In The Spine Journal, Specialists Repudiate Medtronic Research - NYTimes.com

In an extraordinary move, a group of spine specialists are publicly repudiating the research of other experts that has backed the widespread use of a Medtronic bone growth product. In a series of reports published in a medical journal on Tuesday, the specialists called the research misleading and biased.

The repudiation, appearing in a full issue of The Spine Journal devoted to the topic, represents a watershed in the long-running debate over conflicts of interest for the sponsorship of scientific studies by makers of drugs and medical devices. It is extremely rare for researchers to publicly chastise colleagues, and editors of leading medical journals said they could not recall an instance in which a publication had dedicated an entire issue for such a singular purpose.

Medtronic, the nation's biggest maker of medical devices, has been facing intensifying scrutiny over its promotion of Infuse, the bone growth product at the center of the controversy. The bioengineered material is used primarily in spinal fusions, a procedure in which spinal vertebrae are joined to reduce back pain.

Infuse is used in about a quarter of the estimated 432,000 spinal fusions performed in this country each year. The articles published on Tuesday charge that researchers with financial ties to Medtronic overstated Infuse's benefits and vastly understated its risks by claiming there were none.

"It harms patients to have biased and corrupted research published," five doctors wrote in a joint editorial that accompanied the reports. "It harms patients to have unaccountable special interests permeate medical research."

"The spine care field is currently at a precarious intersection of professionalism, morality and public safety," Dr. Christopher M. Bono, editor of the special edition, said in a statement. "As physicians and journal editors, we felt an obligation to present a thorough examination of this controversial issue."

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http://www.nytimes.com/2011/06/29/business/29spine.html?

Missing: A death forces a physician to ponder the way she communicates with her patients and their families. Rochester Review • University of Rochester

I stared down at my name typed next to the word "Defendant." Below my name, small print said, "You are hereby required to appear and defend the complaint filed against you . . . "

What complaint? More neat typing filled another line with "the Estate of Helen F. Simmons, Deceased." Helen? I knew her. Deceased? Oh, no. She was in her 40s, but she'd already had at least one heart attack. I realized I hadn't seen her for a while. My god, what had happened?

That was a subpoena. That's how I heard about my first malpractice suit.

On the next page was, "estate of helen f. simmons, deceased, plaintiff, vs. merilee d. karr, m.d., defendant." And there was the answer I was looking for, "Complaint: Wrongful Death Based on Medical Negligence."

Oh, my god. Deceased. It was me. I killed her. My knees swam, and I couldn't breathe.

Finally. It was like I'd been waiting for this. With every decision and every patient since medical school began, I've grilled myself: What if this is wrong? What else might this person have? What if I'm wrong? We all do, on this end of the stethoscope. Now a woman was dead, and I was no longer the only one accusing me of negligence and malpractice. All the doubt that came with my diploma slammed home. Finally I knew. I just wasn't good enough.

As I stared at the subpoena on my desk, the bustle and chatter of the clinic swirled around me, and I realized that the whole clinic knew. No one had spoken to me since the subpoena had arrived. When I looked up, Cheryl, our office manager, stood next to me. She asked me how I was doing, and I told her I wasn't sure. She made phone calls: Our malpractice insurer would assign a lawyer to defend me. Our office would copy the patient's chart for the lawyer. I wanted a copy, too. I read it until late that night, and over the following months, looking for one thing—what had I done wrong?

The subpoena arrived in March. My last note in Helen's chart was from the previous August—nine months after we had first met. She had gone to our community hospital with chest pain, and was admitted for overnight tests. The next day, December 24, I was responsible for our hospital patients. Helen had not had a heart attack, according to her tests, and her pain was gone. But she was, I realized, a time bomb. She had heart disease up and down her family tree, she smoked, and her blood pressure was high. There was a heart attack out there with her name on it.

She was friendly, telling jokes in her hospital bed. I told her she hadn't had a heart attack, but that I was worried she would sooner or later.

She wasn't worried. She wanted to go home and have Christmas.

So I decided to get her attention. Her EKG that morning was essentially normal. But not entirely. One of the EKG squiggles is called a Q wave, a dip before the spike with each heartbeat. Dead heart muscle shows deep Q waves, as low as the spike is high. The normal EKG also has Q waves, but little ones, less than a third the size of the spike.

Helen's EKG had normal Q waves. But that's not what the EKG computer said. The interpretation programs that come with the machines are hypersensitive. I suppose the reasoning is that oversensitivity is better than undersensitivity. Right on her EKG, the machine had printed "Probable inferior infarct, old." I had a teaching aid.

I told Helen she could go home. Then I showed her the EKG, and told her that, though her chest pain the night before had not been a heart attack, it looked like she could have had a small heart attack already, sometime in the past.

Her eyes got big. I waited. She said she'd tried to quit smoking before, gotten crabby, and started again. I said quitting was hard, but worth it.

I didn't see her again for a month. One day in January she came in with bad chest pain. She looked terrible, frightened and crying. I ran a quick EKG—very abnormal—and sent her right up to the hospital. That was her only official heart attack. When I saw her later in the hospital she was calmer, and very serious. She had actually quit smoking a few days before. She'd tried to exercise, probably not a good idea at the time.

A few days later the cardiologists reopened a cholesterol-plugged artery in her heart. After that, she exercised regularly without chest pain. She lost weight and stayed off nicotine. I saw her every month or two through the winter, spring, and summer, congratulating her on her progress and adjusting her meds. She had another bout of chest pain that spring, and stayed in the hospital overnight. That time her morning labs showed no heart attack. She was 44 years old.

That brought me, time-travelling through the chart, up to our last visit, in August. So far I hadn't found a lethal error, so it must have been in that last visit. In detail after detail, her chest pain that day fit the pattern of heartburn, not heart pain. The pain was almost constant—angina lasts for a few minutes at a time. She did not have the left arm heaviness or nausea that she had had with her previous heart attack. Most convincingly, she said she could work out for hours in the gym without pain. I ran an EKG on her, and it was normal.

It sure sounded like heartburn. I gave her an acid blocker, and scheduled a phone call for the next day. In that phone call, she said the medication helped. So I gave her a stronger acid blocker. And never saw her again.

I didn't talk to my partners about all this. In medicine we don't talk about our mistakes. I sent a lot more people to the hospital for chest pain. I no longer trusted my teachers or my books to tell me the difference between heartburn and a bad heart.

I knew Helen had died sometime after seeing me that August. I didn't know how she died, or when, until the pre-trial deposition of Helen's adult daughter, months after my subpoena arrived. Helen's daughter found her in bed one morning, ten days after that last appointment. Helen had died in her sleep.

Oh.

That meant that what had probably killed Helen was her heart suddenly jumping into a bad rhythm. Heart muscle damaged by a previous heart attack can fall into a strange rhythm at any time. We didn't then, and still don't, have any good way of predicting which damaged hearts are likely to do that, or when.

