February 2009 Archives

If you want to get a picture of the crazy quilt of US health care, take a look at the new Dartmouth Atlas Project report.

It shows that:

Medicare spending is rising more than twice as fast in Dallas as in San Diego.

Medicare is spending nearly three times more on seniors in Miami than in Honolulu.

In the image below, Wausau, Wisconsin is shown with rapidly rising Medicare costs amidst a sea of otherwise lower-spending Midwest hospital regions. Why?

Or you can go to this full interactive scroll-over-your-region map.

A news release accompanying the report says:

“This illustrates how huge inefficiencies in the U.S. health care system are hamstringing the nation’s ability to expand access to care.

The authors argue that the differences in growth are largely due to discretionary decisions by physicians that are influenced by the local availability of hospital beds, imaging centers and other resources—and a payment system that rewards growth and higher utilization."

“To paraphrase a line from the gun control debate: technology doesn’t drive the growth in health care spending; people do,” said lead-author Dr. Elliott Fisher, principal investigator for the Dartmouth Atlas Project and director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practice. “The good news is that in many regions, spending is growing relatively slowly. Reformers can learn from these regions and put in place policies that help them sustain what they are doing now, and encourage high-cost, high-growth regions to change their ways.”

“This work demonstrates why health reformers should work to realign private and public payment schemes to benefit quality performance over the volume of services,” said Dr. Risa Lavizzo-Mourey, president and CEO of the Robert Wood Johnson Foundation. “Clinicians who successfully provide high quality care and slow spending growth should be rewarded, not penalized.”

“This is an opportunity for physicians to lead,” said Dr. Julie Bynum, co-author and assistant professor of Medicine at Dartmouth Medical School. “But even though doctors still make most of the critical decisions about how and where their patients get care, they will need help from payers and policymakers. Physicians operate under the rules of a system that is rigged to reward high-cost care.”

More maps are available online.

So is the study, published in the New England Journal of Medicine.

There's an important message for consumers here. This isn't just academic policy wonk talk. Health care consumers need to know that there's tremendous variation in the way health care is practiced in this country. There is tremendous uncertainty about best practices and best treatments. And - repeat after me -

MORE IS NOT ALWAYS BETTER - NEWER IS NOT ALWAYS BETTER - IN HEALTH CARE.

What if consumers could calculate the benefits and risks of taking a prescription drug as easily as they can gauge the carbs and calories of an Oreo cookie?

That's the way Natasha Singer started her piece in the New York Times yesterday about a new proposal for improved benefits-and-harms disclosure on drug ads.

Dartmouth's Steve Woloshin and Lisa Schwartz propose that the F.D.A. require new facts boxes on ads - somewhat akin to nutrition fact panels — "numerical tables that quantify the benefits of taking a drug compared with a placebo, and that list the odds of having side effects."

Woloshin told the Times: “We thought, if you could do it for Cocoa Krispies or Diet Coke, why couldn’t you do it for Lunesta or other drugs?”

Other excerpt:

The Dartmouth researchers, in one example, used data from a published study of the insomnia drug Lunesta to create a benefit box showing that volunteers who took the sleeping pill nightly for six months typically fell asleep 15 minutes faster than people on a placebo. The table, e-mailed to a reporter, also indicates that volunteers taking Lunesta typically slept for six hours and 22 minutes — or only 37 minutes longer than the placebo group. There was no difference in life-threatening side effects among the groups.

In 2007, Sepracor, the maker of Lunesta, spent about $293 million on advertisements for the sleeping pill, the highest ad spending that year among drug brands, according to Nielsen.

Ron Winslow has an important piece in the WSJ today based on this week's JAMA study:

Tricoci P, Allen JM, Kramer JM, et al. Scientific evidence underlying the ACC/AHA clinical practice guidelines. JAMA 2009; 831-841.

Winslow's lede:

Heart disease is among the most studied illnesses in all of medicine, yet just 11% of more than 2,700 recommendations approved by cardiologists for treating heart patients are supported by high-quality scientific testing, according to new research.

