"When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov
''Once you tell people there's a cure for something, the more likely they are to pressure doctors to prescribe it.'' -Robert Ehrlich, drug advertising executive.
"Opinions are like sphincters, everyone has one." - Chris Rangel
If people were more fully exposed to the cost of their medications, wouldn't it be rational to decide that maybe the benefits are not enough? For example -- my anti-hypertensive costs X dollars a month to cut my risk of heart attack/stroke etc. by Y amount (I won't pretend to make up numbers, as a surgeon I have no idea what X and Y are) who should make the choice whether it's worth it?
I have not formed an opinion on that, but everybody I've read on the subject takes up the debate as if that point is obvious. To me the question is if you handed the patient an extra $100/month and told him/her that they could use it to pay for medication or for McDonalds, would they choose the medication? And for those that choose McDonalds, why should the company think that their health is worth more than they do?
Interesting point, and it's actually a conversation I had with a patient yesterday. He's had no insurance coverage for over a year now. He gets his diabetes medication from the pharmaceutical company under a hardship program. He's not taking his cholesterol medication, nor is he taking his ACE inhibitor to protect his kidneys. I usually see diabetics whose disease is well-controlled every six months, but he's seeing me once a year. Ditto with the lab work to monitor his disease. I wrote his orders for his lab work on three different order sheets and told him which I felt was the most important and which the least important to get, so he could find out the cost and make the decision which to have done.
He reminded me three times during the visit that he "scraped and scrambled to get up the money to come in," but then as he was leaving he mentioned that he was considering radial keratotomy. Would he be a good candidate? The cost? $1500. (I didn't ask where that money was coming from. Maybe he hit it lucky in the lottery.) Being able to do without glasses is obviously worth more to him than taking optimal care of his diabetes.
Yet, it's his money, and his decision. Maybe he would be happier living fewer years without glasses than several years longer with them. It's not the choice I would make, but that doesn't make it wrong. Then again, I wasn't inclined to down-code his office visit to a cheaper than usual rate after that. (Which is something I usually do for him, although he doesn't know it.) Why should I subsidize his radial keratotomy?
UPDATE: A reader wrote to excoriate my patient's ophtalmologist for offering him the older radial keratotomy procedure instead of the newer, more reliable PRK or LASIK. Indeed, he may have been offered the latter but used the older term to describe them. Our conversation was centered more around the economics of his decision, and the importance of attending to his diabetes, so the distinction flew past me at the time. For readers out there considering eye surgery, PRK or LASIK is superior to radial keratotomy. posted by Sydney on
12/06/2003 04:37:00 PM
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Psychological Terrorism: Austrian department store workers say that incessant Christmas music is psychological terrorism:
A trade union in Austria calls it 'psychological terrorism' and has launched a campaign urging a halt to the practice on behalf of those forced to endure the repetitive loop of songs.
The campaign, launched this week as the holiday shopping season got well under way, advocates that carol playing be limited to just an hour a day, between 3 p.m. and 4 p.m., to help limit the damage to workers' mental health.
Workers 'become aggressive and develop an aversion to Christmas music,' explained Gottfried Rieser, a member of the Union of Private Employees.
The union is one of the leaders of the campaign to stop the day-long music.
'It gets to the point where on Christmas Eve, when they're at home with their families, they can't stand Silent Night or Jingle Bells one more time,' Mr. Rieser said. posted by Sydney on
12/06/2003 09:21:00 AM
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Supply and Demand: The CDC's admonition that everyone get a flu vaccine has been heeded too well - the manufacturer's have run out:
The nation's two vaccine makers, Aventis Pasteur and Chiron, said they had shipped out all the vaccine they had made, a total of about 80 million doses. That is in sharp contrast to last year, when 10 million doses were left over and thrown away, said Dr. Michael Decker, vice president for scientific and medical affairs of Aventis Pasteur. Because flu strains vary from year to year, a new vaccine must be formulated each year.