What killed Helen is called sudden cardiac death. There's one good drug that keeps a heart in its proper rhythm, but it can only be given intravenously, with careful monitoring. The story of heart rhythm drug development is a search for a safe, effective pill that patients can take at home—there's still a long way to go.

Helen had died of something that I couldn't have predicted or prevented.

Maybe I hadn't screwed up. Maybe I was good enough to do this. Not perfect. But good enough to care for people and help them, as much as nature and technology would let me.

I wasn't prepared for that. Learning from my subpoena that I wasn't good enough to be a doctor hurt. But it was no surprise. It was like the other shoe dropping, a constant theme of medical training. Learning I hadn't done anything wrong—at least not this time—I didn't know what to make of that.

I did know that, whatever the facts, whatever the legal outcome, I would always be responsible for Helen's death in her family's eyes. And if the jury agreed, others would consider me responsible. My name would be on national lists of doctors who had lost malpractice suits—the bad-doctor lists.

The trial took 10 days, at the red brick county courthouse a few blocks from the clinic.

In her testimony, Helen's daughter gave me another side of her mother's story—the part about working out in the gym for hours without chest pain. She testified that Helen could only stay on the exercise machines a few minutes before she had to stop—and rest until the chest pain went away.

Helen had lied to me. Perhaps that was fair—I had lied to her. Patients and doctors lie to each other for all sorts of reasons. I lied to her to save her life. Helen lied, I think, because she was playing a role, the good patient. She told me what she thought I wanted to hear. Maybe she wanted to hear me congratulate her again on how well she was doing.

But I didn't see through her. That's where I failed. I don't know if I could have helped, but missing that will always be with me. How many other cheerful lies and half-truths have slipped past me?

I "won" the case and went back to work. I call it my first malpractice suit. There hasn't been a second—yet—but I don't want to get overconfident.

Merilee Karr '75 is a family physician practicing in Portland, Ore. This essay is adapted from one she wrote for Silence Kills, a 2007 collection of personal essays about medical errors and communication published by Southern Methodist University Press. © 2007 by Merilee Karr.

http://www.rochester.edu/pr/Review/V70N4/gazette03.html

Silence Kills Study - Silent Treatment

In the 2005 study, Silence Kills: The Seven Crucial Conversations for Healthcare, VitalSmarts and the American Association of Critical-Care Nurses uncovered the conversations that are particularly difficult and yet particularly crucial for healthcare professionals to master. Key findings include:

• 84 percent of doctors have seen coworkers take shortcuts that endanger patients
• 88 percent of doctors work with people who show poor clinical judgment
• Fewer than 10 percent of physicians, nurses, and other clinical staff directly confront their colleagues about their concerns

The 10 percent of healthcare workers who confidently raise crucial concerns observe better patient outcomes, work harder, are more satisfied, and are more committed to staying in their jobs. If more healthcare workers could behave like the influential 10 percent, the result would be significant reductions in medical errors, increased patient safety, higher productivity, and lower turnover.

Download the 2005 Silence Kills Study:

http://www.silenttreatmentstudy.com/silencekills/SilenceKills.pdf

http://www.silenttreatmentstudy.com/silencekills/

Silence Kills - Speaking Out and Saving Lives - Audio Clips and Excerpts from the Book

The twelve essays collected in Silence Kills present a compelling, and often frightening, insider look at the lack of communication and understanding currently plaguing the American health care system.

These stories explore a wide and complicated range of experiences—a doctor is pressured into sending a patient home from the emergency room but later must face his decision when the patient suddenly dies; a physician deals with the doubt brought on by a malpractice lawsuit and must come to terms with the fact that even doctors are fallible and human; a woman fights for her mother’s mental health against a system eager to over-medicate the elderly; and more—but all share one thing: a frustration with a system that hinders communication and often leads to unnecessary suffering.

As Abraham Verghese states in his introduction: “These essays strive to break the silence, to ask the questions that should be asked, that should have been asked. They illustrate how easily pride, misunderstanding, laziness, denial, poor data-gathering, avarice, expediency, selfishness and, above all, poor communication can undo the best of technology, the best that medicine has to offer.”

Inspired by groundbreaking research by VitalSmarts, a global leader in organizational performance and leadership, and the American Association of Critical-Care Nurses (AACN), and supported by the Jewish Healthcare Foundation, Lee Gutkind, editor and founder of Creative Nonfiction, has collected the essays in this volume. The hope is that these voices, speaking out, taking action and risks, will inspire others to make changes that will improve communication within our troubled health care system.

http://www.silencekillsbook.com/silence_kills.html

Dealing With the Depressed or Dangerous - Inside Higher Ed

How far can colleges go to stop students who are threatening to commit suicide?

It's a fundamental question for college and university officials who work in the fields of student affairs, counseling and mental health -- and for the lawyers who may have to deal with the aftermath, and sometimes see mental health issues as a minefield of potential litigation.

At a session Tuesday here at the annual meeting of the National Association of College and University Attorneys, experts in legal affairs and mental health urged colleges to do all they can to get students who are threatening to harm themselves into treatment, or to get them off campus if the situation continues to deteriorate.

In the past decade, the number of college students with severe mental health issues has climbed. The development is often attributed to better early intervention and psychiatric drugs that enable students to function normally and attend college who wouldn't have been able to do so in the past. "That's a wonderful thing," said Paul Lannon, an outside lawyer for several New England colleges who moderated the session.

But the increase has also been accompanied by several high-profile lawsuits, and the conclusion colleges and universities draw from those could be "damned if you do, damned if you don't."

After a Massachusetts Institute of Technology sophomore, Elizabeth Shin, committed suicide by setting her dorm room on fire in 2000, her family sued MIT for $28 million. They argued that the university's counseling system failed Shin, who had a documented history of depression and threats before she killed herself. The suit was eventually settled confidentially.

In 2006, Jordan Nott, a former student, sued George Washington University, claiming that he had been forced to withdraw from the university after seeking help for depression. Nott also reached a confidential settlement.

The federal government has intervened in some similar cases through complaints students filed with the Department of Education's Office of Civil Rights, which has come out against universities who force students to leave campus because of mental illness, including a case at Bluffton University, in Ohio, in 2004.

In their presentation, three legal and mental health experts emphasized that a tough approach could have its place, as long as due process procedures are followed. Their advice included suggestions for ways to make sure students get needed care on campus, and for procedures university officials can follow if they believe a leave of absence is in the student's, or the institution's, best interest.

They cited as an example the University of Illinois at Urbana-Champaign, which instituted a suicide-prevention program in the 1980s after a study of 19 students who had killed themselves between 1977 and 1984. Most had previously worked with psychologists or psychiatrists, but not on the campus, and had a history of suicide attempts, said Paul Joffe, a clinical psychologist at the university's counseling center.

The program required reporting of any suicide threats or attempts to the counseling center. The students who had made the threats, or who had tried to kill themselves, were required to attend four "assessment sessions," arranged through the campus counseling office. Students who did not comply could be withdrawn from classes.

