Thursday, April 8, 2010

To Cut Health Costs, U.S. Needs to Learn to Say No -

How can we learn to say no?

The federal government is now starting to build the institutions that will try to reduce the soaring growth of health care costs. There will be a group to compare the effectiveness of different treatments, a so-called Medicare innovation center and a Medicare oversight board that can set payment rates.

But all these groups will face the same basic problem. Deep down, Americans tend to believe that more care is better care. We recoil from efforts to restrict care.

Managed care became loathed in the 1990s. The recent recommendation to reduce breast cancer screening set off a firestorm. On a personal level, anyone who has made a decision about his or her own care knows the nagging worry that comes from not choosing the most aggressive treatment.

This try-anything-and-everything instinct is ingrained in our culture, and it has some big benefits. But it also has big downsides, including the side effects and risks that come with unnecessary treatment. Consider that a recent study found that 15,000 people were projected to die eventually from the radiation they received from CT scans given in just a single year — and that there was "significant overuse" of such scans.

From an economic perspective, health reform will fail if we can't sometimes push back against the try-anything instinct. The new agencies will be hounded by accusations of rationing, and Medicare's long-term budget deficit will grow.

So figuring out how we can say no may be the single toughest and most important task facing the people who will be in charge of carrying out reform. "Being able to say no," Dr. Alan Garber of Stanford says, "is the heart of the issue."

It's easy to come up with arguments for why we need to do so. Above all, we don't have a choice. Giving hospitals and drug makers a blank check will bankrupt Medicare. Slowing the cost growth, on the other hand, will free up resources for other uses, like education. Lower costs will also lift workers' take-home pay.

But I suspect that these arguments won't be persuasive. They have the faint ring of an insurer's rationale for denying a claim. Compared with an anecdote about a cancer patient looking for hope, the economic arguments are soulless.

The better bet for the new reformers — starting with Donald Berwick, the physician who will run Medicare — is to channel American culture, not fight it. We want the best possible care, no matter what. Yet we often do not get it because the current system tends to deliver more care even when it means worse care.

It's not just CT scans. Caesarean births have become more common, with little benefit to babies and significant burden to mothers. Men who would never have died from prostate cancer have been treated for it and left incontinent or impotent. Cardiac stenting and bypasses, with all their side effects, have become popular partly because people believe they reduce heart attacks. For many patients, the evidence suggests, that's not true.

Advocates for less intensive medicine have been too timid about all this. They often come across as bean counters, while the try-anything crowd occupies the moral high ground. The reality, though, is that unnecessary care causes a lot of pain and even death. Dr. Berwick, who made his reputation campaigning against medical errors, is a promising (if much belated) selection for precisely this reason.

Can we solve the entire problem of rising health costs by getting rid of needless care? Probably not. But the money involved is not trivial, and it's the obvious place to start.

Learning to say no more often will be a three-step process, and if the new agencies created by the health act are run well, they can help with all three.

The first is learning more about when treatments work and when they don't. "All too often," the Institute of Medicine reports, the data is "incomplete or unavailable." As a result, more than half of treatments lack clear evidence of effectiveness, the institute found. It says the most promising areas for research include prostate cancer, inflammatory diseases, back pain, hyperactivity, and CT scans vs. M.R.I.'s for cancer diagnosis.

As part of the health act, a Patient Centered Health Research group will have an annual budget of $600 million. Relative to total health spending, that's a paltry sum. But it's real money relative to what's now being spent on such research.

The second step — and maybe the most underappreciated one — is to give patients the available facts about treatments. Amazingly, this often does not happen. "People are pretty woefully undereducated about fateful medical decisions," says Dr. Michael Barry of the Massachusetts General Hospital, an advocate for sharing more with patients.

Dale Collins Vidal, a reconstructive breast surgeon at the Dartmouth-Hitchcock Medical Center, told me a story about a patient's husband who asked to sit in on the medical team's discussion of his wife's case. The doctors said no, because they were uncomfortable with him knowing about the uncertainty surrounding the case. "The paternalism is a little more kind-hearted than it was in the past," Dr. Vidal says, "but it's still paternalism."

When patients are given information about potential benefits and risks, they seem to choose less invasive care, on average, than doctors do, according to early studies. Some people, of course, decide that aggressive care is right for them — like the cancer patient (and palliative care doctor) profiled in this newspaper a few days ago. They are willing to accept the risks and side effects that come with treatment. Many people, however, go the other way once they understand the trade-offs.