There's still vaccine out there - in doctor's offices and in health departments, but once they deplete their supplies there will none left. (I ran out two weeks ago and wasn't able to find anymore, which left me scratching my head everytime I read a report in the paper quoting a CDC official as saying "there's plenty of influenza vaccine this year.")
The problem is that it's very difficult to match supply to demand. Last year, the manufacturers had to throw out 10 million doses, that's at least $50 million dollars in loss, perhaps more. (I'm guessing that the manufacturer's cost is about $5 a dose, since it's $8 a dose from the distributors.) Like any good business, the vaccine manufacturer wants to keep excess to a minimum. There's just been more demand this year because of the reports of widespread flu in Colorado, and the deaths of young children. The death rate so far this year is the same as it usually is, but the young children have caught people's attention, and more healthy people are seeking flu vaccine for themselves and their children.
Vaccines are one instance (at least vaccines that really make a difference in public health) in which it might not be a bad idea to avoid the free market.
The CDC and medical groups have started surveying doctors and health departments to determine if -- and where -- vaccine shortages might be occurring. If there were a serious outbreak of flu in some areas of the country, while other areas had unused vaccine, the CDC would help to redistribute remaining stocks, the Times reported. posted by Sydney on
12/06/2003 09:16:00 AM
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Choices: A new study shows that people who have to pay more for their drugs are less likely to take them:
Researchers at Harvard Medical School, who reported their results in today's New England Journal of Medicine, examined what happened to employees whose companies raised medication copayments dramatically or moderately. At the unnamed company that raised copayments dramatically, 16 percent of workers who were taking ACE inhibitors for high blood pressure stopped taking the medication altogether; 32 percent of workers taking proton-pump inhibitors for heartburn stopped, and 21 percent taking statins to lower cholesterol discontinued their medicine.
The study did not follow these patients to determine whether their health deteriorated.
The study showed that most people switched to less expensive alternatives (49 percent) although a minority dropped the drugs completely:
Among the enrollees who were initially taking tier-3 statins, more enrollees in the intervention group than in the comparison group switched to tier-1 or tier-2 medications (49 percent vs. 17 percent, P<0.001) or stopped taking statins entirely (21 percent vs. 11 percent, P=0.04). Patterns were similar for ACE inhibitors and proton-pump inhibitors. The enrollees covered by the employer that implemented more moderate changes were more likely than the comparison enrollees to switch to tier-1 or tier-2 medications but not to stop taking a given class of medications altogether. (NOTE: "Tier-3" means they were the most expensive choices on the insurance plan's formulary, "tier-2" is moderately expensive, "tier-1" is least expensive.)
This, however, does not necessarily mean that patients are sacrificing their health for monetary concerns. Proton-pump inhibitors for indigestion are frankly overused. Older, less expensive drugs work just as well. And ACE inhibitors can be successfully replaced with older, less expensive drugs to adequately treat hypertension. (The study didn't break the data down into diagnosis groups.) And just earlier this week, the British Medical Journal published data showing that statins are over-rated in preventing heart disease when compared to aspirin, which is a fraction of the cost.
The spin that the paper is being given is that employers are endangering the health of their employees by switching to plans with higher co-pays, but the paper is far from conclusive on the matter. Now, if they had found that diabetics stopped taking their insulin or their oral diabetic medications when copays went up - that would suggest a problem. But, they didn't look at drugs that are indispensable to their users. posted by Sydney on
12/04/2003 09:31:00 AM
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Influenza Update: Colorado has seen a sharp upswing this week in cases of influenza:
Colorado reported 6,306 cases Wednesday, an increase of 1,619 from Monday. Although it's early in the season, Colorado has already had more cases than in the previous two flu seasons combined, 6,239. Colorado is one of 10 states with a widespread flu outbreak, the federal Centers for Disease Control and Prevention said.
