"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
London Calling: There's a malpractice crisis in France, too, it seems. How bad is it? So bad the surgeons there are not only striking, they're fleeing to London:
The surgeons will board Eurostar trains on August 30 and congregate either in Wembley Conference Centre or the Great Hall, Westminster - the exact venue has not yet been fixed - until September 5 to avoid being 'requisitioned' by French local authorities during their strike.
'We're expecting about half the country's 6,000 surgeons to take part and most of the rest will refuse to perform any non-emergency operations for a week,' said Philippe Cuq, one of the organisers. 'The government is going to have to wake up to this crisis.'
Dr Cuq said the sums reimbursed by French social security for surgical interventions had not increased 'by a single centime' for more than 15 years, while surgeons' insurance premiums had risen by up to 500% since 2002 alone.
There was a time not so very long ago when the thought of three thousand Frenchmen descending on London would have struck fear in any Englishman's heart. Changes. Strange changes. posted by Sydney on
7/23/2004 12:00:00 AM
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Thursday, July 22, 2004
Amendment Wars: Things are getting ugly in Florida, where lawyers and doctors are fighting each other state constitutional amendments. The doctors want to write limits to lawyers fees into the state constitution - "30 percent of the first $250,000 in all medical malpractice damage awards and 10 percent of all damages above $250,000." The lawyers, who you will remember, always claim that their resistance to tort reform is about protecting the little guy, not their wallets, have countered with - count them - three amendment proposals:
MEDICAL ADVERSE INCIDENTS: Would allow public access to records of patient injuries by health care providers and facilities.
PHYSICIAN CHARGES: Would require doctors to charge patients the lowest fee negotiated with a health insurance plan for services, regardless of whether the patient is covered by the plan.
PHYSICIAN LICENSING: Would strip the license of any medical doctor found to have committed three or more cases of medical malpractice.
What if all four amendments pass? Florida could become the only state in the union with no doctors and no lawyers.
Monopsony: Another excellent and engaging medical blog that I've been remiss in adding to my blog list is Galen's Log. Lots of good stuff over there today, including a discussion of the monopsony of the healthcare market. posted by Sydney on
7/22/2004 09:42:00 PM
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Costs vs. Benefits: Something interesting happened this week in the New England Journal of Medicine. Not only did it publish a study showing a new approach to colon cancer chemotherapy prolongs survival, but they also published an accompanying article calling into question its cost (requires subscription):
The combination of irinotecan and cetuximab for second- and third-line treatment of metastatic colorectal cancer, as described by Cunningham et al. in this issue of the Journal (pages 337–345), increases the median survival by 1.7 months. In the United States, the regimen costs approximately $30,790 for an eight-week course. Assuming that an average patient continues to receive treatment until the median time to progression, 8 months of front-line therapy followed by 4.1 months of irinotecan–cetuximab therapy would cost $161,000.....These cost estimates are exclusively for drugs; they do not include the costs of preparation, administration and supervision, or supportive medications. They presume that every single milligram of drug is effectively utilized. Yet cetuximab, for example, is manufactured only in a 100-mg vial, and because the medication cannot be stored for long periods, leftovers go to waste, particularly in small practice environments.
....The Centers for Medicare and Medicaid Services (CMS) has made decisions about coverage on the basis of the "reasonable and necessary" clause in the original statute that established Medicare in 1965. There has been no political will to deny coverage for effective interventions on the basis of cost. The public has engaged very little in the deliberations used to reach influential decisions about Medicare coverage.
And as a result, the majority of the media coverage of the study has been more critical than it would have been. Instead of getting headlines that exaggerate the positives of the study, we're getting much more accurate headlines like this. Kudos to the Journal for finally raising the issue. They should do this in every issue - examine honestly the cost as well as the benefit of the therapies that are being touted in its pages.