About half the medical recommendations for heart patients have limited scientific backing, according to (the study). Instead, they are based mostly on expert opinion -- subjective viewpoints where consensus is often lacking.

Kudos to Jamie Hirsh and the Consumer Reports team on another terrific "reality check/ad watch" - this time on "stealth" ads for the stop-smoking drug Chantix.

CR has done several of these now, but they can't do them fast enough in my view.

The truthtelling that should be done on direct-to-consumer drug ads is a huge task.

Remember: we're one of only two countries on the globe that allows direct-to-consumer drug ads.
And New Zealand - the other - has been making noise about adopting a ban.

Which would leave us where we often are in health care: #1 atop the world!!!!

Just not in ways we should be proud of.

Someone stop me if you ever hear me say that I've seen the worst TV health news piece. The bottom keeps dropping.

This piece is a contender for bottom-dweller.

(Note: before you can actually enjoy the piece, you'll have to watch a CBS promo in this clip for all the awards they've won. And you'll see at the end their tagline, "Very Good News." This piece, I warn you, will not win an award and was NOT very good news.)

Watch CBS Videos Online

Let's recap:

A young woman whom the anchorman calls "healthy...gorgeous" but who wants to rid herself of a tiny fat pouch in her belly gets lunchtime liposuction. The surgeon comes on the set with her to chat with the anchorman. But in more than 5 minutes (an eternity in TV news!), they fail to discuss:

• evidence
• how widely the costs vary from the $3,000 the promoting-surgeon cited
• whether insurance pays for it.

Viewers should ask themselves: if this "healthy, gorgeous" young woman wanted to have a little fat pouch removed and if she were in your insurance pool and if insurance covered it, would you want your premiums to go up as a result?

Why don't we have news stories about that?

That would be journalism. This was free advertising: 5 minutes worth!

So there’s money in the stimulus plan to create a process to compare treatments, tests and procedures – “comparative effectiveness” is the goal.

Of course the UK has had such an agency for a decade.

It has the nice-sounding acronym of NICE but many critics don’t think it’s so nice. It stands for the National Institute for Health and Clinical Excellence.

Matthew Holt had a good article about NICE last August.

And on the recent 10th anniversary of NICE, BMJ editor Fiona Godlee wrote about it an issue of the journal that contained a series of articles about NICE. She wrote:

Controversial from its inception and constantly in the public eye, NICE’s survival alone is surely something to celebrate. …

NICE is a national treasure. It needs critical friends. Perhaps beyond sheer survival the clearest signs of its achievement over the past 10 years are its undiminished unpopularity with the drug industry and its growing popularity with governments around the world. As Nigel Hawkes quips in his report on NICE’s global expansionism "the drug industry would love to have exported it, preferably somewhere like Mars."

Maybe, finally, the US can adopt and refine some of the “comparative effectiveness” steps that the UK and other countries have been taking for years in the face of the medical arms race and out-of-control health care costs.

A college basketball player just gets out of the operating room and headlines across the country call the surgery a success!

I hope Dyson has a great recovery.

But such knee injuries have changed many hoopsters' careers. Inane headlines like this promote the deification of surgeons and the "instant fix" image of surgery that can be so far from the truth.

I had ACL reconstruction surgery for a basketball injury in 1987. I'm still playing hoops weekly against undergrads. So I know the surgery can work. But I also remember how hard I worked at rehab. You can't call it a success just because they sewed him up.

Remember the wise old warning: "The operation was a success but the patient died."

If there's any doubt about the impact of public relations efforts on news coverage of health products, look at what the PR company Fleishman-Hillard brags about on its website. They describe a campaign for a diarrhea vaccine. From their website:

Don't Leave Home Without It

Fleishman-Hillard launches Dukoral. A three-pronged media relations campaign resulted in 19 million impressions (triple the project goal), physician acceptance and consumer demand for Dukoral.

