See Consumer Reports' list of the 10 most overused medical tests and treatments. Synopsis:
BACK SURGERYHEARTBURN SURGERY
PROSTATE TREATMENTS
IMPLANTED DEFIBRILLATORS
CORONARY STENTS
CESAREAN SECTIONS
WHOLE-BODY SCREENS
HIGH-TECH ANGIOGRAPHY
HIGH-TECH MAMMOGRAPHY
VIRTUAL COLONOSCOPY
You can quibble with the list, but you can't help but commend CR for raising public awareness about the medical arms race. And this list is just part of a broader special section on overspending on overtreatment.
What could possibly be wrong with screening newborns for congenital health problems?
The same things that can go wrong with any screening progams: false positives, lack of followup, etc.
A Wall Street Journal story today does a good job explaining the unintended impact of recent widespread newborn screening programs.
NBC's Jim Cummins, a TV news veteran whom I was fortunate enough to work with at my very first job at WTMJ in Milwaukee more than 30 years ago, has died.
Michelle Greppi of TV Week writes:
Jim Cummins, who worked his way up through Midwest stations to a three-decade career as a correspondent with NBC News, died Friday. He was 62 and had been diagnosed with cancer after retiring from NBC News earlier this year.In an e-mail to staffers, NBC News President Steve Capus described Mr. Cummins as “a gentle giant of a man” who had “spent decades making Americans feel right at home, with his down-to-earth, warm reporting style, delivery and presence. During a distinguished career with NBC News, Jim covered all kinds of breaking news assignments and memorable features.”
He is survived by wife Connie and six children, who Mr. Capus said were with him when he died.
“Jim and Connie had a vision for life after NBC. A damnable cancer diagnosis came a short time after he left the job, and those plans took a backseat to a courageous battle,” Mr. Capus said.
Capus put it very well - Jim was a gentle giant and his warm reporting style was so effective in today's whirlwind, "cram it all into 22 minutes" broadcast newscasts. I remember him carefully re-reading his scripts and then revising to match the film. I remember him digging on the phone. He was a terrific listener. He could stay calm and clear-headed amidst the frenzy of a newsroom or of a chaotic breaking news event. And he had a huge heart. As a young reporter, I was so impressed.
I never would have lasted in TV news as long as I did if I hadn't started off working with and learning from some terrific journalists - Cummins, and Pete Wilson who died recently after a long career in San Francisco TV news, certainly at the top of the list.
The Boston Globe has an interesting story about questioning the value of annual physical exams. Excerpts:
"...annual exams are still phenomenally popular: A study released last month found that 64 million Americans a year get a physical or gynecological exam, costing $7.8 billion and outpacing visits for respiratory conditions or high blood pressure.But researchers and some health plans increasingly voice deep skepticism about the value of scheduling a separate annual exam for a healthy person. There's little scientific evidence, they maintain, to justify the time, money, and expertise being invested in a ritual that consumes appointment slots, especially when patients with immediate aches and pains can't squeeze into a doctor's frenzied schedule."
Former Congressman Billy Tauzin, a friend of the drug industry when he was in Congress. and now head of the Pharmaceutical Research and Manufacturers of America, has launched his own TV show to boost the industry's image.
The show is called "Healthcare Campfire with Billy Tauzin."
Doesn't that sound cozy?
Until an episode appears on a TV station in your market, you can read more about it.
Read Maggie Mahar's essay on her HealthBeat Blog.
It's about how physician ratings services that look only at "trust, communication, availability, and environment" but fail to measure quality of care and health outcomes are not exactly what the patient ordered - or needs.
She concludes:
"A more credible version of what the Zagat system purports to be—a system that empowers patients to understand and manage their relationship to doctors—is the paradigm of shared decision-making.Very briefly let me just say that: “shared decision making” is a process which allows doctor and patient to share valuable information. First, the doctor describes the relevant risks and benefits of all treatment alternatives, and the patient shares with the physician all relevant personal information that might make one treatment or side effect more or less tolerable than others. Numerous studies indicate that when patients have the opportunity to participate in medical decision making with their physician, the patient-physician dialogue improves, and patient well-being improves as well.
This is the real deal when it comes to empowering patients to take control of their “health care decision making.” Presumably a doctor who engages in shared decision making will score high on the metrics of trust and communication—no conflict there.
