Saturday, April 30, 2011

When spouses gain weight and physicians wimp out

A friend of mine is in great physical shape but her husband (We'll call him "Mr. B") has gained 40 pounds since they were married five years ago. He also has familial hypercholesterolemia, and several of his relatives have had heart attacks at young ages. Mrs. B is distraught; she is worried about her husband's health, and has tried to gently nudge him towards healthier eating habits and regular exercise (as well as taking a statin for his cholesterol). Unfortunately, the nudges were received as nagging, and a wedge has formed between them in their relationship.

Last week my friend planned a trip to a primary care physician in the hopes that he would educate Mr. B about the dangers of being overweight and not treating his high cholesterol. "Surely Mr. B will listen to an expert" she thought, "then perhaps he'll realize that he has to change his behavior."

Unfortunately, the primary care physician didn't offer any health counseling to Mr. B. Not only did he not mention that Mr. B should lose weight, but he didn't provide any warnings about the dangers of untreated, very high cholesterol levels. He merely reported that Mr. B's total cholesterol was 300, and that a statin was indicated.

Mrs. B was crestfallen. She was depending on the physician's authoritative input to help her come up with a strategy to steer her husband towards better health. Now Mr. B was left with the impression that things were more-or-less OK, and that his wife's concerns were exaggerated.

Studies have shown that patients are more likely to change their behavior when a physician provides the rationale for it. This power to influence patients is often under-utilized, even though it can save lives. Wives, family members, and loved ones rely on their physicians to have the courage to say things that are difficult to hear. It's our job to do so, even though it pushes us beyond our comfort zone at times.

I wonder how many missed opportunities there have been in my office visits with patients? I know that I don't counsel overweight and obese patients to lose weight at each encounter, nor do I always remember to discuss the barriers to success with them. Sometimes I end up focusing on a patient's chief complaint to the exclusion of their overall wellbeing.

Like smoking cessation, weight loss can be a real challenge. It may require many attempts before long term success is achieved. But we need to keep fighting the good fight and have the courage to speak up and tell our patients the hard truth about their waistlines. I know that there are spouses out there who would really appreciate our help with their own "Mr. B's." As for my friend, I'm going to send her some literature about the risks of obesity and very high cholesterol. Perhaps it's not too late to influence him?

This post by Val Jones, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.
Friday, April 29, 2011

Advice on treating muscle strains runs hot and cold

Along with blisters and sprains, muscle strains are among the most common afflictions for active persons in the outdoors. Common medical dogma is to use the "RICE" approach for sprains and strains, rest, ice (application of cold), compression, and elevation.

295.365 - October 22, 2010 by meddygarnet via Flickr and a Creative Commons licenseThis is more applicable to sprains (e.g., an ankle sprain) than to strains, because the sprained body part is usually a limb (ankle, knee, wrist) that is amenable to this approach. Strains more often involve larger muscle groups, such as those in the back, chest, thigh or abdomen, or difficult-to-approach areas, such as the neck or groin.

Prevailing theory for treatment of a muscle strain is that one applies external cold for 24 to 48 hours, and discontinues it after 72 hours, at which time one begins application of external heat. The rationale is that swelling (from leakage of blood and tissue fluid) and inflammation prevail in the first two days, and that after three days, one wishes to increase local circulation and augment reabsorption of the fluid that has collected. There is some science to this, and these recommendations have been around for as long as I can recall.

I just read a paper titled "Heat or cold packs for neck and back strain: A randomized trial of efficacy," authored by Gregory Garra and his colleagues (Acad Emerg Med. 2010;17:484-9). The purpose of the study was to compare the pain-relieving benefit of heat versus cold in the treatment of back and neck strains. The authors started out with the scientific hypothesis that there would be no difference between the two temperature modalities. Patients included in the study were 18 years of age or older. All of the patients received 400 mg of ibuprofen orally and then were assigned in a random fashion to receive 30 minutes of either a heating pad or a cold pack applied to the injured body region. A variety of methods were used to assess pain before and after therapy.

There were 31 patients in the heat-treated group and 29 patients in the cold-treated group. In the final analysis, there was no difference between the groups either in their demographics or in response to the therapies. The authors admitted that pain relief may have been due to the painkiller anti-inflammatory drug ibuprofen, and not to the heat or cold therapies. However, if there was an additional beneficial effect from the heat or cold, no difference between the two was noted.

So, what can we conclude from this study? Really, not much. The confounding factor of administration of ibuprofen interferes with any direct conclusion about the heat and cold, other than that in combination with ibuprofen, neither appears to offer an advantage over the other. Indeed, there wasn't even a control group, which in this case would have been ibuprofen administration alone without adding heat or cold. What if ibuprofen alone generated the same amount of improvement? Furthermore, how about a longer duration of heat/cold therapy? Might that have yielded more or less improvement? What about time to complete resolution of symptoms? It would have been interesting to follow these patients until their pain was completely resolved, to determine if despite the rapid effects upon pain relief, there were any implications to time to total resolution of symptoms (and presumably, healing).

Based on this particular study, I really cannot draw any conclusions, so will stick with the dogma until someone reports something to make me change the traditional approach. My advice to the readers is to stick with cold first for acute muscle strains, then transition to heat after 72 hours.

This post by Paul S. Auerbach, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

QD: News Every Day--ER visits rising from primary care referrals

Almost all (97%) of emergency room physicians reported treating on a daily basis patients who were referred to them by primary care doctors, going against a widely-held assumption that people are choosing to go to the emergency department instead of seeking primary care, a survey found.

At the same time, another 97% of emergency physicians also report treating on a daily basis Medicaid patients who could not find any other doctor to accept their health insurance, according to a survey by the American College of Emergency Physicians.

Two-thirds of emergency visits occur after business hours, when doctor's offices are closed and patients have nowhere else to turn. Emergency room visits reached an all-time high of nearly 124 million in 2008, according to the Centers for Disease Control and Prevention (CDC), and are expected to rise nationwide.

Physicians responding to the poll attribute the overall increase in emergency patients to patients without health coverage (28%) and a growing elderly population (23%) are seen by physicians as the most important reasons for the overall increase in ER patients.

And, 89% of physicians believe the number of visits to the emergency department will increase as health care reforms are implemented, with 54% of them expecting to see a significant increase.

The organization warned that health care reform legislation that provides insurance coverage but reimburses doctors at Medicaid rates could exacerbate a lack of access to medical care.

"This poll confirms what we are witnessing in Massachusetts, that visits to emergency rooms are going to increase across the country, despite health care reform, and that health insurance coverage does not guarantee access to medical care," said Sandra M. Schneider, MD, president of the American College of Emergency Physicians.

ACEP conducted the poll from March 3 to March 11 by e-mail.

Existing drugs for orphan diseases
National Institutes of Health researchers have created a database of approved drugs to find off-label therapies for orphan diseases, seeking cures for 6,000 rare conditions among the 27,000 compounds approved for human use in North American, Europe and Japan.

The search could benefit up to 25 million Americans, the agency announced in a press release.

The database applies information from the NIH's Chemical Genomics Center Pharmaceutical Collection browser. This publicly available, Web-based application lets users explore drugs by name, chemical structure, approval status and indication. The ultimate goal is to collect all of the more than 7,500 compounds that have been tested in humans. Because of the time and expense of creating new drugs, today, therapies are available for less than 300 rare diseases.

NIH offered several examples of repurposed drugs, such as thalidomide, which despite its devastating teratogenic effects is now used against leprosy and multiple myeloma.

Another example cited by NIH is periodic childhood fever associated with aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA). From blood samples, researchers detected overactive genes in the patient's immune response, including interleukin-1. From these data, researchers hypothesized that anakinra, which prevents interleukin-1 from binding to its receptor, could be therapeutic. They injected anakinra into five children on the second day of their PFAPA fevers and all showed a reduction in fever and inflammatory symptoms within hours.

"This is a critical step to explore the full potential of these drugs for new applications," said NIH Director Francis S. Collins, MD, PhD. "The hope is that this process may identify some potential new treatments for rare and neglected diseases."
Thursday, April 28, 2011

QD: News Every Day--Self-referral MRIs led to more low back scans, surgery

Orthopedists and primary care physicians who start doing their own magnetic resonance imaging (MRI) rather than refer patients for low back pain appear to do more MRIs. And among orthopedists, this leads to more surgery and more health care spending, but not so much among primary care physicians.

