Aaron E. Carroll's Blog, page 109

When Time is More Valuable than Money

The following originally appeared on The Upshot (copyright 2018, The New York Times Company).

Many of us are busy at work, but even at home, there is a lot of work to do. Meal preparation, cleaning, yard work, home maintenance and child care consume considerable time for the typical American.

Much of it isn’t fun, contributing to friction in relationships and taking time away from more pleasant activities that increase happiness. Instead of bickering over who will do the vacuuming, would family life be better if we just outsourced the job?

One survey found that 25 percent of people who were divorced named “disagreements about housework” as the top reason for getting a divorce.

In a working paper that cited that survey, scholars at the Harvard Business School and the University of British Columbia examined whether buying timesaving services could improve relationships. The study, which involved over 3,000 people in committed relationships across a variety of tests, revealed that those who spent more money on timesaving services were more satisfied with their relationships, in part because they spent more quality time with their partners.

This is, admittedly, a first-world issue. Some don’t have the luxury of paying others to cook for them (eating at a restaurant counts here), tend to their yards or clean their homes. But sharing apps like TaskRabbit are making it easier for more people to find less expensive help for routine chores.

Perhaps this could do wonders for some relationships.

According to the working paper, timesaving purchases help protect couples from the negative impact of typical and uncontrollable relationship stressors, like unexpected pressure at work.

Results like these may be unsurprising. Time-related stress — having too little time to relax — is associated with reduced feelings of well-being and increased depression. Stress doesn’t just affect our mood; it can also harm our health.

Using some of our income to buy more time for leisure can improve well-being, according to a study published in the Proceedings of the National Academy of Sciences. Outsourcing at least a few tasks each month — about $100 to $200 worth — can increase life satisfaction.

That finding came from surveys of over 6,000 people in the United States, Canada, Denmark and the Netherlands. Among American workers, half had spent money to buy time, largely by relieving themselves of cooking, shopping and home maintenance tasks.

The results held even after controlling for income, so it doesn’t seem as if buying time is merely an indicator of being wealthier, which may also increase satisfaction. In fact, the researchers found a stronger relationship between satisfaction and buying time among lower-income groups.

But just to be sure that buying time tends to cause greater life satisfaction, the researchers conducted a randomized experiment. Participants in the trial were given $40 on each of two consecutive weekends. On one of those weekends, they were randomly assigned to spend the money on something that would save them time (like going out to eat instead of cooking). On the other weekend, they could make only a material purchase that would not save time (like buying a new shirt).

“When people spent the $40 to save time, they reported being in a more positive mood and feeling less stressed,” said Ashley Whillans, lead author of both the National Academy of Sciences study and the working paper about couples, and an assistant professor at Harvard Business School. “But it is important to note that even if spending a little to buy time increases well-being, spending a lot may not.”

In other words, you can also overdo it. Ms. Whillans and colleagues found that spending $100 to $200 per month on timesaving services maximized satisfaction, but spending more started to reduce it.

This could be because outsourcing may cause you to feel as if you can’t do anything yourself. Or perhaps it’s because of the challenges of managing others. Or maybe when you buy so many services, you’re bound to feel some aren’t done well and regret having not saved the money.

In a finding from other work by Ms. Whillans, outsourcing unpleasant tasks may also cause some people to feel guilty, because they’re transferring the unpleasantness to someone else.

Research on this topic may also be useful to companies. During the 2013-2014 academic year, Stanford University School of Medicine offered timesaving vouchers to doctors as rewards for certain types of work.

Doctors who filled in for colleagues, engaged in mentorship and served on committees earned vouchers that could be redeemed for home services (like housecleaning or laundry) or work tasks (like manuscript editing or website design). A recently published study of the program found that it increased perceptions of wellness and satisfaction, and increased productivity.

Stanford could have rewarded employees with cash bonuses instead of timesaving vouchers. But as Ms. Whillans’s study suggests, people may actually be happier by saving more time. In addition, employees who feel more supported by their employers perform better and quit less.

This means that small contributions to this trade-off — saving time over money — may have benefits for employers as well as individuals. It may even save some marriages.

@afrakt

JAMA Pediatrics Podcast: Learn about a new paper this week!