On the Other Hand: The article dealing with the cost of the drug puts most of the blame on the pharmaceutical industry and implies that there should be price controls on drugs. I suppose that would be one way to reduce costs. Make it unprofitable for them to develop the drugs in the first place. But clearly, the real focus of the debate should be on whether or not theses sorts of drugs are worth their price in the first place. Few people would be willing to spend $30,000 of their own money for one and half more months of sickness. Why are we so willing to spend someone else's money for it? And why would doctors recommend it? posted by Sydney on
7/22/2004 10:15:00 AM
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Going Digital: The federal government is trying to spur widespread adoption of electronic medical records. Electronic medical records would be a lot nicer than paper records, but the issue of security is a big problem. And cost. Electronic medical record software for an office can cost up to $15,000 to $20,000. That's a lot of money. To be sure, the security issues should be solvable. After all, banks and on-line stores handle sensitive financial information without any problem. But having that sort of professional security drives up the price. And with the cost of medical malpractice insurance going up and up, it's getting harder and harder for the average practice to find the spare change for electronic medical records. That could be a new AMA slogan - Tort Reform for EMR! posted by Sydney on
7/22/2004 09:58:00 AM
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All That Money Can Buy: My take on the Kerry Health Plan at Tech Central Station. In brief: it's folly to be willing to spend the entire -or even the majority - of the federal budget on healthcare, because today's healthcare market is insatiable. My profession is constantly expanding the treatments available and the definition of disease (and health) without regard to the cost. As long as the healthcare consumer bears no responsibility for the bill, there's no hope of reining in the monster.
And here are some other thoughts on Kerry's plan that wouldn't fit into the column:
1) The idea that the middle class will be well-served by Medicaid is misbegotten. Medicaid reimburses so poorly, it's hard to find doctors who will accept it. Those who do, do so as an act of charity. For the poor. No one's going to be willing to do that for their middle class compatriots. So, either no one would sign up for it - which would save the Kerry plan from being the disaster it has the potential to be, or the reimbursement levels would have to go up, which would mean it will be much more costly than the $650 billion estimate it currently carries.
2)Kerry mentioned in the Times interview that money could be saved by making people with chronic diseases participate in disease management programs. The current conventional wisdom holds that these programs save money in the long run by improving the control of chronic diseases and thus reducing complications. This hasn't been the experience in my practice. One of the major insurers in our area uses this sort of service. In addition to paying me to care for and monitor the progress of my diabetics, chronic lungers, and depressed patients, they also pay an outside consulting firm to call them up every six or eight weeks to see how they're doing. In the case of diabetics, they also send them a home testing kit to check their urine and blood for the same routine tests that I check. But, the nagging and the tests never seem to change anything. The non-compliant remain non-compliant and poorly controlled. The well-controlled remain just as well-controlled as they were before they entered the program. My chronic lungers are about the same. Those with severe disease still get wheezey when the environmental conditions are right or if they get a respiratory infection. And there's absolutely nothing gained with the depressed patients, most of whom have chronic, well-controlled depression. No one's been saved from suicide by those frequent phone call check-ups. From where I stand, these programs just increase the cost to the insurance company, and eventually to the patient through higher premiums.
I will add that there is one chronic disease program that seems to make a difference, but it isn't one that's offered through the insurance company and run by an organization 500 miles away. It's the congestive heart failure monitoring done by one our local hospitals. Patients report their weight and their symptoms periodically (in some cases daily) and have their medication adjusted by their physician accordingly. That has kept one or two of my formerly frequent fliers out of the hospital for several weeks at a time. Until they get tired of participating.
UPDATE: here's a detailed point-by-point analysis of both the Bush and the Kerry plans for healthcare financing. posted by Sydney on
7/22/2004 09:50:00 AM
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Will Weight Watchers, Jenny Craig, Atkins and other programs win Medicare approval? Atkins' medical director, Dr. Stuart Trager, said he plans to find out. posted by Sydney on
7/21/2004 08:36:00 AM
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Expanding Markets: New research is claiming that those cholesterol-lowering miracle drugs, statins, are OK for kids. The study in question, however, was a small and brief one - just around 100 children in the drug and control groups. They were observed for two years to check for side effects. The researchers used carotid artery ultrasound to determine if they had an advancement or regression of cholesterol-induced vascular disease while taking Pravachol. They found regression, though it's not clear how the change in the ultrasound image correlates with actual clinical changes. For example, how do they correlate with the future incidence of heart disease in these kids with high cholesterol.
