Archive for October, 2010

The Best Medicine

Friday, October 29, 2010 // Uncategorized

9/24/2009 12:54:03 AM

Getting Well: It’s About Time

  • By MELINDA BECK

  • What cures colds, flu, sore throats, sore muscles, headaches, stomach aches, diarrhea, menstrual cramps, hangovers, back pain, jaw pain, tennis elbow, blisters, acne and colic, costs nothing, has no weird side effects and doesn’t require a prescription?

Plain old-fashioned time. But it’s often the hardest medicine for patients to take.

“Most people’s bodies and immune systems are wonderful in terms of handling things—if people can be patient,” says Ted Epperly, a family physician in Boise, Idaho, and president of the American Academy of Family Physicians.

“I have a mantra: You can do more for yourself than I can do for you,” says Raymond Scalettar, a Washington, D.C., rheumatologist and former chairman of the American Medical Association. But, he says, “some patients are very medicine-oriented, and when you tell them they aren’t good candidates for a drug they’ve heard about on TV, they don’t come back.”

[pjHEALTHCOL] Robin Eley

An estimated one-third to one-half of the $2.2 trillion Americans spend annually on health care in the U.S. is spent on unnecessary tests, treatments and doctor visits. Much of that merely buys time for the body to heal itself.

And while temporary relief from symptoms is nothing to sneeze at, it adds up to a considerable amount of spending: $5.4 billion annually on cough and cold remedies, $2.7 billion on headache remedies and $411 million on chest rubs and other analgesics, according to Nielsen Co. Americans also spend an estimated $1 billion on unnecessary antibiotics that don’t even relieve the symptoms of viral infections, and contribute to antibiotic resistance. But some patients are so insistent on getting antibiotics that doctors give in.

“I have colleagues who say, ‘You can take this pill and get better in two days, or do nothing and get over it in 48 hours,’ ” says Dr. Scalettar.

Even H1N1, or swine flu, for all the uproar, almost always resolves in a few days with no treatment. The Centers for Disease Control and Prevention is urging physicians to use Tamiflu, an antiviral medication, sparingly to prevent shortages and avoid antiviral resistance. Only people who are hospitalized or at high risk for complications should get Tamiflu, according to the CDC.

The list of “self limiting” maladies—those that require no outside treatment—range from minor annoyances to what might appear to be more serious musculoskeletal problems. “Muscle aches and pain, minor traumas, sprains and strains typically do not need to be seen by a doctor,” says Dr. Epperly, who recommends his organization’s Web site, www.FamilyDoctor.org, as a resource to look up symptoms and health concerns. “Nausea, vomiting and diarrhea are typically time-limited. People will start to see improvement in two or three days—just watch that you’re not throwing up blood,” he says. If so, call your doctor.

Almost all viral infections resolve on their own, unless you have a compromised immune system. As a rule of thumb, Dr. Epperly says, infections in the nose, throat, stomach and upper respiratory tract tend to be viral. Infections elsewhere in the body are likely to be caused by bacteria, and those can get worse without antibiotics. About 80% of urinary-tract infections resolve on their own, for example, but about 20% develop into more serious kidney or blood infections. And even if they don’t, the symptoms can be very uncomfortable.

Parents are often extremely eager to “do something” for children who complain of sniffles, stomach aches, scrapes and fevers. Yet kids are generally very resilient, writes Lara Zibners, an emergency pediatrician, in her book, “If Your Kid Eats This Book, Everything Will Still Be Okay.” (For a fever, she advises calling the doctor if the patient is a baby younger than three months and has a fever over 100.4 degrees. For kids older than that, other symptoms are more important than the thermometer—especially if a child is listless, irritable, unusually sleepy, refusing to eat or drink, or having trouble breathing.)

Some chronic maladies follow predictable courses, according to many medical experts ,whether or not they are treated.

Colic is almost always gone in four months. Some 70% of acne is gone three to four years after it first appears. “Frozen shoulder”—a painful restriction of the shoulder joint—is typically painful for three to six months and stiff for the next four to six months, and resolves completely after one to three more months. Temporomandibular joint (TMJ) pain tends to go away by itself in 18 months. Sciatica resolves on its own in three weeks in 75% of cases.