Tools by Carl Johan via Flickr and a Creative Commons licenseWhen you buy a new hammer, the world starts to looks more like a nail.

Researchers identified nonradiologist physicians who appear to begin self-referral arrangements for MRI between 1999 and 2005, as well as patients who had a new episode of low back pain. They then developed regression models to look at the relationship between MRIs and back surgery and health care spending. Results appeared online in the journal Health Services Research.

Access to MRI equipment is a strongly correlated with patients receiving MRI scans. Once a physician has access, there's a 2% to 4% jump in MRI use that persisted for orthopedists but not for primary care doctors.

In the primary care setting, MRIs had no causal effect for getting surgery. But orthopedist patients were 34% more likely to undergo surgery within six months of an MRI.

And in the orthopedic setting, receiving an MRI was associated with $4,161 more health care spending in one year, "substantially more than the cost of the MRI scan alone and consistent with the significant increase in surgery use," the researchers wrote. There was no statistically significant increase in spending among primary care patients.
Wednesday, April 27, 2011

QD: News Every Day--Close games can cause more traffic accidents

Fans at close sporting events have more post-game traffic accidents, researchers have found.

It's been known that the stress of championship game itself can trigger more heart attacks in the days surrounding the event. But close games may trigger more alcohol-related incidents, and/or increase testosterone, leading to aggressive driving.

The current hockey and basketball playoffs are being determined by more rivalries and down-to-the-wire series than previous years, with just one example being hockey's Flyers-Sabres game 7 throwdown.

The authors examined data from 271 highly anticipated professional and collegiate football and basketball games, including playoffs and rivalries, over an eight-year period. The authors recruited avid sports fans to rate the closeness of the games.

They then cross checked the national Highway Safety Administration's traffic fatality database with the dates of the games to determine how many fatal traffic accidents occurred in those cities on the dates of the games.

"We find that the closer a game is the more automobile fatalities there are, especially those involving alcohol," the authors said in a press release. "This increase in number of fatalities, however, only happens in locations with high numbers of winning fans (game sites and winning hometown)." The study found no increase in traffic fatalities in the losing teams' hometowns.

High levels of testosterone produced from vicariously winning a close game seem to influence how winning spectators drive home, according to the authors.

"It would be wise to allow for a 'cooling off' period, where one could bask in the glory of victory safely," the authors conclude. The study will appear in the December 2011 issue of the Journal of Consumer Research.
Tuesday, April 26, 2011

QD: News Every Day--*#`&! Swearing really does ease pain

Swearing really can relieve pain, but only if one doesn't do it daily.

Researchers at Keele University in England have considered this topic before, and most recently, they studied whether people who swear more often in everyday life get as much pain relief from cursing as those who swear less frequently.

My Hand, 1992 by styro via Flickr and Creative Commons licenseResearchers recruited 71 participants who completed a questionnaire that assessed how often they swore. Pain tolerance was assessed by how long participants could keep their unclenched hand in icy water (5° C, capped at 5 minutes) while repeating a chosen word. The word was either a swear word (self-selected from a list of five words the person might use after hitting their thumb with a hammer) or a control word (one of five they might use to describe a table). Interestingly, one person was excluded from the study because they did not list a swear word among their five choices.

Results appeared in NeuroReport.

Swearing increased pain tolerance and heart rate, and decreased perceived pain compared with not swearing. But, the more often people swear in daily life, the less time they were able to hold their hand in the icy water when swearing compared with when not swearing.

Researchers originally hypothesized that swearing is a maladaptive pain response, but the opposite was true. Swearing produces a hypoalgesic effect, more so in women than men, and there was a greater increase in heart rate in females.

Another gender difference was uncovered in people who tend to make a big deal of bad situations--to catastrophise. Swearing's hypoalgesic effect was present in females regardless of that tendency, but in men, swearing's efficacy diminished the more they tended to catastrophise.

"While I wouldn't advocate the prescription of swearing as part of a medicalised pain management strategy, our research suggests that we should be tolerant of people who swear while experiencing acute pain," said one of the researchers in a press release. "Indeed, I occasionally receive letters from members of the public recounting episodes in which they, as adults, have been chastised for swearing during a painful episode. They feel that my research findings vindicate their actions."

As they damn well should.
Monday, April 25, 2011

Breast cancer complexity in personalized medicine

Scientists at Washington University School of Medicine in St. Louis have conducted the single largest cancer genomics investigation to date by sequencing the entire genomes of tumor from 50 breast cancer patients. They compared the cancer DNA to healthy cells in the same patient and found mutations that only occurred in the cancer cells. They uncovered incredible complexity in the cancer genomes of these tumors that had more than 1,700 mutations, most of which were unique to the individual.

To undertake this study, the oncologists and pathologists worked with the University's Genome Institute to sequence more than 10 trillion chemical bases of DNA, repeating the sequencing of each patient's tumor and healthy DNA about 30 times to ensure accurate data. Huge computing facilities were required to analyze this amount of data. All patients in the trial had estrogen receptor positive breast cancer.

The researchers found that two mutations were relatively common in many of the patient's cancers. One is present in about 40% of estrogen positive breast cancer and the other present in about 20%. They found a third mutation that controls programmed cell death and is disabled in about 10% of estrogen-receptor-positive cancers. This mutated gene allows cells that should die to continue living. Only two other genes had mutations that recurred at the 10% level.

They found 21 genes that also significantly mutated, but at much lower rates. Even though these mutations were relatively rare, they still involve thousands of women and are very important to understand.

These highly detailed genome maps are an important first step to designing therapy that is personalized to the patient. We do not know why treatment works for some women and not others. It may also help us understand aggressive types of breast cancer that are difficult to treat and occur in young women and African-American women.

Individual and personalized medicine is only possible when the cancer's genetics are known in advance. We are getting closer each day.

This post originally appeared at Everything Health. 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.

QD: News Every Day--U.S. spending on medicines grew modestly in 2010

Fewer physician office visits and fewer new therapies lead to less use of medicines by patients and a modest increase compared to previous years.

A 2.3% increase in spending on prescription medicines in the U.S. last year is nearly half the 5.1% growth rate in 2009, reports the IMS Institute for Healthcare Informatics. Total dollars spent on medications in the U.S. reached $307.4 billion last year, or real per capita spending of $898, up $6 from 2009.

Greater use of generics, loss of patent protection for major branded products, slower demand and less spending on new therapies, as well as fewer visits to physicians, contributed to lower spending on medicines.

The total volume of medicines consumed in oral or nasal form increased 0.5% in 2010, but that's a 0.3% decline on a per capita basis. Medicines administered by injection or infusion increased 0.2% last year, or a per capita decline of 0.6%, primarily the result of reduced use in hospitals.

The number of visits to doctor offices was down 4.2% in 2010, extending a declining trend that began in mid-2009. Also, the number of patients starting new treatments for chronic conditions declined by 3.4 million last year. High unemployment, rising health care costs, and the loss of health care coverage all played a role, the report said.

The average patient copayment was $10.73 in 2010, down 20 cents from 2009, mainly due to the increased use of generics. Insurance paid for slightly fewer dispensed prescriptions, while there were more Medicare Part D prescriptions in 2010 than since the program's inception in 2006.

The average cost of oral or inhaled medicines, which made up 60% of overall spending last year, declined 0.1% in 2010 due to changes in price as well as in the mix of generics and branded products.

Spending on brands declined 0.7% in 2010, while spending on branded and unbranded generics rose 4.5% and 21.7%, respectively. Generics now account for 78% of all retail prescriptions dispensed. On average, more than 80% of a brand’s prescription volume is replaced by generics within six months of patent loss.

The top therapy class was oncologics, with $22.3 billion (3.5%) in 2010 spending, the lowest increase ever recorded in that therapy class. The next four classes were respiratory agents, at $19.3 billion; lipid regulators, at $18.7 billion; antidiabetes drugs, at $16.9 billion; and antipsychotics, at $16.1 billion. Growth in spending among these classes ranged from 0.9 percent for lipid regulators to 12.5 percent for antidiabetes medications.

