Saving a life - according to the doctors

A conversation in the bikur cholim room:

"Doctor, if a man had chest pain, can he walk home for two hours [on Shabbos]?"

"It depends what kind of pain."

"The doctors said it wasn't heart pain. Can he walk home? I don't think it's safe to walk home. The rabbi said he could take a car home."

From this conversation (which went on for some time) I learned a number of things. One of them was that the guy in question (who got to ride back to Borough Park on late Friday night via car service - I wonder if he got dropped off a couple of blocks from home?) has 11 kids in his house. No wonder he's having chest pain.

The other was that the Satmar rebbe (the recently deceased one? one or more of his quarreling heirs?) apparently was of the opinion that presenting to the hospital with chest pain was enough of a sofek pikuach nefesh to make riding in a car on the Shabbat permissible.

This raises all sorts of questions, predominant among which (as usual) is whether this opinion as relayed to me by Some Random Satmar Guy is faithfully rendered at all. Maybe the Satmar rebbe (or various present-day quarreling rebbes) holds nothing of the sort. If that's the case, never mind.

However, let's assume that the above rendering is true. Then two questions: (a) is a doctor the right person to ask for the definition of sofek pikuach nefesh? (b) if a doctor is the right person to ask, how would she judge?

A doctor might not be the right person to ask because one might hold (I don't, but one might) that halachic categories are to be determined by halachic authorities. Just as pikuach nefesh has a halachic cutoff (several, actually, but "a dangerously ill person" being the most prominent among them), so does sofek pikuach nefesh. The problem is that while there are intricate discussions about the precise definition and interpretation of safek sfeika, the issue of sofek itself is something I'm not aware of any conclusive opinions about. Is doubt probabilistic, intuitive, psychological?Thus even the strict constructionists - which I am not - who believe in immutable and exactly specified halachic categories would have great difficulty specifying a sofek pikuach nefesh, let alone a pikuach nefesh, without the help of health workers.  

The question is, how are we to translate halachic categories into medical ones? There are sick people who look terribly ill to the layperson but a doctor knows (or is said to know!) that these people will get better. The converse is true. 

Then it is not rabbis alone to whom we need to have recourse in the definition of sofek pikuach nefesh (as I write this I more and more realize that pikuach nefesh itself has the same definitional complexities), but health care professionals (most often doctors) together with rabbis. 

I don't think doctors can make the definitions; that's for halachah to work out with their help. But doctors do need to figure out some way to translate their thoughts into lay-cum-halachic language. And that is difficult, for epistemologic, not just lexical reasons.

In the next post I consider how a doctor might answer the question, "Will I die with this chest pain, doctor?" In the interim, though, consider the possibility that the doctor is not the right person after all, but the community. 

An example of this position is found in an interesting article by a Rabbi M. M. Farbshtein (I don't know if I'm transliterating his name correctly) in the journal Assia (my translation):

[T]he question up to what level of possibility [doubt, sofek] something is considered sofek pikuach nefesh does not have an objective answer, but rather [is according to] the assessment of the community that the activity was done for the sake of saving a life [pikuach nefesh]. The situation in which such an activity is required is considered to be "sofek pikuach nefesh."

The question then becomes: what community are we talking about, and how does it decide?

That's too big for now. We'll return to the doctors in the next post. What does "risk of death" mean for a doctor contemplating a patient with chest pain?

Death and the sleepless resident

It turns out that work-hour regulations for residents do nothing one way or the other for patient mortality. (Or almost nothing.) I'm not sure what this tells us. Were work-hour regulations really instituted on the theory that this would directly benefit patient mortality? There are other indices, I think, which are more likely affected (patient-provider relationships, morbidity, error rate), even though they are harder to study.

Take two different patients who both die in their second week of hospitalization. Patient A is cared for by well-rested residents; patient B, by zombies. I think patient A received the better care by a number of measures, even if mortality-wise they're even.

Hospital performance
Does it make a difference?

Maybe you know that you can now compare hospitals with regard to a number of "performance measurements." This does not refer to how well Mass General can play the hammered dulcimer, but to a number of indices that are considered basic to acute hospital care. Does the hospital give aspirin to everyone having a heart attack? Are people with heart failure encouraged to quit smoking when they leave the hospital? Et cetera. These indices are considered important not just on the experts' say-so, but because they have been associated in the scientific literature with improved outcomes. People who take aspirin after a heart attack live longer (and have fewer repeat MIs) than those who don't; smoking hurts heart failure; etc. These studies are, in general, randomized trials of large populations.