The researchers also looked for side effects from Pravachol among the kids, such as delayed growth, liver damage, and delayed puberty, and found none. The kids studied were ages 8 to 18, but the paper never tells what the actual age distribution was, only that the median age was 13. This is important. It matters whether or not most of the children were hovering around 13 or whether they were equally distributed from the age of 8 onwards, since drugs would have more potential to harm the developing pre-pubertal child than the already pubescent. I would still be reluctant to put a growing child on cholesterol-lowering drugs. posted by Sydney on
7/21/2004 08:31:00 AM
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Comprende: The obesity-is-a-disease message is getting through loud and clear. This is not necessarily a good thing. During one of my encounters yesterday, I noticed my patient had lost 12 pounds in the past month. I asked him if he'd been trying to lose weight. He smiled proudly and said "Nope." Then he recounted how wonderful it was to be twelve pounds lighter. He was less short of breath, his knees didn't nearly as much, his pants were loose. Everything about his demeanor said, "Congratulate me. I'm finally healthy." I wish I could have shared his joy, but I couldn't. Unexplained weight loss is a bad sign, a very bad sign. Although it can be the symptom of a benign, easiliy treatable disease such as an overactive thyroid, it can also be a manifestation of a lurking cancer. And that's the first thing that comes into a doctor's mind.
I thought of two of my aunts who had always struggled unsuccessfully with their weight. They were happy, too, when they lost weight unexpectedly. The last time I saw one of them was at a family reunion. This particular aunt was always so self-conscious about eating in public, but here she was unabashedly eating a slice of apple pie - a la mode. She noted that this was the first time in her life that she could eat anything she wanted and not worry about gaining weight. And she looked so happy. She was in an advanced stage of emphysema. The work of breathing was so hard for her that it burned up more calories than she could take in. She had to wear oxygen all the time, and she could barely rise from the table, but her weight was no longer a burden. (She died a few months later.) My other aunt was absolutely ecstatic when for the first time in her life she began to effortlessly shed pounds. But after thirty pounds and three months, she was diagnosed with metastatic ovarian cancer. She's no longer with us, either.
So you can understand why I wasn't excited about this weight loss. I explained the importance of investigating his changing weight, but he would have none of it. He knew only one thing. I was raining on his parade. He pointed out to me how dangerous obesity was. Why, don't I know it's a disease? But the look he gave me was the worst of all. It was an "I-can't-believe-you're-this-stupid-didn't-you-go-to-med-school-or-at-least-read-the-papers?" kind of look. I hope he follows through on the work-up I ordered, but I have a bad feeling the next thing I'll be seeing from him is a request to transfer his records.
UPDATE: A reader notes a key difference between obesity here and obesity in Europe:
I have just returned from a trip to Europe. I noticed that there were significantly fewer morbidly obese people (at least in public). Those who were obese seemed to be older. Another interesting fact was that a member of our party who has trouble with weight lost weight during the trip as well. There are two interesting things with respect to this. First, most things including food cost about twice as much in Europe. Secondly, there are many fewer cars and a much wider use of public transportation. Obviously, most people eat less because of the cost and walk farther because they use public transportation. Rather, than obesity being a disease, cars and cheap food are a disease! posted by Sydney on
7/21/2004 08:14:00 AM
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'We have wireless-enabled intravenous (IV) pumps that automatically gather essential medication information from a central database to ensure the safety of our patients. This allows us to focus more on patient care, rather than administration,' said Wiesenberg. Each smart IV medication system is equipped with an 802.11b PCMCIA card that communicates with a central server that stores medication profiles. These profiles are continuously downloaded to each IV pump to ensure no errors in the distribution of medication to patients. posted by Sydney on
7/20/2004 09:20:00 PM
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More Additions: I've added the excellent group medical blog The Lingual Nerve to the blog list to the left. Interesting posts on the differences between Ph.D. and M.D. students and on learning to be a doctor in general. posted by Sydney on
7/20/2004 05:24:00 PM
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Book Review: Who doesn't want a flat, wash board stomach? A "six-pack" as they say. It's a hallmark of youth. Something we enjoy before time and gravity work their mischief on our bodies. No one's immune. The little pot belly is as much a hallmark of age as gray hair and wrinkles. But David Zinczenko, editor-in-chief of Men'sHealth magazine has a solution - the Abs Diet: The Six-Week Plan to Flatten Your Stomach and Keep you Lean for Life. Or maybe it's the solution of his co-writer, Ted Spiker, it's hard to tell. They both get credit for writing it, but there are a lot of personal singular pronouns sprinkled throughout the book. At any rate, the solution is this: Fat is a slug. Muscle is a furnace. Increase your muscle mass and you'll burn more calories, thus losing weight and keeping it off - especially in that fat-hording belly area.