Analyses are based on prescription-bound products, including insulins that are available without a prescription. OTC products are excluded. IMS used its own proprietary data and products to create the report.
Saturday, April 23, 2011

Homeopathy: Why is fraud legal?

Imagine hearing a commercial on the radio:
Send us money, and we won't send you anything in return.

No one would do that, right? How about this:
Send us your money and we'll send you an empty box.

Better? Not much. Now how is that different from:
Send us money and we'll send you stuff we'll call medicine that we claim will help you, but there's no actual active ingredients in it at all.

I don't think there's one bit of difference. Wouldn't you agree that that commercial is fraud, pure and simple? The problem is that the general public doesn't understand that the word "homeopathic" means "diluted beyond the point where it contains any active ingredients."

I've recently heard commercials for homeopathic vertigo treatments, eye drops for allergies, irritable bowel, and spider veins on legs. I'm tempted to contact the radio station and complain, but stopped short realizing that their first question is going to be, "But is it legal?"

That's the problem: it is. So what I want to know is, why?

I understand the structural reasons: There's lots of money to be made defrauding naive consumers, and those who rake it in by exploiting ignorance have convinced gullible legislators, both state and federal, to make it legal. But that doesn't make it right.

Seeing packages of homeopathic remedies sit next to actual, active chemical medicines on pharmacy shelves makes my blood boil. Who in their right mind would pay nearly $10 for sugar pills? Someone who doesn't realize that "homeopathic" means diluted out of existence, i.e., the vast majority of the general public.

Someone ought to do something. Because homeopathy is fraud; and fraud shouldn't be legal.

This post by Lucy Hornstein, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.
Friday, April 22, 2011

Childhood education may be the key to reducing health care costs

In a recent op-ed in the San Francisco Examiner, William Dow, a professor of health economics at the University of California-Berkeley, commented on the importance of education as a means of enabling more people to afford health care insurance. In my view, education is important not simply because an educated population can more easily pay for health care. The main importance is that educating children will allow those children and their children to have healthier childhoods, less burden of disease as adults, access to more personal and communal resources to deal with whatever disease they have and less need for health care, and that translates into less health care spending. Let me frame this in terms of the San Francisco Bay Area.

In a series of articles in the Contra Costa Times last year, Susanne Bohan and Sandy Kleffman described the striking differences in life expectancy in poor vs. wealthy ZIP codes in East Bay. Life-expectancy in Walnut Creek (94597) was 87.4 years, but it was only 71.2 years in Sobrante Park (94603), where household incomes are about half and poverty >20%. That's a gap of 16.2 years. We find that, in addition to a shorter life-expectancy in Sobrante, the inpatient hospital utilization rate is double the rate in Walnut Creek. Poverty is not only tragic. It's expensive.

Bayview/Hunter's Point is a poor area that's across the Bay in San Francisco. In an article in last month's New Yorker about Nadine Burke's clinic for the poor in Bayview/Hunter's Point, Paul Tough described the community as "a bleak collage of warehouses and one-story public housing projects." Like Sobrante Park, its poverty rate is >20%, double San Francisco's average, and hospital utilization in Bayview/Hunter's Point is double the rate of San Francisco's wealthy areas, such as Marina and Twin Peaks.

Now let's look at education. In Sobrante Park and Bayside/Hunter's Point, where life is short, health care spending high and poverty prevalent, only 40% of adults completed high school and only 5% achieved bachelor's degrees. In contrast, in Walnut Creek, Marina and Twin Peaks, where lives are long, poverty rare and spending low, >95% completed high school and 40% have bachelor's degrees. These high-education areas resemble Japan, where high school completion rates are also >95%, as they have been for decades, and where life expectancy is best and health care spending is least.

So I agree with Professor Dow. While other factors contribute to high health care spending, poverty contributes the most, and if the goal is to control health care spending, we must educate children. Of course, they will need more than good schools. They'll need safe neighborhoods, adequate nutrition, a nurturing environment and more. But without vast improvements in how poor children grow into adults, constraining health care spending will remain a distant dream.

This post by Richard A. Cooper, FACP, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

QD: News Every Day--Physicians demand more pay for on-call duties

Physicians more likely to be paid daily or annually for on-call duties than in previous years. 35% reported receiving on-call compensation daily and 21% reported receiving an annual payment for on-call coverage in 2010. Invasive cardiologists reported the highest median daily rate of on-call compensation at $1,600 per day on call. General surgeons earned a median of $1,150 per day and urologists earned $520 per day for on-call coverage.

The Medical Group Management Association reported that OB/GYN physicians in single-specialty practices received median compensation that was twice that received by their peers in multispecialty practices ($500 versus $250, respectively). Invasive cardiologists reported a 33% difference in median on-call compensation between single-specialty ($1,000 per day) and multispecialty groups ($750 per day).

Physicians now are more likely to be compensated for on-call coverage than in the past, and the amount is increasing year to year, said an MGMA representative. "Physicians realize the value of their time and services and are negotiating compensation for on-call coverage."

Michigan sets apology law for medical mistakes
Michigan became the 36th state to allow physicians to apologize to patients without that admission being used against them in malpractice cases.

The law covers "a statement, writing, or action expressing sympathy, compassion, commiseration, or a general sense of benevolence relating to the pain, suffering, or death of an individual, that was made to that individual or to his or her family" but not to direct admissions of fault or negligence.

The University of Michigan Health System is one of several that noted a decrease in malpractice cases against it when it implemented a more open style of physician apologies and transparency in adverse outcomes.

FDA sets 5-year plan
The Food and Drug Administration released its Strategic Priorities, a five-year plan to enhance the agency's capabilities in five key areas: scientific advances, imported goods, food compliance and enforcement, minority health, and emergency countermeasures. FDA Commissioner Margaret A. Hamburg, FACP, selected the five areas as strategic priorities.

Advancing regulatory science and innovation
Dr. Hamburg emphasized the first priority, advancing regulatory science and innovation, which covers emerging fields such as genomics, stem cells and nanotechnology as they apply to new medical products.

"Science underlies everything we do at this agency," Dr. Hamburg wrote, "and to serve the public health we must have the capacity to effectively oversee the translation of breakthrough discoveries in science into innovative, safe, and effective products and life-saving therapies for the people who need them most."

Strengthening the safety and integrity of the global supply chain
More than 20 million import lines of food, devices, drugs, and cosmetics were imported in fiscal year 2010, more than three times the number of imports 10 years ago. Previous imports that proved defective included contaminated heparin, melamine-tainted pet food and counterfeit glucose test strips.

"The growing challenges of globalization have far outstripped the FDA's resources for inspection and quality monitoring, and the inability to maintain adequate oversight means potential risk to consumers grows every year," the report stated. "Addressing these challenges will require a paradigm shift--to a focus on prevention, on stopping threats before they ever become reality. The border must be viewed as a final checkpoint for preventive controls, rather than the primary line of defense against unsafe imports."

Strengthening compliance and enforcement activities to support public health
The FDA Food Safety Modernization Act, effective Jan. 4, authorizes the agency to mandate a recall of unsafe food if a food company fails to do it voluntarily. The law also provides a more flexible standard for administrative detention, lets the agency prevent distribution of unsafe food, and directs the agency to improve its ability to track both domestic and imported foods.

Addressing unmet public health needs of special populations
Women and minorities have been underrepresented in clinical trials, making it difficult to assess whether a medical product will be safe and effective for them. The FDA created a new Office of Minority Health and an office for orphan diseases last year.

The agency is also going to increase pediatric research and labeling, including validated endpoints for studies in newborns.

Advancing medical countermeasures and emergency preparedness
There are few FDA-approved medical countermeasures, such as drugs, vaccines, diagnostic tests, personal protective equipment and supplies, to respond to terrorist acts, natural disasters and other public health emergencies. In cases of widespread emergencies, there is limited capability to develop a new medical countermeasure or ramp up production once an event is detected. The agency will improve its regulatory process to increase capacity.
Thursday, April 21, 2011

In defense of primary care, and of sub-sub-sub-specialists

An article in the March 24 New England Journal of Medicine called Specialization, subspecialization, and subsubspecialization in internal medicine might have some heads shaking: Isn't there a shortage of primary care physicians? The sounding-board piece considers the recent decision of the American Board of Internal Medicine to issue certificates in two new fields: (1) hospice and palliative care and (2) advanced heart failure and plans in-the-works for official credentialing in other, relatively narrow fields like addiction and obesity.

