Sunday, October 31, 2004
The push for open access.
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"Four-star hospitals? Thumbs up or down on medical clinics? MRIs listed from "$" to "$$$"?
One of the biggest challenges for the hot, new "consumer-driven" health plans might be delivering them without looking like a restaurant review."
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"I have a confession to make. I am a drug company executive who believes we should legalize the reimportation of prescription drugs. I know that I have a different opinion from that of my employer on this matter, but to me, importation of drugs is about much more than money; it is about saving American lives."
Op-ed from the Pfizer insider, Peter Rost (via over my med body!).
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Saturday, October 30, 2004
"In Northern California alone, Kaiser spends $55 million a year on chronic-care management programs. "But what's really expensive is if we don't take care of these people and manage their chronic conditions," said Dr. Robert Mithun, chief of internal medicine at Kaiser's medical center in San Francisco.
Dr. Mithun's comment may seem like no more than common sense, but it does not reflect the typical logic of the dominant fee-for-service model of health care. Most doctors and hospitals get a fee from insurers for each patient visit, clinical test, surgical procedure or day a patient spends in a hospital. In practice, the fee-for-service system is often an invitation to do more of everything - more visits, more tests, more surgery. What gets done is what gets paid for, and insurers usually do not pay for preventive care or chronic care management provided by nurses or in group classes, like the ones at Kaiser."
How true. Insurers are moving away from preventive measures instead of embracing it. In the long run, the focus on prevention will be key in controlling costs.
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"Imagine being unable to find supplies of a medicine that limits damage from a spinal cord injury, a medicine that improves the health of a premature baby, or a medicine that fights systemic bacterial infectious.
Each of these drugs, and dozens of others, are in shortage in the United States right now. On any given day, 50 to 80 drugs, many of them life-saving, may be difficult or impossible to find. Some patients die waiting for them, or because a frustrated doctor substituted another drug without having adequate training.
The larger story behind the flu vaccine shortage is that drug supply disruptions in the United States have become routine."
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"Voters in six states will decide, on Nov. 2, the fate of ballot measures on lawsuit reform. In the past lawyers have prevailed in nearly all such battles. Will things be different this year?" (via Overlawyered).
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Arafat watch
Here is the latest update on Yasser Arafat:Yasser Arafat underwent medical tests on Saturday and a senior Palestinian official said doctors had ruled out for the time being that the PLO leader was suffering from leukemia . . .There are many causes for a low platelet count - otherwise known as thrombocytopenia. The normal platelet count in adults ranges from 150,000 to 450,000/microL - thrombocytopenia is defined as a platelet count less than 150,000/microL.
Palestinian officials said the first of a battery of tests for cancers and other disorders showed no immediate risk of the 75-year-old dying. They said a full analysis could take until as late as Wednesday . . .
Arafat went into the French hospital with an abnormally low count of blood platelets -- a condition that can be caused by leukemia -- but the number of platelets had since doubled, a Palestinian official said . . .
A complete blood count (documenting the low platelet count as well as the counts for the other blood lines) and a peripheral smear are the initial tests. The diseases to rule out immediately are thrombotic thrombocytopenic purpura-hemolytic uremic syndrome and acute leukemia - each of these diseases require relatively rapid treatment.
Causes of low platelets involve decreased production (acute leukemia, bone marrow invasion with tumor or fibrosis, myelodysplastic state, vitamin B12 or folic acid deficiency) or increased destruction (disseminated intravascular coagulation (DIC), chronic lymphocytic leukemia, or Hodgkin's disease).
A presumptive diagnosis of idiopathic thrombocytopenic purpura (ITP) is made when the history, physical examination, complete blood count, and examination of the peripheral blood smear do not suggest other etiologies for the low blood count. If this is the case, treatment is normally with steroids or intravenous immune globulin.
The most comprehensive test would be bone marrow aspiration and biopsy, and I'm sure this test will be done if not already. We'll see in the coming days.
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Friday, October 29, 2004
"Given the choice between a raise and more generous health care coverage, most workers would opt for the coverage . . ."