They decide the risk of incontinence and impotence isn't worth the marginal chance of preventing prostate cancer. Or they choose cardiac drugs and lifestyle changes over stenting. Or they opt to skip the prenatal test to determine if their baby has Down syndrome. Or, in the toughest situation of all, they decide to leave an intensive care unit and enter a hospice.

The health act requires Medicare and other agencies to help hospitals and doctors give patients more information — which is practically a no-lose proposition. In the course of receiving more control and more choice, two distinctly American values, patients will probably help hold down costs.

The final step is the bluntest. It involves changing the economics of medicine, to reward better care rather than simply more care. Health reform doesn't go nearly far enough on this score, but it is a start.

The tax subsidies for health insurance will shrink, which should help people realize medical care is not free. And doctors who provide good, less expensive care won't be financially punished as often as they now are.

None of these steps will allow us to avoid the wrenching debates that are an inevitable part of health policy. Eventually, we may well have to decide against paying for expensive treatments with only modest benefits. But given how difficult that would be for this country, it makes sense to start with the easier situations — the ones in which "no" really is the best answer for patients.

"In the United States, I don't know that we're ever going to get to a point where we limit health care spending," as Dr. Vidal says. "But maybe we could get patients to the same place on their own."

Wednesday, April 7, 2010

In Sleepless Nights, a Hope for Treating Depression -

Is there anything good about insomnia? Could there possibly be any upside to a long, torturous sleepless night?

To answer the question, let's look at another condition entirely.

Postpartum depression affects between 5 percent and 25 percent of new mothers.  Symptoms — including sadness, fatigue, appetite changes, crying, anxiety and irritability — usually occur in the first few months after child birth.  There is a simple way to alleviate postpartum depression in just a few hours: sleep deprivation.

If a depressed mother stays up all night, or even the last half of the night, it is likely that by morning the depression will lift.  Although this sounds too good to be true, it has been well documented in over 1,700 patients in more than 75 published papers during the last 40 years.[1]  Sleep deprivation used as a treatment for depression is efficacious and robust: it works quickly, is relatively easy to administer, inexpensive, relatively safe and it also alleviates other types of clinical depression. Sleep deprivation can elevate your mood even if you are not depressed, and can induce euphoria. This throws a new light on insomnia.

More ...

Riskier Surgeries for Back Pain Raise Costs -

A study of Medicare patients shows that costlier, more complex spinal fusion surgeries are on the rise -- and sometimes done unnecessarily -- for a common lower back condition caused by aging and arthritis.

What's more alarming is that the findings suggest these more challenging operations are riskier, leading to more complications and even deaths.

''This is exactly what the health care debate has been dancing around,'' said Dr. Eugene Carragee of Stanford University Medical Center.

''You have one kind of operation that could cost $20,000 and another that could cost $80,000 and there's not good evidence the expensive one is being used appropriately in the majority of cases,'' Carragee said.

Add to that the expense for patients whose problems after surgery send them back to the hospital or to a nursing home and ''that's not a trivial amount of money'' for Medicare, said Carragee. He wrote an accompanying editorial in the Journal of the American Medical Association where the federally funded study appears Wednesday.

The cost to Medicare, just for the hospital charges for the three types of back surgery reviewed is about $1.65 billion a year, according to the researchers.

All the patients in the study had stenosis in their lower backs, a painful squeezing in the spine that's most common in people over 50. The researchers compared the risks for three different types of surgery for the condition: decompression, simple fusion and complex fusion.

''All operations aren't the same and some seem to be associated with higher complication rates than others,'' said lead author Dr. Richard Deyo of Oregon Health and Science University in Portland. ''It's not necessarily true that the more aggressive surgery is better, at least in terms of safety.''

There's little agreement about the best way to treat chronic lower back pain, and much depends on what's causing the pain.

Patients should ask their doctors about alternatives to complicated operations, Deyo said. Could steroid injections and physical therapy be tried? Would a simple decompression procedure be as helpful as a spinal fusion and with less risk?

In a decompression procedure, the simplest method in the Medicare study, a surgeon cuts away part of the bone that's painfully pressing on nerves. It can cost about $30,000 in hospital and surgeon fees.

For a fusion, a surgeon binds two or more vertebrae together using a bone graft, with or without plates and screws. The researchers defined a complex fusion as one involving three or more vertebrae or more than one side of the spine. Fusions cost $60,000 to $90,000.