The essay caught my attention because I do think it's true that we need more well-trained specialists, as much as we need capable general physicians. Ultimately both are essential for delivery of high-quality care, and both are essential for reducing health care errors and costs.

Primary care physicians are invaluable. It's these doctors who most-often establish rapport with patients over long periods of time, who earn their trust and, in case they should become very ill, hold their confidence on important decisions, like when and where to see a specialist and whether or not to seek more, or less, aggressive care. A well-educated, thoughtful family doctor or internist typically handles most common conditions: prophylactic care including vaccinations, weight management, high blood pressure, diabetes, straightforward infections like bacterial pneumonia or urinary tract infection, gout and other routine sorts of problems.

On the other hand, specialists can be lifesaving when highly detailed expertise matters. There are limits to how much a general internist knows about chemotherapy, for example. Even within the field of medical oncology, a subspecialty of internal medicine, there are doctors who only see patients with particular kinds of cancers.

When I had breast cancer, for example, I chose an oncologist whose practice consists almost entirely of patients with breast cancer and related diseases. If someone in my family has a lymphoma, I'd advise them to consult with someone who, for the most part, treats patients with lymphoma and similar disorders. Why? Because each of these cancers represent a complex group of malignancies, and successful therapy depends in part on the doctor's familiarity with each of the specific subtypes and the relevant, current data for those. Treatment of lung cancer involves choosing among a different set of drugs than would be considered for brain or kidney cancer.

I mention oncology, here, because I'm most familiar with this field. But the same holds, for example, in the subspecialty of infectious diseases. Knowing about all the new HIV drugs, in pregnant women, children and adults, involves a different set of knowledge than knowing about parasites in the tropics, and that differs from knowing about viral and other, unusual infections in patients are immunocompromised after kidney, heart or lung transplants.

In each of these settings, expertise can reduce errors because specialists are more likely, in the first place, to establish a correct diagnosis and, next, to prescribe the right therapy based on the best evidence available.

The same holds for other medical specialties, apart from internal medicine. As I've described before, the radiologist who interpreted my routine mammogram and follow-up sonogram was a breast imaging specialist. The orthopedist who reconstructed my spine is a scoliosis spine surgeon. I am confident that I wouldn't be here and feeling as well as I do if it weren't for their expertise.

You could argue that it's impossible to provide these kinds of sub-sub-specialists to people in rural areas, or that it's too expensive, but I don't think either of these factors should be limiting. To a large extent, experts might work with primary care providers and communicate with patients via telemedicine and Skype-like technologies. As for surgical subspecialties, it may be that patients would find it worthwhile to travel to a regional center where a specialized procedure is done routinely, as opposed to having an operation in a local hospital where the doctors perform a certain kind of surgery, say a laparoscopic splenectomy, for example, only a few times each year.

There's a tradeoff, as discussed in the NEJM piece, between increasing use of specialists and fragmentation of care. I think this concern is legitimate, based on my experiences practicing medicine and as a patient. But I do think we need specialists and sub-specialists if we want doctors who can answer their patients' questions, i.e. who really know what they're doing.

I was a bit surprised that the article mentions a survey of physicians in which the majority of respondents reported that "professional image" was the primary reason for seeking subspecialty credentials. While this may be true, I don't think doctors' motivation matters in this. From the public's perspective, what's important is that hand surgeons know how to do hand surgery, and that a heart specialist knows how to interpret an echocardiogram, and that the hospitals where they work not let them practice if they're not appropriately credentialed.

In cutting health care costs, or in trying to so, I don't think it makes sense to reduce the number of physicians or to short-cut their educations by way of 3-year medical schools. Rather we need well-trained primary care doctors we can rely on, who know the limits of their knowledge as much as they understand medicine, and top-notch specialists, both.

This post originally appeared at Medical Lessons, written by Elaine Schattner, ACP Member, a nonpracticing hematologist and oncologist who teaches at Weill Cornell Medical College, where she is a Clinical Associate Professor of Medicine. She shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology and as a patient who's had breast cancer.

QD: News Every Day--PQRI, e-prescribing payouts rose in 2009

The Physician Quality Reporting System paid $234 million to nearly 120,000 physicians in more than 12,000 practices for 2009 reporting, and e-prescribing incentives paid $148 million to more than 48,000 physicians and other eligible professionals in the same time period. Most of the money has gone to ambulatory care settings such as physician offices.

Participation in the Physician Quality Reporting System has grown at about 50% every year, on average, since the program began, according to a press release from the Centers for Medicare and Medicaid Services.

On average, 2009 bonus payments for PQRS were $1,956 per eligible professional and $18,525 per practice. The average bonus payment for e-prescribing was just over $3,000 per eligible professional and $14,501 per practice. Physicians and other eligible professionals who satisfactorily reported PQRS quality measures data for 2009 were paid in the fall of 2010.

One of CMS' main goals is to collect information about care practices. CMS Administrator Donald Berwick, MD, explained, "Most beneficiaries get their care in the physician office; however, this is the care setting for which we have the least amount of data about quality of that care. The Physician Quality Reporting System and the e-prescribing program help bridge the knowledge gap so we can better understand the care millions of patients receive from physicians and other care providers every day."

Based on reported data on the 55 measures that have been a part of the system since it began in 2007, providers have improved the frequency for which they deliver recommended care by about 3.1% on average. Of the 99 measures that were part of the system in 2008 and 2009, performance improved at about 10.6% on average. In some cases, gains have been even more dramatic, CMS reported.

Finally, providers who choose not to participate in PQRS and e-prescribing will receive payment reductions from Medicare beginning in 2012 and 2015, respectively.

Drug spending slows
In other news, fewer physician office visits and fewer new therapies slowed the previous rise seen in the spending on medicines.

A 2.3% increase in spending on prescription medicines in the U.S. last year is nearly half the 5.1% growth rate in 2009, reports the IMS Institute for Healthcare Informatics.

More use of generics, loss of patent protection for major brands, slower demand and less spending on new therapies, as well as fewer visits to physicians, contributed to lower spending on medicines, the report said. The number of visits to doctor offices was down 4.2% in 2010, continuing a declining trend that began in mid-2009.

Also, the number of patients starting new treatments for chronic conditions declined by 3.4 million last year. High unemployment, rising health care costs, and the loss of health care coverage all played a role, the report said.

The total volume of medicines consumed in oral or nasal form increased 0.5% in 2010, but that's a 0.3% decline on a per capita basis. Medicines administered by injection or infusion increased 0.2% last year, or a per capita decline of 0.6%, primarily the result of reduced use in hospitals. Total dollars spent on medications in the U.S. reached $307.4 billion last year, or real per capita spending of $898, up $6 from 2009.

The average patient copayment was $10.73 in 2010, down 20 cents from 2009, mainly due to the increased use of generics. Insurance paid for slightly fewer dispensed prescriptions, while there were more Medicare Part D prescriptions in 2010 than since the program's inception in 2006.

The average cost of oral or inhaled medicines, which made up 60% of overall spending last year, declined 0.1% in 2010 due to changes in price as well as in the mix of generics and branded products.

Spending on brands declined 0.7% in 2010, while spending on branded and unbranded generics rose 4.5% and 21.7%, respectively. Generics now account for 78% of all retail prescriptions dispensed. On average, more than 80% of a brand's prescription volume is replaced by generics within six months of patent loss.

The top therapy class was oncologics, with $22.3 billion (3.5%) in 2010 spending, the lowest increase ever recorded in that therapy class. The next four classes were respiratory agents, at $19.3 billion; lipid regulators, at $18.7 billion; antidiabetes drugs, at $16.9 billion; and antipsychotics, at $16.1 billion. Growth in spending among these classes ranged from 0.9 percent for lipid regulators to 12.5 percent for antidiabetes medications.