Here's a map of influenza rates nationwide (from data a little more than a week old), and here's some information about drugs available to treat the flu. You can also find more than you probably want to know about influenza, it's treatment, and prevention here
Sometimes I Feel Like I'm on Another Planet: Just one of those days. Got a call from a patient who injured her finger two days ago and wanted to be seen. Offered an appointment today, but no, didn't want to come to the office and risk being exposed to sick people. Wanted a referral to the ER instead. They aren't sick in the ER? posted by Sydney on
12/03/2003 06:15:00 PM
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Preventing Miscarriages: A new high-resolution ultrasound may be instrumental in preventing miscarraiges, or at least in predicting when they're likely to happen:
In a study of 1,530 pregnant women, it predicted embryonic heart failure and miscarriage with 99% certainty just six weeks into pregnancy.
...The scan, which uses a probe inserted into the vagina, allows researchers to identify congestive heart failure in embryonic babies.
It works by measuring the speed of red blood cells moving through foetal blood vessels.
Lead researcher Dr Jason Birnholz said: "The chances the pregnancy will continue are very high, about 95%, when Doppler ultrasound confirms embryonic heart function at six weeks.
"Over 99% of pregnancies with an abnormal Doppler pattern do not continue."
They speculate that giving oxygen to mothers with slow-flowing embryoes may cut the miscarriage rate - but it's all speculation and needs a lot more study before it becomes applicable to real life. posted by Sydney on
12/03/2003 08:05:00 AM
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Not so Innocent Bystanders: British researchers are working on cellular level radiation therapy for cancer. Kill one cell and it takes its neighbors with it:
British scientists have found a way to fire radioactive particles at individual cancer cells, paving the way for new forms of radiotherapy, which will be less damaging to healthy tissue.
A study at Cancer Research UK’s Gray Cancer Institute in London has revealed that such microbeams of radiation can kill many more cancer cells than they hit directly, as the “zapped” cells send out signals which tell their neighbours to commit suicide.
Interesting.
UPDATE: A reader with experience in radiation and medicine emails:
The headline "British scientists have found a way to fire radioactive particles at individual cancer cells" rang a bell for me, but it was from a long time ago.
I was spelunking through the history files for an early experimental high energy electron beam linac that ran at Michael Reese from about 1957 to 1986. There was a headline in the Chicago Tribute, (circa late 1950's) "Atom Smasher Fires Electronic Bullets Against Cancer"
Don't get me wrong, Reese was an early leader in electron beam treatments, and they did wonders for some tumors, (breast CA for example,) but they weren't magic bullets.
In the intervening years I can think of the following ideas:
Hyperthermia with radiation
High LET radiation beams
Neutron Beams
Proton Beams
All were useful, (with the possible exception of Hyperthermia,) but none
really improved on the cell kill ratio between healthy and cancerous cells.
Big Prostates/Big Bucks: The always controversial subject of prostate cancer screening is in the news again:
In a survey of 7,889 men, researchers found that 32.5 percent of men over 75 received PSA blood tests an estimated 1.5 million men a year.
Medicare typically pays $25.70 for the lab work, federal officials said, suggesting that more than $38 million a year is spent on those tests for older men. Federal officials said more than $90 million was paid out last year for PSA tests for Medicare recipients of all ages.
"Most patients with an elevated PSA do not have prostate cancer," said Yao. Even if prostate cancer is first detected in a 75-year-old, the chances are very high that the patient will die of some other disorder before the slow-growing cancer could cause death, he said.
Why is that a big deal? Because chasing down those false positives gets even more expensive (and much more invasive) than the test itself:
The PSA test does not detect cancer directly. Instead, it determines, in effect, whether a patient has too much prostate tissue. That excess tissue can be caused by inflammation, by enlargement common to older men, or by cancer. A positive PSA test has to be followed up with a biopsy or other procedures before cancer can be confirmed.
