Wednesday, September 30, 2009

QD: News Every Day

ACP Internist begins a daily digest of primary care in the news, debuting with an update on health care reform's messy reconciliation in Congress, good news about Medicare access (as health care currently stands) and what a national EHR network would look like.

Most recently for health care reform:
Two Democratic proposals to create a government insurance plan to compete with private insurers failed, while members of Congress turn their attention toward paying for abortion and insurance coverage for illegal immigrants. Now, Sen. Max Baucus is looking to revise a key financing provision after an analysis showed its tax burden would fall on seniors. In the wake of voting, amendments, provisions and alternatives are being slung left and right (politically, as well as figuratively.)

Since it's not a news cycle without something on H1N1, hundreds of New York state's health care workers protested a mandate that medical professionals get seasonal and swine-flu vaccines. But state health commissioner Richard F. Daines, FACP, told Gannett News Service, "This isn't the time to pump air into a completely deflated argument about vaccine safety."

Other issues internists should also be aware of include:
The Government Accountability Office found that less than 3% of Medicare beneficiaries had major problems accessing physician services, even while more people used the benefit and the number of services per beneficiary increased. More physicians are accepting Medicare, too. Unfortunately for Medicaid, it's far too easy to fraudulently access addictive drugs--65,000 instances costing of about $65 million in 2006 and 2007.

Finally, doctors' offices and hospitals are slowly, slowly moving toward electronic health records. Another view on the issue is instead of one national database, there'd be a "network of networks."
Tuesday, September 29, 2009

A reverse disparity!

Feeling bummed about the loss of your job or your retirement account? Good news! You may be less likely to suffer a retinal detachment. Scottish researchers have found that the risk of retinal detachment is directly related to wealth. "The rate of retinal detachment was 15.4 per 100,000 population among the most affluent patients, compared with 13.6 per 100,000 for the second-most affluent patients, 9.3 per 100,000 for the third-most affluent patients, and 6.9 per 100,000 among the least affluent patients," HealthDay reported.

They have no idea what might cause this disparity. (Or why it matters, we would add.) But the news provides a pleasing contrast to this recent depressing article in Slate which discusses the links between poverty, obesity and poor health.
Monday, September 28, 2009

Medical News of the Obvious

It's time for another medical-education themed journal issue (thanks, JAMA), which means it's time for more Obvious Facts about Med Students:

They say stupid stuff on Facebook.
They make mistakes when they're tired and upset.
Cutting people open makes them nervous.
If they're well-trained, they'll do a better job. And from TIME, if they're working their first day, they're deadlier.

In other MNO, researchers hypothesized in October's American Journal of Preventive Medicine that adults who play video games would have poorer perceptions of their health, greater reliance on Internet-facilitated social support, more extensive media use, and higher BMI. Needless to say, they found what they were looking for because the survey was done over the Internet among people living in the Seattle-Tacoma area, nearby to the headquarters of a rather famous software company.
Friday, September 25, 2009

'Robo-pills' boost Rx compliance

Novartis is testing microchips embedded in prescription drugs to remind patients to take their medicines.

A receiver on the patient's shoulder picks up the signal. If the patient forgets, the chips sends patients a text message.

20 patients using valsartan (Diovan) increased compliance from 30% to 80% after six months, reported the Financial Times.

It adds new meaning to the term "telemedicine."

Readers polarized about town hall meetings on health reform

About half of ACP Internist and ACP Hospitalist readers saw the summer's town hall meeting on health care reform as a failure, according to results of a survey. The reasons why were as polarized as the open-ended responses readers gave.

Some perceived the meetings as a success because they saw the meetings reflect their own points of view on health care, pro or con. Others saw the meetings as failures because of their tenor, or the outcomes of specific events.

The angry rhetoric caused respondents to express concerns not only for health care reform, but for democracy. One said, "They were a success in that people came out to speak; they were a failure in that the democratic process of debate was cast aside for emotional rhetoric."

Some called for more physician and hospital leadership on the issue, and from ACP itself. "Physicians must become leaders in this debate so that Americans get meaningful, full reform that benefits the majority of our citizens."

Eyewitness respondents provided first-hand reports on their own town hall meetings, or in one case, a lack of meeting. Rep. John Tierney (D-Mass.) instead had a telephone conference.