But from a long-term perspective, the reduction of medical care to Zagat snippets may be counter-productive with regards to moving toward shared decision making, because it reinforces the notion of health care as consumption. Treating doctors like restaurants perpetuates the notion that health care is like any other commodity: we want it fast and we want it now. In reality, real empowerment demands active engagement and a certain measure of personal responsibility.
The danger is that in relying on superficial measurements of service, patients will get comfortable with the quick fix approach, and we take two steps back with regards to truly integrating patients into health care as active participants."
Good post on Maggie Mahar's Health Beat blog on how loosely the term "socialized medicine" is applied, and how such loose terms sink public understanding.
No Monday morning quarterbacking here. Just the usual reminder to journalists and consumers that - while in the opera, it ain't over till the fat lady sings - in health care and medical research, exuberance over new ideas such as new drugs maybe ought to be restrained until long-term evidence is in.
Pfizer's announcement this week that it would shelve the insulin-inhaler drug Exubera and take a $2.8 billion pretax hit on the product is a real world reminder. The company faced a far weaker sales market than anticipated, perhaps much of it due to doctors' safety concerns about the drug.
Back when the drug was approved in January 2006, on our HealthNewsReview.org website, we reviewed an AP story about the drug's approval and noted about that story:
"Overall, there is little quantitative information on the efficacy of the new form of insulin compared with the existing method of insulin delivery. While investors may be interested that this could be a "$1 billion a year seller for Pfizer", diabetics who are considering inhaled insulin would appreciate quantitative information on the risks and benefits of Exubera."
I hope journalists are paying attention.
See this terrific story on TheScientist.com.
It's about "an informal group of scientific researchers who had met through various workshops sponsored by the UK charity, Sense About Science. Over the past several months, the researchers started chatting about all the bothersome ways that certain advertisers... well, advertised.
The researchers were particularly irritated by companies that used scientific-sounding claims to back their products and market them to the public."
The article concludes: "The project, says Alice Tuff, director of program research at Sense About Science, is meant to encourage other scientific researchers to openly question marketing schemes using scientific-sounding information. "It's easy to say 'that annoys me' and not do anything about it," she says. "All it takes is phone call or letter to make companies more aware of what they put on their Web sites."
A new study published in the Journal of the American Medical Association gives perhaps the best picture yet of how extensive are industry-academic relationships are in medicine. The authors surveyed department chairs in the 125 accredited allopathic medical schools and the 15 largest independent teaching hospitals in the United States. 67 percent of the 688 eligible department chairs completed the survey.
It showed that "almost two-thirds (60%) of department chairs had some form of personal relationship with industry, including serving as a consultant (27%), a member of a scientific advisory board (27%), a paid speaker (14%), an officer (7%), a founder (9%), or a member of the board of directors (11%). ... More than two-thirds of chairs perceived that having a relationship with industry had no effect on their professional activities, 72% viewed a chair's engaging in more than 1 industry-related activity (substantial role in a start-up company, consulting, or serving on a company's board) as having a negative impact on a department's ability to conduct independent unbiased research."
The authors concluded:
"Failure to address the existence and influence of industry relationships with academic institutions could endanger the trust of the public in US medical schools and teaching hospitals."
The Associated Press reports:
Dr. Jerome Kassirer, a former New England Journal of Medicine editor and frequent critic of industry influence over doctors, called the study eye-opening."I was appalled by the results," Kassirer said. "No one knew that so many chairs of medicine and psychiatry were paid speakers. We've never had that data before."
The Chicago Tribune today has a good story about how annual medical checkups are overrated. As the story explains:
That's because there is scant scientific evidence showing that yearly checkups help prevent disease, death or disability for adults with no symptoms. Many tests and procedures performed during the visits have questionable value, experts say.
When many journalists continue to push checkups and screening tests in the absence of good evidence, it is refreshing to see an evidence-based story like this.
OK, I've read some of the news stories you have about the drop in U.S. cancer deaths.
Some experts cite cancer screening as one of the possible factors. I, too, would like to look closely at cancer screening - but for a different reason.
Could it be that today's aggressive cancer screening is finding many early pseudo-cancers that may not turn out be deadly, but which are still categorized as a "cancer" diagnosis?
