Ben Goldacre, a British physician and writer, makes a prediction in this week's BMJ (subscription required for full article access):
"I'd like to make a sage prediction, seeing as it's early December. One of the joys of watching bad science coverage in the media—as I have done for four years now—is that you start to spot patterns: and this year, just like every Christmas, as regular as mince pies, I can confidently predict a specific rash of stories: they will explain solicitously that chocolate is good for you—"actually"—and red wine is even better.It's not much of a prediction, since in the world of public relations, Christmas has started already. "Choxi+" is milk chocolate with "extra antioxidants," and the newspapers are fawning over it already: "too good to be true," says the Daily Mirror; "chocolate that is good for you, as well as seductive," says the DailyTelegraph. The company is said to "recommend" two pieces of its chocolate a day. "Guilt free," says the Daily Mail: it's "the chocolate bar that's ‘healthier' than 5lb of apples." Meanwhile, Sainsbury's is promoting Red Heart wine—with extra antioxidants—as if drinking the stuff was a duty to your grandchildren.
These products represent triumphs of over-extrapolation from observational data, and laboratory hunches. ...
The antioxidant story took a bit of a blow, of course, when people started to do placebo controlled randomised trials with antioxidant vitamin supplements, to see what happened: because overall they seem to do nothing, or at worst, reduce life expectancy. And that's when you might start to think, well now, perhaps people who eat fresh fruit and vegetables are, just like the people who drink red wine in decorous moderation, living healthily in all kinds of ways. Much like the people who buy vitamin pills. Lusty walks around country mansions. Cycling to work. That kind of thing.
Of course there may yet be something valuable in the antioxidant story, although it's probably not going to be as simple as dishing them out by the spoonful. And of course observational studies aren't inherently evil or useless: they're frequently fascinating, as part of a puzzle. These are all interesting theoretical research findings, as we try to puzzle out the roots of cancer and heart disease.
But they make a pretty thin excuse for flogging chocolate and alcohol. And somewhere out there—right now—a researcher is rubbing their hands with glee, poring over a press release, picturing themselves in the Today programme studios, planning some choice quotes for the Daily Telegraph: something racy about mince pies cutting heart disease because of the raisins, perhaps, or red wine helping you run faster. Well, it's Christmas. Have another."
The Wall Street Journal offers a terrific and troubling profile of one man who went over his $1.5 million health insurance cap when a staph infection spread throughout his body, and was stuck with a $1.2 million hospital bill.
It's not just the 47-million uninsured who need help.
The Wall Street Journal reports on an article in this week's New England Journal of Medicine :
"Doctors are ordering too many unnecessary diagnostic CT scans, exposing their patients to potentially dangerous levels of radiation that could increase their risk of cancer, according to Columbia University researchers."
The New York Times magazine on Sunday offered a fascinating insider view from a physician who agreed to work for a drug company as a speaker.
A report entitled "Shock & Awe Hits Home," released by Physicians for Social Responsibility details more than $650 billion in long term costs as well as mental disabilities and disruptions to families of returning veterans of the Iraq War.
Blogger John Mack writes about the marketing of the drug Amitiza. He says the drugmaker, Takeda, engages in disease-mongering with a claim he found on the Amitiza website: "Chronic Constipation touches the lives of up to 28% of adults in America. Both men and women suffer from it, but the condition is two to three times more common in women."
Mack responds:
"What exactly "touches upon" means is anybody's guess. Nevertheless, the 28% figure is dutifully repeated in media stories.In fact, the media go even further and cite these numbers given to reporters by Takeda: "Constipation affects 42 million American adults, and 12 million could be characterized as suffering from chronic idiopathic constipation, the condition for which Amitiza is indicated..."
Let me whip out my trusty Microsoft desktop calculator and do some math.
How many US adults are "touched upon" by "chronic constipation?" There are about 220 million US adults over the age of 20. 28% of that equals about 62 million people. Clearly, that's a much greater number than 42 million adults that are said to suffer from simple "constipation" and much greater than the 12 million sufferers of "chronic idiopathic constipation," which is a form of constipation having an unknown cause. The latter is the "official" FDA approved indication for Amitiza. All the other numbers about simple constipation and "touched upon" seem to have been thrown in to confuse us into thinking that this drug is indicated for a much larger population than the FDA gives it marketing approval for."