Another reader related opinions from Alaska, where "There were standing ovations opposing 'socialized medicine' and increased taxation. The senator's response to a young uninsured mother's plea to 'What should I do?' for her child with asthma was disappointing. It boiled down to: 'Contact my office, I may be able to get samples from the drug company, and in this country the emergency room will never turn you away.'"

Another reader complimented Rep. Charles A. Gonzalez (D-Texas) on his town hall in San Antonio at the end of August. "The opposition (some brought in on charter buses) was loud and intermittently disruptive. Rep. Gonzalez did an excellent job of explaining HR 3200 and answering questions. If there were any initially neutral persons in attendance, I think they might have had their questions answered."

But disruptions and misinformation prompted many readers to view the meetings as a failure, due to either hecklers or the congresspeople themselves. Others cited the lack of focus on solutions, as well. "Misinformation, incorrect perceptions and strangely focused ideology ruled the day rather than any real conversation."

Others saw success despite the messy process.

"While many [meetings] were devastated by hecklers and got the bulk of the media coverage, some were successful and educated people and got the issue out there. ... It is rejuvenating to see Americans participating in democracy by discussing issues relevant to the future of our nation."

Another summed up, "They gave the public a chance to express concerns and fears. Whether this helped the legislators is yet to be seen."
Thursday, September 24, 2009

Saving health and money

Last month, I asked for some data on the cost-effectiveness of preventive care. The American Journal of Public Health has obliged. In a new study reported by HealthDay, researchers evaluated the cost and health benefits to be gained by preventing several chronic diseases. They found that preventing a patient's hypertension would save $13,702 in lifetime medical spending, while prevention of diabetes would save $34,483, and preventing obesity would save $7,168. Unfortunately, those cost arguments for tobacco cessation programs turn out to be wrong: quitting smoking would result in an increase of $15,959 in lifetime medical costs.

Since only the abstract of the study is free, I also didn't get to find out how one would successfully prevent all these conditions. The key to preventing obesity, especially, seems like a secret we would all like to know.
Wednesday, September 23, 2009

Who says H1N1 isn't cool?

Check out the rapping family practioner who won the national competition to create a flu-prevention public service announcement:

Tuesday, September 22, 2009

Maybe it's not health care's fault.

The failure of the U.S. to match longevity statistics of other developed countries is well-known, but a column in today's New York Times offers a different explanation for the gap. To put it simply, it's lifestyle (particularly smoking) that sets us apart from these other countries, not the quality of our health care, according to researchers. "Dr. Preston and other researchers have calculated that if deaths due to smoking were excluded, the United States would rise to the top half of the longevity rankings for developed countries," the Times reports.

The good news is that many Americans have quit smoking in the past decade or so, so we should be seeing continuing gains in health. The bad news is that we're working hard to make up the difference by getting fatter.
Monday, September 21, 2009

Smokers finding air becoming rare in which to indulge

Kids playing at Edwin Pratt Park, 2002 from the Seattle Municipal Archives via FlickrOutdoor smoking faces bans in big cities as the largest review to date concludes that public smoking bans reduce heart attacks by 26% annually, and the effects can be measured in as few as six months.

New York City’s health commissioner said a week ago that he wanted to ban smoking at parks and beaches. Mayor Michael R. Bloomberg released a response that he wanted "to see if smoking in parks has a negative impact on people’s health."

Yeah, it does, according to research in the Sept. 29 issue of the Journal of the American College of Cardiology. A systematic review and meta-analysis of 10 reports from 11 geographic locations in the North America and Europe compared heart attack rates before and after public smoking bans. The studies involved 24 million people and observations of the effect of the bans ranged from two months to three years.

Thirty-two states and cities have banned smoking in public places and workplaces. Recently entering into the fray is Rockville, Md., which voted the same night as New York's proposal to ban smoking within 40 feet of city parks and may push for a more comprehensive ban. A nationwide ban on public smoking could prevent as many as 154,000 heart attacks each year, the study concluded.

Steven Schroeder, MACP, director of the Smoking Cessation Leadership Center University of California, San Francisco, said, "Several years ago, the idea that secondhand smoke was harmful to the heart was a theory and one with some controversy attached, but this article moves us from the theoretical to fact and to practice. The reduction in heart attacks associated with public smoking bans is a big deal."