The result shifted the followup on suicidal behavior from the mental health system into the judicial affairs system. Students weren't punished for being suicidal, but the university set the expectation that they would seek help and try to improve the situation, including attending the required assessment sessions, Joffe said. A mental health court was created to deal solely with suicidal threats and attempts, and students were given due process rights and sanctions if they did not comply with the assessment requirement. "In an instant, everything changed, as soon as we mentioned consequences," Joffe said.

In the 21 years that followed, the suicide rate dropped 45 percent, and those students who killed themselves did so "out of the blue," with no recorded previous attempts or threats.

From the legal perspective, litigation is far more likely in cases of students who threaten or attempt to commit suicide before actually doing so, as was the case with Shin at MIT, Joffe noted in a written handout distributed to attendees. "Out of the blue" suicides are far less likely to lead to lawsuits because they are less foreseeable. And requiring students to do something to help themselves, such as attending counseling, is less likely to lead to litigation than is withdrawing the students from classes, he said. A clear policy with requirements, like the assessment sessions, also puts institutions on more solid legal ground if they choose to force a student to withdraw.

Joffe disputed the common description of suicide attempts as a "cry for help," recasting them as a type of violence where a university zero-tolerance policy should apply. Before the 1984 study and the assessment requirement, suicide had been considered in a different category from other problems with students, he said. In cases like campus drinking, the university didn't hesitate to look at the individual students and the context, or to apply expectations for future behavior and next steps, he said.

But suicidal students were treated as victims, and they weren't given any expectations for how they should behave to improve the situation. "Is it in anyone's interest to do that?" he said. The new procedures gave students more responsibility.

Few students were withdrawn because of the University of Illinois policy. For campuses with a less thorough prevention system, Linda Schutjer, the senior associate legal counsel for the Colorado State University System, offered advice on dealing with students who pose immediate problems and are less forthcoming.

"You've got to do what you've got to do," said Schutjer, who was an associate general counsel at George Washington University when Nott was withdrawn. (She did not discuss that case during the session.) Even if a student doesn't want to leave campus, or if parents are adamant that they don't want the student to come home, the university should force the issue if officials believe it will save the student's life, she said.

She provided the college lawyers in the audience with an overview of due process proceedings for students who could be sent home for mental health reasons. Students whose psychological problems can't be helped through "reasonable accommodation" can be withdrawn from school, she said, but they must be notified and have an opportunity to respond. Minimal due process can be taken under exceptional circumstances, she said.

"It may well be, unfortunately, that someone is in a psych ward in the hospital, and you have to deliver a letter to someone who's in the psych ward to say, 'We're going to put you out involuntarily,' " she said, adding that the student might have 24 hours after release to respond.

Universities should seek as much information about students' mental states as they can, she said. But in cases when documentation is incomplete or students refuse to have the records released, officials can make a decision with the information they have.

When students are asked to leave, there should be a clear process for determining when they are ready to return, said Richard Kadison, chief of mental health services at Harvard University. The more specific and individualized those requirements are, the more likely they are to succeed, Schutjer added.

All three members of the panel emphasized that as many officials as possible should play a role in getting students psychological or psychiatric help when they need it, but that sometimes that help might not take place on campus. "Academic institutions aren't designed to be halfway houses and partial hospital programs," Kadison said.

http://www.insidehighered.com/layout/set/print/news/2011/06/29/lawyers_discuss_issues_of_suicidal_students

Primary-care doctors are an endangered species - latimes.com

The days of the old-fashioned family doctor who knows us intimately and treats our kids — and our grandkids — are fading fast.

Instead, we're more likely to find ourselves searching for a doctor who will take our insurance, then waiting weeks for an appointment and hours in the waiting and exam rooms. Our doctor will rush in and rush through a series of pokes and prods and a checklist of questions, check off some codes on our record, then rush out again.

None of this makes us very happy — or, for that matter, the doctor either.

Primary-care doctors take care of the young, the old and the in-between; the sick, the well and the dying. Ideally, they're familiar with us and our family history, have a comprehensive overview of our various ailments and medicines and provide us continuity in the world of fragmented medical specialties. But their trade, they say, is getting trickier and more time-consuming, and that's fast making them an endangered species.

Patients, they say, want more from their doctor these days — more office hours, more email and phone contact, more follow-up, more coordination with specialists and insurers, more discussion about options and more expertise on more topics (aided and abetted by that constant TV-ad refrain, "Ask your doctor if X is right for you").

And the healthcare system expects more of doctors too — more preventive services, more care for chronic diseases, more healthful lifestyle coaching, more screening for depression and risky behavior (guns? cigarettes? bike helmets?), more delicate discussions (prostate biopsy? end-of-life wishes?), more documentation and now electronic records too.

Numerous studies have found that when primary care works well, patients are healthier, with better management of chronic diseases and fewer emergency-room visits and hospitalizations. All that saves healthcare dollars too.

But many doctors say there is not enough time in a typical 15- to 20-minute office visit to cover all the tests, inquiries and procedures recommended by medical schools, the U.S. Preventive Services Task Force and other organizations — even when dealing with a healthy patient.

"It's almost overwhelming," says Dr. Christine Sinsky, a primary care physician at Medical Associates Clinic and Health Plans in Dubuque, Iowa. "I think many of the new expectations are laudable and yet can't be delivered by one person working all by themselves."

And so doctors must give some things short shrift. A conversation about prostate cancer screening that would ideally take 10 minutes gets maybe a minute, says Dr. Mark Friedberg, a researcher at the Boston office of the nonprofit Rand Corp. who practices two mornings a week at a Brigham and Women's Hospital clinic in the Massachusetts city. "Physicians don't have time to really do optimal primary care," he says.

The situation is worse, he adds, when you factor in the increasing number of patients with complex conditions such as asthma, diabetes, obesity or heart disease. They require more frequent visits, and the list of steps recommended for their care is steadily growing.

Rushed office visits are only a part of the problem: Growing too are activities outside the exam room. Every prescription refill request should trigger a review of a patient's medical records. Every lab test, imaging result and specialist report should be interpreted in light of the patient's overall treatment plan.

Doctors are now meant to keep registries of patients with chronic diseases and periodically reach out to them to make sure their conditions are managed.

"It's common to have two hours of documentation work to do at home after the kids are in bed," Sinsky says — and there's no formal way to bill for these tasks or receive productivity Brownie points for doing them.

Studies back up these doctors' gripes. It would take 10.6 hours a day for a physician to follow all the treatment recommendations for patients with 10 common chronic diseases, including diabetes, heart disease, high blood pressure, depression, asthma and arthritis, according to a 2005 study in the Annals of Family Medicine. That doesn't leave much time for a 6-year-old's school physical or his mother's brush with the flu.