If you find more non-deadly cancers but still call them cancers the death rate is automatically going to drop.
I haven't seen anyone address that possible phenomenon. How big a piece of the pie could this represent?
Princeton health care economist Uwe Reinhardt writes, in this week's BMJ:, about the "The US muddle over a child's right to health care." Excerpts:
"Up to eight million children of poor American families are without health insurance—so why is there a dispute over children's right to health care?After the demise of President Bill Clinton's health reform plan in 1994, I posed for readers of JAMA (the Journal of the American Medical Association) this question: "As a matter of national policy, and to the extent that a nation's health system can make it possible, should the child of a poor American family have the same chance of avoiding preventable illness or of being cured from a given disease as does the child of a rich American family?"
That question has long been answered in the affirmative in most other industrialised nations. In the United States it evokes irritation. ...
These issues come to mind on the day President George W Bush has vetoed a bill that would extend health insurance coverage under the State Children's Health Insurance Program (SCHIP). ...
The battle over SCHIP is a classic US health policy debate in which seemingly technical jargon such as "crowding out" private insurance, arguments over the relative "efficiency" of private versus government medicine, and endless body counts on the number of children actually without health insurance camouflages much deeper and chronic ideological divisions.
When I wrote my commentary for JAMA a decade ago I was not at all seeking to use children as a tool of socialist propaganda. Rather, I sincerely—and naively, it turns out—believed that Americans could at least settle on the distributive ethic that should govern health care for the US children who are effectively disenfranchised. Alas, Americans cannot agree on the role of children in their society, from conception through to adulthood, let alone on their children's right to health care. Thus the kids must muddle through as usual—through the ideological muddle of the nation's adults.
An editorial (pdf file - pages 3 & 4) in the BMJ this week comments on the "muted" reaction to the new guidelines on screening mammography for women in their 40s that were released by the American College of Physicians in April. Rather than calling for universal screening, they recommend that women make an informed decision after learning about the benefits and harms of mammography.
The authors support the guidelines because, they say, no right choice exists and because screening has mixed effects – some women will benefit (by avoiding death from breast cancer) but others will be harmed by unnecessary treatment. So the next step is to ensure that women understand what is likely to happen if they do or do not undergo screening.
The authors say that for every 1000 women screened over the next 10 years less than one life will be “saved” for younger women and about three lives will be saved for older women.
But screening has several harms, say the authors. False positives – abnormalities detected at mammography that often cause women to undergo repeat testing (or perhaps biopsy) to rule out cancer - are the most familiar and can cause short term anxiety, inconvenience, and sometimes unnecessary biopsies. But they think that overdiagnosis is the most important harm of screening.
Overdiagnosis is the detection of lesions that meet the pathological criteria for cancer but would not progress to cause symptoms or death, they explain. Women who are overdiagnosed can only be harmed by treatment – they cannot benefit because no treatment was needed. Harms include disfiguring surgery, side effects of chemotherapy or hormonal therapy (such as nausea, fatigue, and hair loss), and injury from radiation.
Calculating the chance of overdiagnosis is challenging, but the authors estimate that, for every 1000 women screened over the next 10 years, up to five aged 40-49 and up to nine aged 50 and over may be affected.
South Florida Sun-Sentinel columnist Michael Mayo blogs:
"So much for the old stereotype of a fedora-wearing reporter pounding out copy on deadline, cigarette dangling from his mouth. Or the days of sportswriter Oscar Madison chomping on his cheap stogie.Starting next year, employees of my company will have to pay a $100 per month fee (that’s $1,200 per year) if they smoke. Or if anyone in their family who gets health insurance from the company smokes.
Have any of you all gotten a similar notice from your company’s health plan?
I don’t smoke, and neither does my wife or 22-month-old daughter, but I was completely shocked when I got the letter yesterday from Tribune Company (corporate parent of the South Florida Sun-Sentinel) outlining the changes to our 2008 health plans:
“Tobacco use fee – Tribune employees who use tobacco products (or
have covered dependents who do so), will pay a $100 per month fee
(per family) in addition to their medical premium. Smoking cessation
programs will be offered to assist those who use tobacco in leading
a smoke-free lifestyle. The fee will be waived upon completion of
the program.”Naturally, this makes me wonder what other unhealthy sins will be surcharged in coming years.