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Pri-Med, brought to you by . . .
I'll be attending Pri-Med in Boston tomorrow at the new Boston Convention and Exhibition Center (I'll take a break for the Red Sox parade). I know that drug companies provide a lot of the funding, but this is going a bit too far.First, my registration credentials folder was compliments of Boehringer Ingelheim and Lilly. Opening up the folder greeted me with this: "The difference between Stress and Urge Urinary Incontinence is more than a cough".
As I flip through the materials, I find my Expocard (used to record CME credits) with Lexapro and Namenda plastered over it.
Of course I didn't miss the full-page handout about Crestor.
I wonder if all the drug companies screaming for my attention will drown out any useful information learned.
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As expected, the FDA is holding off on Merck's new COX-2, Arcoxia. I've been bombarded with ads saying it's "coming soon". I guess not.
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"Only 26 percent of women enrolled in commercial health plans who were eligible for screening were tested in 2001 . . . Only 38 percent of eligible women in Medicaid plans were screened, the report said."
Screening for Chlamydial infection is important since it can cause urethritis, cervicitis, pelvic inflammatory disease (PID), and result in ectopic pregnancy, infertility, and chronic pelvic pain in women. It is a strong recommendation from the USPSTF in sexually active women under the age of 25.
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"On the mad, mad quest for a flu shot? Take the flu-shot special, a high-speed ferry from Seattle to Victoria, B.C., that offers a scenic ride across the Strait of Juan de Fuca and a vaccine stop in Canada; 2,000 people already have reservations. Or hop on the Flu Bus from Grand Forks, N.D., for a rollicking journey to immunity in Winnipeg, Canada, for $99 round-trip, with lunch at Olive Garden or Red Lobster and a flu shot thrown in."
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Thursday, October 28, 2004
"The study shows that people in the U.S. face longer wait times to see doctors and have more trouble getting care on evenings or weekends than do people in other industrialized countries. At the same time, Americans were more likely to receive advice on disease prevention and self-care than others."
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"With the suturing and unsuturing of Curt Schilling's ankle, the dawn of "episodic medicine" has arrived. Episodic medicine is aggressive treatment for the now, and it inherently contradicts our "quality of life" policy . . .
But there are consequences. What about the cost? Who pays for these procedures? What are the limits? Already, new technologies, new pharmaceuticals, and new procedures are stretching the medical dollar. Does everybody have the right to "episodic" care or do we ration it based on some yet to be determined set of standards? Since we are still in the embryonic stages of "episodic" medicine, protocols, and policy decisions can be implemented more easily now than later. The implications need to be monitored not just by doctors but also by coaches and parents."
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BMJ with a theme-issue on evidence-based medicine.
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PointofLaw is hosting a featured discussion on medical malpractice: "This month, we're looking into medical malpractice once more. In lieu of a back-and-forth format, this month we're inviting comments from some leading thinkers on medical malpractice reform to discuss a new paper by Daniel Kessler of Stanford Business School . . ."
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"The Milliman actuarial firm projects what will happen if Wyoming enacts a cap on non-economic damages. According to Martin Grace's summary, the study's simulation model 'suggests that the cap [at a level of $250,000] will reduce losses and loss adjustment expenses by about 15%.'"
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Wednesday, October 27, 2004
"Lying on a résumé isn't a crime - except when a doctor does it."
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What an interesting article in bringing up a salient point.
To a physician, this scenario is all too familiar — we call it "sign-out" — but in a way, the anthropologist would be right: it is a peculiar ritual, this daily transfer of patients from one medical team to another. As I write this, at the end of a frantic afternoon, 18 residents are simultaneously handing off patients to one another in the noisy emergency room. In the medical units of the hospital, hundreds of such exchanges happen every week. And yet, ubiquitous as the sign-out is, it remains one of the most poorly examined transactions in medicine . . .Since physician teams cannot cover a given hospital patient 24-hours a day, the ritual of "sign-out" is critical. Whether it is from the day-shift to night-float or the post-call team to the on-call team, it is not uncommon for hospitalized patients to have 2 to 3 separate physician teams responsible for their care in a single day. Therein lies the danger. Like a game of "broken telephone", communication between teams offers a dangerous time for details to slip through the cracks. The art of "signing out" becomes all the more important since residency programs are strictly enforcing the 80-hour per week work rule. Similar to a relay - the more handoffs that are required, the greater the chance the baton is dropped.