Dukoral, the first and only oral vaccine for protection against most common causes of Traveller's Diarrhea. For the project spokespeople were identified in key Canadian Markets (Vancouver, Toronto, Montreal-bilingual) willing to speak to the media about Dukoral. The spokespeople represented Dukoral to travel, healthcare and consumer media. All media coverage has had a direct impact on the target audiences. Media coverage incorporated key messages about Travellers' Diarrhea and Dukoral's role in the prevention of this potentially serious illness. Attributed to the extensive media coverage physician have reported to sales team that many patients have asked for Dukoral bringing in articles consumers themselves have read.

Journalists love toilet jokes in their stories. Melody Petersen, in her book, Our Daily Meds: How the Pharmaceutical Companies Transformed Themselves into Slick Marketing Machines and Hooked the Nation on Prescription Drugs, wrote that too many journalists too easily fall into drug company plans to create a market for a drug, such as, in one case, a drug for “overactive bladders.” “Dozens of journalists at newspapers and television stations across the country wrote stories about the disorder said to be destroying the lives of millions of Americans,” she wrote. “Editors and television news directors loved these reports. Silly stories of people running to the toilet brightened the day’s news.”

Dukoral is not yet approved by the FDA.

Thanks for the tip to Alan Cassels, who also points out questions about the vaccine's effectiveness and its cost.

Former US Senator David Durenberger (R-Minn.), in his weekly e-mail newsletter, quotes George Halvorson, CEO of Kaiser-Permanente, the largest health maintenance (health and healthcare delivery and financing) company in the world.

"Expecting our massive, very well-financed, high revenue, high margin, high growth, healthcare infrastructure to voluntarily reduce costs and prices and expecting them to voluntarily and spontaneously improve either outcomes or care quality is unfortunately naive. It is almost entirely funded by a steady and massive stream of fees and cash payments that have no linkage to either care quality, efficiency or results. It is magical thinking to believe that health care delivery can, or even could, reform itself in any significant way. There is no economic reward for improving care."

Last year the Kaiser Family Foundation asked me to research and write a report on the state of health journalism in the US. That report will be released and discussed at a news conference in Washington, DC, in three weeks. The announcement was made yesterday:

Which should you believe? Clinics like this that promote their technology, offering cool $50 coupons?

Or the U.S. Preventive Services Task Force, which states:

* The U.S. Preventive Services Task Force (USPSTF) recommends against electron-beam computerized tomography (EBCT) scanning for coronary calcium for either the presence of severe coronary artery stenosis (CAS) or the prediction of coronary heart disease (CHD) events in adults at low risk for CHD events.

* The USPSTF found insufficient evidence to recommend for or against routine screening with ECG, ETT, or EBCT scanning for coronary calcium for either the presence of severe CAS or the prediction of CHD events in adults at increased risk for CHD events.

Beware of promotions of "simple 5 minute" tests. The picture - and the story - is much more complicated than the enticing ads admit.

Beware of anyone telling you to "know your score." Know the facts before you worry about putting another score, another measurement, another reason to be anxious in your head.

I bit my lip for more than six months, but after about 10 calls from reporters in the past two months, I decided to say everything I had to say in a guest column in the Minnesota Daily , which has taken heat from University of Minnesota medical school administration for its reporting on the school’s conflict of interest recommendations process.

I feel for those young journalists who have been trying to do a good job reporting on this bungled affair, but who have been stonewalled by many medical school faculty. It’s easy to take shots at young journalists; it’s harder to reach out and help them learn and improve. Across the University campus in the past eight years I’ve been appalled by the way student journalists have been treated by faculty, staff and administration.

In this case, I think the med school has an awful lot of introspection to do before it starts pointing fingers.

The University's senior vice president for Health Sciences, Frank Cerra, raised a false dichotomy in his guest column in the Daily this week, writing:

“I want to state clearly that this University, our Medical School and all health sciences schools must have industry relationships. … to suggest we sever all ties with industry is a mistake with enormous consequences for the nation’s health.”

I never heard anyone suggest that all ties with industry be severed.

But the following comments are more troubling.