It always has been an imperfect test, but the media and interest groups (such as the professional societies of urologists) have made it a central aspect of men's wellness. As a result, conveying the nuances of the test is very difficult in the context of an office visit which has in all likelihood already been devoted to a host of other issues - complaints that need to evaluated, concerns that need to be addressed. Which is why this isn't surprising:
Among the elderly men who participated in the survey, 88 percent said they got the PSA test at the advice of their doctor, but only 66 percent of those who got the test recall a discussion with the doctor about the risks and benefits of the test. For a test of questionable value, Yao said virtually all the doctors should have frank discussions with patients.
Those frank discussions aren't happening because many doctors have in the back of their mind that if they don't order the test and the patient comes down with prostate cancer in a few years, which is certainly in the realm of possibility given its prevalence rate in elderly men, the doctor's going to get the blame - and the malpractice suit. On the other hand, if he does the test and the patient goes through urological consults and invasive testing the patient's going to be grateful that his doctor was "thorough." (And actually more than 66% probably had discussions with their doctors, they just might not recall them because they've been obscured by other, more pressing aspects of their visits.)
And one more thing. It isn't at all surprising that more men have PSA levels done than fecal occult blood testing to screen for colon cancer. The PSA is a simple blood test. The fecal blood test requires the patient handle his own stool. Understandably, it has a notoriously high non-compliance rate.
UPDATE: A reader reminds me that there are over-the-counter test kits to screen for blood in the stool that don't require handling excrement. I'm not sure how their sensitivity compares to the traditional testing methods, but they're better than doing nothing, I'm sure.
posted by Sydney on
12/03/2003 07:46:00 AM
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A new study finds that virtual colonoscopy, a method that uses a C.T. scanner for colon cancer screening, can be just as effective as traditional colonoscopy in finding polyps, the mushroomlike growths from which most cancers arise.
Patients having the 15-minute virtual screening test simply lie down and hold their breath for about 10 seconds, exhale, then hold their breath again while a C.T. scanner X-rays their colons, creating detailed, three-dimensional images of the walls. With traditional colonoscopy, patients are sedated while a doctor threads a long flexible tube into the colon, spending half an hour viewing its walls in much the same sort of detail. Then they wait in a recovery room for about an hour as the sedative wears off.
But, it's as expensive as a traditional colonoscopy (anywhere from $500 to $2,000) and this is the first study that found it to be effective:
Virtual colonoscopy has been around for nearly a decade, but it has never been on the recommended list of screening tests. In previous studies it missed as many as half of even the large polyps that are most worrisome. The difference this time, said Dr. Pickhardt, is in the method.
The study researchers used a computer program that revealed the colon in three dimensions. Most other virtual colonoscopy has involved two-dimensional slices created from C.T. scan images. The patients in the new study also drank a fluid that labeled fecal material so doctors did not confuse it with polyps.
The accompanying editorial in the New England Journal (available without subscription today, although you have to download a pdf version) points out that the other difference between this study and others is that the researchers didn't include the non-precancerous polyps the virtual colonoscopy failed to find.
That may not make much of a difference clinically since those types of polyps don't go on to become cancer, but the other interesting aside is that only 50% of the study subjects said they would choose the virtual colonoscope over the conventional one if given a choice. That's not too surprising. Most of my patients tell me the worst part of the colonscopy is preparing for it (cleaning the bowels out completely.) And if a virtual colonoscope finds polyps, then the patient has to go on to a regular colonoscope to have them removed, which means another prep. Yuk. posted by Sydney on
12/02/2003 08:19:00 AM
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Slim Down or Else: We have ways of pounding you into line with the latest trend in medicine:
The U.S. Preventive Services Task Force said that standard obesity treatment should go far beyond casual advice to shed a few pounds. Instead, the group recommended that doctors prescribe intensive behavior therapy at least twice a month in either individual or group sessions led by a team of health professionals such as psychologists, registered dietitians and exercise instructors. Treatment should continue for at least three months, the task force advised.