So prepare for your TV shows and your Reader's Digest to be blocked up by new ads for this constipation drug.
We may be preaching to the choir with many of our attempts to improve health journalism if we only reach reporters. The editors to whom they report may be the most important group to reach to effect change.
With that goal, I'm grateful that The American Editor, a publication of the American Society of Newspaper Editors, published my article, "Misplaced priorities in health news coverage."
We’re in the middle of the November TV ratings/sweeps period. TV stations at these times often suddenly like to show a great interest in health care stories because their consultants tell them that viewers want health care news. (Why they don’t give it this attention the rest of the year is unknown.) But health care is not a topic that you can suddenly dust off and act like you understand it. There must be a daily commitment to the issues and to understanding what’s important for consumers to understand.
Last week, WCCO, a top-rated station in a major market (Minneapolis) delivered a story with a tone that suggested that the station felt it had uncovered a major issue: that health plans were giving doctors a financial incentive to prescribe a certain percentage of generic drugs.
Here’s the full text of the story.
It never explained why generic drugs are important in the nation’s cost control effort (if there is one).
It never interviewed a physician about his/her practice of prescribing generic drugs.
It quickly threw out a line that said “This practice is known as ‘pay for performance' ” – never explaining anything about the much broader definition of “pay for performance” or why it is being implemented in settings across the country or why many health policy experts think it is a wise move.
It profiled a patient who didn’t match the contrived controversy the station was presenting. The patient said he tried generic drugs but he suffered side effects, so his doctor prescribed a brand name drug. So what’s the story? No one forced anyone to do anything. And the patient says he’s now happy. Controversy? More like viewer confusion!
For some reason, WCCO only mentioned two health plans that use the generic incentives but there are others who do this that weren’t named.
Anyone who knows me knows I'm no apologist for the health insurance industry, but I felt compelled to get health plans' reaction to this story.
Spokesman Greg Bury of Medica (which was named) wrote me:
The piece did little to educate consumers about generic drugs and their role in treatments, the practice of medicine and efforts to control health care costs.As it was pointed out to WCCO, the drugs qualifying for the incentive have the exact same active ingredients as their brand-name counterparts. The FDA ensures that they are the same. Generic drugs started out as brand name drugs; therefore, one could argue that they are a safer starting point for treatment thana brand name drug because of their track record for safety and efficacy.
Generic drugs help control the rising cost of health care. They typically cost 80-90% less than their brand name counterparts. These savings are passed along to patients because their lowest copay level typically applies. The cost structure of generics also helps slow the rise of health care premiums that are paid by plan sponsors - employers for most people - and consumers themselves.
Overall, the story is a missed opportunity to point out the value of generic drugs in the health care system. One has to wonder if WCCO is interested in helping its viewers understand the system and how they can benefit from it or if they are more interested in stirring controversy to boost ratings. We are in a sweeps period, aren't we?
Medical director Dr. Pat Courneya of HealthPartners (also mentioned in the story) wrote me:
The story sets up a false dichotomy, suggesting that brand name drugs are inherently superior in some way to generics. Despite decades of effort by the pharmaceutical industry to sow doubt about the safety and effectiveness of generic drugs, the evidence shows they are both safe and effective. They now account for the great majority of the drugs prescribed to patients. Doctors write these prescriptions despite the billions of dollars spent to market brand name alternatives. They do not do so disregarding the best interests of their patients.Primary care doctors (I am a practicing Family Physician) would be insulted by the implication that we could be expected to "prescribe a certain number, percentage of generics, whether it's in the best interest of the patient or not." If I were told that, I would immediately protest and possibly contact an attorney. I have never been told to do anything whether it was in the interest of the patient or not, and I hope anyone who is would speak up.
Individual doctors do not get bonuses. Our financial rewards go to the medical groups – not individuals. Some medical groups use the money to further improve care for patients. For example one medical group used HealthPartners bonus to purchase a glucometer for their clinic so that diabetes patients could test their blood sugar and have the results in the exam room. The group was motivated to improve care for diabetes patients which is another measure in pay for performance.