Activities outside the exam room consume about 20% of a primary-care doctor's workday, according to a physician survey reported in the Journal of General Internal Medicine in 2010. This tally includes telephone and email interactions that often substitute for office visits.

Many of us prefer these virtual visits: Our time is precious too. But they are a problem for doctors because most healthcare insurers, including Medicare, reimburse doctors only for face-to-face visits, a payment model called fee for service. And even many aspects of office visits are essentially free, because primary-care doctors must bill for their time using only five codes for Medicare and most commercial insurers.

"If you can't find a code that describes what you are doing, you don't get paid," said Dr. Roland Goertz, president of the American Academy of Family Physicians, which represents more than 100,000 doctors and medical students.

But for many primary-care doctors, the frustration is not so much about pay as about all the things that interfere with their ability to spend adequate time with their patients.

The number of U.S. medical school graduates opting for primary care dropped almost in half between 1999 and 2009, according to the latest statistics, though the trend has reversed a little in the last two years. They're flocking instead to specialties such as anesthesia and dermatology. Meanwhile, primary-care doctors are leaving their practices to become specialists or employees of hospitals, with set hours and salaries.

The trend comes at a point when they have a pivotal role to play in a nation suffering from more and more chronic diseases and higher healthcare expenses, experts say.

So what's to be done?

Four physician groups — the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Assn. — believe the answer lies with a different way of patient care, known as patient-centered medical homes. It's an idea that germinated in the late 1990s as a way to provide patients more access to primary care — with longer office visits and office hours, more convenient electronic scheduling, a team approach to managing patients' health and more email and telephone contact with physicians.

To date, more than 100 primary-care practices in the U.S. — a tiny fraction — have restructured themselves as patient-centered medical homes. Some are pilot programs funded by President Obama's Affordable Care Act.

For these "homes" to work, experts say, medical practices need to move away from paying doctors just for face-to-face visits to a system that pays them a set amount for each patient, including services outside the exam room, so that the doctor can focus on keeping patients healthy rather than checking off codes.

The medical homes also require well-functioning teams of doctors, physician assistants, nurses and other staff that share responsibility for patient care, says Sinsky, whose 115-physician group in Dubuque was an early adopter of the model. "That's hard for small or solo practices. It requires more infrastructure, and that doesn't happen for free," she says.

And there are other complexities. Ideally, the medical home model would give doctors more time with their patients — to make this happen, some advocates suggest that doctors should have fewer patients. But this could exacerbate the shortage of primary-care doctors, Sinsky says.

Another suggested alternative is scheduling fewer individual office visits with patients and more group visits — say, bringing together several obese patients to meet with a nutritionist — and offering more care remotely, such as having diabetes patients email their blood sugar or blood pressure results from at-home monitors rather than come to the office for them to be checked.

An even better solution, some say, could be to relieve physicians of more tasks that support staff could reasonably do — such as renewing prescriptions or ordering routine tests.

"You don't need a doctor to order a mammogram every two years for a woman 55 years old," says Dr. Thomas Bodenheimer, a professor of family and community medicine at UC San Francisco who practiced medicine for 32 years. A healthcare coach — who is a trained medical assistant — could do that just as easily, and could also handle a good chunk of the counseling about healthful living and disease management that is a key part of primary care.

Finally, perhaps it's time to allow doctors to focus on medicine and let the mass media and public service outreach handle topics such as seat belts, sun block, domestic violence and drugs, says Dr. Victoria McEvoy, medical director and chief of pediatrics at Mass General West Medical Group in Waltham, Mass. Obviously, adolescents should be discouraged from alcohol use, for example — but McEvoy notes that there's little evidence to suggest that advice from a physician actually convinces a risk-taking teen to lay off.

There are some nonmedical issues that just might stay in the doctor's office, though.

"I write letters to the electric company on behalf of my diabetic patients, pleading with them not to turn off the power. The cost to the system would be just too great if the insulin pump failed," Friedberg says. "No dermatologist will ever help you with your power bills."

http://www.latimes.com/health/la-he-primary-care-doctors-20110627,0,6729644,full.story

Doctor shortage: Why can't we just churn out more physicians? - By Brian Palmer - Slate Magazine

The Obama administration is recruiting "mystery shoppers" to pose as patients, call doctors' offices, and see how hard it is to get an appointment, especially with government health insurance. Critics say the study is a waste of taxpayer money. One family physician told the New York Times, "Everybody with a brain knows we do not have enough doctors." If everyone knows we have a doctor shortage, why don't we make more?

Money, mostly. The fastest way to produce more doctors in the United States would be to expand the capacity of the country's residency programs—the three- to six-year training stint that medical school graduates must complete before becoming licensed to practice on their own. But there are several barriers to doing that, not least of which is money. The federal government gives hospitals about $100,000 per resident per year to subsidize salary and training but has (for the most part) frozen the number of positions eligible for that subsidy at 1996 levels. Hospitals have expanded their residency programs modestly in that time, especially in high-earning specialty fields such as dermatology and radiology. But they argue that they don't have the money to keep up with demand.

Some economists suspect (PDF) there's something more nefarious going on than a simple lack of funds. In order for a hospital to take on more residents, it has to apply to the Residency Review Committee, a group comprised of 20 representatives of medical associations and one nonvoting government representative. Cynics claim that the groups deliberately restrict the flow of doctors so that demand for medical services will outstrip supply and salaries will remain high.

There's not much empirical evidence to support the claim, however. The Residency Review Committee insists that its job is to maintain the quality of education and that it permits hospitals to expand their residency programs if the institution has a solid track record and sufficient faculty mentors to shepherd the trainees through their apprenticeship. Also, in many fields, a resident can't graduate without performing a prescribed number of certain procedures. If a hospital doesn't have enough patients, it simply can't accommodate more residents.

Although residency programs aren't big enough to satisfy the nation's need for doctors, medical schools aren't even cranking out enough graduates to stock them. Today, nearly one-half of the doctors filling internal medicine, pediatric, and family practice residency programs come from abroad. That's because, anticipating a looming doctor surplus, medical schools stopped growing 30 years ago (PDF), and they aren't producing many more graduates today than they did in the early '80s.

Recently, medical schools started growing again, and they're now on track to increase the number of students 30 percent above the 2002 baseline by 2013. But since the new U.S. graduates will simply displace many graduates of foreign medical colleges (PDF), this expansion won't necessary result in a net gain in doctors. Besides, the increased number of spots at the med-school level doesn't represent a quick fix: It takes at least seven years between the day a fresh-faced idealist takes her seat at a medical school and the time she emerges from residency as a licensed, massively sleep-deprived physician.

http://www.slate.com/id/2297780/

Headlines - Kaiser Health News

Kaiser Health News (KHN) is a nonprofit news organization committed to in-depth coverage of health care policy and politics.

