Monday, March 22, 2010

Stupak shtup

Did Stupak finally shtup himself instead of millions of poor Americans, as he had intended to? I think so, and with the Catholic nuns, no less. The man who has been living up to his unfortunate name by trying to derail the healthcare bill because of the non-existent threat of public money funding abortions is now turning on himself, apparently. In a MSNBC interview, as reported here in the NYT, he evidently disparaged the importance of a large and influential group:
"With all due respect to the nuns, when I deal or am working on right-to-life issues, we don’t call the nuns."
Can we hear this again? You don't call the nuns?!!! I think what he meant to say is that we don't call on WOMEN! I for one, though not Catholic, am taking this very personally. I truly believe that it has to do with disparaging the opinions of those who do not hold economic power, particularly the poor women of our nation. "We do not need to listen to them because they are not the ones electing us" is the implication of this stupid stupid remark.

Well, Bart, I do hope that you enjoy the self-stupping that this represents. With this remark, more than any other in the previous few weeks or months, you have shown your true colors. Go back to where you came from and enjoy the fall-out!

Tuesday, March 9, 2010

Lies, big lies and... epidemiology?

Now, as you know, I am a big fan of epidemiology. I do not believe that a randomized controlled trial is the be-all-and-end-all in evidence generation, and a well done observational study can add to our reservoir of knowledge much more efficiently. Of course, I, as many others, acknowledge certain limitations of epidemiologic design. However, many of them can be overcome with careful design and analysis.

I have to confess, though, that over the last week I have bumped into two news stories that have made me cringe. The first, reported a couple of days ago and based on a Kaiser study, showed that people
drinking at least four cups of coffee a day were 18 percent less likely to be admitted with a heart rhythm disturbance than those who drank no coffee at all.
So, great, the public may take away the message that drinking coffee prevents a-fib. Well, I have to say that the reporting of this was measured and tried to avoid this unfortunate inference of causality. Yet, it left enough room to imply that yes, perhaps there is a causal link. So, what's wrong with that?

Bear with me while I bring in the second example of a study that bugged me this week, based on the Women's Health Initiative. You may recall that the WHI is the large NIH-sponsored study that a few years ago turned hormone replacement therapy on its head. The study had a randomized component and an observational component. So, the newest analysis shows that women
who drank the equivalent of one to two drinks a day -- be it beer, wine, or liquor -- were 30% less likely than non-drinkers to become overweight or obese.
 Do you see the similarities? So why am I bothered? To me this is the classic case of a high potential for confounding by indication. What's that you say? That is a situation in which a subject that has the exposure in question (in these two cases coffee and alcohol) is inherently different from one who does not, and this difference is what determines the probability of the exposure itself. Why should this present a problem in a study where the authors carefully adjusted for confounding, which is true for both of the studies? It is a problem because the kind of confounding that this represents is impossible to tease out without real-time attention to the subject.

Here is how it would work in the case of coffee study. Say I am a person with paroxysmal (occasional) a-fib, and I have noticed that if I drink so many cups of coffee per day, I get into brief episodes of palpitations. Not enough to send me to the doctor's office or the hospital, but enough to start thinking about cutting out caffeine. So, I stop drinking caffeine, and continue with my baseline frequency of a-fib attacks. You see the problem? Is it possible (or even probable) that those people who drink four or more cups of coffee per day somehow have an inherently higher threshold for slipping into their a-fib than those who do not? And if the answer is "yes", then the four cups become a marker for someone who can tolerate them, rather than the cure for a-fib. You can construct a similar explanation with the two drinks and weight.

So, while I love epidemiology and its methods, I am wary of hanging my hat on associations that may likely be explained by confounding by indication. And although the stories were reported with many caveats, human nature may prevent us from hearing the nuance. It is clear that in both these instances the burden of proof is on the researchers to show me that I am wrong.      


Thursday, March 4, 2010

Republican healthcare paradox

Reading the transcript in the WSJ of the remarks at the President's Healthcare Summit by Paul Ryan, the ranking Republican on the House Budget Committee reminded me of an occasional altercation during my childhood. When a friend would break a favorite toy, the temptation was to ask for the impossible: I want it back exactly the way it was, right now! Over the years this kind of a debating style thankfully dwindled in favor of more reasonable and logical solutions. How is it that our political discourse has spiraled into the childish domain of the unreasonable?

Here is the disconnect: on the one hand, as Mr. Ryan points out, the Obama-supported healthcare bills may bend the cost curve in the wrong direction, increasing drastically the deficits and creating empty promises for the future generations. This is clearly undesirable. But where was Mr. Ryan when Sarah, Michelle and the tea baggers were crying "death panels" and government sanctioned euthanasia when the talk came around to curbing the potentially unnecessary and marginally effective care that ravages our healthcare system? How can we have it both ways? Is it not obvious that if tthe amount of healthcare delivery continues its upward trajectory, the bill accompanying it can do nothing but continue to go up as well?

The Republicans insist that they merely object to governmental intervention in the healthcare market, and they would be delighted to craft legislation that promotes free market solutions to this mammoth that is killing America. Really? When was the last time any congressional legislation promoting "free markets" helped the people who are struggling? If the fact that in 2004 the top 0.01% of the US population controlled 6% of the nation's wealth is any reflection of the success of such legislative efforts, well...

This spin machine has got to stop. We need to demand that our legislators speak honestly and rationally about this complex multifaceted issue. The reality is that all Americans need to do some soul-searching in order to make the adult decisions that need to be made. What are we willing to give up and what are the trade-offs we are willing to accept? As difficult and as unusual it is for us to think of giving something up, make no mistake about it: we must give some things up.

So, no more sound bites! Give us the respect of an informed and cordial debate without leaving out critical pieces. Stop running for office and govern!