If WCCO - or any news organization - invested in a full-time health care journalist - someone who fully developed health care reform issues such as generic substitution and "pay for performance" in its entirety - such pieces of naive, incomplete, pseudo-investigative journalism would not see the light of day. And the viewing audience would be better off.
Princeton economist Uwe Reinhardt, in an essay in the BMJ, writes:
"Although, by providing health care on an uncompensated basis, American physicians and hospital executives seek to promote the public good, their benevolence is led by an invisible hand to engender a situation of which society must be ashamed.For more than half a century now US health professionals have sought to operate, for the nation's ever growing number of poor and uninsured citizens, an informal health insurance system by providing care to them without being compensated. ...
Why, it may be asked, can such private benevolence add up not to the public good but to the public bad? The answer is that this benevolence gives undue moral cover to politicians who shirk their duty. To illustrate, in a speech on health reform in Cleveland, Ohio, on 10 July 2007, President Bush casually shrugged off the plight of the uninsured with the remark, "I mean, people have access to health care in America. After all, you just go to an emergency room"—with nary a concern expressed over how these emergency rooms will cover their costs. The president, of course, merely repeated here the mantra of politicians opposed to universal, government led health insurance that "to be uninsured in America does not mean going without care."
Although it is a fact that Americans who are critically ill are entitled by law to critically needed health care delivered by the nearest hospital, whether or not they can pay for it, the mantra misses the fact that such care is usually untimely. Uninsured children with asthma, for example, are more likely to be hospitalised than similarly situated, insured children, and so are uninsured diabetic people, to offer but two examples among many. In its 2003 report Hidden Costs, Hidden Value Lost: Uninsurance in America, the Institute of Medicine of the US National Academy of Sciences had estimated that, largely because of the lack of timely medical intervention, some 18 000 Americans die prematurely each year for want of health insurance.
Absolutely without intending to do so, the efforts of US healthcare providers to cater to uninsured people have aided and abetted great irresponsibility among the nation's political leaders, thereby perpetuating the plight of the uninsured. This is so because the benevolence of health professionals has provided political leaders with moral coverage for resisting any and all efforts to move the nation at long last to fully universal health insurance. By their benevolent ingenuity healthcare professionals in the US have, albeit unwittingly, allowed politicians to go to church or synagogue and feel right with God, just after voting down the latest proposal for universal coverage.
To identify this uniquely American phenomenon is, alas, not to provide a solution. In principle, America's providers of health care could force the hands of politicians, if they colluded in refusing to pull the politicians' coal out of the fire in this way. In practice that might engender a prolonged period of intense suffering among poor people, one that could last years before touching the conscience of the legislatures. It would not leave the providers of health care feeling right with God. And thus health professionals will continue to use their ingenuity to keep the US in the club of civilised nations, for which we must thank them."
The Wall Street Journal reports:
"Over a period of several years, drug maker GlaxoSmithKline PLC was so concerned about a prominent physician's negative views of its diabetes drug that it engaged in a concerted effort to intimidate him and stifle his opinion, a report by the U.S. Senate Finance Committee found.The report offers a window into the rarely acknowledged practice among drug companies of monitoring and seeking to influence the opinions of leading physicians, who can make or break a drug's sales.
The Senate Finance Committee released the report Thursday, after researching Glaxo's relationship with John Buse, a diabetes expert and professor of medicine at the University of North Carolina in Chapel Hill. In 1999, Dr. Buse began expressing concerns about the cardiovascular risks of Avandia, one of Glaxo's top selling drugs.
The Senate Finance Committee investigated the matter because it has jurisdiction over Medicare and Medicaid and wants to ensure that they are paying for safe and effective medicines, the report says. The committee, led by Montana Democrat Max Baucus and Iowa Republican Chuck Grassley, didn't recommend any particular action. It said it feared the Avandia case was part of a "troubling pattern of behavior by pharmaceutical executives."
"The effect of silencing [Dr. Buse's] criticism is, in our opinion, extremely serious," the report concludes, noting that patients may have needlessly suffered heart attacks during the period. "Had GSK considered Avandia's increased cardiovascular risk more seriously when the issue was first raised in 1999 by Dr. Buse, instead of trying to smother an independent medical opinion, some of these heart attacks may have been avoided," the report says.