KHN's mission is to provide high-quality coverage of health policy issues and developments at the federal and state levels. In addition, KHN covers trends in the delivery of health care and in the marketplace.

http://www.kaiserhealthnews.org/Headlines.aspx

Mistakes In Outpatient Care Raising Concerns - Kaiser Health News

The focus of patient safety efforts in recent years has been on problems in hospitals rather than in outpatient settings such as doctors' offices and urgent care centers. Hospitals have come under scrutiny for everything from medication errors and hospital-acquired infections to 
wrong-site surgeries. But a recent study found that serious errors that result in malpractice awards also occur frequently in outpatient settings, suggesting that more attention needs to be paid to the mistakes that happen outside the hospital.

The study, published June 15 in the Journal of the American Medical Association, found that of 10,739 malpractice claims paid on behalf of physicians in 2009, 48 percent were in the inpatient setting, while 43 percent were in the outpatient setting. (An additional 9 percent of payments involved events that occurred in both settings.) The study also found that the proportion of malpractice claims paid for errors that occurred in outpatient settings increased slightly between 2005 and 2009.

Most people receive health care in outpatient settings: There are more than 950 million visits to physician offices annually, compared with just 34 million hospital discharges, according to the Centers for Disease Control and Prevention.

The new study's lead author said she was surprised by the findings. "There were a remarkably high number of cases in the outpatient setting, and the outcomes weren't trivial," says Tara Bishop, an internist who works at the Department of Public Health at Weill Cornell Medical College in New York. In both inpatient and outpatient settings, the most common outcomes were major injury or death.

Sherril Ismay went to an urgent care center in Grand Junction, Colo., one night in January 2009 to have her right foot examined. She didn't think she had a serious problem, but it was swollen and sore, and red around the joint of her big toe. The physician assistant who examined her gave her a diagnosis of gout, prescribed pain pills and a gout medication, and sent her back to the hotel where Ismay, then 57, was staying. (At the time, she was working as an oiler maintaining heavy equipment on a gas pipeline construction site.)

After two days in bed with worsening pain, Ismay got up one morning and saw red streaks running up her leg past her knee. She knew right away it could be a sign of serious infection. A co-worker took her to the urgent care center. The doctor on duty examined her, and the next thing she knew, she was in an ambulance on her way to the hospital.

It turned out that Ismay had necrotizing fasciitis, commonly referred to as flesh-eating bacteria, a potentially life-threatening infection that destroys soft tissue. Over the months that followed, doctors amputated more and more as they struggled to contain the infection. Her leg now ends an inch below the knee. She had to give up her job, which required a lot of walking over uneven ground, and now lives with her sister. "I was so strong and healthy," she says. "I never had any idea this could happen to me."

Ismay's lawyer, who filed a malpractice lawsuit in January, says that by not taking proper steps to diagnose Ismay's condition, whose symptoms were consistent with both gout and infection, the physician assistant breached the standard of care. The PA should have withdrawn fluid from the joint to look for infection, says Natalie Brown, a personal injury lawyer with Leventhal, Brown & Puga in Denver. "More important, she never told her to follow up with a physician or look out for signs and symptoms of infection," says Brown. "I don't think infection was even on her radar."

Diagnostic errors were the No. 1 reason for adverse events that resulted in malpractice payouts in outpatient settings, according to the JAMA study, while surgical adverse events accounted for the biggest share of claims paid for incidents that occurred in hospital settings. Only a small fraction of medical problems result in medical malpractice actions, of course, but the paid-claims data do give some idea of the prevalence and severity of adverse events in various settings, according to the study's authors.

Unfortunately, while more care is being provided in outpatient settings than in hospitals, it's often tougher to address patient safety problems there. For one thing, providers must rely heavily on patients to follow their instructions in outpatient settings, in contrast to hospitals, where clinicians have more control, says Tejal Gandhi, the chief quality and safety officer for Partners HealthCare in Massachusetts. Gandhi, an internist by training, has written extensively about patient safety in outpatient settings.

In addition, small practices may not have the resources or staff to tackle quality and safety issues. And since patients may see different providers, there are many opportunities for information about diagnoses or treatment to fall through the cracks.

One of the biggest challenges is to improve diagnoses in the outpatient setting. After all, if someone is in the hospital, clinicians start from the perspective that the person is sick. In an outpatient setting, "you see a lot of people with chest pain, and the vast majority of the time it's nothing - a pulled muscle, a little heartburn," says Gandhi. Identifying that one person whose chest pain signals a heart attack, "it's like finding a needle in a haystack."

http://www.kaiserhealthnews.org/Features/Insuring-Your-Health/Michelle-Andrews-on-errors-in-outpatient-care.aspx

New Prostate Cancer Drugs Extend Lives, but Raise Costs - NYTimes.com

A group of new drugs is promising to prolong the lives and relieve the symptoms of men with advanced prostate cancer, but could also add billions of dollars to the nation's medical bills.

In the last 15 months, three new drugs that extended the lives of prostate cancer patients in clinical trials have been approved by the Food and Drug Administration and several other promising medicines are in clinical trials. Before last year, only one drug had been shown to improve survival — docetaxel, which was approved in 2004.

"What a great time it is in prostate cancer," Dr. Daniel J. George of the Duke Cancer Institute proclaimed earlier this month at the annual meeting of the American Society of Clinical Oncology.

And it's a great time for the drug makers, with several drugs competing to fill a niche for longer-term survival. Analysts estimate that some of the new drugs, particularly Dendreon's Provenge and Johnson & Johnson's Zytiga, could reach annual sales of $1 billion or even much more.

The recently approved drugs and most of those in development are for cases in which the disease has spread beyond the prostate gland and is no longer held in check by hormone therapy.

Men with that late-stage cancer had a median survival of about a year and a half using docetaxel. The new drugs each added two to five months to median survival when tested in clinical trials. Doctors say that men taking more than one of the drugs in succession would be expected to live more than two years.

But the price of these drugs has already stirred concerns about the costs of care among patients, providers and insurers. For example, Provenge costs $93,000 for a course of treatment, while Zytiga costs about $5,000 a month. Another of the new drugs, Sanofi's Jevtana, costs about $8,000 every three weeks.

With other pricey drugs on the way, said Joel Sendek, an analyst at Lazard, "We could be talking easily $500,000 per patient or more over the course of therapy, which I don't think the system can afford, especially since 80 percent of the patients are on Medicare."

Medicare has already fired what some analysts interpret as a warning shot over prices, conducting a yearlong inquiry into whether to pay for Provenge. In its final decision, due Thursday, Medicare is expected to pay for the drug when used according to the label.

Medicare officials denied that price was the reason for the review. But some patient advocates and politicians portrayed the review as a step toward rationing.

Private insurers are also paying only if drugs are used according to the label, according to doctors and patient advocates.

"The reality is, there's pushback," said Dr. Oliver Sartor of Tulane University.

Still, for now, one company's price is prompting the next one to follow suit.

"The pricing environment is encouraging and getting better for us," Andrew Kay, the chief executive of Algeta, told securities analysts earlier this month, after announcing that his company's experimental drug had extended median survival nearly three months in a clinical trial.