“Finally, I expected more fairness, more facts and less innuendo from the Daily than the coverage during the past several weeks. It’s unfortunate that this important effort continues to be misrepresented by a few who seem to want to influence the outcome outside of the process. The faculty of the Medical School have brought forth their thinking. This is their voice…”

How does he know the effort was misrepresented? He never attended one of the task force meetings. Whom does he refer to as the “few who seem to want to influence the outcome outside of the process”? That’s a pretty vague broad-brushed attack against anyone who comments.

But his emphasis on the faculty’s thinking and the faculty’s voice is most troubling of all.

That shows the lack of a grasp for the importance of public input on the school’s conflict of interest policy – the very point of my guest column.

I hope something good comes from all of this discussion.

There are WMD’s lurking inside your body. And you better find them ASAP.

In its health section today, the Washington Post gives men of all ages screening test advice – much of it not grounded in the best medical evidence or at least not reflecting real controversies in health care.

They do one of those “What To Do In Your 20s, 30s, 40s, 50s…” columns that news organizations find so appealing and that I find so incomplete.

Sanjay Gupta and CNN have done the same thing

So has the Star Tribune and many other news organizations.

Among the questionable advisories from the Post:

• Telling men in their 30s to “sign up for complete physicals”
• Telling men in their 40s to get a complete physical every two years

There was no mention of the controversies surrounding such recommendations - some experts calling it wasteful.

• Telling men in their 40s to start skin cancer screening.

Aren’t they aware that the US Preventive Services Task Force just last week stated :

“ the current evidence is insufficient to assess the balance of
benefits and harms of using a whole-body skin examination by a
primary care clinician or patient skin self-examination for the
early detection of cutaneous melanoma, basal cell cancer, or
squamous cell skin cancer in the adult general population.” ???

They go on to tell men in their 50s to have prostate cancer screening. (They do say the pros and cons should be discussed, but the recommendation for such screening stands nonetheless.)

Again, the USPSTF states: “the current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75 years.”

What the Post promotes may be one doctor’s – or some doctors’ - opinion(s). But for a major newspaper to state these as if they were handed to Moses on stone tablets is wrong. There are uncertainties. There is controversy. Screening tests can cause harm - not just benefit. And good journalism should reflect that.

Some of the very disparate views about how health news should be covered in the daily news media were on display recently at a debate, sponsored by the Guardian newspaper, held during a Lancet conference in London. BMJ associate editor Rebecca Coombes wrote about it in last week's journal. Excerpts:

The event exposed the gulf between detail obsessed academics and time poor, space hungry, national newspaper journalists. As doctor, research fellow, and Guardian columnist, Ben Goldacre bemoaned the Daily Mail for its insistence on "dividing all the inanimate objects in the world into those which can cause or cure cancer," the professional journalists became exasperated with him for seeing the media as a monolithic organisation.
...
But journalists could not be straitjacketed into writing like academic researchers (said one journalist who) referred to a "prescriptive and irritating" code of conduct issued by the Royal Society a few years ago, which gave journalists a checklist to use before filing any story. It asked questions such as, is your story scaremongering? If reporting on a clinical study, make sure all conflicts of interests are identified, that independent sources were used, and so on. "All this in a 200 word story, give me a break". There was, he said, a breed of "academics who want journalists to act as a transmission belt for their ideas."

"Scientists expect us to include every counter story, every caveat, but you don’t have that luxury [as a journalist]. And your stories are competing with every other field of human knowledge. The person I have in mind when I write a story is the man or woman on the tube holding on to the bar, or the person online who is only two clicks away from a story about the latest antics of Britney Spears."

I wish I could have been there.

The "prescriptive and irritating code of conduct" and the "checklist" sounds very much like our HealthNewsReview.org approach - although I would never refer to it as a code of conduct. But, yes, some US journalists might call it prescriptive and irritating.

Most that we've heard from don't, though.

We actually have two surveys out in the field right now:

1. Of all members of the Association of Health Care Journalists;
2. Of all journalists whose work we've ever reviewed on HealthNewsReview.org

The response rate has been abysmal. I know that health journalists feel they have been surveyed to death. Nonetheless, here are some responses:

• I love it. There's so much awful health reporting out there in very respected publications. It is important to train reporters and to make the public aware of what to look for in stories. Keep up the great work.
• Wish we'd known about it sooner.
• You're doing good work and maybe I just need to be reminded more to use it.
• The web site is helpful in forcing me to improve the quality of my work.