This week, the Food and Drug Administration forced Glaxo to add a strong new warning to Avandia's prescribing label about potential heart-attack risks for patients taking the drug.
A Glaxo spokeswoman, Nancy Pekarek, said the company strongly disputes the committee's conclusions. She said Glaxo had tried to correct Dr. Buse's "inaccuracies" about Avandia but had never tried to intimidate or silence him."
The Wall Street Journal reports on questions being raised about genetic screening, egg freezing and other high-tech fertility therapies. Excerpt:
"As medical science continues to churn out ever-more-sophisticated methods to treat infertility -- from egg freezing to genetic screening of embryos -- desperate would-be parents rush to embrace the latest techniques. But some fertility experts worry that procedures of limited benefit are unfairly raising patients' hopes.Just last month, a new embryo-screening technique created immediate buzz when it was announced at a meeting of fertility experts. A parent group hailed it as a "breakthrough" that may improve women's chances of having a baby through in-vitro fertilization. The American Society for Reproductive Medicine, which hosted the meeting, awarded the technique a prize for outstanding research.
But that same day, a related group of experts issued a warning. A committee of the ASRM, together with the Society for Assisted Reproductive Technology, released a statement urging caution about certain kinds of genetic embryo screening, due to insufficient scientific evidence about the usefulness. A similar concern was noted about egg freezing -- or oocyte cryopreservation -- for healthy woman who want to preserve their eggs for use later in life. The statement called the technique "experimental."
Such warnings join a host of concerns -- including some raised by a recent study in the New England Journal of Medicine -- that question the usefulness of advanced fertility treatments for many patients. While such treatments are offered with all kinds of caveats that no baby is guaranteed, the marketing of them may play into the fears of patients facing an emotionally fraught decision. At their worst, critics say, some treatments may interfere with patients' goal of having a baby. And they are expensive, often costing thousands of dollars."
U.S. Senator Charles Grassley (R-IA) has asked Medicare how it "assesses the content of the journals of science and medicine that it uses, in part, to make decisions about Medicare payments."
In a news release Grassley said, “I want to make sure the federal government relies on the best available science and that’s science that is peer-reviewed and free of bias."
In the letter to Medicare, he wrote: "Conflicts of interest have been proven in peer-reviewed studies to have a significant impact on scientific outcomes. Accordingly, it is important that scientific journals maintain policies of transparency and financial disclosure. ... With this issue in mind, it is troubling that few journals require authors to reveal who funded their research. Indeed, a 2001 study examined the top 1000 journals in science and medicine. The researchers found that only 16% of the journals had conflict of interest policies."
The Integrity in Science Watch program says that Medicare recently named 11 journals to the list of medical journals used to justify reimbursement for off-label use of cancer drugs. At least one of the journals did not require authors to disclose conflicts of interest and more than half did not require registration of clinical trials prior to publication, according to an Integrity in Science Watch survey."
Minnesota Medicine this month has a good summary of our work to date with HealthNewsReview.org.
You must see Consumer Reports' terrific new "antidote to TV drug ads" - its new AdWatch feature.
In it, they dismantle the claims made in the ads for the drug Requip for restless leg syndrome.
I've spoken with some folks at CR and they're very pleased with the initial response to the new feature and plan many more like it.
The UK newspaper, The Independent, reports:
"Multinational drug companies are showering doctors in the developing world with gifts and inducements to persuade them to prescribe drugs of dubious value, an investigation has revealed.Intense marketing of medicines has resulted in up to half of drugs being wrongly prescribed, the campaign group Consumers International says in its report Drugs, Doctors and Dinners. It calls for a ban on gifts to doctors.
A GP in Malaysia, Rafik Ibrahim, who practises near the capital, Kuala Lumpur, described how in a period of five weeks in August last year he spent 17 hours with drug-sales representatives who approached him on behalf of 25 drug companies. In Pakistan, doctors who wrote 200 prescriptions for one high-price drug were offered the down payment on a new car.
Multinational companies are turning to the developing world as profits stagnate in the West. But regulation in these countries is weak and drug sales representatives can influence prescribing by the inducements they offer.