Mr. Kay said he had initially thought that his company, which is based in Norway, would charge about $25,000 for a typical course of treatment with the drug, Alpharadin. But with the rival drug Jevtana costing about $50,000, Algeta and its partner, Bayer, are considering a higher price.

About 218,000 men in the United States get prostate cancer each year and about 32,000 die, according to the American Cancer Society.

In many cases, the cancer is caught before it has spread beyond the prostate gland and can be cured with surgery or radiation therapy.

If the cancer has spread, men usually are given drugs, particularly Abbott Laboratories' Lupron, that suppress the body's production of the hormone testosterone, which can fuel tumor growth.

The new drugs, for now at least, are for use when this hormone-deprivation therapy has stopped working.

"This is a small subset of people with prostate cancer," said Dr. Charles Myers, a prostate cancer specialist in private practice in Charlottesville, Va., who is a survivor of the disease himself. However, he noted, "It's the group of people who are dying."

Provenge was approved in April 2010 for patients whose cancer was late-stage but not yet causing many symptoms.

Once symptoms, mainly bone pain, have appeared, men are likely to receive docetaxel, a generic drug also sold by Sanofi as Taxotere .

Two other new drugs are approved for use only after docetaxel has been tried. One, Sanofi's Jevtana, is a chemotherapy drug in the same class as docetaxel; it was approved in June 2010. The other is Johnson & Johnson's Zytiga, approved this April.

Many patients and doctors are most enthusiastic about Zytiga and Provenge because they are alternatives to chemotherapy, which many men want to avoid because of side effects. Provenge works by training the body's immune system to fight the tumor.

Zytiga is a new form of hormone therapy. While Lupron mainly blocks production of testosterone by the testes, there is still some hormone produced by the adrenal gland or even by the tumor itself. Zytiga, by inhibiting an enzyme called CYP17, clamps down on testosterone production.

Doctors and patients say the new drugs can offer some men a decent quality of life, although they are not free of side effects. For instance, Zytiga, also known as abiraterone, can cause hypertension and liver damage and must be taken with the steroid prednisone.

Many men are likely to try several of the drugs. Mark Maldonado, a retired postal worker in Omaha, said that Jevtana had helped keep his cancer in check without debilitating side effects. But knowing that the drug would eventually stop working, he and his doctor "talked about abiraterone being the next step in our progress through the drugs."

More competition is coming. Takeda Pharmaceutical and Medivation, a San Francisco company, are separately developing other drugs that block testosterone's production or its effects.

Some of the most exciting advances, doctors say, are in the area of fighting the spread of prostate cancer to the bone. Such bone metastases are very common in men with advanced prostate cancer and account for most of the death and disability from the disease.

Cabozantinib, an experimental drug being developed by Exelixis, seems to be able to virtually eradicate bone metastases in some patients, at least as measured by bone scans, something no other drug has done.

Amgen won F.D.A. approval in November for Xgeva, a drug that reduces the risk of fractures and other problems caused by cancer in the bones. The drug can also delay the spread of cancer to the bones, according to the results of a more recent trial.

Dr. Christopher J. Logothetis, of the M. D. Anderson Cancer Center, predicted further progress.

"It's beyond the individual drugs," he said. "One sees a manual now on how to go forward."

http://www.nytimes.com/2011/06/28/health/28prostate.html?

Docs need more time to meet needs - Canada - Canoe.ca

Canadian doctors are finding it increasingly difficult to meet the needs of a growing number of aging patients living with chronic and complex medical conditions, a survey suggests.

Data released from the 2010 National Physician Survey, which surveyed 12,000 Canadian doctors, shows 72% reported the complexity of their patient caseload was placing increasing demands on their time.

The survey found 61% reported administrative duties and paperwork are placing more demands on their time, and 63% said managing patients with chronic conditions was a factor.

"I'm not surprised, but I'm somewhat disappointed at the performance of the health-care system over the last 10 years. We had hoped we'd be farther ahead," said Dr. Andrew Padmos, CEO of the Royal College of Physicians and Surgeons of Canada.

Canada is seven years into its 10-year, $41-billion fix-for-a-generation health accord, graduating more doctors each year. But Padmos said the survey shows the gains are being eroded by the loss of physicians' time and increased frustration due to paperwork, and having to deal complex and chronic illnesses.

"This is a national problem ... There's a great deal of consistency across the country and it begs the need for system-wide changes at a national level. We need a overarching strategic plan from our national and provincial governments to serve all Canadians," said Jeff Turnbull, president of the Canadian Medical Association.

The survey found 61% of urgent care patients can be seen by their family physician within one day - down from 65% in 2007. The survey reported 58% of family doctors across Canada took new patients in 2010, compared to 62% in 2007.

http://cnews.canoe.ca/CNEWS/Canada/2011/06/27/18342446.html?cid=rssnewslast24hours

Doctor and Patient: When the Doctor Has Epilepsy - NYTimes.com

One day during medical school, my classmates and I learned that one of the most well-liked doctors-in-training in the hospital had had a seizure while leading morning work rounds.

The sight of him writhing had caused the other doctors and nurses on the ward to panic. Some stood mute, frozen with fear. An intern, believing that the seizure arose from low blood sugar levels, took his half-eaten jelly doughnut and held it against the mouth of his seizing colleague. Others yelled to the ward secretary to "call a code," and continued to do so even after another dozen doctors and nurses had already arrived on the floor.

The young doctor eventually recovered. But for many of the medical students and doctors who heard about the episode or were on the wards that day, the dread of that morning would linger long beyond our years of training. Epilepsy was, and remains, a frightening and mysterious malady.

For the last 20 years, Dr. Brien J. Smith has tried to change how doctors and patients view epilepsy. Earlier this year, Dr. Smith, chief of neurology at Spectrum Health in Michigan, became chairman of the Epilepsy Foundation. Being elected head of a national organization does not seem unusual for a doctor who is a well-recognized authority and advocate in his or her field. What is extraordinary is that Dr. Smith knows firsthand about the disease and what his patients experience: He learned he had epilepsy when he was in high school.

"Every day I see how off-base health care workers are with seizures and epilepsy," Dr. Smith said recently. "There's a lot of stigma attached, a lot of stereotypes regarding cognitive abilities and how seizures should look."

I spoke to Dr. Smith and asked him about his advocacy work, his diagnosis and how being a patient has affected his interactions with patients and colleagues.

More ...

http://well.blogs.nytimes.com/2011/06/23/seeing-epilepsy-from-the-patients-point-of-view/?

Startup Wins Funding For iPhone App To Scan Skin For Melanoma - The Washington Post

How would you feel about an iPhone app that claimed to be able to tell if that mole on your arm was not looking too healthy? That's the claim of Skin Scan, an iPhone medical app available now on the Apple App Store. The startups has secured €50,000 Euro in seed funding from Seedmoney.