Will there be fees for alcohol use? Eating fast food? Having high cholesterol? Not adhering to proper weight/body mass guidelines?
The other thing that gets me is that there’s no reward for not being a smoker. If the company imposed a surcharge on smokers and then gave a proportionate break to all the non-smokers I could maybe be a little more positive about the whole thing.
Instead, everyone’s premiums, deductibles, co-pays and out-of-pocket maximums are going up next year. In my case, my annual out-of-pocket maximum for each family member is going from $1,250 per person to $2,000 per person. And that’s not even including prescription drugs. And that’s in addition to my $4,000 share of the annual premium that I’m paying.
Yikes. I’ve seen the future, and it’s damn expensive."
On this blog I have been remiss not to weigh in on the recent and ongoing debate over children's health insurance and the SCHIP or State Children's Health Insurance Program.
Not surprisingly, some of the wittiest commentary has come from Jon Stewart and Stephen Colbert. Their segments within the past week should not be missed.
Stewart's coverage on the Daily Show includes a biting commentary from John Oliver.
On the Colbert Report, the host said:
"If we really care for our kids, we should deny them health insurance now to immunize them against expecting it as adults. If we don’t, when they grow up, who knows what other unrealistic things they’re going to expect? You know, if we fund Head Start now, later, they’ll expect education. If we fund school lunches now, later, they’ll expect food."
Who spent more time exploring the issues and looking at the debate: Comedy Central? Or ABC, CBS, NBC, CNN, MSNBC, Fox?
Two New Zealand authors warn in this week's BMJ that Europe should avoid opening the Pandora's box of direct-to-consumer (DTC) drug advertising, and learn from what has happened in New Zealand.
The authors write that the European parliament is considering allowing the drug industry to have a much greater role in providing information to patients, with no restriction on the type of media. But they urge Europe to learn from the New Zealand experience. (New Zealand and the U.S. are the only two developed countries that allow DTC drug ads.)
Concerns about the impact of DTC ads on public health led the New Zealand Ministry of Health to reconsider the ad trend. But the advertising was allowed to continue with self regulation and a promised further review of compliance with the rules never took place.
So, the authors write, advertising became more widespread and proved extremely effective. For instance, intensive advertising of celcoxib and refecoxib on prime time television, aimed specifically at long term use in the elderly, resulted in widespread prescribing, despite early warnings of their cardiac risks. Similarly, just a few TV ads promoting oral terbinafine for toenail infections resulted in a doubling of national prescriptions within weeks.
Still, the New Zealand government has been unable to pass the necessary legislation to ban DTC ads, despite strong opposition from health professional groups and almost complete (90%) opposition from independent consumer and patient organizations.
The authors warn that allowing DTC ads in Europe will not help consumers make better decisions about medicines but will increase the pharmaceuticalization of health and will expose more of the population to new medicines (many of which offer little benefit over existing medicines) at a time when long term safety is unknown.
It will also rapidly drive up drug costs with major implications for already stretched health budgets - all of which will be of net harm to the overall public health, they warn.
Statement of Dr. Sidney Wolfe, Director of the Health Research Group at Public Citizen:
"The idea of behind-the-counter-drugs is not new. The Food and Drug Administration (FDA) has previously considered creating a third class of drugs - an intermediate step between prescription medications and over-the-counter drugs - but has not supported the idea, citing the need for more research. That need still exists today.It's been 12 years since a U.S. General Accounting Office report, commissioned by Congress, raised serious questions about the usefulness of adding another class of drugs. The report looked at how similar systems - in which pharmacists distribute certain drugs without a doctor's prescription -were faring in 10 countries. The possible risks of behind-the-counter sales, due to inadequate counseling by pharmacists, the costs, usefulness and logistics of adding this third layer of distribution were foremost among the concerns.
There's little evidence that these concerns have been addressed. Many questions still remain unanswered. Will pharmacists have the training and the time to explain the drugs and side effects to patients? Who will pay for that training? Will this third class pull more from drugs currently sold over the counter or from those requiring a prescription? And will drug companies push to get their current prescription products into this class to avoid regulation? Will behind-the-counter availability effectively turn the drug store counter into a vending machine, free from doctor's oversight? The FDA needs to put more research behind the plan before it tells Congress it's OK to put more drugs behind the counter."