For all the misery it causes, 80% to 90% of back pain resolves with only “conservative measures” (which include anti-inflammatory drugs, rest, heat, physical therapy and chiropractic treatments). “Sometimes it take days to weeks, sometimes it takes weeks to months, but pain lasts more than three months in only about 10% of cases,” says Michael J. Yaszemski, chief of orthopedic spine surgery at the Mayo Clinic in Rochester, Minn.

Whether to operate even in those remaining cases is controversial, he says. With acute lumbar disc herniation, studies have found that two and five years later, there’s little difference between patients who had surgery and those who did not. But surgery can sometimes provide relief faster.

“There are those patients who feel they just can’t wait—like Joe Montana,” says Dr. Yaszemski of the former San Francisco 49ers quarterback, who made headlines when he returned to playing football just eight weeks after spinal surgery in 1986.

Many patients are relieved to hear that they don’t need to take medicine, have a blood test or undergo surgery for what ails them. But some feel embarrassed to have taken the doctor’s time or frustrated because they think the doctor isn’t taking their situation seriously. (“Much depends on the way you tell them,” says Dr. Scalettar. “There are some arrogant doctors.”)

And some patients resent paying for a visit when all the doctor provides is reassurance that they’ll get better with time. “If a patient says, ‘You mean, I’m paying $100 for you to tell me there’s nothing wrong?’ I say, ‘There is something wrong—a virus,’ ” says Dr. Epperly. ” ‘But more importantly, I can tell you what’s not wrong: it’s not meningitis or cancer or a brain tumor or some other life-threatening illness. And if the pain doesn’t go away in a few days, please, please tell me, and we’ll investigate further.’ ”

“The longer you’ve known someone, the easier that conversation is,” Dr. Epperly adds.

Indeed, applying what some call “a tincture of time” requires time on the doctor’s part as well. Explaining why a medication or CT scan or MRI isn’t necessary, or what signs to look for if an ailment isn’t getting better, often takes more time than writing a quick prescription.

Of course, there are symptoms that people should never ignore, since they could signal a serious illness or a condition that could get worse, not better, with time. Contact your doctor immediately if you experience any of the following:

  • Crushing chest pains—the classic signs of a possible heart attack.
  • Sudden numbness or weakness on one side of the body, confusion, trouble speaking or severe headache—which could indicate a stroke.
  • Sudden, severe headaches.
  • Any major injury, especially involving loss of consciousness.
  • Coughing up, throwing up or excreting blood.
  • Suicidal or homicidal urges.
  • Flashing lights in your vision—which could be a detached retina.
  • Inability to breath—which could be a severe allergic reaction.
  • Recurrent tooth pain. “You can typically give a tooth ache 24 hours,” says Dr. Epperly. “If it’s an abscess that would require a root canal, it won’t get better by itself.”

The bottom line: Don’t hesitate to call your doctor if you have persistent pain or a loss of function or anything unusual for you. It’s worthwhile to rule out something serious that does need medical attention. But if the doctor says you will get better on your own, that’s a powerful prescription itself.

—Email: [email protected] Printed in The Wall Street Journal, page A30

Copyright 2009 Dow Jones & Company, Inc. All Rights Reserved

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Good News and Bad News About H1N1 Vaccine

Friday, October 29, 2010 // Uncategorized

9/22/2009 10:45:42 PM

First the good news:

The first shipments of H1N1 vaccine will go out the first week in October.  3.5 million doses of Flu Mist are scheduled to be shipped followed by the inactivated (injectable) vaccine.

The bad news:

To accomplish this herculaen task, they have had to delay shipment of the rest of our seasonal flu vaccine.  This makes sense, the H1N1 is the biggest problem now.  Optimal timing for the seasonal flu vaccine is late October and early November.  This is the time when the rest of our vaccine is due to arrive.  In the meantime, we hope to begin vaccinating persons at risk for H1N1.  If you haven’t yet received your seasonal flu vaccine, don’t panic.  There will be ample vaccine and ample time.  Our patients may call and we’ll take your name and call when it comes in.  The following is the CDC guidelines for H1N1 vaccinations.

The CDC’s Recommendations for Influenza A (H1N1) 2009 Vaccine

Target groups for initial vaccine supplies include pregnant women as well as children and young adults.

The CDC has released its recommendations for use of influenza A (H1N1) 2009 monovalent vaccine. Although the vaccines are not licensed yet, the target date for the first available supply is mid-October 2009. State and local health officials will distribute vaccines, depending on local conditions.