Either Skin Scan is going to get people to see a doctor earlier, thus potentially saving lives. Or it's going to make hypochondriacs of us all. I can't decide which. Suffice it to say this appears to be one clever app. Because it also asks for your location, Skin Scan is also producing a live map of how our moles are looking around the globe. The implication for the app are very interesting – Skin Scan could end up mapping skin cancer rate across the planet, if it gets this right.

The app takes a picture of a mole on the skin, then uses a proprietary algorithm to look at the fractal-like shapes which exist in human skin (have a look up close, you can see little triangles in normal skin, honest). It then calculates if the shape of the mole means it is is developing normally, or abnormally thus in a into a potential cancerous melanoma.

http://www.washingtonpost.com/business/technology/startup-wins-funding-for-iphone-app-to-scan-skin-for-melanoma/2011/06/27/AGKASZnH_story.html

The robot doctor will see you now - The Globe and Mail

Some doctors are known for their less-than-superb bedside manners. In their defence, they're only human.

But it's possible the human element will play less of a role in the future as machines take more responsibility for diagnosing diseases, assigning treatments and ensuring hospitals run smoothly and efficiently.

Don't expect computers to replace doctors. But as advancements in artificial intelligence continue to unfold, a growing number of computer experts, health professionals and businesses believe machines will have an increasingly important role to play. While that could result in more accurate diagnoses, fewer mistakes and cost savings, experts also warn that relying too heavily on machines could backfire. For instance, computers with inaccurate or incomplete information could give the wrong diagnosis, putting lives at risk.

Computer scientists who study artificial intelligence (AI) are developing machines that can provide answers to questions, identify key patterns in data and predict trends – to make machines that have human-like intelligence and abilities but can also operate more quickly and more efficiently, making fewer mistakes.

Medicine and health have emerged as areas that can benefit greatly. AI applications rely heavily on sifting through large amounts of data to identify patterns or come up with answers, which can make a difference in health care.

One important possibility is improved medical diagnoses. AI systems that are programmed to understand known diseases, symptoms and risk factors could quickly and easily make a diagnosis that a doctor could then verify in a physical exam. This means a patient could get access to vital medical treatments more quickly, which could be critical in certain situations. It could also save time and money.

"If you had somebody who had a really rare disease, then that might not be the first thing that the physician would think about," said Cory Butz, a computer science professor at the University of Regina, who spoke about AI recently at the University of Cambridge. "But the ... machine could go through all the possibilities and raise the issue, [saying] 'perhaps the person has this illness,' much quicker than the human would think about it."

The use of AI could also negate any bias that could affect a doctor's decisions. For instance, research has suggested some doctors have a bias against smokers, which could affect how that patient is diagnosed and treated.

The Mayo Clinic recently conducted an experiment to see whether AI systems could truly assist physicians. Researchers used "teachable software" that mimics the human brain to help diagnose potentially fatal cardiac infections in the hope of eliminating the need for an invasive exam.

The researchers introduced the system to countless real-world scenarios to help it evaluate symptoms correctly. After examining data from nearly 200 patients, the software correctly diagnosed the infection in nearly all cases.

The study was based on clinical data from previous patients, but if the software was introduced to hospitals, it could help patients and result in major savings. Similar systems could also help reduce medical errors, improve the accuracy of medical tests and help hospitals reduce inefficiencies.

Although it's clear many bugs need to be worked out before AI applications play a major role in day-to-day medical decisions, many are optimistic about future possibilities.

Recently, the famous IBM computer Watson appeared at a conference of health and computer science experts in Toronto. The computer was made famous earlier this year when it beat human contestants on the game showJeopardy! But company officials believe the computer's future lies in making medical diagnoses. Earlier this year, it announced a partnership with Massachusetts-based Nuance Communications Inc., a speech and imaging solutions firm, in a bid to get a product on the market.

But Prof. Butz also warned that any AI-based health care applications would need strict limits. Although machines are highly efficient, they are only as good as the information that has been programmed into them. For instance, the names of diseases could be fed into the machine incorrectly, or the system might not have the functionality to compare a person's symptoms against their risk factors for disease.

"I don't think that you would ever have a robot doctor or a robot physician," Prof. Butz said. "If you make a mistake diagnosing a patient, there could be drastic and even fatal consequences to that. The software system will always simply be aiding a human expert."

http://www.theglobeandmail.com/news/technology/the-robot-doctor-will-see-you-now/article2074992/?cmpid=nl-news1

U.S. Plans a Stealth Survey on Access to Physicians - NYTimes.com

Alarmed by a shortage of primary care doctors, Obama administration officials are recruiting a team of "mystery shoppers" to pose as patients, call doctors' offices and request appointments to see how difficult it is for people to get care when they need it.

The administration says the survey will address a "critical public policy problem": the increasing shortage of primary care doctors, including specialists in internal medicine and family practice. It will also try to discover whether doctors are accepting patients with private insurance while turning away those in government health programs that pay lower reimbursement rates.

Federal officials predict that more than 30 million Americans will gain coverage under the health care law passed last year. "These newly insured Americans will need to seek out new primary care physicians, further exacerbating the already growing problem of P.C.P. shortages in the United States," the Department of Health and Human Services said in a description of the project that it submitted to the White House.

Plans for the survey have riled many doctors because the secret shoppers will not identify themselves as working for the government.

"I don't like the idea of the government snooping," said Dr. Raymond Scalettar, an internist in Washington. "It's a pernicious practice — Big Brother tactics, which should be opposed."

According to government documents obtained from Obama administration officials, the mystery shoppers will call medical practices and ask if doctors are accepting new patients and, if so, how long the wait would be. The government is eager to know whether doctors give different answers to callers depending on whether they have public insurance, like Medicaid, or private insurance, like Blue Cross and Blue Shield.

Dr. George J. Petruncio, a family doctor in Turnersville, N.J., said: "This is not a way to build trust in government. Why should I trust someone who does not correctly identify himself?"

Dr. Stephen C. Albrecht, a family doctor in Olympia, Wash., said: "If federal officials are worried about access to care, they could help us. They don't have to spy on us."

Dr. Robert L. Hogue, a family physician in Brownwood, Tex., asked: "Is this a good use of tax money? Probably not. Everybody with a brain knows we do not have enough doctors."

In response to the drumbeat of criticism, a federal health official said doctors did not need to worry because the data would be kept confidential. "Reports will present aggregate data, and individuals will not be identified," said the official, who requested anonymity to discuss the plan before its final approval by the White House.

Administration officials said the survey would yield an enormous benefit to the government while imposing an extremely limited burden on doctors.

The new health care law includes several provisions intended to increase the supply of primary care doctors, and officials want to be able to evaluate the effectiveness of those policies.

Federal officials said the initial survey would cost $347,370. Dr. Hogue said the money could be better spent on the training or reimbursement of primary care doctors.