There's a very large chasm between what we know and what we do, especially when it comes to lifestyle issues like smoking, alcohol, and eating. We know what's good for us, but our hearts long for the things that are bad for us. I'm not convinced that forcing people to go to counseling twice a month is going to make much of a difference in the long-run in their dietary habits. And frankly, I have reservations about how my patients would receive this. They don't want to go to counseling when they're obviously depressed and need it, are they going to go to learn to restrain appetites and exercise more?
By publishing the guidelines, the Task Force is sending a signal to the insurance industry that they should pay for intensive counseling and behavioral modification programs for obesity. And you know what that means - higher premiums down the road for all of us. It would be nice if they would at least consider the cost when they make these recommendations. posted by Sydney on
12/02/2003 07:55:00 AM
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Caesarean Risks: As more and more women are electing to have Caesarean sections to avoid the labor of labor and delivery, researchers are finding more reasons against it:
Doctors at the Rosie Hospital in Cambridge, England, who studied data on 120,000 births in Scotland between 1992 and 1998, found that stillbirths were higher among women who had previously had a child by Caesarean section.
'Delivery by Caesarean section in the first pregnancy could increase the risk of unexplained stillbirth in the second,' Gordon Smith, who headed the research team, said Friday in a report in The Lancet medical journal.
'Our best estimate is that for every 1,000 women with a previous Caesarean section, there will be one additional stillbirth in comparison if they hadn't had a previous Caesarean section,' he added in an interview.
Here's what the study found (requires free registration):
For 120,633 singleton second births, there were 68 antepartum stillbirths in 17,754 women previously delivered by caesarean section (2·39 per 10 000 women per week) and 244 in 102,879 women previously delivered vaginally (1·44; p<0·001).
That's a stillbirth rate of 0.4% for mothers who had prior caesarean deliveries and of 0.2% for mothers who haven't. Well, at least they aren't writing that the risk is doubled. My humble advice, don't blame yourself if you've had a C-section and a subsequent stillbirth. With or without C-sections, the risk is pretty small. posted by Sydney on
12/01/2003 07:53:00 AM
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Heart Attack Genes: Researchers have discovered a gene responsible for repairing damaged coronary artery walls, at least in one Iowa family:
Interest in the Iowa family began when one of its members, a 61-year-old man who suffered a heart attack, told doctors that eight of his 10 siblings also had heart attacks at about the same age.
Doctors eventually traced 26 close family members with heart problems. The researchers took blood samples for DNA analysis in the hope of finding a common genetic link to the disorder.
The study found that a region of chromosome 15 - one of the 23 pairs of chromosomes in the human genome - contained a linkage 'hotspot' that was known from previous studies to include a gene called MEF2A.
The gene is involved in the repair and maintenance of artery walls and the research team found that the family members who had suffered heart attacks also possessed a deletion mutation within the MEF2A gene.
None of their relatives, or 119 other, unrelated individuals without heart problems, possessed the same defect. This suggested that the defect causes the build-up of fatty deposits inside the vital arteries supplying nutrients to the heart.
And what is to be gained from this information?
Dr Topol said the immediate benefit would be to develop a test that could identify people within the same family who are carrying the defective gene. 'There are 100 members of this family. We can tell now in kids aged 10 whether they have the heart attack gene or not.'
Other factors, such as smoking, increase the chances of an earlier heart attack for those people carrying the defect but the total avoidance of an attack is not possible, he said. "We're not talking about an increased risk. If you're not run over by a truck or get another disease first, you're going to have a heart attack," he said.
Lucky kids. They'll get to spend their whole lives expecting their unavoidable heart attack at sixty - unless a treatment for the genetic defect is discovered. Will they be more likely to smoke and indulge in other heart-damaging activity because the inevitable is unavoidable? Will they check in for their cardiac cath and cornary artery intervention in their early fifties to avoid the ineveitable at sixty? Will it do any good to intervene early? Or will they end up with restenosis since they're genetically unable to repair their artery walls? It's a conundrum. posted by Sydney on
12/01/2003 07:50:00 AM
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