What's missing is the link between populations, outcomes, and hospitals. Do hospitals that perform better according to these indices reap the benefits (in terms of reduced morality for their patients) that the literature of populations would indicate? If a hospital gives more of its heart-attack patients aspirin than another hospital, will the first hospital have a lower rate of death due to heart attacks than the second? It seems plausible.

Comes a study by Werner and Bradlow to answer this question. In brief, the answer seems to be "Yes, but not much." To continue the MI (heart attack) example: eight percent of all hospitals surveyed were in the 75th percentile of achieving all reported measures. (That is, all the things that are supposed to happen before or after an acute MI in a hospital happened seventy-five percent of the time or more in these hospitals.) When these hospitals were compared to those in the 25th percentile, the mortality due to heart attacks at one year after the event was about two percent less. For pneumonia (another disease represented among the performance standards), the difference is about one percent.

So that's it? A hospital does everything right, more often than the other guy, and the mortality rate is only reduced by a few percentage points? The indices must be less closely related to mortality than we thought. The authors, however, as responsible scientists, take a more nuanced take. First, if you amortize the few percentage points' worth of difference over thousands of patients -- perform the thought experiment of moving all the patients who get seen at the "worst" 25th percentile to the "best" 75th -- the number of lives saved would reach the thousands. Secondly, we need to remember that wholesale improvements in mortality take societal and medical revolutions, like large-scale reductions in smoking, introduction of the intensive care unit, or (perhaps!) government intervention to reduce consumption of trans fatty acids. If "mere" organizational optimization (boring paper-pushing, hospital by hospital) can make a few percentage points' difference, then something small can be huge indeed.

There are the typical limitations and qualifications to attach to any study, of interest mostly to specialists like me. For instance, this is a "cross-sectional" study, overlaying snapshots of performance measures with snapshots on mortality -- not a more time- and resource-consuming, but potentially more rigorous, follow-up of a population over years to see if implementation of such performance standards leads in cause-and-effect fashion to improvement in mortality. And, of course, it's always problematic to compare the mortality rates of Raucous Public Hospital to Fancy Private Hospital, which differ for reasons much deeper than performance standards. It's possible (even expected) that even after controlling for every possible variable that could confound the relationship between performance and mortality, there are some factors still left out.

These caveats aside, this study may be a small but encouraging sign.

Prosperity = death?
This week's epidemiology abstract.

While mortality has decreased over the past century, superimposed on that decline have been occasional spikes. This study endeavored to confirm this observation by correlating economic with mortality indices in a statistical way. I haven't read the article yet, but the abstract piques my interest.

Increasing mortality during the expansions of the US economy, 1900–1996
Author: Granados, José A Tapia
Source: International Journal of Epidemiology, Volume 34, Number 6, December 2005, pp. 1194-1202(9)

Background In Western countries mortality dropped throughout the 20th century, but over and above the long-term falling trend, the death rate has oscillated over time. It has been postulated that these short-term oscillations may be related to changes in the economy.

Methods To ascertain if these short-term oscillations are related to fluctuations in the economy, age-adjusted total mortality and mortality for specific population groups, ages and causes of death were transformed into rate of change or percentage deviation from trend, and were correlated and regressed on indicators of the US economy during the 20th century, transformed in the same way.

Results Statistically and demographically significant results show that the decline of total mortality and mortality for different groups, ages and causes accelerated during recessions and was reduced or even reversed during periods of economic expansion—with the exception of suicides which increase during recessions. In recent decades these effects are stronger for women and non-whites.

Conclusions Economic expansions are associated with increasing mortality. Suggested pathways to explain this deceleration or even reversal of the secular decline in mortality during economic expansions include both material and psychosocial effects of the economic upturns: expansion of traffic and industrial activity directly raising injury-related mortality, decreased immunity levels (owing to rising stress and reduction of sleep time, social interaction and social support), and increased consumption of tobacco, alcohol and saturated fats.

Keywords: Economic conditions; macroeconomic factors; economic recession; unemployment; mortality determinants; age-specific death rates; causes of death; demography

Pollution and cancer in China

The recent article in the Times is harrowing, starting from its title. But the scientific questions it raises are just as important as the sympathy and disquiet it evokes. There are two issues here. First, what is the relationship between the recent increased pollution in rural China and cancer rates (or death rates due to cancer) in those regions? Secondly, apart from the epidemiologic facts, why are the people interviewed in the article so sure that they have cancer?