And then this:

You live in a bubble. Newspapers are imploding, we are struggling to deal with virtually no resources and increased demand for content and you offer no insight into how to produce quality stories under the circumstances. In a perfect world, we would all gladly embrace your guidelines, but it's far from a perfect world and you're obviously not acknowledging that.

This is why we need a conversation. Our ten criteria are our attempt to give insight into how to produce quality stories under the current circumstances. And I don't live in a bubble. Next month the Kaiser Family Foundation will release a report I wrote based, in part, on interviews with about 50 health journalists.

Our ten criteria are not an academic exercise. They are not an attempt to turn news into a medical journal. They are key questions we think any consumer should ask about any claim made by anyone about new health care treatments, tests, products or procedures.

I always ask journalists: if not our criteria, what criteria do you employ in choosing health news stories and in deciding how to write about them?

That tends to be a very short discussion, because there usually isn't a comeback.

Because too often health news is treated as if it is only two clicks away from Britney Spears news in the paper. And maybe readers don't want that. And maybe that's why you're losing them.

Newer is not always better. Evidence is important. Simple themes, oft forgotten in health journalism.

Back in October, an Atlanta Journal-Constitution story talked of the wonders of virtual colonoscopy, saying it replaced the dreaded colonoscope and lessened patient risk. It used these words to refer to the technology: "science fiction, Star Wars, video game, Disney World."

Also in October, the Wall Street Journal promoted the growing popularity of virtual colonoscopies.

Neither story mentioned the fact that the U.S. Preventive Services Task Force had stated that same month that "The evidence is insufficient to assess the benefits and harms of computed tomographic colonography as a screening modality for colorectal cancer."

Last week's announcement that Medicare may stop paying for virtual colonoscopies also got little news attention. At least the New York Times reported it. Excerpts:

The Centers for Medicare and Medicaid Services said in a decision posted on its Web site that there was "insufficient evidence" to conclude that virtual colonoscopy "improves outcomes in Medicare beneficiaries."

...the United States Preventive Services Task Force, which advises the government on prevention, said last year that there was insufficient evidence to assess the benefits and harms of the CT technique. Some private insurers pay for the tests; others do not.
...
In its analysis, Medicare said many studies supporting virtual colonoscopy were done in people with a mean age around 58, so results might not fully apply to Medicare's older population.

For instance, older people are more likely to have polyps. So the proportion of people who would have to have a conventional colonoscopy after a virtual one would be greater. That would make the CT scan less cost-effective.

"The specter of the government coming between doctor and patient raised its head again," Trudy Lieberman writes, about a CNN segment that she says "ranks among the most irresponsible health stories I’ve seen over the past year."

Which reminds me: what's the update on the Surgeon General choice?

Do you think Daschle's conflict of interest issues may have given the President second thoughts?

When will journalists learn?

They didn't learn from the pleconaril hype - an episode I documented wherein 1,000 stories over five years described this drug-in-development as a "super drug...wonder drug...cure...like man landing on the moon...like the search for the Holy Grail." It bombed.

So here's the New York Times headline on new research published yesterday in the journal Science:

Different versions of the story did have different takes of skepticism, but both that I saw turned to the same source - a spokesman from Viropharma, the company that tried to market pleconaril!!!! Excerpts:

Even so, it might be difficult to kindle the interest of pharmaceutical companies. While the new findings are “an interesting piece of science,�? said Dr. Glenn Tillotson, an expert on antiviral drugs at Viropharma in Exton, Pa., he noted that the typical cost of developing a new drug was now $700 million, “with interminable fights with financiers and regulators....How much relevance it will have for the pharmaceutical industry, I'm not certain.�?

HealthDay's lede was worse. It made it a statement of fact, saying:

Today's medical breakthrough: a cure for the common cold.