As I mentioned in a previous post, I’m now the Web and Social Media Editor at JAMA Pediatrics. One of the new projects we’re working on is a podcast where I discuss a paper form the journal. I’ll do my best to pick good ones. Usually, they will also be free to read – we’ll put them outside the firewall. That way, if you enjoy the podcast, you can also go read the paper.

Please consider giving this a listen, and subscribe! Doing so makes it more likely that I’ll be able to keep doing this.

This week is “Association Between Use of Acid-Suppressive Medications and Antibiotics During Infancy And Allergic Diseases in Early Childhood”.

Audio summary here. Subscribe to the podcast at iTunes, Google Play, iHeartRadio, Stitcher, or by RSS.

@aaronecarroll

Help me learn new things in 2018 – The Fall of Rome/The Dark Ages!

This post is part of a series in which I’m dedicating a month to learning about periods in history this year. The full schedule can be found here. This is month two. (tl;dr at the bottom of this post)

Let’s get one thing out of the way, first. It seems like the phrase “The Dark Ages” has fallen out of style. I, having finished high school in the long ago, was unaware of this. I won’t be using it the rest of this post.

This time period covers an ENORMOUS length of time. It’s almost unfathomable. Still – the Roman Empire managed to hold on in various forms throughout this period. It seems like a long time ago, but the staying power is almost too big to comprehend.

I’m grateful to readers who suggested I not just focus on Western Europe for this month. While the empire seemed to collapse into chaos and barbarians more quickly in the West, forming totally new countries, things were very different in the East.

The first book I read was The Fall of the Roman Empire: A New History of Rome and the Barbarians by Peter Heather. A variety of theories exist as to who the Roman Empire collapsed. Some think that corruption took it apart from within. Others think that it became too big to be sustainable. Heather argues it was the barbarians. He shows how the Huns started interfering with the somewhat fragile balance of power in Western Rome, which forced many goths to move into the Empire as refugees. It wasn’t easy to absorb them. The Romans tried to regain control, and it didn’t go well. They lost to the Goths at Hadrianople (something almost unthinkable at the time), and they were sacking Rome thirty years later. The Vandals went after western Europe, and then North Africa. This was critically important (and something I never understood). The Western Roman Empire was hugely dependent on Northern Africa for its food. It’s like the United States’s Midwest. It was the farmland, and in the mid-fifth century, the Romans lost it.

The Huns used a different battle tactic than any others the Romans faced before. They fought on horseback, with a whole different type of bow, and they were perfectly suited to destroy an otherwise unbeatable Roman army. Why they came out of the Steppes of Eastern Europe isn’t totally understood, but they did, and they crushed everyone. By the time Atilla arrived, they were destroying armies from France all the way back to Eastern Rome. Ironically, when Atilla died, it likely hastened the collapse of the Roman Empire. Everyone took advantage of the situation, and the Vandals wound up defeating the Byzantine Armada in a tragic battle that pretty much ended the Western Empire. The Eastern Empire, on the other hand, went on for a long, long time.

As a contrast, consider How Rome Fell: Death of a Superpower by Adrian Goldsworthy. He argues that Rome collapsed from within. His book begins with Marcus Aurelius (who is basically the Emperor who dies at the beginning of the movie Gladiator). At that time, the Emperor ruled, but still relied pretty heavily on the Senate to back him up and implement his will (and army). But the system had a big flaw – the Emperor chose his successor, often from his family, and always with the military behind him.

His son Commodus (the bad guy played by Joaquin Phoenix in Gladiator) wasn’t so good, and things went South. He was assassinated, and the military sort of took over. Over the next century or so, most Emperors only made it a few years before being assassinated, overthrown, or killed. Emperors were popping up all over, wherever an army chose a new one, and they’d fight with each other. Eventually, things quieted down; but it was too late.

The new Emperors had to rely on a growing bureaucracy to rule the empire. Corruption was inevitable. The smaller Senate might have been able to hold together a national sense of purpose, but local rulers in the far reaches of the Empire didn’t share this feeling. Mistrust became common, as did fear of losing power. Emperors began to travel extensively to control the Empire, and, of course, they could not.