The writing is engaging and often witty (Zinczenko? Spiker?). Sentences such as "Commercial bread baking has followed the same path as Michael Jackson - the whiter it gets, the less wholesome it becomes" and "Like the mother-in-law who tries to tell you how to raise your kids, fructose screws up a system that was working perfectly fine without it." sprinkle the prose, making what has the potential to be a very dull subject almost interesting. Although no references are listed, many are mentioned to bolster the authors' nutritional claims, making it, unfortunately, impossible to check up on them.
The basics of the diet are sound: eating frequent, small meals each day rather than three large meals (the better to keep the munchies at bay), avoiding the empty calories of alcohol, and allowing yourself one diet-free day each week. The rest of the diet is on shakier ground - relegating foods to "power" groups, each of which is supposed to give you certain health benefits - building muscles, promoting weight loss, strengthening bone, fighting cancer, etc. While certain foods certainly enjoy the reputation of doing these things, their influence is small. No one should count on any one type of food to save them from pathology. The other centerpiece of the diet is the ingestion of something called "smoothies," a blended drink of yogurt, peanut butter, whey, and whatever else you can think of to give it some sort of flavor (berries, bananas, etc.) The authors say they're delicious. I'll take their word for it. Do they work? They probably do provide a certain sense of fullness that helps the dieter stick with their regimen - kind of like a homemade Slimfast.
But, of course, if a true six-pack abdomen is what you're looking for, diet alone won't do it. You need to exercise those muscles to make them firm and strong, and the Abs Diet has no shortage of exercises for strengthening and tightening those abdominal muscles. In fact, exercise is as key to the program as diet. And rightly so. The program calls for some sort of exercise daily, which is a sensible approach to losing weight and keeping it off.
Will the diet give you a six pack in six weeks, as one of its opening chapters claims? Will it increase your "staying power"? Maybe. But it's highly doubtful that the regimen, or any regimen, will turn this into this. Time's touch is not a gentle one, nor one so easily reversed.
UPDATE: I forgot to mention that this was cross-posted at Blog Critics, where this interesting comment was also posted:
That's one thing almost all these diet books have in common: they each have a strong undercurrent of fear. That may seem like an odd thing to say, but it's there -- perhaps even in just the odd line, but that's a dead giveaway (pun intended). This is a fear of aging, and of death, and I find it totally inexplicable. It's almost a clinic morbidity, a phobic state, and it makes people pathological devotees of one diet after another.
There's an exhausting sameness to these books and I'm starting to wonder about the audience. Does anyone go out and read them one after another, trying them all? Who are the Linda's and the Rosalyn's and the Marsha's who invariably fill the interstices with their "personal" experiences? I suspect they're probably entirely imaginary.
What none of these books tell you is the most obvious: cut out the junk food, exercise *regularly* (and that doesn't mean violent games of squash once a week) and just make sure your diet is something you can live with. None of these fad diets can give you that -- it's impossible to live forever on high-protein-high-fat-no-carb or vice-versa.
The historical evidence also doesn't support this kind of skewed eating. The point is to achieve permanent weight loss *if you have a clinical obesity condition*. Otherwise it may not be necessary, medically speaking. It's just that our society is now quickly turning body fat into a taboo, somewhere below incest and patricide. Our self-image is increasingly determined by our perception of others' perceptions of us rather than logic.
Most diet and health books also don't allow for human frailty. Everyone is bound to fall off the wagon once in a while. I mean, for how long can you resist that burger, fries and coke meal? I like Zinczenko's advice to allow yourself one off-day every week. Agatston (the South Beach diet, so far the most sensible of the lot) says something similar. That is probably the one thing you can grow old with -- gracefully.