A brief, incomplete survey of the epidemiologic literature (oh, let me come clean here: I just went to Medline, typed in "China+epidemiology+pollution," and read a bunch of abstracts. It's Google for epidemiologists!) indicates both rather more and less than is pointed to in the Times. The rural residents complain of gastric and other GI cancers, and the available literature (much of which is, not surprisingly, available only in translated abstracts of Chinese-language articles) points to increased rates of esophageal cancer after exposure to polluted water. (I should note that the tricky part of epidemiology is figuring out the contribution of many different factors. "Correlation does not imply causation" might be tattooed on the body of every epidemiologist.)But there are also a number of articles which point to a broader array of deleterious effects, from nasopharyngeal cancer to hepatitis B infection (which can lead to primary liver cancer). A few studies, as well as the Times article, mention what would seem to be a more acute endpoint: frank toxicity due to astronomical levels of various toxins, effluents, and general nasty chemicals in well- and riverwater.

The Times article implies that the rise in cancer rates due to pollution is a recent phenomenon, of the past couple of decades. I think this is true in a sense, but the sense was corrupted due to necessary abridgment for journalistic purposes. The course of events probably goes something like this: over the past few decades, maybe since the economic liberalization that was allowed during the 70s and 80s (my Chinese history is weak, but I think this is right), industrial activity has produced and allowed widespread pollution. This pollution has indeed led to increased cancer among rural Chinese -- but only because rural Chinese are living longer (due to improved nutrition and hygiene) and are thus able to develop cancer during their additional lifespan. In these polluted rural areas, it's only over the past decade or so that these cancer cases have reached a critical mass that can't be ignored.

Another possibility is that these diseases among rural Chinese, though probably to be laid at the feet of polluters (and the Chinese public-health establishment, necessarily weakened by totalitarianism -- cf. the recent SARS mess), are also caused by simple toxicity due to the ingestion of a high concentration of pollutants.

This is just rank speculation, of course, but it's speculation that I would bet Chinese public-health workers and epidemiologists have to engage in, to decide whether cancer is, in fact, pandemic in rural China and what to do about it (besides, obviously, cracking down on pollution).

* * *

It's not clear from the article in the Times that the people interviewed do in fact have cancer. (They are horribly ill, but it's not apparent from what.) I think that in some cases they might be extrapolating from changing causes of death among people they know. As the Chinese get richer, their causes of death may shift from infectious diseases (with which many rural Chinese may already be acquainted) to the so-called "diseases of affluence" -- heart disease, stroke, and cancer. As it turns out, the Chinese Red Cross recently released a study of widespread ill-health among urban Chinese. [Strangely enough, the study isn't mentioned on the CRC's Web site. Maybe it's on the Chinese site -- can anyone tell me?]

* * *

China's the most populous country in the world, with huge populations that are urban, rural, urbanizing, or migrating from city to country. I hope China deals with its public health problems in a way that will serve as a model for other systems.

Life and death by the numbers

If you have a basic fascination about the causes of disease and their distribution -- go get yourself a Ph.D. in epidemiology, and we can commiserate! Failing that, you can play around with the sortable statistics of the New York City Community Health Profiles.

I'm not actively involved in researching these issues (though I'd like to work for the Department of Health someday). Nevertheless, here are some observations I don't understand.

Highbridge and Morrisania (in the Bronx) has the dubious honor of the highest all-cause mortality rate of any city neighborhood. Mortality from heart disease is highest in the Rockaways, but stroke mortality is highest in East Harlem -- and each of these is found pretty far down the list for the other cause of death. Why is this?

Chelsea and Hell's Kitchen, sorry, I mean Clinton, in Manhattan, seem to have a higher infant morality rate than other neighborhoods in Manhattan (although there are no confidence intervals on the rates presented, so it's hard to tell). The infant hospitalization rate is also higher than many other boroughs. Again, why is this?

(Part of the answer is certainly the fact that Chelsea/Hell's Kitchen* is poorer than most other Manhattan neighborhoods, although how much longer this will stay the case is open to question.)

I could go on like this for hours. These general issues are more and more classified under what's called social epidemiology, an attempt to elucidate and interrelate the different strata of causal factors that affect disease in the individual and society. (The latest issue of Epidemiologic Reviews is devoted to this subfield, and the rigor of some articles made me feel somehwat less skeptical toward social epidemiology in general.)

*Yes, I could write "Chelsea/Clinton," but I won't. So there.