can acquire an infection there you didn’t come in with, called nosocomial infections. Reducing the problem means limiting the use of antibiotics only to those cases in which they are really necessary and choosing the correct antibiotic. It also means strict isolation and handwashing techniques for caregivers of patients infected with these bacteria to limit the spread to others.

This problem is not going to go away. It will probably get worse. Although researchers are always working to develop new antibiotics to stay one jump ahead of the bacteria, we can’t count on this approach, either.

Antibiotics have been miracle drugs since the 1940s, saving millions of lives. If we are complacent about the issue of resistance, we will be back in the dark days before that.

 

We may have finally bent the cost curve in medical inflation

September 11, 2012  |  General  |  No Comments

Even people who do not follow the controversy about healthcare funding are aware of the fundamental root of the problem: inflation in healthcare costs has long exceeded inflation of everything else in the economy. This aggressive increase has reached the point where healthcare costs now consume about 16% of our entire gross domestic product (GDP). Although this trend has happened in other Western countries, it has nowhere else been as marked as here. We spend 50% more on health care than the next nearest European nation (Norway) and twice as much as most of Europe. (Nice graphics of this here.) Yet our health outcomes are no better. There is great disagreement about what the most important driver of our accelerating costs is, but everyone agrees that without some moderation in the rate our attempts at healthcare reform are doomed.

But we may have some breathing space that gives us time to figure out what to do about it — healthcare inflation has moderated in the past several years. A key point is that this moderation is not just because of our recent great recession, because it began over two years before the recession. An insightful perspectives article in a recent edition of the New England Journal of Medicine shows what is going on. The graph below illustrates the cost of healthcare which is in excess of what would be predicted if it matched the rest of the economy (zero means the same as the rest of the economy). If you look at the different colors, red, physician costs, have actually dropped below the rate for the rest of the economy. The blue bars show hospital costs, and they are the biggest chunk.

There is another way to look at this, which is to lump together various time periods as it relates to total personal health care costs. That also makes for an easier graph.

What you can see is that excess inflation in total personal healthcare costs during the past three years was half what it was during 2003-2005. Note, however, that the rate of increase has bumped up again, especially hospital costs.  Also note that physician costs are still negative, indicating that at least now physicians aren’t contributing to healthcare inflation.

What’s going on? If it wasn’t the recession that cause this encouraging trend, what was it, and how can we continue it? Healthcare wonks are trying to disentangle cyclical components, such as elevated unemployment rates, from structural components. The latter could include things like changes in physician and hospital practices. The authors are hopeful that many of these positive influences will remain, no matter what happens to the rest of the economy:

Some increase in growth over the next few years is possible, but we expect that excess growth will remain, on average, significantly below 1% (excluding a one-time jump associated with the ACA coverage expansion). A repeat of the rapid growth seen at the end of the 1990s seems unlikely, thanks to ongoing structural changes in the health care system and our vastly different fiscal situation: the federal budget surplus in the late 1990s reduced the pressure on the government to constrain health care spending; no such surplus is on the horizon today. Moreover, in an era of increased price transparency, the private sector is not likely to ratify substantial cost shifting.

I hope they’re correct, because the path we were on was unsustainable.