Barbara Tuchman’s A Distant Mirror: The Calamitous 14th Century was completely different. She followed the life of a reasonable high level French noble to give a flavor of how life and politics changed for France in the 1300’s. That time was pretty much a disaster. We begin with the plague, which killed like a quarter of all people. So… not a good start. Then, we see how chivalry ruined everything further. A desire to achieve valor on the battlefield led to a number of unbelievable military disasters (including Crecy, which I was aware of thanks to Warren Ellis’s Crecy, a brilliant graphic novel that covered the battle from the English side.) The Hundred Years War was as much the fault of the French nobility as anything else.

Her main character – Enguerrand de Coucy serves as sort of a “Forrest Gump” to be there for all the momentous occurances. It works. The book is well written, and it makes me glad I wasn’t there. Lots of treason and lots of popes. Utter chaos. It seemed like half the rules were mad, likely from inbreeding.

Finally, The Fate of Rome: Climate, Disease, and the End of an Empire by Kyle Harper has a whole other hypothesis: climate change. I kid you not. Using all kinds of bone records and such, he makes a case that the Empire really did well in the first two centuries because it was warm, wet, and there were few pandemics. Things changed after that. Disease, in the form of plagues, had a huge impact. So did the temperature in general. People have wondered for a long time what brought the Huns out of the Steppes, and this is as good an argument as any. It’s also possible that there’s a dual cause things going on. Perhaps Rome at its peak was more able to withstand external climate change, but once it was weakened, these changes pushed it over the edge. He notes four main turns: (1) Pandemics during the age of Marcus Aurelius, (2) Drought, pestilence, and political change in the middle of the third century, (3) The Huns coming out of the Steppes, and (4) Bubonic plague coupled with a small ice age.

Harper writes well, and I thought his book was constructed a bit more for the lay reader. Take that or leave it.

All of this was fascinating, but I’m ready for something completely different. Bring on the American Revolution!

tl;dr: If you want to read three different theories on why Rome fell, there are three books you can try. The Fall of the Roman Empire: A New History of Rome and the Barbarians argues it was external forces,  How Rome Fell: Death of a Superpower argues it died from within, and  The Fate of Rome: Climate, Disease, and the End of an Empire argues it was climate change. All are good.

@aaronecarroll

 

Help me learn new things in 2018 – The Revolutionary War! (What should I read?)

I’m going to spend April learning about the history of The Revolutionary War. You’ve already given me some great ideas. I want to post them here, so you can help me prioritize what to read. If you think I’m missing something, please tell me. I’m opening comments, or you can tweet me.

Whirlwind: The American Revolution and the War That Won It by John Ferling
John Adams by David McCullough
1776 by David McCullough
American Revolutions: a Continental History by Alan Taylor
American Colonies: The Settling of North America by Alan Taylor
Angel in the Whirlwind: The Triumph of the American Revolution by Benson Bobrick

What do you all think? Any thoughts on the order?

@aaronecarroll

What We Know (and Don’t Know) About How to Lose Weight

The following originally appeared on The Upshot (copyright 2018, The New York Times Company).

The endless array of diets that claim to help you shed pounds tend to fall into two camps: low fat or low carbohydrate. Some companies even claim that genetics can tell us which diet is better for which people.

A rigorous recent study sought to settle the debate, and it had results to disappoint both camps. On the hopeful side, as The New York Times noted, people managed to lose weight no matter which of the two diets they followed.

The study is worth a closer look to see what it did and did not prove.

Researchers at Stanford University took more than 600 people (which is huge for a nutrition study) aged 18 to 50 who had a body mass index of 28 to 40 (25-30 is overweight, and 30 and over is obese). The study subjects had to be otherwise healthy. They couldn’t even be on statins, or drugs for Type 2 diabetes or hypertension, which might affect weight or energy expenditure. They were all randomly assigned to a healthful low-fat or a healthful low-carbohydrate diet, and they were clearly not blinded to which group they were in.

All participants attended 22 instructional sessions over one year in groups of about 17 people. The sessions were held weekly at first and were then spaced out so that they were monthly in the last six months. Everyone was encouraged to reduce intake of the avoided nutrient to 20 grams per day over the first eight weeks, then participants slowly added fats or carbohydrates back to their diets until they reached the lowest level of intake they believed could be sustained for the long haul.

Everyone was followed for a year (which is an eternity for a nutrition study). Everyone was encouraged to maximize vegetable intake; to minimize added sugar, refined flour and trans fat intake; and to focus on whole foods that were minimally processed. The subjects were also encouraged to cook at home as much as possible.