You know, I've always wondered about those testimonials in diet books, too. posted by Sydney on
7/20/2004 11:24:00 AM
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Treading Water: They say that taking the Alzheimer pill Aricept once a day will delay the onset of Alzheimer's if you're a little forgetful:
Mild cognitive impairment, according to the National Institute on Aging, is more severe than aging-related memory problems such as forgetting to pick up something at a store. But it is not as severe as Alzheimer's disease, which is characterized by forgetfulness and dementia -- disorientation and confusion. Yet four in 10 people with mild cognitive impairment go on to develop Alzheimer's within three years.
The study found that donepezil slowed progression to Alzheimer's in the first 18 months of a three-year study; thereafter, there was no difference between the drug and sugar pills. On average, researchers said, the medicine slowed the disease by about six months.
Some questions. Most people with mild cognitive impairment don't go on to develop Alzheimer's at all (6 out of 10), so how do you decide whether or not you need to take the drug? Presumably you have to take the drug from one to one and half years to gain the six month delay in developing Alzheimer's. Aricept costs $130 a month. That's $1560 for a year's worth or $2340 for a year and a half. Would that be worth a six month reprieve from out-right dementia? Maybe for some. But some of us might prefer to use that money (assuming it would be our money and not the government's or an insurance company's) for a nice vacation while we still have all our marbles. Especially if it isn't going to make any difference in the long run. posted by Sydney on
7/20/2004 08:53:00 AM
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The weight of the medical evidence is overwhelming: when sedentary people become active and start eating a diet rich in fruits and vegetables these lifestyle changes improve health dramatically - and this holds true for people of all ages, shapes and sizes.
What such changes usually do not do is make 'obese' people appreciably thinner. Yet the weight loss industry will now fight to pour billions of Medicare dollars into its already fat coffers, despite the fact that higher-than-average weight is not a health risk for seniors, and that there is an extremely powerful association between weight loss and premature death among the elderly.
Politicians demand much of science and scientists that they cannot deliver, particularly in the area of certainty. Scientists may sometimes be seduced by the glamour of politics to the extent that they say they can provide that certainty. Science and the public would be better served by scientists keeping a healthy distance from grandstanding politicians. posted by Sydney on
7/20/2004 08:35:00 AM
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Monday, July 19, 2004
Tough Love: Radiologists are playing hardball with expert witnesses among their ranks. (They're the most commonly sued specialty, so they have ample reason for scrutinizing their ranks for false witness) posted by Sydney on
7/19/2004 08:35:00 PM
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Medical History: Cronaca has two posts up on medical anthropology issues. The first is archeological proof that Medieval monks really were gluttons. The second is about new insignts into the madness of King George - looks like arsenic played a role. Historians have long thought that he suffered from porphyria because there were written records about his urine being dark at times. But acute arsenic poisoning can also darken the urine. George III had several close calls vis a vis assassination during his reign, perhaps someone was trying to do away with him quietly. On the other hand, arsenic was a popular ingredient of medications and cosmetics in those days, so it could have all been accidental. posted by Sydney on
7/19/2004 11:03:00 AM
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Physician, Heal Thy Robot: Medical schools are turning to robotic simulators as a replacement for real patients. Students can practice everything from life support to drawing blood on them:
Immersion's widely used CathSim, which combines computer images with an 'arm' to insert the needle, makes students go through all the steps of a blood draw, from confirming a patient's identity to pushing the needle in the until they feel the 'pop' as it enters a vein.
I suppose that's better than learning to draw blood on each other, which is what we had to do in med school. posted by Sydney on
7/19/2004 11:02:00 AM
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Pulse of the People: I usually try to avoid talking politics in my practice, but once in a while it creeps into the exam room conversation. My practice is a diverse one, and the mood of my patients has never failed to mirror the mood of the nation. In the 2000 election, it was clear that people were ambivalent about the two candidates. One was as good as (or as bad as) the other, so it was no surprise that the election was as close as it was. So far, this year looks like it might be a close one, too. (Looks like Kerry thinks so, too.)
Some of the comments I've been hearing these past few weeks do not bode well for the Republicans. A normally very pleasant, mild-mannered elderly patient apologized for missing her appointment the week before because her return from vacation was delayed by an airline cancellation. She blamed Bush. Air Force One had landed and delayed things at the airport. "I hate that guy," she said. (She also thinks we should be spending tax dollars on drugs for the elderly, not arms for the army.) Another patient, during a mental status exam, answered the question "Who is the President of the United States?" with "That's one I'll never forget. George W. Bush, that idiot who got us into this mess in Iraq."