Analyses are based on prescription-bound products, including insulins that are available without a prescription. Over-the-counter products are excluded. IMS used its own proprietary data and products to create the report.
Wednesday, April 20, 2011

QD: News Every Day--Soldiers' brain injuries may benefit from nutrients

Soldiers with traumatic brain injury (TBI) should get protein and calories immediately and continue them through the first two weeks of treatment to reduce inflammation and improve outcomes, reported the Institute of Medicine, based on evidence from several studies of severely brain-injured patients.

B vitamin choline, creatine, n-3 fatty acids and zinc are the most promising areas of investigation, and the Department of Defense should give them priority attention, the report said.

Several other nutritional approaches show potential for reducing brain injury symptoms, but there is not yet enough evidence about their effectiveness to recommend their adoption. Antioxidants, flavonoids, ketogenic diets and vitamin D have less supporting evidence that has come solely from animal studies or extrapolated from research in people with different conditions.

Priorities outlined in the report could generate information that provides health professionals with a fuller picture of which nutrients and dietary approaches work safely and most effectively. This information could also lead to new evidence-based clinical guidelines. There are few well-supported guidelines to inform health professionals' use of foods and dietary supplements to treat brain-injured patients, so clinicians employ a wide range of practices, the report said.

The IOM study focused on the potential role of nutrition in protecting against or treating the immediate and near-term effects of TBIs. It did not evaluate the role of nutrition in rehabilitation or address long-term health effects associated with brain trauma, such as post-traumatic stress disorder, Alzheimer's disease, pain, and depression.

Like many other advances in military health, the research could eventually carry over into the civilian population. TBIs contribute to nearly one-third of all injury-related deaths in the United States. For example, between 1.6 million and 3.8 million sports-related TBIs occur annually, including those not treated by a health care provider.

Is watchful waiting too difficult?

The rise of prophylactic double mastectomy in women with increased risk of breast cancer has been a topic of recent discussion. In particular, this trend has been observed amongst women with the diagnosis of unilateral carcinoma in situ, or pre-invasive breast cancer. While it has been known that in women with genetic cancer syndromes, including BRCA1 and BRCA2, double mastectomy reduces risk, the efficacy of the approach is uncertain in women with other risk profiles, yet more women and surgeons seem to be doing it.

Knowing when to test, treat and act is part of art of medical practice. The ability to convey this information effectively is also an art. Both patients and doctors may have a hard time embracing watchful waiting with respect to many forms of cancer and pre-cancer. In the case of cancer of the cervix, it is known that infection with human papillomavirus (HPV) is causative in cancer development. However, only a small percentage of those infected actually go on to get cancer. Low grade dysplasia, a condition that is early in the cervical cancer development continuum, frequently spontaneously resolves without treatment. Fortunately, in the case of cervical cancer, there is now a vaccine to prevent high risk HPV infection.

"Watchful waiting" has been most discussed as a treatment strategy for prostate cancer. Treatment for prostate cancer, including radical prostatectomy, is fraught with side effects that may negatively impact quality of life. The watchful waiting approach is most commonly agreed upon for older men with medical co-morbidities, or limited life expectancy. However a recent study in the New England Journal of Medicine followed men who were screened for prostate cancer with PSAs and found no mortality benefit to early detection at 10 years, calling into question the utility of screening even younger men.

In the case of breast cancer, the United States Preventive Services Task Force published its revised guidelines for breast cancer screening in the fall of 2009 suggesting that mammography screening be delayed in most women until age 50. These recommendations were in part based on the finding of "adverse effects" resulting from overzealous screening procedures. Although breast cancer screening in women ages 40 to 50 is known to be effective for early detection, its use is associated with the detection of a range of abnormalities of the breast, which lead to further evaluations including follow-up mammograms, MRIs and biopsies. Of course, these procedures are anxiety-provoking and costly. What's more, pre-cancerous breast disease, as is true with other precancerous conditions, may not always progress to invasive cancer.

Invasive cancer of the breast arises from pre-invasive conditions of breast tissue, the most benign of which is ductal hyperplasia, followed by atypical ductal or lobular hyperplasia, followed by ductal and lobular carcinoma in situ (DCIS). Even the carcinomas in situ (considered stage 0, cancer) vary in their genetics, histological characteristics and aggressiveness. The differentiation amongst these pre-cancerous conditions may be subtle and subject to variable interpretation depending on the pathologist. The appropriate management of these conditions, once detected, remains controversial.

In the past several decades the diagnosis of pre-malignant breast disorders has grown, paralleling the increased use of screening mammography. DCIS is characterized by many of the same histological and genetic features as invasive breast cancer. In DCIS, however, no invasion through the duct basement membrane occurs. DCIS represents 20% of malignancy detected by mammography. 90% of women in which this condition is detected are asymptomatic at the time of diagnosis. Longitudinal studies of the natural history of DCIS in untreated women suggest that 15 to 60% will develop breast cancer in the affected breast after 10 years. This is a broad range and at this point it is not well-understood what factors cause breast cancer to develop in some women with DCIS, while cancerous changes to regress in others.

DCIS is typically diagnosed after microcalcifications are detected on mammogram by means of stereotactic needle biopsy. The current standard of care involves wider surgical excision of surrounding breast tissue. In 10 to 15% of cases invasive cancer is detected in the excised tissue. However, the impact of DCIS treatment on breast cancer mortality is unclear. In addition, there is no evidence to support the removal of an unaffected breast in cases where the DCIS is unilateral.

With medicine's current focus on early detection and the abundance of information that it may provide, it becomes increasingly important to make sure that our remedies are not worse than our diseases. After all, as much as we may not like to hear it, we are all diseased, and in effect, pre-cancerous. "First do no harm," is part of the Hippocratic Oath. It may be easier, and perceived as less risky, to do another test, or to recommend a treatment to a patient in lieu of engaging in a detailed discussion of risks and benefits.

In many cases the risks of pre-cancerous conditions are not well delineated. I am very much in favor of using current medical technology and information to detect cancer and pre-cancer. However in doing this, both doctors and patients must question what will be done with the information that we discover, and develop comfort that watchful waiting can sometimes be a good option when abnormalities are detected.

Juliet K. Mavromatis, FACP, is a primary care physician in Atlanta, Ga. Previous to her primary care practice, she served on the general internal medicine faculty of Emory University, where she practiced clinical medicine and taught internal medicine residents for 12 years, and led initiatives to improve the quality of care for patients with diabetes. This work fostered an interest in innovative models of primary care delivery. Her blog, DrDialogue, acts as a conversation about health topics for patients and health professionals. This post originally appeared there.
Tuesday, April 19, 2011

Doctors dismiss self-diagnosis as 'cyberchondria'

Many doctors roll their eyes whenever patients bring in a stack of research they printed out, stemming from a Google search of their symptoms.

A piece by Zachary Meisel in describes a familiar scenario: The medical intern started her presentation with an eye roll. "The patient in Room 3 had some blood in the toilet bowl this morning and is here with a pile of Internet printouts listing all the crazy things she thinks she might have."

The intern continued, "I think she has a hemorrhoid."

"Another case of cyberchondria," added the nurse behind me.

It's time to stop debating whether patients should research their own symptoms. It's happening already, and the medical profession would be better served to handle this new reality.

According to the Pew Internet and American Life Project, 61% of patients turn to the web to research health information. That number is from 2009, so presumably, it's higher today. Health information online is akin to the Wild, Wild West. Stories from questionable sites come up on Google as high, or higher, than information from reputable institutions.

For instance, I recently wrote that, when looking for CPR videos online, many of the videos that come up on YouTube were of questionable accuracy.

Dr. Meisel comes up with some sensible ideas of how doctors can help patients in this era of abundantly online health information: ... doctors can guide their patients to Internet sites that exclusively present current, peer-reviewed and evidence-based health information.

And, perhaps more importantly,

... doctors and nurses are going to have to shed the presumption that the Internet makes patient care harder. The sanctimony that comes with the eye roll and the cyberchondriac label may be an extreme example, but it's still a problem if doctors continue to walk into the exam room with the belief that patients always need to be disabused of the wrong and sensationalistic information they picked up while trolling the Net.

Getting online and helping patients navigate through the trove of health information on the web is a new physician responsibility for the 21st century, like it or not. It's what I try to do here on, along with the links I post on Facebook and re-tweet on Twitter.