Medical News of the Obvious

This may come as news to those of you who were unsure of the purpose of that black rectangular thing in your living room, but not to the rest of us. Researchers put toddlers and parents in a room either with no TV or one where they could pick a show to watch.

"The study authors found that while the TV was on, parents spent about 20 percent less time talking to their children and were less active, attentive and responsive to their kids, resulting in a decrease in the quality of the interactions," reports HealthDay. Only 20 percent? Clearly this sample didn't include any fathers watching playoff games.

American values and health care

Health care reform opponents from ragesoss via Flickr
I read a good post from the New York Times about Health Care Reform and 'American Values' and it got me a thinkin' ... just what are American Values when it comes to health care? Usually I get a little anxious when I see "American Values" in a sentence, because what usually follows is something about rugged individuality, pulling oneself up by bootstraps, getting the damn government out of our lives and those damn immigrants and welfare mothers who won't work and want to live off others.
Health care reform proponent from ragesoss via Flickr
But I have listened to about ten thousand patients over the past 25 years, and I have a good idea of what these Americans want for health care. They are the silent majority ... the people who work, study, raise their kids and seldom call into a radio talk show. They don't have time to go to town hall meetings and shout slogans.

They range from age 17 to 101 and most of them are middle class. They come in all races ... Asian, black, white, Pacific Islander and mixes of all.

Some are wealthy enough to have multiple homes and private planes.
Some are uninsured and watch their health care spending very closely. Most were thrilled to get Medicare and I've never heard a complaint from a Medicare patient.

Here is my list of what these Americans think about health care:
--They do agree that everyone should be covered for basic health care and would pay higher taxes if they could believe that there would not be fraud and waste. (The recent banking meltdown has destroyed all confidence that government can regulate or be independent from special interests.)
--They want choice of physicians and hospitals.
--They are sick of insurance companies and all feel like they have been screwed in one way or another. They are shocked at how little insurance companies pay toward the doctor visit and the way those fees are discounted.
--They are technocentric and want tests, imaging, referrals and think "more is better" when it comes to health care. They think tests are cures. Because of the perverse incentives, the "more is better" philosophy benefits doctors and hospitals, but not necessarily patients.
--They fear losing insurance if they have it.
--They are confused about the current reform debate and mostly fear losing whatever coverage they now have, because they know how impossible it is to get by without any coverage at all.

There are no such thing as "American Values" because we are a diverse group of people. But we all have certain things in common. We want to be healthy. We don't want to be screwed by anyone (big business or the government).

We want to be able to manage our own health care but we don't want to have to decide between numerous health plans every year with pages of information that cannot be understood. We are tired of not knowing where all the trillions of dollars really are being spent.

We want to know the price of a service up front, and we want a trusted physician to help us decide if that is how our money should be spent. We want smart, committed physicians to know us, and not hurt us.

Sounds American to me.

Toni Brayer, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.
Thursday, September 17, 2009

Will taxes make us skinny?

Probably not, concedes an article in the NEJM calling for a tax on sugar-sweetened beverages. Efforts to discourage people from drinking caloric beverages have usually not resulted in significant weight loss, their analysis of the literature concludes. But a soda tax is still worthwhile, in their opinion, because it can reduce the degree of weight gain and provide funding for other public health efforts. Think of it like the tobacco tax. Will drinking a Coke soon carry the cost and stigma as toting pack of cigs?

Not if the soft drink manufacturers have anything to do with it, reports the New York Times. Obama may like the idea but it's going to be a hard sell, given the level of organized opposition. The opponents of the soda tax are calling themselves "Americans Against Food Taxes," the NYT says. The group's name might hint at the difference in understanding that has led to this conflict--do they really think that soda is a food?
Wednesday, September 16, 2009

There are still other health policy issues.

With the media and political attention focused on the health insurance coverage debate, it may be hard to get anyone in the U.S. to think about other policy issues that affect health. But a group of prominent docs, including ACP president Joseph Stubbs, are giving it a try. They published a letter in BMJ and The Lancet urging politicians to take strong action on climate change. (ACP Internist has covered the likely human health effects of climate change before.) As the Washigton Post reports, the issue will come to a head when the United Nations meets in December to replace the Kyoto treaty. Maybe with a push from the medical community, the U.S. can do better than last time (when we failed to ever ratify the protocol).
Tuesday, September 15, 2009

Everything is out to get you.