Keep the tissue box handy. This one isn't as imminent as these headlines and ledes might lead you to believe.

This headline - and others like it - applauded a gift to one new children's hospital in Minneapolis-St. Paul.

But there continues to be little discussion of why the existing players in this market couldn't collaborate and therefore there are now two major construction projects involving two competing pediatric care entities in the Twin Cities.

And now there will be FIVE different pediatric facilities within a stone's throw of each other.

In this economy?

Why isn't there a public discussion about this?

Boston, Philadelphia - even Milwaukee - must be wondering what's going on here. Why don't we who live here wonder out loud about what's going on here?

"You are pre-diseased." That's the title of a CBC radio program with Alan Cassels exploring "the gestalt of our time in a world where, it seems, more and more overdiagnosis is becoming the norm, where everyone is, more or less, prediseased."

(Part one airs tomorrow night - part two next week.)

Cassels interviews Dartmouth's Gil Welch, who says:

"I think the generic problem is somewhat like the "check engine" lights on your car. Do you have check engines lights? My first car was a '75 Ford Fairlane. There were only two things monitored: my oil pressure and my engine temperature. I now drive a Volvo that is 10 years old, but it is checking about 25 different engine functions. And sometimes a check engine light comes on, and you’re really glad to know, and it leads to something you want to do something about. Sometimes the check engine light is just a nuisance, and it just keeps flashing on and off and the mechanic can’t fix it. And some of the audience might have this experience where they went to get it fixed and it made matters worse. And if you had that experience, you’ve had some of the experience of overdiagnosis and that’s what I’m worried about. We’re putting more and more check engines lights on the human body. We have to ask ourselves if that is really the best way to get to a healthy society. We’re constantly monitoring for things to be wrong. Is that really the best way to achieve health?"

AP's Lauran Neergaard wrote a good story about the shared decision-making focus of last week's Foundation for Informed Medical Decision Making (FIMDM) Policy & Research Forum in Washington, DC.

Excerpt:

A new University of Michigan study of how 3,000 patients made common medical choices suggests patients frequently have misinformation. Fewer than one in five could name the most common side effect of cholesterol-lowering statin drugs they were considering, for example. Moreover, patients said their doctors discussed treatment advantages more than the disadvantages.

As promised, I'll blog more about this Forum when I get the chance. Fascinating data worthy of more attention.

For now, you should go to the FIMDM website, and click on the middle section labeled, "Transforming the Patient Experience: Four stories of informed decision-making." The video available there is a terrific demonstration of shared decision-making through the words of four actual patient examples. Watch the video. It's time well spent.

OK, so I’m happy that Wikio ranks my blog in the top 20 of health blogs.

And at this moment, this blog ranks about as high as it ever does on another site, edrugsearch.com’s Healthcare 100 with a ranking of 58.

But you must realize that there’s almost no assessment of quality of content by some of these rankings. The edrugsearch site uses 8 different metrics –counting things like incoming links or blog feed subscribers.

I recently was talking with one of the guys who runs the edrugsearch site and he says their ratings are only as good as the data they are fed by other sites like Technorati, Bloglines, Yahoo and Google.

So, again, while I’m pleased to get any recognition for this little mom-and-pop blog, something is wrong with the rankings when top blogs like Maggie Mahar’s Health Beat Blog is at #62, a Washington Post health blog is at 82, Joe Paduda’s Managed Care Matters blog is at 94, and Merrill Goozner’s terrific Gooznews.com is at 110.

The journal PLoS Medicine offers an online debate on the practice of ghostwriting in medical journals. Their background to the debate:

"Ghostwriting occurs when someone makes substantial contributions to a manuscript without attribution or disclosure. It is considered bad publication practice in the medical sciences, and some argue it is scientific misconduct. At its extreme, medical ghostwriting involves pharmaceutical companies hiring professional writers to produce papers promoting their products but hiding those contributions and instead naming academic physicians or scientists as the authors. To improve transparency, many editors' associations and journals allow professional medical writers to contribute to the writing of papers without being listed as authors provided their role is acknowledged. This debate examines how best to tackle ghostwriting in the medical literature from the perspectives of a researcher, an editor, and the professional medical writer."