India was one of the fastest-growing markets last year, with sales increasing 17.5 per cent to $7.3bn. But the health commission, in 2005, labelled 10 out of the 25 top-selling medicines as being "irrational or non-essential or hazardous".
Richard Lloyd, of Consumers International, said: "The pharma industry sees the developing world as a trillion-dollar opportunity... but consumer health expenditure in these countries can ill afford to be squandered." He added: "The best way to ensure patients in the developing world get rational impartial treatment is... to ban gifts for doctors." "
Blogger Jay Parkinson gets hot about Pfizer's attempt to stave off generic competition for Lipitor. Excerpt:
"Many of you may have heard the ads recently playing all over the airwaves about the benefits of Lipitor, the best-selling drug in America. Here’s a little history behind these ads. Pfizer developed Lipitor years ago and aggressively marketed it touting it’s safety and effectiveness. It rose to the top and brings in over $12 billion dollars in annual sales. It’s had some competitors (such as Merck’s Zocor) but with all of the marketing to doctors and consumers, Lipitor secured over 40% of the market for cholesterol-lowering drugs. About 18 months ago, Merck lost Zocor’s patent and Zocor became available as generic simvastatin. Doctors have been switching their patients to simvastatin in droves. Some health insurance companies are even paying their doctors $100 for each switched patient! Not surprising. It’s very cost effective to switch patients because simvastatin can be had for about 10 cents a day, whereas Lipitor can be about $4 a day. Based on this cost difference, there are maybe 50 patients throughout the entire country who should still be on Lipitor…and that’s a big maybe.In the past 18 months, Lipitor’s share of the market has decreased ten percent but currently still retains 30% of the market. Ten percent of $22 billion dollars is not pocket change. Pfizer’s not going down without a fight even when the patent on Lipitor will expire in March 2010. They’ve doubled their advertising for Lipitor (which was previously $140 million dollars in 2006) and gotten some jackasses like Dr. Robert Jarvik on board to sell their souls for Money…or…umm…Science. He invented the artificial heart. He is citing a joke of a study based on Science (or rather Money) and completely funded by Pfizer that says Lipitor decreases risk of heart attacks when compared to patients on Simvastatin. They also have Dr. Louis W. Sullivan (another jackass) on board with a sponsored propaganda tour of the United States promoting the benefits of Lipitor (well, not officially, the actual argument in this speaking tour is against insurers and their influence on medical decisions). I hope that fool’s propaganda tour rolls through NYC. I’d love to ask him one question:
“If Lipitor costs 400% percent more than generic simvastatin, shouldn’t there be a 400% added benefit to keeping patients on Lipitor?”
From Integrity in Science Watch, a publication of the Center for Science in the Public Interest:
"Nearly 50 orthopedic surgeons, many affiliated with the nation’s top teaching hospitals, each earned over $1 million a year in consulting contracts and royalties from the five companies that make artificial knees and hips. The payment disclosures were posted on the companies’ websites last week as part of a $311 million anti-kickback settlement between four of the firms and the U.S. attorney for northern New Jersey. The complaint had accused the companies of using consulting contracts as an illegal kickback scheme to get surgeons to use a particular company’s artificial joints. ...With seniors accounting for nearly 70 percent of the knee and hip replacement market, Medicare spent $16 billion on the procedures last year. A typical knee replacement costs $33,000, according to Medicare records. A spokesman for Christopher J. Christie, the U.S. attorney in Newark, said the investigation into the alleged kickback scheme is ongoing."
This weekend, the New York Times had a terrific story on Pfizer's battle to pump life into Lipitor to stave off generic competition. Excerpt:
"It is shaping up to be the biggest shift yet to a generic drug, potentially saving the nation $2 billion a year or more in prescription costs.And scientists and doctors say that for most of the 16 million people in America who take drugs to reduce cholesterol, the low-priced alternative will work as well as the name-brand medicine — Lipitor, which is made by Pfizer and is the nation’s most widely prescribed drug.
While Lipitor itself is not available as a generic, a very similar drug made by Merck, Zocor, lost its patent protection last year. The generic version of Zocor, simvastatin, is now much cheaper than Lipitor, leading insurers to press doctors and patients to switch.