In 1994, a team led by Laura Petersen examined this sort of question in a rather simple experiment: they followed 3146 patients admitted to a medical service and recorded the preventable errors that occurred.1 When the investigators explored the risk factors for errors, they found something remarkable: coverage by a second team of physicians was one of the strongest predictors — almost three times as likely as coverage by a single team to correlate with an adverse event.
These results are even more salient today. Since July last year, residency programs have begun to ease into the 80-hour workweek — a stringent set of regulations mandated by the American Council for Graduate Medical Education (ACGME) that restricts working hours for residents and interns. That regulation means more physicians rotating through shifts, more cross-coverage, more sign-outs — and more opportunities for error. And there, perhaps, lies the rub: the new work regulations are supposed to make medicine safer by decreasing the number of overworked, sleepy doctors. Ironically, it may be precisely these changes that expose patients to errors made in the process of handoff.
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"The researchers, led by Charles Czeisler at Brigham and Women's Hospital in Boston, found that interns working more than 80 hours a week committed 36 percent more serious medical errors than interns who kept a less arduous schedule.
When it came to diagnosing illness, the sleep-deprived interns made 5.6 times more serious mistakes than their rested colleagues, the research showed."
The studies are found here.
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"About 35 per cent of Australian women do not have regular Pap smears and more than 60 per cent of people visiting a GP do not receive any diet or lifestyle advice that would improve their overall health.
Patient dissatisfaction also was high, with 23 per cent of Australians surveyed saying the local health system should be rebuilt completely."
It seems like heath care is an issue down under as well.
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"The risk is not huge. But the drugs work so well and so safely -- and are advertised so aggressively -- that they're among the most-used drugs in the U.S. . . .There seems to be one extra case of pneumonia among every 100 people who take acid-suppressing drugs for one year."
The study is from JAMA and is found here. It is an observational, retrospective study - so this isn't the most robust data. However, it makes a point that not all medications are as benign as they seem. Remember, simple aspirin or NSAIDs can cause stomach bleeding or ulcers, now acid-blockers may be associated with pneumonia. In general, the acid-blockers are a pretty safe class of medications - although now, the risks and benefits should be critically weighed, especially in the immunocompromised, or those with chronic lung disease susceptible to pneumonia.
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Tuesday, October 26, 2004
"The Drug Enforcement Administration has reversed its support for a set of negotiated guidelines designed to end a controversy over the arrests of hundreds of pain specialists who prescribed powerful narcotics for their patients. The agency took the document off its Web site earlier this month, less than two months after announcing it with great fanfare."
This seems to be in response to the defense in a lawsuit introducing the guidelines as evidence. Just goes to show when dealing with pain management, there is a fine line between good medicine and criminal medicine.
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Chris Rangel talks about the "reflux" explanation for Ashlee Simpson's lip-synch incident this past weekend.
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Hosted by code blog: tales of a nurse. The weekly best of the medical blogs.
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Monday, October 25, 2004
"While it might not be a bad idea from one perspective to give trial attorneys a taste of life without physicians, surely we have a higher calling—to practice in "purity and holiness," as the original Hippocratic oath says, or with "uprightness and honor" as in "A Physician's Oath," used by some med schools today. It's risky, but the sick need the benefit of our art and practice. We're used to caring for the unwanted and unlovable no matter what their lifestyle or profession, including trial lawyers."
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"Doctors and lawyers are battling over ballot initiatives in four states this year, with very mixed signals from the voters at the moment."
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"Of the four main kinds of thyroid cancer, the papillary type is by far the most common. The cure rate is about 95 percent among younger people. But among older people, the cure rates for papillary thyroid cancer are often lower."
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Sunday, October 24, 2004
"Scenario: How do you decide whether to prescribe a new drug?