Kudos to Chen May Yee and the Star Tribune for a front-page story on how screening tests offered by for-profit companies may cause more harm than good and may be a waste of money.

I slammed the Strib almost exactly one year ago for a non evidence-based article promoting screening tests.

So let this blog posting be further evidence that I'm not out to bash all health care news - just the schlock.

Today's Strib story - by a smart, dedicated journalist - showed enterprise, depth, and a concern for how readers may be misled and hurt by profit-driven screening promotions.

The BMJ this week states:

The relationship between the drug industry, academia, healthcare professionals, and patients has reached an all time low and few doubt that it is in the interests of all parties to improve it. A recent report from the Royal College of Physicians attempts to define a path towards achieving a more productive relationship. Here we set out five contrasting views on what the ideal relationship between industry and prescribers and patients should be and what steps need to be taken to achieve it.

Editor Fiona Godlee writes:

"As our cover image shows, it takes two to tango. It’s time for the profession to take a lead. This means saying no to gifts and hospitality, ensuring that research and clinical collaborations are transparent and unbiased in their design and reporting, refusing to be a guest or ghost author, declining the role of paid opinion leader, paying our way for information and education, and refusing industry support unless it is entirely transparent and in patients’ or the public’s best interests."

Former New England Journal of Medicine editor Marcia Angell writes:

"I believe there should be no relationship between the drug industry and either prescribers or patients. Drug companies are investor owned businesses with a responsibility to maximise profits for their shareholders. That is quite different from the mission of the medical profession, which is to provide the best care possible for patients. I start with this simple fact, because it is so often obscured by the industry’s public relations. ...We need to stop accepting the fiction that marketing, whether to prescribers or patients, is good education."

And Harlan Krumholz and Joseph Ross propose six standards to restore trust:

1. dispense with promotional activities such as direct to consumer advertising and distribution of drug samples in settings where prescribing decisions are made.

2. forgo gifts.

3. clinicians, researchers, academic institutions, clinics, and hospitals must disclose all payments and gifts from industry, regardless of size or whether they were paid directly, through a third party, or to a charity or other organisation.

4. industry sponsorship of continuing medical education must stop because it diminishes credibility regardless of its quality.

5. industry sponsored clinical studies should be visible, accountable, and comply with mandatory standards set by institutional review boards, data safety and monitoring boards, and steering committees to protect patient volunteers. In addition, external investigators should receive the study’s raw data and rights to publication. Seeding trials and ghostwriting should be prohibited. Trials should be publicly registered and their results should be posted within two years of completion regardless of peer review publication. Registration should include naming members of the data safety and monitoring board and steering committee (which is ideally composed of non-employees), investigators, and pre-specified data analysis plans including primary and secondary outcomes.

6. let’s accept divergent views, defend free speech, and acknowledge that there is great value in the respectful exchange of ideas. We need to overcome an unfortunate history of intimidation exhibited by some companies against physicians who have expressed opinions that did not favour their product. We also need to eliminate efforts by opinion leaders at some academic centres to leverage funding from companies in exchange for favouring industry products or neutralising critics.

The Boston Globe may be shutting down its venerable health/science news section. Details and speculation here.

And NBC News should consider shutting down its health coverage if it can't get any better than this.

That paper was honored yesterday by the Foundation for Informed Medical Decision Making with an award for Excellence in Health Journalism. The Foundation, which presented the award yesterday at its Research and Policy Forum in Washington DC, chose the Milwaukee newspaper because of its consistently high ratings by HealthNewsReview.org- the only organization of its kind in the US that reviews the quality of health news reporting nationwide each day.

"We were very surprised and pleased by this recognition," said Becky Lang, the Journal Sentinel's health and science editor. "In the current media environment of instant Internet coverage and reduced staffing in credible news outlets, the pressure is on for us to keep the standards high. It is even more important than ever for us to provide health stories that are meaningful, accurate, reader friendly and that delve deeper than the surface. We welcome this kind of oversight."