All the participants took a glucose tolerance test as a measurement of insulin sensitivity. Some believe that insulin resistance or sensitivity may affect not only how people respond to diets, but also how well they adhere to them. The participants were also genotyped, because some believe that certain genes will make people more sensitive to carbohydrates or fat with respect to weight gain. About 40 percent of participants had a low-fat genotype, and 30 percent had a low-carbohydrate genotype.

Data were gathered at the beginning of the study, at six months and at one year. At three unannounced times, researchers checked on patients to see how closely they were sticking to the instructions.

This was a phenomenally well-designed trial.

People did change their diets according to their group assignment. Those in the low-fat group consumed, on average, 29 percent of their calories from fats, versus 45 percent in the low-carbohydrate group. Those in the low-carbohydrate group consumed 30 percent of their calories from carbohydrates, versus 48 percent in the low-fat group.

They did not, however, lose meaningfully different amounts of weight. At 12 months, the low-carbohydrate group had lost, on average, just over 13 pounds, compared with more than 11.5 pounds in the low-fat group. The difference was not statistically significant.

Insulin sensitivity didn’t make a difference. People who secreted more or less insulin lost no more or less weight in general on either a low-fat or low-carbohydrate diet. Genetics didn’t make a difference either. People who had genes that might indicate that they would do better on one diet or the other didn’t.

In fact, when you look at how every single participant in this study fared on the diet to which he or she was assigned, it’s remarkable how both diets yielded an almost identical, curving range of responses — from lots of weight lost to a little gained. It wasn’t just the averages.

Some have taken this study to prove that avoiding processed foods, eating more whole foods, and cooking at home leads to weight loss. While I’d like that to be true — I have advocated this healthful approach in my Upshot article on food recommendations and in a recent book — that’s not what this study showed. Although that advice was given to all participants, there was no control group in which that advice was omitted, and so no conclusions can be made as to the efficacy of these instructions.

Others have taken this study as evidence debunking the idea that counting calories is the key to weight loss. While that wasn’t the main thrust of this study, nor the instructions given, participants did reduce their intake by an average of 500-600 calories a day (even if they didn’t count them). This study didn’t prove the unimportance of calories.

The researchers also asked everyone, not just those in the low-carb group, to avoid “added sugars.” Therefore, we can’t really say anything new about added sugars and weight loss.

What this study does show is that people who have staked a claim on one diet’s superiority over another don’t have as strong a case as they think. It’s hard to overstate how similarly these two diets performed, even at an individual level.

It shows us that the many people, and the many studies, suggesting that we can tell which diets are best for you based on genetics or based on insulin levels might not be right either. Almost all of the studies that backed up such ideas were smaller, of shorter duration or less robust in design than this one. Granted, it’s still possible that there might be some gene discovered in the future that makes a difference, but those who think they’ve found it already might want to check their enthusiasm.

This study was focused mostly on people who were obese, so people looking to lose just a few pounds might benefit more from one diet or the other; we don’t know. It’s also worth noting that the people in this study received significant support on both diets, so the results seen here might not apply to those attempting to lose weight on their own.

You should be wary of those who tell you that they know what diet is best for you, or that there’s a test out there to tell you the same. Successful diets over the long haul are most likely ones that involve slow and steady changes. The simplest approach — and many have espoused it, including Jane Brody recently here at The Times — is to cut out processed foods, think about the calories you’re drinking, and try not to eat more than you intend to.

The bottom line is that the best diet for you is still the one you will stick to. No one knows better than you what that diet might be. You’ll most likely have to figure it out for yourself.

@aaronecarroll

Healthcare Triage News: Yellow Fever, Theranos, and Low Nicotine Cigarettes

On this Healthcare Triage News, we’re talking about an outbreak of Yellow Fever in South America, and why there aren’t enough doses of the highly effective vaccine on the market. We’ll also look at developments in the huge and fascinating Theranos case, with all the fraudulent blood tests, and we’ll look at new, lower nicotine requirements for cigarettes.



@aaronecarroll

Healthcare Triage: Teeth Aren’t Just for Chewing. So Why Doesn’t Medicaid Cover Dental?