It seems to be one of those days when the health media is focused on all the ways everyday life can kill you. Hope you're reading this blog from a hypoallergenic bunker. Just a quick survey reveals: Chlorinated pools can give your kids allergies or asthma. Air pollution raises blood pressure. And your showerhead may be harboring dangerous bacteria.

But don't get depressed about all this, or that could hasten your death from cancer. There is some positive news in the other direction, however. A new study found that metformin, a diabetes drug that thousands of Americans are already taking, can lower the risk of cancer. At least if you're a mouse.
Monday, September 14, 2009

Medical News of the Obvious

It's like the scientists think if they keep reporting the same evidence, eventually someone will listen. A new study in Archives found that exercise is still good for you. And it's never too late to start. "The benefits associated with physical activity were observed not only in those who maintained an existing level of physical activity, but also in those who began exercising between ages 70 and 85," said the press release. Actually, sounds like a good excuse to wait another couple of decades before starting that workout routine.

Or maybe you can get your exercise in the bedroom. As long as you don't have allergies, that is. A new study, reported by HealthDay, finds that snot is not sexy. According to a study of 350 untreated sufferers of allergic rhinitis, 83% said that their allergies affected their sex lives. Perhaps the most obvious part of the study was the solution offered by researchers: shut the bedroom window.
Friday, September 11, 2009

What did Obama mean?

Obama's nod to malpractice reform got Republicans on their feet the other night, but he was wisely vague about his specific intentions. A Washington Post article helpfully explains what the administration's approach to malpractice reform would likely really entail. As with the whole overall, the current plan sounds like it's along the lines of what he talked about during the campaign. Gets points for consistency, at the very least.

And, to compensate, some light reading for a gloomy (at least here in Philly) Friday afternoon--a CDC report of preschool teachers accidentally eating brownies spiked with pot. A couple of notes: First, California's medicinal marijuana laws must have made the drug awfully easy to come by that magic brownies are now selling on the street for $1.50. Second, one of the teachers went to the hospital and was treated with antibiotics. I'm no doctor but I'm pretty sure "being sky high" is an off-label use for any antibiotic.
Thursday, September 10, 2009

Patients finding shopping around for medical costs easier online

a little light shopping by iboy_daniel via Flickr.comPatients looking to save some money on expected medical procedures have taken to comparison shopping and planning ahead for high costs and co-pays. Hospital systems, Web sites and the states are compiling the costs of procedures and posting them online so patients can comparison shop or budget ahead before their procedure or test.

The list of comparison services available is extensive, as are their lists of tests and procedures: maternity, knee replacement, appendectomies, colonoscopies; some systems compare hundreds of providers and services.

Consumers are driving this trend, but so is the Internet. Hospitals see it as one more way of making more informed decisions, while one Web site founder compared it (crassly, I thought) to buying a car, including haggling over prices to get steep discounts.
Wednesday, September 9, 2009

Does FRAX lead to Fosamax?

Advances in osteoporosis treatment (along with some other mystery factor) have meant fewer broken hips, but a new NY Times article argues that clinicians may have gone too far in treating reduced bone density. According to the story, some docs are using the new FRAX diagnostic tool (which we covered in an article about male osteoporosis) to diagnose large numbers of patients with osteopenia. Many of these patients are then being prescribed bone-building drugs despite the lack of evidence for that treatment plan. So you get unnecessary medication side effects and additional health care costs out of what was supposed to be a helpful free tool. Oops.

On the subject of health care costs, an incidental point in the story is interesting. In the ACP Internist article on osteoporosis, experts talked about the unreimbursable expense of DXA scanning. According to the Times, there's a change on that front: drug companies are now paying for doctors' offices to install the scanners in the hopes of selling more osteoporosis drugs.
Monday, September 7, 2009

Medical News of the Obvious

It seems safe to assume that this week's researchers of the already-known have been to a bar before, given that they're grad students at one of the top-ranked party schools in the country. Perhaps, in fact, their hypothesis was cooked up over a happy hour pitcher or two. Because even they are not denying the obviousness of their undertaking.

"It may seem intuitive that cheaper alcohol can lead to higher intoxication levels and related consequence--such as fighting, drunk driving, sexual victimization, injury, even death--especially among the vulnerable college student population," a study author told HealthDay.