But doctors need to shed their disdain the Googling patient first, before more can get online to help them.

This post by ACP Member Kevin Pho, MD, originally appeared on MedPage Today's, social media's leading physician voice. Voted best medical blog in 2008, and with over 46,000 subscribers and 40,000 followers on Facebook and Twitter, is the Web's definitive site for influential health commentary.

QD: News Every Day--Physicians are peeking behind Dr. Oz's curtain

A handful of physicians are collaborating to take Mehmet Oz, MD, to task on what they're calling outlandish claims and bad medical advice. Their suggestion is to no longer pay attention to that man behind the curtain.

David H. Gorski, MD, PhD, at the blog Science-Based Medicine went after Dr. Oz for hosting segments about faith healing and consulting psychics. Dr. Gorski pulls no punches, saying, "Dr. Oz has in some ways imitated Oprah and in some ways gone her one better (one worse, really) in promoting the Oprah-fication of medicine. And this season has been a particularly bad one for science-based medicine on The Dr. Oz Show."

(Dr. Mehmet Oz may be using his "Degree in Thinkology" to come up with some of his show topics.)

Val Jones, MD, the woman behind the curtain at, joined the crusade against Dr. Oz, saying that he'd descended from "competent and caring cardiothoracic surgeon whose research interest was reducing preoperative stress" to "America’s chief snake oil salesman." She is organizing a campaign to drown out the bad information with better messages. (As a disclosure, ACP Internist's blog contributes to and draws posts from

ACP Member Peter A. Lipson, MD, also wanted to clear the air about primary and secondary prevention of heart attacks, "one of an internist's most important tasks, given that heart disease is one of the three top killers of North Americans."

Dr. Lipson writes that Dr. Oz's recommended advice too simplistic and over-reaching. Dr. Lipson's advice: "Everyone knows that good eating and exercise are good. Having someone repeat it over and over, and telling you it is a sure thing to prevent heart attacks is idiocy. Set goals, aim toward them, and use the data to guide you."

Bryan Vartabedian, MD, didn't originally take up the cause, but he did share a post with his Twitter audience. He found himself being threatened professionally, in turn, as persons unnamed contacted him directly about repeating attacks on Dr. Oz.

He wrote, "The last two DMs [direct messages, in Twitter-speak] made me realize how health celebrity is potentially dangerous for the consuming public. The celebrity offers unique authority in the eyes of the public. When patients trust a source like Mehmet Oz the implications for health behavior can be dramatic--both for good and bad. Even physicians may be disinclined to question their position."

(Dr. Oz must be conferring with his peers on this.)

But once physicians began to peek behind Dr. Oz's curtains, they may not be able to stop. Or to win, either. Celebrity medical doctors such as Andrew Weil, Drew Pinsky and Deepak Chopra (all trained in internal medicine, by the way, and Dr. Chopra is an ACP Fellow ) command huge audiences. Even if a vanguard of medical bloggers dislike considering alternative medicine as a topic, or even outright unscientific snake out, they may not be able to drown it out.
Monday, April 18, 2011

QD: News Every Day--Primary care job market ticks slightly upward

Physician turnover has increased from 6.1% in 2010 compared to 5.9% the previous year, according to the 6th annual Physician Retention Survey from Cejka Search and the American Medical Group Association (AMGA).

The groups' reports and findings in the 2008 survey suggested that the worsening economy and plummeting home sales cause physicians to delay retirement and relocation--key drivers of recruitment and activity, the recruitment firm reported in a press release.

Growth in the Gross Domestic Product and the bottoming out of the housing market may partially explain the uptick in turnover in 2010, the release said. Respondents in the 2010 survey said they believe that physician retirement will increase (27%) or continue at the current rate (65%).

The survey was e-mailed to the entire AMGA medical group membership (383 organizations. Survey data was collected from November 2010 through January 2011. The 62 respondents (16.2%) collectively employed 17,624 physicians.

The composition of the respondent group reflects changes in the health care industry as groups consolidate, more physicians choose employed opportunities and women pursue careers in medicine. The average size of the groups responding to the survey has nearly doubled in the last six years, from an average of 146 physicians to 284 physicians. Female physicians comprised 34% of physicians represented in the 2010 survey, compared with 28% in 2005.

The survey also noted that:
--In the 2010 survey, 51% of respondents said they do not encourage physicians to delay their retirement. Of those who try to keep physicians in practice, they most frequently incent them with flexible hours (90.6%), no call (62.5%) and/or reduced call (65.6%).
--Since 2005, the part-time workforce has grown by 62%. This trend tracks with the change in profile of today's medical workforce, in which the two fastest growing segments are female physicians entering the practice and male physicians approaching retirement.
--In the 2010 survey, 13% of male physicians practiced part-time and 36% of females practiced part-time, compared to 7% and 29%, respectively, in 2005.
--The majority of medical groups (73.8%) believe mentoring reduces turnover, but just more than half (56.1%) assign a mentor to newly hired physicians.
--For those who do assign a mentor, a formalized program makes a difference. The turnover rate was lower (5.3%) for groups that have written goals and guidelines compared with those who do not assign a mentor (6.3%).
--Respondents' consensus is that the hiring of physicians and other clinicians will accelerate through 2011.
--The majority of medical groups (83%) will hire more or significantly more primary care physicians, indicating that an already competitive physician market may become more so. Nearly as many said they will be hiring more or significantly more specialists (79%) and advanced practitioners (78%).

Radiation and overuse from CT scans threatens patients

Many patients erroneously believe that X-rays and CAT scans have no risk. In their minds, they are non-invasive studies that can cause no harm. Since there are no incisions or anesthesia, they regard the experience as having the same risk as taking a family photograph. How wrong they are.

In my mind the danger from non-invasive radiology studies may surpass the risk of hard core medical treatment. True, radiology tests won't puncture an organ or a blood vessel, as a surgeon or a gastroenterologist can. Imaging studies do not cause direct damage, but they may lead patients onto the medical battlefield. These diagnostic tests are an insidious force that draws patients into a spiral of direct risk and medical overutilization.

Is this post a shot at radiologists? No, it's a shot at all of us. Remember, radiologists never order CAT scans; the rest of us physicians do. I certainly am distressed with the obsessive manner that my radiology colleagues interpret studies today, identifying innocent, tiny "abnormalities" that will then light a fuse for further studies. In many of these cases, the CAT scans were ordered for defensive purposes, and the radiologists' interpretations often keep the defensive medicine train lumbering forward.

On July 1, 2010, the New England Journal of Medicine, the most prestigious medical journal in the world, published two commentaries on CAT scans and medical imaging. While readers are free to review the first and second essays in the journal, I will summarize the major points here.

--Nearly 400 patients in the U.S. who underwent brain-perfusion scans are known to have received an overdose of radiation. How many folks have received a 'brain sizzle' that we do not know about?
--Radiation doses from CAT scans are hundreds of times higher than standard X-rays.
--There is persuasive medical evidence that radiation is carcinogenic.
--Physicians like me who order scans have limited knowledge of radiation doses and toxicity.
--Technology exists and can be further developed to reduce radiation exposure to patients.
--There are no evidence-based standards on the proper role for medical imaging tests. It's a free for all.
--CAT scans are overutilized. Amazingly, about 10% of the U.S. population undergoes a CAT scan each year. So far, I've never undergone one. How much longer can I hold out?
--Individual patients should have their radiation exposure history tracked.
--Physicians often order CAT scans and other imaging studies believing this will lower their risk of being sued for medical malpractice. I can vouch for this in my own experience.
--Radiologists, also seeking to lower their legal risk, routinely identify insignificant abnormalities and advise that these 'lesions' be evaluated and scanned in the future to verify that they have not changed.
--Effective tort reform is one mechanism to reduce the number of unnecessary imaging tests.
--Scans are routinely ordered when the probability that the disease exists is low. I have addressed the consequences of this approach in a prior post.
--Radiologists serve as technicians, rather than serve as medical consultants to assist clinicians.
--Medical students are not trained to rely upon medical evidence with regard to imaging tests. Bad habits learned in medical school tend to be sustained throughout a career.