I've also been hearing bizarre comments that make me think this will be a particularly nasty election. One patient just recently began collecting social security and was complaining about the meagerness of her payments. She told me it was Bush's fault. Someone from the social security office told her (or at least she understood them to say) that the Administration had changed the rules so that her payments were lower than what they would have been four years ago. As far as I can tell, that's patently false. Social security payments are based on your highest yearly earnings rate. Another patient told me she could no longer get her medications from a discount distributor in Florida because "Bush put a stop to it." She's always paid for her own medications, so she didn't lose an employer-funded drug benefit to the new Medicare drug discount program, so I'm not sure what she's talking about, but she said that someone from the discount pharmacy told her it was the Republicans who were behind the change. She's also paying less at the local pharamcy than she was through the mail order firm, but she's still mad as heck that she had to change.
When I heard the social security story I thought there must be some partisan hack at the social services office spreading disinformation. But after hearing the pharmacy story I've got to think it's something worse and more widespread - a willingness to believe the worst about Bush, no matter how cock-eyed the story. That shouldn't be surprising, I suppose, given the type of media coverage he gets. They're all too willing to believe the worst, too. It's the Michael Mooring of America.
And yet, there are also indications that people aren't that happy with the Kerry/Edwards duo, either. When I examine people's eyes, I shine the light of my ophthalmoscope on whatever magazine happens to be in the front of the wall rack and tell them to focus on the celebrity on the cover. This week, in one exam room, it's been Kerry and Edwards on the cover of Time. I say "Focus on that million dollar smile," and invariably the response is a deep disapproving grunt, often accompanied by comments like, "ambulance chaser," or "it's a crime those lawyers can make that much money." (Somehow, it's Edwards they always focus on, not Kerry. Maybe his smile looks more like a million.) And then there's my own mother, a devout Democrat who's never voted for a Republican in her life but who says she doesn't think she can vote for Kerry/Edwards. It's the tort reform thing. She sees it as a threat to the future of her beloved grandchildren.
It's certainly not as valid or significant as a political poll, but that's the Medpundit office prediction for election 2004 - an extremely close race, a nasty campaign (which it already was even before the primaries ended), and a slight advantage to Kerry.
UPDATE: A reader who works with Social Security responds:
There've been no substantive changes in Social Security benefit computation in quite a while. I ought to know, since that's where I work. The current basic formula was adopted in the Carter administration, in fact, with changes in the Clinton administration. It's amusing that the only presidents who can reduce Social Security payments are Democrats. In essence, a worker's benefit is based average earnings, the earnings being indexed for inflation. There's a complicated formula that is based on changes to the consumer price index, but nothing that an adminstration can change from year to year. The big Clinton change was to raise the age of "full retirement" slowly. This means that anyone who starts getting benefits before "full retirement" gets slightly less. Medicare policy is set in Health and Human Services, but I don't think they've done anything dramatic. I suppose there might have been some regulatory changes due to implementing the Medicare prescription benefit, but I wouldn't know. posted by Sydney on
7/19/2004 11:00:00 AM
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When Giants Walked the Earth: The passing of a pioneer in psychiatry, who felt that drugs were overused:
Dr. Mosher was convinced that supportive, social relationships could help his patients rebound from psychosis. He viewed the illness as a coping mechanism, a response to years of various traumatic events that caused the person to retreat from reality.
"Basically what they're saying is: 'Hey, folks, I'm out of here. I'm constructing this world as it pleases me, and I don't need to pay attention to that world out there. I'm going to live in this one because that one out there hurts,' " he said in a 2003 interview with the San Diego Weekly Reader.
...In his later years, Dr. Mosher wrote and spoke widely about his cynicism toward the pharmaceutical industry's influence on physicians. He resigned from the American Psychiatric Association in 1998, citing an "unholy alliance" between psychiatrists and drug makers.
Dr. Mosher is gone, but the unholy alliance lives on.