Medicaid doesn’t cover dentistry. But dental health affects many different aspects of a person’s life. Bad teeth can cause social difficulty, and make it hard to find employment, aside from the fact that an unhealthy mouth can lead to or exacerbate many conditions.



This video was adapted from a column Austin wrote for the Upshot. Links to further reading can be found there.

@aaronecarroll

JAMA Pediatrics Podcast: Learn about a new paper each week!

As I mentioned in a previous post, I’m now the Web and Social Media Editor at JAMA Pediatrics. One of the new projects we’re starting THIS WEEK is a podcast where I discuss a paper form the journal. I’ll do my best to pick good ones. Usually, they will also be free to read – we’ll put them outside the firewall. That way, if you enjoy the podcast, you can also go read the paper.

Please consider giving this a listen, and subscribe! Doing so makes it more likely that I’ll be able to keep doing this.

This week, I’m covering “Vaccination Patterns in Children after Autism Spectrum Disorder Diagnosis and in their Younger Siblings”:

This audio summary reviews a matched cohort study investigating whether children, after receiving an ASD diagnosis, receive their remaining scheduled vaccines according to ACIP recommendations, and compares vaccination patterns of younger siblings of children with ASD to those of younger siblings of children without ASD.

Audio summary here. Full article here. Subscribe to the podcast at iTunes, Google Play, iHeartRadio, Stitcher, or by RSS.

@aaronecarroll

A ‘right-to-try’ explainer

Gilbert Benavidez is a Policy Analyst with Boston University’s School of Public Health. He tweets at  @GBinsolidarity. 

‘Right-to-try’ legislation recently passed in the House after having previously passed in the Senate. The bills will now move on to a conference committee. If you haven’t been following the bills, this explainer will bring you up to speed.

What is the ‘right-to-try’?

Roughly speaking, the concept of ‘right-to-try’ is to increase access of terminally ill patients to experimental drugs or medical products. The legislative manifestation of this goal on the Federal stage has been toward the establishment of a means by which terminally ill patients could access experimental drugs (those that have passed Phase I of the Food and Drug Administration (FDA) clinical drug trial process) without getting FDA approval.

The patient’s rights movement behind right-to-try is made up of multiple organizations, led largely by the Goldwater Institute, an Arizona-based conservative think tank. The Goldwater institute has spearheaded successful efforts to get state level legislation passed in 38 states. The right-to-try is also supported by the President.

But, over 75 patient groups oppose the legislation, saying that it creates “false hope” and “…would cause serious harm to the most vulnerable patients.” Former FDA commissioners are also pushing back against the bill. For ease of exposition, I will use the term ‘triers’ for participants in this movement.

What’s the landscape now?

Currently, to access experimental treatments, patients can either enroll in clinical trials or seek ‘compassionate use’ exceptions from the FDA. Triers see the FDA requirements for compassionate use as red tape and that they seek to circumvent. Those requirements are:

The patient and a licensed physician are both willing to participate.
The patient’s physician determines that there is no comparable or satisfactory therapy available to diagnose, monitor, or treat the patient’s disease or condition.
The probable risk to the person from the experimental treatment is not greater than the probable risk from the disease or condition.
The FDA determines that there is sufficient evidence of the safety and effectiveness of the experimental treatment to support its use in the particular circumstance.
The FDA determines that providing the treatment will not interfere with the initiation, conduct, or completion of clinical investigations to support marketing approval.
The sponsor (generally the company developing the investigational product for commercial use) or the clinical investigator (or the patient’s physician in the case of a single patient expanded access request) submits a treatment plan that is consistent with the FDA’s statute and applicable regulations.
The patient is otherwise unable to obtain the treatment or to participate in a clinical trial.

Research by Jarow et al. shows that from 2005-2014, over 1000 compassionate use applications were received per year by the FDA’s Center for Drug Evaluation and Research. All but 0.3% of them were approved. In October 2017 the FDA made the process even easier. Now, use of the drug can go forward with approval from merely one Institutional Review Board (IRB) member at the prescribing physician’s facility, as opposed to approval from the entire IRB.

What are the bills about?