The researchers analyzed data on more than 32,000 Medicare patients who had one of the three types of surgeries in 2007.

About 5 in 100 patients who had simple or complex fusions suffered major complications such as stroke compared to 2 in 100 with decompressions. The risk of death within 30 days after surgery was different too: 6 in 1,000 for complex fusions compared with 5 in 1,000 for simple fusions and 3 in 1,000 for decompressions.

The study didn't address how successful the various types of surgeries were at relieving pain.

More than half the patients who had complex fusions had a simple stenosis, which usually calls for decompression alone. They did not have the curvature of the spine or a slipped vertebra -- additional conditions that might suggest a fusion is needed. There's not much evidence for doing a complex fusion for a person with simple stenosis, Carragee and other experts said.

''It certainly looks like there's more complex surgery being done than we have very good evidence to support,'' Carragee said.

Rates of complex fusions in Medicare patients rose 15-fold from 2002 to 2007, while decompressions and simple fusions declined, the study found. Although the overall procedure rate fell, hospital charges grew 40 percent.

Aggressive marketing of devices used in complex fusions is likely playing a role in the increase, Deyo said. The marketing includes ads in medical journals and lectures by surgeons on the payroll of device manufacturers.

Allegations of kickbacks to spine surgeons for using products and questionable financial arrangements to doctors as consultants have plagued the multibillion-dollar industry. One company, Medtronic Inc., reached a $40 million settlement with the U.S. Justice Department in a whistleblower case that included allegations the company paid doctors to use its spine surgery products. The company denied any wrongdoing.

Dr. Charles Rosen, a spine surgeon at the University of California, Irvine, founded the Association for Medical Ethics to nudge doctors toward scientific evidence over vested interests. Forty-nine spine surgeons have joined, pledging to refuse any type of compensation or earnings from companies for using a product.

Rosen applauded a provision in the new health care law that requires device makers and others to file annual reports to the government on their financial ties to doctors. Patients will be able to look up possible conflicts in a government database.

''Too much fusion surgery is done in this country and often for inappropriate reasons,'' Rosen said. While complex fusions are needed for some conditions, he said, patients ''should not hesitate to get a second opinion.''

The New York Times: Search for 'medicine' > Section: Health

Tuesday, April 6, 2010

FDA Approves New Formulation For OxyContin

The U.S. Food and Drug Administration approved a new formulation of the controlled-release drug OxyContin that has been designed to help discourage misuse and abuse of the medication.

OxyContin is made to slowly release the potent opioid oxycodone to treat patients who require a continuous, around-the-clock opioid analgesic for management of their moderate to severe pain for an extended period of time. Because of its controlled-release properties, each OxyContin tablet contains a large quantity of oxycodone, which allows patients to take their drug less often. However, people intent on abusing the previous formulation have been able to release high levels of oxycodone all at once, which can result in a fatal overdose and contributes to high rates of OxyContin abuse.

The reformulated OxyContin is intended to prevent the opioid medication from being cut, broken, chewed, crushed or dissolved to release more medication. The new formulation may be an improvement that may result in less risk of overdose due to tampering, and will likely result in less abuse by snorting or injection; but it still can be abused or misused by simply ingesting larger doses than are recommended.

"Although this new formulation of OxyContin may provide only an incremental advantage over the current version of the drug, it is still a step in the right direction," said Bob Rappaport, M.D., director of the Division of Anesthesia and Analgesia Products in the FDA's Center for Drug Evaluation and Research.

"As with all opioids, safety is an important consideration," he said. "Prescribers and patients need to know that its tamper-resistant properties are limited and need to carefully weigh the benefits and risks of using this medication to treat pain."

According to the U.S. Substance Abuse and Mental Health Services Administration's National Survey on Drug Use and Health, approximately half a million people used OxyContin non-medically for the first time in 2008.

The manufacturer of OxyContin, Purdue Pharma L.P., will be required to conduct a postmarket study to collect data on the extent to which the new formulation reduces abuse and misuse of this opioid. The FDA is also requiring a REMS (Risk Evaluation and Mitigation Strategy) that will include the issuance of a Medication Guide to patients and a requirement for prescriber education regarding the appropriate use of opioid analgesics in the treatment of pain.