While I Was Away: So much happened. Obesity is no longer a risk factor for disease, but an official disease, which is a bad move for all of these reasons and more. Having named it a disease the onus is now on the medical profession to cure it, or at least that will be the way it will be perceived.
The new guidelines issued Monday by the American Heart Association and the federal government were aimed at preventing heart attacks. They were written by nine of the country's top cholesterol experts. At least six have received consulting or speaking fees, research money or other support from makers of the most widely used anti-cholesterol drugs.
...The heart institute posted information on industry ties of the new guidelines' authors on its Web site Friday. Cleeman said all the authors except him "have some connection with industry.
...Newsday first reported on the conflicts in Thursday's editions. They said six authors had earned money specifically from cholesterol drug makers, including Pfizer Inc., Merck & Co., Bristol-Myers Squibb and AstraZeneca LP.
They estimate that the new guidelines will add 7 million new choleseterol drug users to the market, but the market share increase will be much larger than that. For there will be a whole subsegment of patients who get placed on second and third drugs or whose doses get pushed to the max to try to meet the ideal cholesterol level. It's a coup for the drug companies, that's for sure. Good to see the media and consumer groups on the ball on this one.
The guidelines are widely reported to be based on good science, but what the reports don't tell you is that the benefits of aggressively treating cholesterol are marginal. Here are the results on which the new guidelines are based:
The Heart Protection Study, which used Pravachol: (587 [5.7%] deaths due to cardiovascular disease in Pravachol users vs 707 [6.9%] in non-users.
PROSPER, which also used Pravachol: 408 (14%) cardiovascular events in Pravachol users vs. 473 (16%) in non-users.
ALLHAT-LLT, another Pravachol study: Coronary heart disease (CHD) rates "were not significantly different between the groups.., with 6-year CHD event rates of 9.3% for pravastatin and 10.4% for usual care."
ASCOT - LLA, a Lipitor study: 2% of those taking Lipitor had a heart attack, fatal or non-fatal, vs. 3% of those not taking the drug.
PROVE IT-TIMI 22,a comparison of Pravachol and Lipitor: Death from heart disease, 1.1% over two years in the Pravachol group vs. 1.4% in the Lipitor group. (figures are available here with a subscription)
Hardly breath taking results, any of them. And certainly hard to argue that the benefits would be worth the cost of the drugs to a patient who had to pay for them. But of course, that's the beauty of it, the people who use them aren't the ones who pay for them.
Also of note, the American Heart Association has a letter writing campaign to urge politicians to combat heart disease and stroke:
Stroke affects 700,000 Americans per year and kills 160,000 annually, leaving many more victims severely disabled. Research and public education about the signs and symptoms of stroke are necessary to lower death and disability rates from this condition. Would you support programs that will help ensure that stroke is more widely recognized by the public and treated more effectively by health care providers?
Would one of those programs include government funding for cholesterol-lowering medication, I wonder? posted by Sydney on
7/18/2004 11:21:00 PM
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Housekeeping: Added some more medical blogs to the blog list at the left, including the relatively new and excellent Mental Notes, by a Texas psychiatrist. (Medical blogs seem to be big in Texas for some reason.) There's also the Catholic physician Mental Pompeii, which is as good as its name suggests, CodeBlueBlog by a radiologist, and the always interesting Kevin, M.D. Not to mention
Medlogs, the medical weblog aggregator that I should have added a long time ago. If there's a medical weblog out there, you can find it at Medlogs.
posted by Sydney on
7/18/2004 09:37:00 PM
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Jumping through Hoops: I wish I could say that completing my on-line yearly board certification test has made me a better doctor, but I can't. In fact, I can't say that it contributes anything beyond what the usual continuing medical education activities contribute, other than taking up more of my time and costing more money.
In the past, maintaining board certification meant taking 50 hours of continuing medical education courses each year and passing a day-long test every seven years. Now, it means all of that plus taking an online test on a given clinical topic each year. The idea is that this will reassure the public (or the watchdogs) that we are policing ourselves. It wouldn't be so bad if the study materials were downloadable, but they aren't. Which means that you can't read them while waiting in line or during a baseball game. It really is a burden of very little benefit. But that's so true of just about every "new" development in medicine, isn't it? posted by Sydney on
7/18/2004 09:37:00 PM
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