Most doctors accept Medicare patients, who are 65 and older or disabled. But many say they do not regard the government as a reliable business partner because it has repeatedly threatened to cut the fees paid to doctors treating such patients. Congress usually steps in at the last minute to avert such cuts.

In many parts of the country, Medicaid, the program for low-income people, pays so little that many doctors refuse to accept Medicaid patients. This could become a more serious problem in 2014, when the new health law will greatly expand eligibility for Medicaid.

Access to care has been a concern in Massachusetts, which provides coverage under a state program cited by many in Congress as a model for President Obama's health care overhaul.

In a recent study, the Massachusetts Medical Society found that 53 percent of family physicians and 51 percent of internal medicine physicians were not accepting new patients. When new patients could get appointments, they faced long waits, averaging 36 days to see family doctors and 48 days for internists.

In the mystery shopper survey, administration officials said, a federal contractor will call the offices of 4,185 doctors — 465 in each of nine states: Florida, Hawaii, Massachusetts, Minnesota, New Mexico, North Carolina, Tennessee, Texas and West Virginia. The doctors will include pediatricians and obstetrician-gynecologists.

The calls are to begin in a few months, with preliminary results from the survey expected next spring.

Each office will be called at least twice — by a person who supposedly has private insurance and by someone who supposedly has public insurance.

Federal officials provided this example of a script for a caller in a managed care plan known as a preferred provider organization, or P.P.O.:

Mystery shopper: "Hi, my name is Alexis Jackson, and I'm calling to schedule the next available appointment with Dr. Michael Krane. I am a new patient with a P.P.O. from Aetna. I just moved to the area and don't yet have a primary doctor, but I need to be seen as soon as possible."

Doctor's office: "What type of problem are you experiencing?"

Mystery shopper: "I've had a cough for the last two weeks, and now I'm running a fever. I've been coughing up thick greenish mucus that has some blood in it, and I'm a little short of breath."

In separate interviews, several doctors said that patients with those symptoms should immediately see a doctor because the symptoms could indicate pneumonia, lung cancer or a blood clot in the lungs.

Other mystery shoppers will try to schedule appointments for routine care, like an annual medical examination for an adult or a sports physical for a high school athlete.

To make sure they are not detected, secret shoppers will hide their telephone numbers by blocking caller ID information.

Eleven percent of the doctors will be called a third time. The callers will identify themselves as calling "on behalf of the U.S. Department of Health and Human Services." They will ask whether the doctors accept private insurance, Medicaid or Medicare, and whether they take "self-pay patients." The study will note any discrepancies between those answers and the ones given to mystery shoppers.

The administration has signed a contract with the National Opinion Research Center at the University of Chicago to help conduct the survey.

Jennifer Benz, a research scientist at the center, said one purpose of the study was to determine whether the use of mystery shoppers would be a feasible way to track access to primary care in the future.

The government could survey consumers directly, but patients may not accurately recall how long it took to get an appointment, and their estimates could be colored by their satisfaction with the doctor, researchers said.

http://www.nytimes.com/2011/06/27/health/policy/27docs.html?hp=&pagewanted=print

347 Million Adults Now Have Diabetes - Health News - redOrbit

A major international study recently found that diabetes cases have more than doubled to 347 million cases since 1980, a number far larger than what experts previously thought and one that suggests costs of treating the disease will also skyrocket.

The research, published in the journal 'The Lancet,' reveals that from 1980 to 2008, diabetes has either risen or gone unchanged in every region of the world. The estimated number of diabetics is much higher than a previous projection that placed the number at 285 million worldwide.

In the new study, worked on with the help of the World Health Organization, researchers found that of the 347 million cases of diabetes in the world, 138 million exist in China and India and 36 million in the US and Russia.

The study included blood sugar measurements from 2.7 million participants aged 25 years or more across the world and used advanced statistical methods for analyzing data.

Diabetes occurs when the cells of the body are not able to take up sugar in the form of glucose. As a result, the amount of glucose in the blood is higher than normal. Over time, this can raise the risk of heart disease and stroke, and can cause kidney damage, nerve damage and harm the retinas. High blood glucose and diabetes are responsible for over three million deaths worldwide each year.

"Diabetes is becoming more common almost everywhere in the world," said Majid Ezzati, from Britain's Imperial College London, who led the study along with Goodarz Danaei from the Harvard School of Public Health in the United States.

"Unless we develop better programs for detecting people with elevated blood sugar and helping them to improve their diet and physical activity and control their weight, diabetes will inevitably continue to impose a major burden on health systems around the world," added Danaei in the joint statement to Reuters.

The new study found that 70 percent of the rise in diabetes cases was due to population growth and ageing, with the other 30 percent due to higher prevalence. The proportion of adults with diabetes rose to 9.8 percent of men and 9.2 percent of women in 2008, compared with 8.3 percent of men and 7.5 percent of women in 1980.

"Diabetes is one of the biggest causes of morbidity and mortality worldwide. Our study has shown that diabetes is becoming more common almost everywhere in the world. This is in contrast to blood pressure and cholesterol, which have both fallen in many regions. Diabetes is much harder to prevent and treat than these other conditions," said Ezzati.

"Unless we develop better programs for detecting people with elevated blood sugar and helping them to improve their diet and physical activity and control their weight, diabetes will inevitably continue to impose a major burden on health systems around the world," added Danaei.

To test whether or not someone has diabetes, doctors measure the levels of glucose in a patient's blood after they have not eaten for 12 to 14 hours, since blood sugar rises after a meal. A "fasting plasma glucose" (FPG) below 5.6 millimoles per liter (mmol/L) is considered normal, above 7 mmol/L is diagnostic of diabetes and an FPG level between 5.6 and 7 is considered pre-diabetes.

There are numerous treatments for diabetes available on the market, in both pill and injection. Global sales of diabetes medicines totaled $35 billion in 2010 and could rise to as much as $48 billion by 2015, according to analysis from drug research firm IMS Health.

The annual meeting of the American Diabetes Association in San Diego will play host to the presentment of new research on experimental drugs and ways to combine classes of drugs to better control blood sugar.

"This is a chronic, progressive condition," said Dennis Urbaniak, vice president of Sanofi's diabetes division. "What we are most worried about is the number of people out there with diabetes that is not optimally controlled."

Diabetes has surged most in the Pacific Island nations, which now have the highest diabetes levels in the world, the study found. In the Marshall Islands, a third of all women and a quarter of all men have diabetes.

In the developed world, North America had the highest level of diabetes cases while Western Europe remained relatively small. Diabetes levels were the highest in United States, Greenland, Malta, New Zealand and Spain; and lowest in the Netherlands, Austria and France.

The study was carried out by an international collaboration of researchers, led by Professor Majid Ezzati and co-led by Dr. Goodarz Danaei, in collaboration with The World Health Organization and a number of other institutions.

http://www.redorbit.com/news/health/2070130/347_million_adults_now_have_diabetes/