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Yes, we can do it. That was John Auerbach's message during today's Summit on viagra Reform. Commissioner of Public cheap cialis for Massachusetts, Auerbach detailed the challenges and successes involved in his state's health reform experience, which began four years ago.

After three years of implementing the reform measures, Massachusetts' uninsured rate is now less than 3 percent — which means the state is nearing its goal of near-universal coverage, Auerbach said. But beyond having access to insurance, how did the state's reform efforts help improve people's health?

In the first year of reform, there was a 7 percent increase in residents receiving flu shots (many of which happened in a doctor's office), colonoscopy rates went up 8 percent, and smoking rates declined sharply, with more than 10 percent of adults enrolled in Medicaid taking advantage of nicotine replacement therapy, Auerbach said.

"We have to show how (reform is) having a short-term impact in terms of improving people's health," he said. "Public health people are good at that."

He also shared his three big lessons from the Massachusetts experience: Public health can help health reform succeed, health reform is not a substitute for public health, and public health must adapt to health reform.

1. Public health can help health reform succeed: Behind the scenes of implementation, public health input was crucial, Auerbach said. When stakeholders gathered to design the new insurance packages, public health folks were they only ones who brought up prevention, tobacco cessation, counseling newly diagnosed patients about chronic disease management, the importance of community health workers, substance abuse and mental health treatment. Public health workers were also the strongest advocates for making sure co-pays and deductibles didn't obstruct residents' access to care. Plus, public health workers are critical in reaching residents who may fall through the cracks.

2. Health reform is not a substitute for public health: Fixing the broken health care system is an expensive endeavor, so policy-makers are always looking for ways to save money — sometimes deciding to cut into public health services. For example, Auerbach said, Massachusetts legislators decided to cut funding for public health family planning services, as they thought the new reform measures would fill in the gap. But public health had the data showing that, among other concerns, many teens didn't want to talk to their parents about their sexual health needs — they wanted to access such services on their own. The data was compelling and the funding was eventually restored.

3. Public health must adapt to health reform: Public health should be at the discussion table and must be able to demonstrate that prevention works to save money. A lot of decisions will be made based on us being able to show cost savings, Auerbach said, and not over a lifetime, but in the short-term.

At the end of the day, Auerbach said, health reform is neither nirvana nor hell (he really did say that). To this blogger, it seemed the lesson was that reform is a give-and-take — almost a trial of errors — but that it is imperative to tackle if we're to keep moving forward.

— K.K.

Above, Massachusetts Commissioner of Public Health John Auerbach speaks to attendees at APHA's Summit on Health Reform. Photo courtesy Jim Ezell/EZ Event Photography

Evidence based cialis: pragmatic, objective, or authoritarian?

In the spring issue of Perspectives in Biology and Medicine, Maya Goldenberg dissects the contradictions of evidence-based medicine (EBM). (I found the article through philpapers.org, which I didn't know about before.) On the one hand, EBM's commitments to pragmatism

are readily apparent in EBM’s clear allegiance to experimental methods of inquiry that set aside past habitual thinking in favor of purely empirical investigation. Indeed, EBM’s promise of “the application of the best research evidence to medical decision-making” (EBMWG 1992) could have been achieved by strictly pragmatic scientific methodology.

On the other hand, EBM lays claim to the marble statuary of objectivism, which is problematic.

[The] objectivist ontology,where the evidence “speaks” and reliable knowledge follows, presents an occupational hazard to (actual) medical practice. Subjective content muddies up even the most rigorous evidence-based practice by the inescapable layers of interpretation and sociocultural influence that enter in the setting of research agendas (including what projects get funded and why), the production of evidence in primary research, and the selection of which evidence is chosen to inform policy and practice.

But EBM's hierarchy of evidence, with the randomized controlled trial (RCT) at the top, rests on shaky grounds itself:

From a pragmatist perspective, the problem is not so much that the gold standard status is tenuous, but that the RCT’s placement of at the top of the hierarchy is so insistently maintained. It is largely in the interest of avoiding dogmatic theoretical commitments that pragmatists endorse a bottom-up approach to theory construction, where localized beliefs must pass the test of experience in order to be elevated to generalizable knowledge claims.There are numerous experimental scenarios in health research where the RCT would not be the methodology of choice,which suggests that the hierarchy of evidence would not pass the rigors of the bottom-up approach to theory building.

EBM's certainty in its own objectivism leads to a blindness: "[t]he hierarchy of evidence is the point at which evidence-based methodology can be charged with authoritarianism." There are some juicy accusations in this article, which I didn't know before, about the financial relationship between EBM "producers" and the editorial boards of certain journals, e.g., BMJ.

However, in her conclusions, Goldenberg is fittingly pragmatic:

In the interest of better science, I propose that EBM’s pragmatic features are worth keeping. By this, I mean that the open-ended critical inquiry should be encouraged, as should comparative clinical research and problem-specific methodology (which may include uncontrolled methods and even reliance on clinical judgment).The rigid hierarchy of evidence, as we have seen, leads to considerable problems for EBM and should be dismantled.The EBM critics,writing from the post-positivist philosophy of science tradition, have amply demonstrated these problems. But the constructive project of revisioning or perhaps recasting the evidence-based approach to medicine requires that the worthwhile aspects of EBM not be discarded along with its flawed features.