The simple answer to this question is, 'Of course I would not use a more expensive medicine to replace an effective one with no side effects.' But in fact such substitutions do occur, and frequently. The drug companies count on it."
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Always try and show up for your doctor's appointment.
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Inadequate mental health care is another reason overburdening the ER: "When their illnesses turn into crises, the only option is an astronomically expensive visit to a public emergency room. Dr. Daniel Garza, medical director for Ben Taub's outpatient psychiatric clinic, says it's not unusual for mental patients to call 911 and be transported by ambulance all in desperate bids to get a prescription filled. In recent months, the doctor says, the number of such cases at Ben Taub has only sharpened."
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"This is not a happy time for medicine. There is an increasing discordance between rising costs and the satisfaction that most patients have with the care they receive. We pay more and get less.
It's not quite true to say that all are dissatisfied. Some are quite happy with the system: CEOs of health maintenance organizations, executives of pharmaceutical companies, personal injury trial attorneys, investors comfortable with profiting from the misfortune of others, and legions of bureaucrats and regulators whose jobs are to maintain the status quo. None of these folks actually provides any care."
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Shame that physicians have to rely on a "boutique" practice in order to do house calls.
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"The dispute will give outsiders a glimpse into the business of health care, where maximizing revenue and minimizing cost take precedence, even at nonprofit institutions such as Mease."
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Detailing the conflict-of-interest issues in the new lipid guidelines.
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"When it comes to getting flu shots for its citizens, the United States
may someday soon look like a giant version of Canada, its national-health-plan neighbor to the north."
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In response to what was written last week on hospitals collecting debt, a physician writes about the lack of patients' personal responsibility.
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"The key is remembering that we're at a crossroads, not a crisis. Our challenge is to pick the right road -- ideally the one that keeps up the pace of progress without sacrificing anyone along the way."
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Saturday, October 23, 2004
"Preventing a flu epidemic that could kill thousands is not nearly as profitable as making pills for something like erectile dysfunction, a decidedly non-fatal condition. Viagra, for example, brings in more than $1 billion a year for its maker, Pfizer. The profits to be made from selling flu vaccine are measly in comparison."
A nice point in a missive detailing our health care ails and proposal for a single-payer system.
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"At least five Montreal hospitals are flouting infection-control
guidelines by sticking patients sick with deadly C. difficile diarrhea
in rooms with uninfected patients."
C. Difficile diarrhea should be able to be controlled with appropriate isolation techniques. The reason that this is not happening is due to staffing cuts, which is simply unacceptable in this day and age.
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". . . people who use their computer to find out more about their condition end up in worse health than those who do not."
I certainly support increased information flow and patient empowerment. However, there is a reason why physicians endure 7 or more years of medical school and residency. It is how the information is interpreted and applied that matters. People who take their health solely into their own hands, without physician guidance, are asking for trouble.
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We can learn something from abroad.
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Friday, October 22, 2004
Hype
As a consumer, you have to see through the hype that the drug companies put out. Medrants points to an excellent article explaining why drug prices are so high - and the role of pharmaceutical hype. One section deals with the Nexium story:Nexium has become a symbol of everything that is wrong with the pharmaceutical industry. The big drug companies justify the high prices they chargeand the extraordinary profits they enjoyby arguing that the search for innovative, life-saving medicines is risky and expensive. But Nexium is little more than a repackaged version of an old medicine. And the hundred and twenty dollars a month that AstraZeneca charges isnt to recoup the costs of risky research and development; the costs were for a series of clinical trials that told us nothing we needed to know, and a half-billion-dollar marketing campaign selling the solution to a problem wed already solved. The Prilosec pattern, repeated across the pharmaceutical industry, goes a long way to explain why the nations prescription drug bill is rising an estimated 17 % a year even as general inflation is quiescent, the Wall Street Journal concluded . . .Another example is Singulair for allergic rhinitis - as has been discussed before:
It is certainly not mentioned in the commercial that Singulair is only good as a 2nd or 3rd line therapy for seasonal allergies. Advertisements like this only do a disservice to both patients and physicians - both of whom takes a backseat to profits on the drug companies' list of priorities.This recent meta-analysis says the same thing:
Leukotriene receptor antagonists are modestly better than placebo, as effective as antihistamines, but less effective than nasal corticosteroids in improving symptoms and quality of life in patients with seasonal allergic rhinitis.Bottom-line: don't always believe the hype you see on TV and have a critical eye towards the evidence.
