Electronic health records? Bleh, not ready, says the Disease Management Care Blog. Clinical decision support? Pfft, overrated, scoffs the DMCB. But mention registries and now you've got the DMCB's lusty attention. These medical-claims-demographic databases promise to offer up easy access to huge swaths of clinical and economic correlations that are just not possible in a single clinical trial. Case in point? The Smoke-free Legislation and Hospitalizations for Childhood Asthma study authored by Daniel MacKay and colleagues appearing in the Sept. 16 New England Journal. These researchers had access to the "Scottish Morbidity Record," a national data warehouse that links information on all individual admissions among the 5.1 million inhabitants of Scotland. They used this data base to examine the impact of the "Smoking, Health and Social Care Act of Scotland," which banned public and workplace tobacco smoking. Before the legislation went into effect on March 26, 2006, hospital admissions among children age 15 years or less for asthma was increasing at a rate of 5.2% per year. After it was passed, the asthma admission rate decreased by 13% per year. The authors went on to mathematically neutralize (statistically control for) the impact of gender, age, urban vs. rural residence, socioeconomic status and number of prior admissions for asthma and the pre-post relationship still held up: there was a 4.4% increase per year before vs. a 20% decrease per year after. If the child population was split into pre-school and school age groups, it was found that the preschoolers were experiencing an annual increase while the school age children were not. When the smoking ban went into effect: afterwards, both groups dropped by 18% and 21%, respectively.
This study is important because it demonstrates how public health measures to control tobacco use in public places has an actionable link to the scourge of childhood asthma. This is probably because the smoking ban was accompanied by decreased tobacco use in the home, perhaps from greater adult quit-rates or voluntary restrictions.
Yet, this study is also important because it's another demonstration of the use of large clinical databases to study population health. This contrasts with the usual gold-standard clinical research approach, involving a two-armed randomized control trial comparing an intervention group (not allowed to use tobacco in public) vs. a control group. If MacKay et al had decided to answer the question that way, we'd still be waiting for an answer. Good thing they and others are demonstrating the value of this alternate approach.
Hopefully, as health reform continues to evolve, Medicare and Medicaid will work through the privacy restrictions and allow greater access to its claims data sets by qualified researchers. Commercial insurers are certainly showing that it's possible with their large multi-state claims data sets and so, by the way are some enterprising patients. Based on the the kind of insights from generated by the Scotland Trial, the upside benefit of registries and the kind of research they can support is just too great to squander.
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1 comment:
Yes, yes, but, but – what was the root cause of all that encouraging data? Federal legislation modifying personal health behavior. Isn't that the main headline here, as well as one of the Holy Grails of health reform and cost control? Now, we may not want to outlaw everything that promotes ill health, such as unhealthy foods and beverages, or polluting products and industries – but we can certainly place a surcharge on them to both modify behavior and to help pay for their untoward health consequence. (Heck, just think of the registry treasure trove that could be produced from the enactment of a national elevator tax!)
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