CT scanning, and related medical technologies, are towering milestones that have revolutionized the medical profession. They have eliminated millions of exploratory surgeries and have allowed physicians to make and exclude various critical diagnoses. We couldn't function without them. Nevertheless, CT scan overuse is rampant, and there are no forces that are curtailing or guiding its use. We are spending billions of dollars on scans that are not medically necessary. I have ordered some of these scans personally, so I acknowledge that my own practice needs remediation.

We describe medical imaging tests as non-invasive, but this is deceptive. First, there is direct risk of harm from accumulated radiation exposure. Secondly, and more importantly, there are the indirect consequences. For many patients, the radiology suite is a danger zone, a trap door that can drop patients into a medical cascade with no way out.

This post by Michael Kirsch, FACP, appeared at MD Whistleblower. Dr. Kisrch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Saturday, April 16, 2011

Pain medicines used more frequently by men with erectile dysfunction

The use of Motrin, Aleve and other non-steroidal anti-inflammatory drugs (NSAIDS) is associated with erectile dysfunction, according to a study by scientists affiliated with Kaiser Permanente.

The apparent link surprised the scientists. They had hypothesized that the commonly used pain-killers would actually reduce the risk of erectile dysfunction since NSAIDS protect against heart disease, which has in turn been linked to the troubling condition.

To reach their surprising conclusion, Steven Jacobsen and colleagues used data from Kaiser's HealthConnect EHR, an associated pharmacy database, and self-reports about NSAID use and erectile dysfunction from an ethnically diverse population of 80,966 men between the ages of 45 and 69.

After controlling for age, ethnicity, race, body mass index, diabetes, smoking status, hypertension, high cholesterol and coronary artery disease, the scientists found that men who used NSAIDS at least 3 times per day for at least 3 months were 2.4 times more likely to experience erectile dysfunction than those who did not consume them on a regular basis. The link persisted across all age categories.

Remarkable in its own right was the finding that overall, 29% of the men in the study reported some level of erectile dysfunction.

The authors emphasized that their findings do not prove that NSAID use causes erectile dysfunction. For example, the study findings could have been confounded by factors not considered by the scientists (such as subclinical disease or the severity of the comorbid conditions that were studied), and the chance that NSAID use was actually an indicator for other conditions that caused erectile dysfunction.

In addition, the scientists recognized that their study had some limitations. These included an inability to temporally link NSAID use and the development of ED, and possible selection bias.

As a result, they cautioned men against discontinuing NSAIDs based solely on the findings of their study. "There are many proven benefits of non steroidals in preventing heart disease and for other conditions. People shouldn't stop taking them based on this observational study. However, if a man is taking this class of drugs and has ED, it's worth a discussion with his doctor," Jacobsen said in an interview.

The write-up appears in the Journal of Urology.

This post by Glenn Laffel, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.
Friday, April 15, 2011

QD: News Every Day--Drug-resistant Staph found in half of U.S. meat, poultry

Drug-resistant strains of Staphylococcus aureus were found in nearly half of meat and poultry samples, and were likely from the animal themselves, a study reported.

Meat Department by Anthony Albright via Flickr and Creative CommonsResearchers collected and analyzed 136 samples of 80 brands of beef, chicken, pork and turkey from 26 retail grocery stores in Los Angeles, Chicago, Washington, D.C., Fort Lauderdale, Fla., and Flagstaff, Ariz. Among the samples, 47% were contaminated with S. aureus, and 52% of the strains were resistant to at least three classes of antibiotics--and some to nine antibiotics.

Translational Genomics Research Institute, a non-profit research organization, conducted the study and published results in Clinical Infectious Diseases.

DNA testing suggested that the food animals themselves were the major source of contamination.

"For the first time, we know how much of our meat and poultry is contaminated with antibiotic-resistant Staph, and it is substantial," said Lance B. Price, PhD, senior author of the study and Director of TGen's Center for Food Microbiology and Environmental Health. "The fact that drug-resistant S. aureus was so prevalent, and likely came from the food animals themselves, is troubling, and demands attention to how antibiotics are used in food-animal production today."

He cited the use of antibiotics at industrial farms as creating "ideal" breeding grounds for drug-resistant bacteria that move from animals to humans.

The U.S. government routinely surveys retail meat and poultry for four types of drug-resistant bacteria, but S. aureus is not among them. The authors concluded that a more comprehensive inspection program is needed.

In case you missed it ...
Medically underserved facilities unable to recruit physicians can apply for a free service being offered by a recruiting firm.

Merritt Hawkins will waive its professional fees and offer an on-site evaluation, consulting on contractual and incentive issues, candidate sourcing, screening, and interviewing for one facility in a medically underserved area.

The offer is open to any hospital, medical group or community with a critical need for a physician that has been unable to find a doctor on its own. Applications are being accepted online until Aug. 15.

Three finalists will be chosen based on the severity of their need for a physician, the time they have been seeking a doctor, and the impact that a lack of physician services has had on the community. One finalist will be chosen.

We've learned everything we need from the Women's Health Initiative, so enough already

This is the study that doesn't end ...
The long term follow up extends ...
Some people started studying hormones in menopause,
And they'll continue publishing more data just because ...

In yet another paper in a major journal, we hear once more from the investigators of the Women's Health Initiative. This time it's the long term outcomes of women who took estrogen alone, now seven years out from stopping their hormones. What new information can we learn from this extensive analysis of new data?



The WHI's been telling us the same thing about estrogen replacement therapy (ERT) and combination estrogen/progestin therapy (HRT) since 2002, and all each subsequent study does is reinforce and expand on that initial data. Unfortunately, it will probably take a few more papers before some folks accept the results of this important study, which, though flawed, continues to inform the practice of menopausal medicine.

Allow me to summarize what we know:
--HRT/ERT does not prevent heart disease when given to women of average age 64 years, or 10 years past menopause.
--HRT/ERT increases the risks of stroke and blood clots, a risks that trends upward with age. Once you stop HRT/ERT, these risks go away.
--HRT/ERT protects against osteroporosis, a benefits that goes away once you stop taking it.
--In younger women, particularly those who have just become menopausal, HRT/ERT may reduce heart disease risks. (The operational word here is may ...)
--HRT increases the risk of breast cancer, on the order of about 1% if you use it for 20 yrs. This risk has been shown in almost every study of HRT ever done, is biologically plausible and supported by the fact that drugs that block estrogen have been shown to prevent and treat breast cancer.
--ERT, when taken alone by women 10 or more years post menopausal, may actually slightly lower breast cancer risks. We think this is because of the way estrogen acts when it is reintroduced after a long absence. Unfortunately, since this is not the way we prescribe estrogen (ie, starting it 10 years after menopause), this benefit is if no use to anyone. So let's stop talking about it already.

On balance, there is no compelling preventive health reason for most women to take HRT, and women who take it live no longer than those who don't.

That said, some women may choose to use HRT to treat menopausal symptom or osteoporosis, conditions for which it is quite effective. But if you use HRT, you must accept a small but real risk of blood clots, stroke and breast cancer. (Although taking low doses through the skin may lower the clot risk.) These risks apply whether the estrogen you take is from pregnant mare's urine, a plant or the moon, whether it is bio-identical or whether Suzanne and Oprah are taking it.

If you're in early menopause and thinking that taking HRT will be good for your heart or brain, you can think it if you want, but I would not take it for these reasons alone. Stick to other proven methods for lowering your heart disease risks: maintain a healthy diet and body weight, exercise, quit smoking and treat high blood pressure or elevated cholesterol that does not respond to these interventions.

Once again, here are my rules for prescribing HRT.

This post by Peggy Polaneczky, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.
Thursday, April 14, 2011

Does communicating with patients take too much time?

I recently participated in a Twitter chat about physician-patient communications. A common refrain from some of the providers in the group was that "there isn't enough time" during the typical office visit for physicians to worry about communicating effectively. What's up with that?

The goal of patient-centered communications is to engage the patient in their own health care. While most physicians endorse the concept of patient centered communications, many seem reluctant to employ such techniques in their own practice. Why? I suspect that many fear that too much patient involvement will increase the length of the visit.