But Pfizer is not letting its flagship drug go down without a fight.
The company has mounted a campaign that includes advertisements, lobbying efforts and a paid speaking tour by a former secretary of the federal Department of Health and Human Services. Pfizer is also promoting a study — whose findings many experts are questioning — that concluded that British patients who switched to simvastatin had more heart attacks and deaths than those who remained on Lipitor.
The Lipitor battle has become a test of the pharmaceutical industry’s ability to defend name brands, even as insurers, patients and doctors seek to whittle the nation’s $270 billion annual prescription drug bill by using generic alternatives whenever possible."
The Wall Street Journal's Health Blog quips that the ad campaign featuring artificial heart inventor Robert Jarvik makes him "nearly as ubiquitous as Verizon’s Test Man."
In his weekly newsletter, former U.S. Senator David Durenberger, now head of the National Institute of Health Policy writes:
“Private insurance giants United Health Group and Humana have priced 1.6 million seniors out of their current prescription drug plans. In some of the largest states in the country these top two Medicare sellers have submitted bids for 2008 which will require beneficiaries to go find other plans. …In traditional Medicare you wouldn't have this problem. It is not taking us long to find that private insurance competition is not necessarily the best nor the cheapest way for Medicare beneficiaries to access prescription drugs.October's AARP Bulletin alerts me "Don't Fall for the Hard Sell." AARP is alerting its members to the downsides of private Medicare rather than Traditional Medicare (or "socialized medicine" as their GOP friends call it.) AARP's problem is with the hundreds of thousands of insurance agents who peddle these new plans and their prescription drug cousins to elderly folks used to dealing with Medicare as they and their parents knew it. These agents get paid a lot more for selling (the private “Medicare Advantage”) plans than drug or medigap plans, something like $250 to $500 per sale. …Starting in January, AARP will be selling its United Health/AARP MA plan. We'll find out then what kind of "trustworthy" agents we will be dealing with.”
Merrill Goozner beat me to the keyboard (damn, he's good) with a followup note about Rudy Giuliani's misguided statement that the US has a far better prostate cancer survival rate than the UK (home of "socialized medicine," as Rudy points out).
In a nutshell, any comparison of prostate cancer survival in the US and UK is apples and oranges because Brits don't love the PSA test like we do. Nobody loves it like we do. Nobody loves screening tests like we do. Nobody wants to find - or count - some of the cases we find and count in our totals: early, non-aggressive tumors that won't kill anyone but which will drive men to anxiety and aggressive treatment.
So our survival rates are - by definition - inflated. We count survivors who wouldn't have died of prostate cancer anyway! Epidemiologists call this "lead-time bias."
Some have said that five-year survival rates are becoming meaningless. Howard Parnes, chief of the Prostate Cancer Research Group at the National Cancer Institute is quoted saying, "When you introduce screening and early detection into the equation, the survival statistics become meaningless. You are identifying many people who would not otherwise be diagnosed."
With U.S. prostate cancer five-year survival rates approaching 100%, some have said "it almost looks like this is not a disease!"
So this isn't nit-picking. There are huge policy implications of a presidential candidate believing that his country's health care system is so much better than another country's - and basing it on such flawed assertions.
Let us help you connect the dots between two news items this week on how the U.S. compares with other countries in health care.
One was Rudy Giuliani's ridiculous assertion: "My chance of surviving prostate cancer, and thank God I was cured of it, in the United States - 82 percent. My chances of surviving prostate cancer in England - only 44 percent, under socialized medicine."
You know, Rudy, the "socialized medicine" rant is becoming as tired as your capitalizing on the 9/11 tragedy for political purposes. (Joe Biden gets the "quote of the campaign" award so far for saying, "There’s only three things (Giuliani) mentions in a sentence: a noun and a verb and 9/11.”) But in this case Rudy tried to deal with facts - not just emotion - and his facts are fatally flawed.
The second came from the journal Health Affairs:
"At a time when the U.S. spends more than double what other countries spend for medical care -- $6,697 per capita in 2005 -- a new Commonwealth Fund seven-nation survey
published today as a Health Affairs Web Exclusive finds that U.S. patients are more likely than any others to report experiencing medical errors, to go without care because of costs, and to say that the health care system needs to be rebuilt completely."