HealthNewsReview.org reviewed a dozen Journal-Sentinel stories and nine of them received high marks with four- or five-star reviews, more than any other newspaper of this size in our experience so far.

A team from the Nordic Cochrane Center has an article in this week's BMJ that begins:

Three years ago, we published a survey of the information given to women invited for breast screening with mammography in six countries with publicly funded screening programmes. The major harm of screening, which is overdiagnosis and subsequent overtreatment of healthy women, was not mentioned in any of 31 invitations. Ten invitations argued that screening either leads to less invasive surgery or simpler treatment, although it actually results in 30% more surgery, 20% more mastectomies, and more use of radiotherapy because of overdiagnosis.Pain caused by the procedure was mentioned in 15 invitations, although it is probably the least serious harm, as it is transient.

Since then, little has changed.

The researchers say most info predominantly discusses benefits with no discussion of harms. And they remind readers:

• If 2000 women are screened regularly for 10 years, one will benefit from the screening, as she will avoid dying from breast cancer.

• At the same time, 10 healthy women will, as a consequence, become cancer patients and will be treated unnecessarily. These women will have either a part of their breast or the whole breast removed, and they will often receive radiotherapy and sometimes chemotherapy.

• Furthermore, about 200 healthy women will experience a false alarm. The psychological strain until one knows whether it was cancer, and even afterwards, can be severe.

They conclude: "The one sided propaganda about breast screening is a global phenomenon that has resulted in misconceptions about its effects."

I’m always amazed that my little blog gets any traffic or draws any links or whatever drives the various ranking services. I usually do this stuff at 6:30 in the morning after one cup of coffee at home - like now. So I'm amazed that my blog has achieved a top 20 health blog ranking from the folks at Wikio. If you visit their site today, you’ll still see a #25 blog ranking for this site. They tell me the #20 ranking will be posted onThursday.

Or is just fear-mongering on the part of industry and special interests?

The Boston Globe and blogger Alison Bass have written about the new Massachusetts "state's regulations, which establish a code of conduct for pharmaceutical company employees, will limit participation by drug company scientists in meetings and continuing medical education courses in Massachusetts." As a result, some medical groups are threatening to move their medical conferences out of Boston.

Blogger Bass writes:

"All three of the medical societies named in the (Globe) article -- The American Academy of Allergy, Asthma and Immunology, the American Society of Gene Therapy and the Heart Rhythm Society -- have received major funding from the pharmaceutical and medical device industry over the years.

Hmmm...could it be that the pharmaceutical and medical device industry had something to do with these rather unsubtle threats?

Spokespeople for two of the groups quoted in The Globe article said they were concerned that the proposed guidelines won't allow presentations by drug company employees at meetings in Massachusetts. According to local public health officials, that's simply not true. The regulations do allow company scientists to present at meetings but the presentations must be objective and cannot be used to flagrantly promote company's products. What a marvelous concept -- and a major departure from business as usual.

One need only visit the medical groups' websites to see the extent of industry funding behind these groups. In the March 2008 annual meeting program of the American Academy of Asthma, Allergy and Immunology, for example, the list of commercial supporters filled a full page, ranging from pharm companies such as GlaxoSmithKline, Merck, Schering Plough and AstroZenica to biotechs like Sepracor, Genentech and Teva Specialty.

Likewise, the Heart Rhythm Society's list of supporters for its May 2008 meeting in San Francisco includes all the major makers of cardiac medical devices: Medtronic, Boston Scientific and sanofi aventis (labeled Diamond Level sponsors), Boehringer Ingelheim (an Emerald Level Sponsor) and Biosense Webster, a subsidiary of Johnson and Johnson (alas only Ruby Level).

Similarly, the American Society of Gene Therapy listed Genzyme as its "partner" for its annual meeting last May in Boston and 15 biotech and medical device companies as major contributors and patrons.

So if The Boston Globe really wanted to do its homework, it could ask these three medical groups just how much money all this corporate sponsorship translates into every year and what kind of pressure the industry put on them to howl about regulations that were, by the way, designed to protect consumers."