Source: U.S. Food and Drug Administration

Monday, April 5, 2010

HubMed: Recent articles related to psychology of medicine

HubMed uses information from PubMed's database, provided by the NCBI through the EUtils web service, to produce a search interface focused on browsing, organising and gathering information from the biomedical literature. Searches can be conducted using the full range of operators available in Entrez/PubMed; when using the default search options, results will be identical to those those of a PubMed search.

Special features of HubMed include date- or relevance-ranked search results; web feeds for regular updates of published literature matching any search; clustering and graphical display of related articles; expansion of query terms; direct export of citation metadata in many formats; linking of keywords to external sources of information; manual categorisation (tagging) and storage of interesting articles.

Sunday, April 4, 2010

Health Law May Strengthen the Doctor-Patient Bond -

At a wedding recently, I met a woman, a freelance photographer in her early 40s. She was intrigued by my work as a doctor and began asking me questions related to her own health. When she showed me a picture of herself with her four children, I realized why. This gaunt woman had lost almost 20 pounds in the month since the photo had been taken and, despite efforts to stop the weight loss, was still losing more.

When I asked what her primary care doctor thought, she mentioned that she had gone once to an urgent care facility. I urged her to see a specialist to undergo testing, perhaps even a colonoscopy; but she brushed aside my suggestions, preferring instead to ask for my professional opinion on foods that might help her gain weight and treatments she could obtain over the counter.

After a few minutes of this awkward exchange, I realized that there was an elephant in the room. The woman had no health insurance. Even if she wanted to follow my advice, she couldn't afford it.

Throughout this past year, and even over the last week, it has been easy to get mired in the myriad provisions of the multiple iterations of the health care bill. But for many health care professionals, all that wrangling has only served to draw attention away from one of the health care overhaul's most salient points: that it would offer, at last, real hope for what has become a crippled, even broken, relationship between patients and doctors.

"Any health care system should be measured against the primacy of the doctor-patient relationship," said Dr. Stacy Tessler Lindau, an associate professor of obstetrics, gynecology and medicine-geriatrics at the University of Chicago Medical Center. Last fall, Dr. Lindau came up with the idea of a doctors' rally in Washington, and in early December, 55 physicians traveled to Capitol Hill to urge legislative leaders to push the health care bill forward. The doctors, unaffiliated with any trade organization, lobbying group or political party, came armed with only a letter signed by more than 500 physicians from diverse backgrounds.

There are doctors who oppose reform because of fears that it might reduce their income. Others believe that individuals' rights to health care are only, and justly, limited by whatever they can afford. But for most practicing physicians and for many patients, the untenable situation of balancing what you should do with what you can do remains a daily challenge. "The doctor may say, 'Here are your prescriptions, and make sure you get the M.R.I.,' " said Dr. Cary P. Gross, another of the rally's organizers and an associate professor of medicine at the Yale School of Medicine. "But the patient is thinking, 'I can't get all of these medications, and I can't afford the M.R.I.' "

These limitations become the silent and discomforting third party in every clinical interaction. Patients may hesitate to divulge which recommendations they have eschewed because of cost concerns; doctors may feel trapped into giving suboptimal care because of insurance limitations; and both may feel uneasy bringing up the subject of money.

Even when doctors and patients do devote time to discussing ways in which medical therapy can be modified to fit within coverage constraints, they do so at the expense of other discussions.

"The physician has to play a game of Twister to figure out how to put together parts of the puzzle so that things will work for the patient," said Dr. Somnath Saha, an associate professor of medicine at the Oregon Health and Science University in Portland and a participant in the pro-reform rally. For the last year and a half, I have been fortunate enough to work within the single-payer system of the Veterans' Administration.

Nonetheless, as I watched President Obama sign the health care bill last Tuesday, I remembered the woman from the wedding. And I remembered the far too many patients from my past who stopped or cut back on medications because they couldn't afford them, who had to be discharged early from the hospital because their insurance wouldn't cover longer stays, or who struggled — and died from — chronic diseases because they had no health insurance.

The bill is not perfect, and much work remains. "If we don't fix the steady rise in costs," Dr. Saha said, "we are still going to end up with patients worried about how they are going to afford their health care."

But one thing is now sure: there is finally new hope for the patient-doctor relationship. The playing field between patients and doctors is closer to being equalized and, for the first time in our lifetimes, there is a real chance that the elephant will at last begin to trundle its way out of our exam rooms.