So you can wrap yourself in the flag all you want while blindly proclaiming the unparalleled pre-eminence of the U.S. health care system - but the facts don't back you up. And raging rhetoric about the horrors of "socialized medicine" don't move us any closer to identifying or addressing problems and solutions.
A news release from the journal Health Affairs:
At its twenty-fifth anniversary health policy summit, Health Affairs named Jack Wennberg, a professor of medicine and community and family medicine at the Dartmouth Medical School, as the most influential health policy researcher of the past 25 years.Through four decades of work, Wennberg has documented the geographic variation in the health care that patients in the United States receive. In 1988 he founded the Center for Evaluative Clinical Services (CECS) at Dartmouth Medical College. Together with his CECS colleagues, Wennberg has produced the Dartmouth Atlas of Health Care, a series of reports on how health care is used and distributed in the United States. In June of this year, Wennberg stepped down as director of the CECS, now known as the Dartmouth Institute for Health Policy And Clinical Practice (TDI).
“When Jack started his work, geographic variation in health care -- and the resulting variation in health care costs -- was largely unknown and unremarked upon,” said Health Affairs founding editor John Iglehart, who presented an award from the journal to Wennberg. “But thanks to Jack’s persistence, the idea that the care you receive is largely determined by where you live -- and not necessarily by what is most appropriate for you -- has become part of the common parlance of health policy.”
Indeed, Wennberg’s work has shown that areas that spend more and provide more services often experience worse outcomes than lower-spending areas that provide less intensive care. In a 2002 Health Affairs article, Wennberg proposed a Medicare reform plan based on reducing unwarranted regional variations in spending by the program. In the latest Dartmouth Atlas, Wennberg and colleagues state that “the Medicare system could reduce spending by at least 30 percent while improving the medical care of the most severely ill Americans.”
Wennberg’s recent work has focused on documenting outcomes and communicating outcomes information to patients. This focus is reflected in his article in the Nov/Dec 2007 issue of Health Affairs. In the first part of a two-part article, Wennberg and coauthors urge the Centers for Medicare and Medicaid Services (CMS) to use its pay-for-performance program to ensure that patients are both informed and empowered to choose appropriate discretionary treatments.
The Nov/Dec article represents the most recent of twenty-two times Wennberg has been published in Health Affairs. The first time came in the summer of 1984, when Wennberg headlined a thematic Health Affairs issue on health care variations. In that issue, Iglehart quoted the then-president of the Institute of Medicine, Frederick Robbins, as stating of widely varying health care practices: “It is not an appropriate way for [the medical profession] to behave.”
Robbins’ injunction notwithstanding, geographic variations in health care have persisted. But today we know far more about these variations, and are far more able to judge the relative cost-effectiveness of differing approaches to care, because of Jack Wennberg’s work.
Here's an example of a story that could confuse the hell out of readers - simply because of the way it's written.
The lead is:
Screening MRIs can uncover potential trouble in the brain, a new study suggests.
But the first quote with the principal investigator is:
"Our study shows that incidental findings are much more frequent than was thought previously."
So what should be the story's point of emphasis? Screening finds trouble? Or screening finds lots of stuff that isn't troublesome?
The end of the article starts to catch up with the real impact of the study when it states:
"(The researcher) said that general screening for these conditions wouldn't be recommended, because it's not yet clear if these asymptomatic conditions should be treated.Dr. Arno Fried, chairman of the department of neurosurgery at Hackensack University Medical Center in New Jersey, agreed.
"Screening would probably create too many problems unless someone was experiencing specific symptoms. ... The problem is what to do about incidental findings," he noted. "What's most important is to correlate clinical status with what we see on the scan. Most of the time, we won't do anything about those incidental findings. Some people will be asymptomatic forever."
Fried suggested that people, "Don't panic when an incidental finding is seen. Many people don't need surgery." He said that while a brain tumor may sound scary, many that are small and aren't causing symptoms don't need to be removed. Aneurysms may require treatment, but if they do, it's generally better that it was discovered early.
The bottom line, said Fried, is that "technology and imaging don't take the place of good clinical judgment. If the technology is taken out of context, it may lead to surgeries that don't need to be done."