Shari Roan of the Los Angeles Times reports on another new aspect to direct-to-consumer health marketing.
"Without even trying, consumers may soon hear more about genetic tests for breast cancer.After quietly offering the test for a decade, the primary supplier of the service, Myriad Genetics, has launched a direct-to-consumer advertising campaign. The test still requires a doctor's order, but the campaign is intended to urge people to talk to their doctors about their risk, the company said. Another company, DNA Direct, has been offering the test directly to consumers for several years, via a website. DNA Direct's test does not require a doctor's order, but the company encourages consumers to discuss the test with their doctors.
Some health professionals worry that people who aren't at high risk for breast or ovarian cancer will overreact to the advertisements and think they should get the test. The test isn't meant for the general population, only for families who have reason to suspect they are at high risk. It's also expensive and usually only covered by insurance if there is a family history of cancer.Others worry that consumers ordering the test online or asking their doctors for a lab order will bypass a discussion with a doctor or genetic counselor about what the test entails and how to interpret the results."
Scott Allen of the Boston Globe wrote an important story, "Cancer scares grow as screening rises." Excerpt:
"For every cancer survivor, there are several "cancer scare survivors" ... who have been told, based on imperfect tests, that they may have cancer when they do not.False alarms are not only stressful, but they also often force patients to undergo uncomfortable follow-up tests or even surgery, only to discover that they are cancer-free. Doctors perform an estimated 2 million biopsies, in which a needle is inserted to extract a tissue sample, on healthy breasts in women and prostate glands in men each year because of suspicious test results.
In one study, more than 500 women with no symptoms of ovarian cancer underwent unnecessary abdominal surgery because a blood test wrongly suggested they had the disease.
Unfortunately, in a nation where "early detection" is a mantra and where new high-tech screening tests are being promoted for lung and breast cancer, despite high error rates, it is increasingly possible that everyone will experience a cancer scare."
Judy Peres of the Chicago Tribune reports:
"As the U.S. enters National Breast Cancer Awareness Month, a new survey suggests raising awareness of the disease is a misplaced priority.The vast majority of women already consider themselves quite knowledgeable about the disease, which is expected to kill 40,000 women in the U.S. this year. But their "knowledge" often includes more myth than fact, the survey found.
"We're surrounded by pink ribbons and other messages about raising awareness," said Fran Visco, president of the National Breast Cancer Coalition, which commissioned the survey. "But these popular efforts lull the public into a false sense that adequate progress is being made.
"There's a lot of misinformation out there," Visco said. "In order to take meaningful action, we need to educate, not just raise awareness."
One "stunning" example, she said, is that people still believe heredity is the cause of most breast cancer cases, although in reality only 5 percent to 10 percent of breast cancer is caused by genetic mutations that can be inherited.
"Women need to understand that just because they don't have a family history, that doesn't mean they're not at risk," Visco said.
The survey, being released Monday, the first day of Breast Cancer Awareness Month, also found that 7 out of 10 women believe eating enough fruits and vegetables can help prevent breast cancer. In reality, there's no good evidence that this is true.
Other findings:
Most women (and nearly two-thirds of those age 18 to 24) believe breast cancer can be prevented. In reality, there are only a few things women can do to reduce, but not eliminate, the risk of developing the disease, such as not drinking alcohol and not taking hormones. The biggest risk factors are being female and getting older.
Nearly all women believe early detection of breast cancer is important for saving lives, and 4 out of 10 think self-exam is the best way to find the disease early, the same proportion that think mammograms are the best way. But large clinical trials have shown that self-exams do not prevent death from breast cancer, although they do lead to anxiety and unnecessary biopsies.
Even mammography screening, which has been shown to reduce the risk of dying of breast cancer, is less effective than most women think, Visco said. Mammograms can be inaccurate and come with unadvertised costs, including the risk of being diagnosed and treated for a tumor that would never have caused problems.
"Women want to believe there's a way to find it early, and that finding it early is enough to save their life," Visco said.
"I understand how scary this is," she said. "We could put out messages that would comfort people, or we could tell them what the reality is. But if we don't face reality, we can't move forward and find solutions."