Helping Patients Face Death, She Fought to Live - Readers' Comments -

Among many readers' comments:

While Dr. Pardi's individual, personal story is by itself sad and
tragic for her, and for those who cared about her and were devoted to
her, Dr. Pardi as a very wealthy and well-connected individual was
able to pursue whatever aggressive treatments and extraordinary care
she wanted to in her frantic wish to cling to life at all costs,
because she could pay those costs. She not only had health insurance
but she also had great personal wealth; her husband was a portfolio
manager. This gave her the wherewithal to pay for whatever she
decided she wanted to try.

This story is so typically American. We laud, highlight, and are
fascinated with the stories of high status and high net worth
individuals like doctors married to portfolio managers, but as a
country we are quick to cumulatively begrudge the average or poorer
hard-working American even the most basic help with basic health
care. For God's sakes, the Arizona legislature just voted to abandon
S-Chip, leaving 47,000 children without health insurance. How many
children, how many ordinary people could have been helped by the huge
fortune of money that was spent on just this one person? She had the
luxury of indulging her every whim, and have her wishes honored to
the nth; she had the means to give herself what the insurance
companies would not countenance, while other people are lying in the
gutter with treatable illnesses, and we as a country just step over
them and keep right on walking.

The other thing about this story that really bothers me is that it's
a sucker punch to the palliative care profession, just when it needs
more good press, so that people can be properly informed about their
options. It is a not-so-subtle sabotage and undermining of a medical
specialty that is trying hard to reverse the current trend of "spend,
baby spend", and help people understand both their personal
situation, and that oftentimes less is more.

While I know that no one really ever knows how they themselves will
deal with something really awful until it actually happens to them,
Dr Pardi's story appears to have the dramatic edge because she had
the means to indulge her denial and her wish to live by doing
whatever she wanted to and having whatever she wanted done for her.
But the reality here is that as a society we can't afford to indulge
each person's every wish, while we have no compunction denying basic
care to hordes of equally deserving, but woefully under resourced
fellow citizens, who might have to mortgage their house or take their
children's tuition money to implement that level of self-indulgence.

My family was so grateful for the care my mother received from the
excellent staff of the Mount Sinai Visiting Doctors Program and the
VNS Hospice Program, all of whom gave her extraordinary basic, good,
common sense care, when she was declining with Advanced Alzheimer's
at the age of 96. It was just the right kind and amount of care for
someone in her condition. And as her family, we felt extraordinarily
lucky to have access to professionals who wanted to spare her from
suffering, from unnecessary aggressive interventions, and make her
comfortable while not unnecessarily prolonging what was a very poor
quality of life at the end.

Helping Patients Face Death, She Fought to Live -

By the time she was 38, Dr. Desiree Pardi had become a leading practitioner in palliative care, one of the fastest-growing fields in medicine, counseling terminally ill patients on their choices.

She preached the gentle gospel of her profession, persuading patients to confront their illnesses and get their affairs in order and, above all, ensuring that their last weeks were not spent in unbearable pain. She was convinced that her own experience as a cancer survivor — the disease was first diagnosed when she was 31 — made her perfect for the job.

In 2008, while on vacation in Boston, she went to an emergency room with a fever. The next day, as the doctors began to understand the extent of her underlying cancer, "they asked me if I wanted palliative care to come and see me."

She angrily refused. She had been telling other people to let go. But faced with that thought herself, at the age of 40, she wanted to fight on.

While she and her colleagues had been trained to talk about accepting death, and making it as comfortable as possible, she wanted to try treatments even if they were painful and offered only a 2 percent chance of survival. When the usual cycles of chemotherapy failed to slow the cancer, she found a doctor who would bombard her with more. She force-fed herself through a catheter and drank heavy milkshakes to keep up her weight.

Over the last decade, palliative care has become standard practice in hospitals across the country. Born out of a backlash against the highly medicalized death that had become prevalent in American hospitals, it stresses the relief of pain; thinking realistically about goals; and recognizing that, after a certain point, aggressive treatment may prevent patients from enjoying what life they had left.

Dr. Pardi had gone into the field because she thought her experience as a patient would make her a better doctor. Now she came face to face with all the ambiguities of death, and of her profession.

She remembered patients who complained to her that she did not know them well enough to recognize that they were stronger than she had thought. Now she discovered that she felt the same way about her own doctors. "I think they underestimated me," she said in an interview last summer.

More ...