Yes, after intensive study (read: hanging out in bars) the researchers concluded that higher drink prices were associated with a decreased risk of patrons being inebriated. Might this also correlate with the lower incidence of vomiting on the floor seen in four-star restaurants as compared to college bars? Further research is clearly needed.
Friday, September 4, 2009

Why can't we be friends ... on Facebook?

Doctors may have nothing to fear about patients reaching out for medical advice via social media.

CNN profiled patients and physicians who've used Facebook to stay in contact with their patients--either for information or for routine clinical contact such as prescription refills. Social media has been a subject of much discussion but not much clarity. While a majority of ACP members use some form of social media personally and professionally, they also have expressed their concerns about privacy and trying to diagnose patients who need face-to-face visits instead.

Plenty of doctors have avoided patient contact even over e-mail, thinking it to be just one more unreimbursed time-drain. (Others have adopted it wholeheartedly: see here and here.)

But doctors may have nothing to worry about after all. Although the article cited surveys that found half of consumers want to be able to e-mail their doctors, a reader survey on CNN's home page showed that, among 240,000 respondents who'd voted through mid-day Friday, only 11% responded that they would want to contact their doctor through social media.

It takes all kinds

Two approaches to the debate over health care reform: civil and thoughtful or totally ridiculous.
Thursday, September 3, 2009

Madison Ave. medicine

Maybe it's the media's infatuation with the new season of Mad Men, but the news today seems to be all about medical marketing. The people trying to improve our health also have sales techniques appealing to all of our basic instincts: disgust, greed, and, well, love of cuteness, for want of a better term.
First up, the New York City health department failed in their effort to tax sugary beverages to deter consumption, so they've gone with a fall-back plan of making them seem totally gross. Look forward to seeing images like the one at left on a subway near you.
The feds have taken a happier approach to flu spread prevention, recruiting Elmo from Sesame Street to their cause. (Check out the CNN story for a hilarious picture of Kathleen Sebelius trying to act serious while standing next to a big, red, fuzzy creature.)
Perhaps the least surprising of today's stories is the new report on how Lexapro was marketed to prescribers. Forest Labs put "money into doctors' pockets and food into their mouths," the New York Times reported. Maybe they should mix it up a little the next time and send Elmo out to lead some "Lunch and Learns."
Wednesday, September 2, 2009

Patients just as likely to sue after apologies

Apologizing for a medical error in full and accepting responsibility may boost patients' perceptions of physicians but may not stop them from suing, according to simulations conducted at Johns Hopkins and reported in the Sept. 1 issue of the Journal of General Internal Medicine.

Researchers created simulated scenarios of three medical mistakes: a year-long delay in noticing a malignant-looking lesion on a mammogram, a chemotherapy overdose 10 times the intended amount and a slow response to pages by a pediatric surgeon for a patient who eventually codes and is rushed to emergency surgery. Actors played out levels of physician apology (full, non-specific and none) and acceptance of responsibility (full or none). 200 adult viewers then evaluated the simulations and reported their impressions. Sample videos used in this study are online.

Viewers who thought that the doctor had fully apologized and taken responsibility gave the doctors much higher ratings (81% vs. 38%; P<0.05) and would refer the doctor (56% vs. 27%; P<0.05), but weren't significantly moved not to sue (43% vs. 47%).

What's not reported in this study was whether the doctor could avoid being named in the eventual lawsuit. ACP's news magazines have reported in the past on ways to apologize and how it affects malpractice litigation.
Tuesday, September 1, 2009

Mediterranean diet trumps low-fat diet for diabetes management

Researchers compared the effects of a Mediterranean-style diet versus a typical low-fat diet for diabetes management in one of the longest-term randomized trials of its kind to assess their effectiveness, durability and safety on the need for diabetes medications in overweight patients with newly-diagnosed type 2 diabetes.

Researchers randomly assigned 215 patients to follow either a low carbohydrate, Mediterranean-style diet or a low-fat diet for four years. Nutritionists and dietitians counseled both groups in monthly sessions for the first year and bimonthly sessions for the next three years. Patients on the low-carbohydrate Mediterranean diet avoided medication, lost more weight, and decreased some coronary risk factors. Results were reported in Annals of Internal Medicine.

After four years, 44% of patients in the Mediterranean-style diet group required antihyperglycemic drug therapy compared to 70% in the low-fat diet group. Patients in the Mediterranean diet group also experienced greater weight loss and an improvement in some coronary risk factors.

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