Take the patient's opening statement, aka "patient agenda" in patient-centered lingo. This is where the doctor asks the patient why they are there. The resulting patient narrative is an opportunity for the physician to obtain valuable information to help assess the patient. Patient centered advocates recommend that physicians use open-ended questions like "What brings you in today?" to solicit the patient's concerns and agenda. Active listening by the physician and paying attention to the patient's emotional cues are also hallmarks of patient centered communications.

The reality is that regardless of how they are asked, patients are often not able to complete their opening statement. That's because many physicians (75% in one study of primary care physicians) interrupt their patients within the first 18-23 seconds once they start talking. According to Jerome Groopman, MD, author of the book "How Doctors Think", this is because doctors often have a hypothesis in mind regarding a diagnosis even before the patient says a word. When patients do speak, there is always the risk that physicians "take off" on the first concern mentioned on the assumption that it is the most important reason for the patient being there.

Here's a personal example. Three times over the last several years my wife developed severe abdominal pain, nausea, vomiting and dehydration. Each time I took her into the emergency room as the problem always seemed to occur at night. The physician would come in and ask my wife what the problem was. No sooner did her opening words "I am a lung cancer survivor" get out of her mouth and the physician was off to the races apparently assuming that her being in the ER was due to her cancer. Chest X-rays were ordered ... the whole works. Yet each time all she apparently needed was to get rehydrated (an IV) and given something to stop the nausea and vomiting. After 6 hours we would go home and she would be fine the next day.

My point is that a lot of time and resources can be misdirected when the patient is not allowed to say what they think is wrong. Not only is there a risk of wasting time, but physicians also risk losing the respect and trust of patients who feel they are not being listened to. Had my wife been allowed to fully explain what she thought she needed, based upon previous experience, she would have been quickly treated and out of the ER.

The take away--The use of patient-centered communications techniques like agenda setting and active listening can go a long way in: 1) obtaining useful diagnostic information, 2) giving patients a sense that they are being listened and that what they have to say is important and 3) building rapport between the physician and patient.

The bottom line--According to researchers, the use of open-ended questions and active listening during the patient's opening statement added 6 seconds to the average visit length. In exchange, according to researchers, patients are more satisfied, adherent and report better outcomes. Not a bad investment for 6 seconds! What do you think?

--Beckman HB, Frankel, RM. The effect of physician behavior on the collection of data. Ann Intern Med. 1984 Nov;101(5):692-6.
--Marvel, K, Epstein, R, Flowers, K, Beckman H. Soliciting the Patient's Agenda, Have We Improved? JAMA. 1999;281:283-287.
--Groopman J. How Doctors Think. Houghton Mifflin. 2007.

This post by Steven Wilkins, MPH, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

QD: News Every Day--Health care reacts to accountable care arrangements

Reactions to the proposed government regulations about accountable care organizations (ACO) see potential for physician profit and for loss, but they also predict a day when such arrangements will be the norm.

The federal government released a proposed rule April 1 that outlines a wide-reaching array of how these arrangements might be created and managed (free registration required). But, organizations that can enter these arrangements eventually will have to, some say.

The government's role is to begin contracting with ACOs for covered lives beginning in January. The goal is to try and recoup between $510 million and $960 million during the first three years through 75 to 150 ACOs that would cover anywhere between 1.5 million to 5 million of Medicare’s 47 million beneficiaries. While there are no projections, some "napkin math" estimates that the savings for Medicare enrollees who participate in ACOs could reach anywhere from $126 million to $438 million, or $32 to $292 per enrollee, in coming years.

But in short, ACOs won't include small and solo practices, and it's not for the faint of heart. Health and Human Services estimated such arrangements could cost $1.7 million to start, based on the experiences of 10 pilot projects. Providers must provide primary care for at least 5,000 patients. And, they will be reimbursed on 65 quality standards organized around patient experience, patient safety and the degree of care coordination, among other areas.

According to a report by The Commonwealth Fund (co-authored by two ACP Fellows, Stephen C. Schoenbaum, MD, MPH, and Anne-Marie J. Audet, MD), a strong base in primary care and the patient-centered medical home is an absolute must.

The report continues that three organizational models could work: advanced primary care practices with specialist referral networks; multispecialty physician group practices; and integrated health care organizations. But other ways work, too, the report notes:
--Blue Cross Blue Shield of Michigan and Community Care of North Carolina use primary care medical home fees to encourage coordination of patient care.
--Geisinger Health System in Pennsylvania uses bundled acute case rates, which cover a range of patient services during a specified time interval around an acute care event, like a hospital admission.
--HealthPartners in Minnesota, Intermountain Healthcare in Utah, Blue Cross Blue Shield of Massachusetts, and Kaiser Permanente use global fees, a payment rate that covers all the health care provided to an individual during a specified time interval.

Pilot programs have shown successes. California Public Employees Retirement System, a two-year pilot that involves 41,000 insured lives, saw (free registration required) in a 10-month span hospital readmissions decline by 17%; average patient length of inpatient stay decline by a half-day, total patient inpatient days decline by 14%, and number of patients who stayed in the hospital for 20 days or more decline by 50%. The pilot is expected to result in $5 million in savings.
Wednesday, April 13, 2011

QD--News Every Day: End-of-life patients spending less time hospitalized, getting more intensive care

Chronically-ill Medicare patients spent fewer days in the hospital and received more hospice care in 2007 than they did in 2003, but their intensity of care increased as well, according to a report by the Dartmouth Atlas Project.

While in the hospital less, patients had many more visits from physicians, particularly specialists, and spent more days in intensive care units, as result of growth in intensive care and specialist capacity, the researchers said.

Intensive interventions can lower a patients' quality of life and cost more, the researchers noted. About one-fourth of all Medicare spending stems from the last year of life, and much of the growth in Medicare spending is the result of the high cost of treating chronic disease, the authors noted. Following patient preferences for end-of-life care may reduce such spending.

The percentage of chronically-ill patients dying in hospitals and the average number of days they spent in the hospital before their deaths declined in most regions of the country and at most academic medical centers. In 2003, 32.2% of patients died in a hospital; by 2007, the rate had dropped to 28.1%. New York City and its boroughs had the highest rates, between 40-45%, while less metropolitan and rural areas could range from 12-20%.

Nationally, patients spent slightly fewer days in the hospital during the last six months of life in 2007 than in 2003, from 11.3 to 10.9 hospital days per patient. Again, geography mattered. In 2007, chronically-ill patients in Manhattan spent, on average, 20.6 days in the hospital during their last six months of life, but in Ogden, Utah, the average was 5.2 days.

Among those academic medical centers where patients spent less time in the hospital in 2007 than in 2003 were the University of Texas Medical Branch Hospitals in Galveston (-5.0 days), the University of Iowa Hospitals and Clinics in Iowa City (-5.0 days) and Tufts-New England Medical Center in Boston (-4.6 days). Ten academic medical centers had increases of at least two days, including Hahnemann University Hospital in Philadelphia (+6.8 days).

Also, chronically-ill patients were significantly more likely to be treated by 10 or more doctors in the last six months of life in 2007 than they were in 2003, as the national rate increased from 30.8% to 36.1%. In 2007, patients in Royal Oak, Mich. received the most intensive care by this measure, with 58.1% of patients seeing 10 or more doctors in the last six months of life. Other regions with high rates included Ridgewood, N.J. (57.6%) and Philadelphia (57.2%). Regions with low rates included Boise, Idaho (14.2%), Salt Lake City (15.0%) and Medford, Ore. (16.4%).

From 2003 to 2007, among the 35 academic medical centers for which data are available, 22 had increases in the percentage of patients seeing 10 or more doctors in the last six months of life. Emory University Hospital saw the largest growth in this rate, from 40.4% to 63.2%, while the University of North Carolina Hospitals in Chapel Hill had the largest decrease, from 45.0% to 35.2%.

Variations in the treatment of chronically-ill Medicare patients depend largely on the systems of care within different regions and hospitals, according to researchers.

"By providing insight into patterns of care, patients can look to these data to get a sense of where care is likely to be more or less intensive," said Risa Lavizzo-Mourey, MACP, MBA, president and CEO of the Robert Wood Johnson Foundation, which funds the Dartmouth Atlas Project. "Providers can look for insights into potential savings they can achieve through improved care of chronic illness that allows patients to remain safely out of the hospital, and policymakers can identify regions that may have promising approaches."