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Thursday, October 21, 2004
What an interesting story describing a complicated ethical and bureaucratic ordeal.
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The BMJ with some tough words for the pharmaceutical industry. Some statements I agree with:
These can often be for quite trivial conditions, such as toenail infections, and they encourage patients to go and see their general practitioner, often in quite strong terms," said Mr Vidler. "At the same time the industry will be advertising drugs to these GPs, and our research shows that GPs often take the path of least resistance and say yes to patients and prescribe the drug even though they feel it may not be the most appropriate thing to do.So true. Many patients come in asking for Lamasil, not knowing that it is a 12-week course of therapy and that liver function tests have to be monitored during treatment. Conveniently left out of the commercial.
Some statements are controversial:
Professor Healy claimed that at least half of articles on drug efficacy that appear in the BMJ, the Lancet, and the New England Journal of Medicine are ghost-written by pharmaceutical companies and that "the most distinguished authors from the most prestigious universities" put their names to them without ever seeing the raw data.I wonder how much of this is true - if so, then we're in bigger trouble than I thought.
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The New England Journal of Medicine makes its case.
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"The press is often in over it's head when reporting on medicine." Completely true. This is where the power of medical blogs can shine - by correcting and interpreting the studies often misreported by the lay press.
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I know how they feel.
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Wednesday, October 20, 2004
Good neighbors.
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A rheumatologist reminisces about Vioxx.
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"The AAPS, along with the Pain Relief Network, has been vocal in denouncing the federal and state doctor prosecutions. The groups Web site warns: 'If youre thinking about getting into pain management using opioids as appropriate: DONT. Forget what you learned in medical school -- drug agents now set medical standards.''"
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"While many elderly Americans are standing in long lines for flu shots, the vaccine is readily available for free to members of Congress and staff at the U.S. Capitol."
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codeblog is hosting next week's Grand Rounds: "To submit an entry for Grand Rounds on October 26th here on codeblog, email me at geena -at- codeblog dot com. Please put 'grand rounds' in the subject line!"
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Tuesday, October 19, 2004
Chris Rangel with thorough, thoughtful analysis on defensive medicine.
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"More than 80 percent of patients seen in emergency rooms have health insurance and a usual source of health care such as a primary care physician." As has been previously mentioned, improving primary care access is key to alleviating ER overcrowding.
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One doctor, one pharmacy
Today's story in the NY Times on chronic pain writes about the practice of some to encourage chronic pain patients to go to multiple pharmacies:The red flags that rightly alert regulators to potential misconduct by doctors are, paradoxically, the very features that can also mark responsible care for intractable pain. These include prescribing high volumes of narcotic painkillers for extended periods, prescribing potentially lethal doses or prescribing several different drugs. In some regions, patients use several different pharmacies, at their doctor's instruction, because some pharmacists are reluctant to dispense large quantities of the medications.A reader responds to this little tidbit:
The NY Times article mentions that some physicians are instructing their chronic pain patients to go to more than one pharmacy. In my opinion, this violates the standard of care for the treatment of chronic pain with opioids. In fact, I consider this to be malpractice. Chronic pain patients taking opioids should get all their pain prescriptions from one doctor, and have all their prescriptions filled at one pharmacy.I'm not sure which regions in the country promotes this practice. With chronic narcotic treatment, strict "pain-contracts" are signed to prevent abuse, specifically stating that one doctor prescribes, and one pharmacy fills. Anything else would be an open invitation for abuse.
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More on the need for vaccine reform by Dr. Henry Miller.
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Fascinating and heart-wrenching diary of a BBC writer diagnosed with a malignant brain tumor.
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If you can can't beat 'em . . . (via PointofLaw).
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