The House and Senate each passed their own, relatively similar, versions of the bill. Both bills would provide a pathway for patients to use experimental drugs outside of clinical trials and without going through the FDA compassionate use process. However, drug manufacturers, sponsors of clinical trials, prescribers, or hospitals could still deny use of experimental drugs. For simplicity, I’ll be focusing on the Senate bill for the remainder of this post, which passed in August of last year.

Originally introduced in January 2017 by Wisconsin Senator Ron Johnson, the bill is intended to “authorize the use of unapproved medical products by patients diagnosed with a terminal illness in accordance with State law…”

Two provisions of the bill are intended to get buy-in from drug manufactures and clinical trial sponsors. One is “Use of Clinical Outcomes,” which states that adverse outcomes (harmful side effects, death, etc.) cannot be used to delay or adversely affect the review or approval of drugs. Moreover, sponsors of clinical drug trials (almost always drug companies themselves) can request that the FDA use the clinical outcomes of triers in the review or approval of the drug. It is not clear in the bill text if such a request must be approved.

The second is the “No liability” provision, which states that patients and their families must waive their right to sue sponsors of clinical drug trials, manufacturers, and/or prescribers. Patients and families are unable to sue if, for example, the drug kills the patient more quickly or more cruelly than the underlying disease would have.

What’s controversial about the bill?

There are many controversies, including undermining of the FDA and providing false hope to patients. I will discuss the three that most concern me.

1. Patient safety. Clinical drug trials are overseen by the FDA and consist of four phases (three phases before the drug is released to market, and, in some cases, a fourth post-market phase, which is not always honored). If something terrible happens, trials in the first three phases can be shut down by the FDA. Under the legislation, triers use of an experimental medication would fall outside of FDA purview. As noted above, the Senate bill text states that adverse clinical outcomes cannot “delay or adversely affect the review or approval” of the drug in question. If something goes awry during compassionate use, the trial would not necessarily be stopped.

2. Patient rights. As noted above, in the current Senate bill text, liability of sponsors, manufacturers, and prescribers is waived. Patients and their families effectively waive their right to sue for damages, unless there is evidence of fraud, misrepresentation, or willful misconduct. As Resnik and Parasidis noted in 2013 in the Journal of Medical Ethics,

The US federal research regulations prohibit informed consent, whether written or oral, from including provisions in which human subjects (or their representatives) waive or appear to waive legal rights.

The bill text here is antithetical to these regulations. The assumed retort is that compassionate use provides drugs to ‘patients’ not research subjects. That is, we are talking about treatment, not research. That leads directly to my last concern.

3. Patient/research subject confusion. As noted above, the bill states that sponsors of clinical trials can request that the FDA use the triers’ clinical outcomes in the drug review and approval process. This further blurs the line between patient and research subject, akin to the ‘therapeutic illusion.’ As Annas writes, the therapeutic illusion occurs when

research, designed to test a hypothesis for society, is confused with treatment, administered in the best interests of individual patients.

The goal of research is generalizable knowledge through experimentation. Research subjects are not patients, though some of them mistakenly believe they are — that the research is being done for their own therapeutic benefit.

The right-to-try bill seems to conflate patients and subjects in the following way. Presumably people administered drugs on a compassionate basis are patients. After all, they are not enrolled in a clinical trial and the point is to let them try a new agent in the hopes it will improve their health. But if their outcomes are used by clinical drug trial sponsors in research, as allowed by the bill, the patients become (or are a lot like) research subjects. But, they are not protected by an IRB or U.S. federal research regulations.

What are the prospects for the bill reaching the President’s desk?

The bill must now go to a conference committee, where members of the House and Senate will hash out what the final version will look like. Given the similarities of the two bills, I imagine the final bill will be on the President’s desk soon where it will be promptly signed into law. My guess is the concerns expressed above, and others, will remain.

It’s time to reform the 340B program

Boston University policy analyst Elsa Pearson and I have a new piece up at STAT about the unintended and undesirable consequences of the 340B drug discount program. That program requires drug manufacturers to sell drugs to some hospitals and clinics at a discount. However, those organizations can get reimbursed from payers at higher prices, pocketing the difference.

That could be sensible, depending on what use that net revenue is put. Research suggests that in many cases it isn’t used to benefit the high cost/high risk populations the program is intended to help. We cover that research.

There are bills in Congress to reform the program. Our piece explains what they are and what they’d do. Go read it!

@afrakt