The CDC recommends that the following five target groups (about 159 million people in the U.S.) receive priority for vaccination: pregnant women, people living with or caring for infants younger than 6 months, healthcare and emergency-response personnel, children and young adults (age range 6 months–24 years), and other adults (age range, 25–64) who have medical conditions that put them at high risk for complications associated with seasonal influenza. If the vaccine supply is not adequate for the target groups, the CDC has defined a subset for initial vaccination. If the supply is adequate, vaccination should be made available to all adults aged 25 to 64. Given that older adults (age, ≥65) have exhibited lower risk for infection, vaccination in this older group is recommended only after demand is met in all younger groups. If the vaccine requires two doses (likely, but not known until licensure), vaccine supplies should not be stockpiled for patients who received first doses and might require another dose. Two inactivated influenza vaccines or one inactivated and one live vaccine can be administered during the same visit; two live influenza vaccines cannot be administered during the same visit.

Comment: As the vaccine becomes available, clinics, hospitals, and office-based practices must adjust usual vaccination programs to accommodate delivery systems (e.g., health department clinics, school programs) initiated by local health departments. The recommendations for standard seasonal influenza vaccine are unchanged, so vaccine administration will require more time. Both thimerosal-free vaccine (for young children and pregnant women) and inactivated and live attenuated vaccines are expected to be available.

Peggy Sue Weintrub, MD

Dr. Weintrub is on the Speakers’ Bureau for Sanofi-Aventis and MedImmune (manufacturers of inactivated and live-attenuated vaccines, respectively).

Published in Journal Watch Pediatrics and Adolescent Medicine September 9, 2009

Citation(s):

Centers for Disease Control and Prevention (CDC). Use of influenza A (H1N1) 2009 monovalent vaccine. Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009. MMWR Recomm Rep 2009 Aug 28; 58:1. (http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5810a1.htm)

Our patients who feel they fit into one of those categories may call and we’ll place your name on a list.  We don’t yet know how many doses of the vaccine we will receive.

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It's Never Too Late To Exercise

Friday, October 29, 2010 // Uncategorized

9/17/2009 11:13:20 PM

More information has become available on the benefits of exercise in the elderly.

Physical Activity Associated with Increased Survival in Elders
Physical activity is associated with increased survival among elderly adults — even when they don’t begin to exercise until they are of advanced age — reports a longitudinal study in Archives of Internal Medicine.
Researchers examined associations between physical activity and mortality among nearly 1900 adults who were interviewed at ages 70, 78, and 85 and followed through age 88. After adjustment for confounders including major diseases, subjects who reported being physically active at the interviews were less likely to die throughout follow-up, compared with those who were sedentary. The survival benefit was seen for subjects who were already active when the study began — and also for those who started to exercise between ages 70 and 78 and ages 78 and 85.
The authors conclude: “Our findings clearly support the continued encouragement of [physical activity], even among the oldest old. Indeed, it seems that it is never too late to start.”
Archives of Internal Medicine article (Free abstract; full text requires subscription)
Physician’s First Watch coverage of previous study showing benefits of healthy lifestyle in older age (Free)

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H1N1 Update

Friday, October 29, 2010 // Uncategorized

9/16/2009 7:38:57 PM

Here’s some news about the vaccine.

H1N1 Update: 2009 H1N1 Vaccines Approved
The FDA approved four vaccines against 2009 H1N1 influenza on Tuesday, according to an agency news release. Several studies have showed that most healthy adults had a strong immune response after one dose. An optimum dosing schedule for children has not yet been determined.
National distribution of the initial lots is expected within 4 weeks.

Here’s some news about how long one is considered contagious if they have the virus.  Previously, people had been told that they could return to school/were no longer contagious 24 hours after they were fever free.  I’m not sure from where that originated.  It didn’t make a lot of sense to me.  as it turns out, it was wrong.

Swine flu contagious longer than thought
– —————————————-
When the coughing stops is probably a better sign of when a swine flu
patient is no longer contagious, experts said after seeing new
research that suggests the virus can still spread many days after a
fever goes away. The Centers for Disease Control and Prevention (CDC)
has been telling people to stay home from work and school and avoid
contact with others until a day after their fever breaks. The new
research suggests they may need to be careful for longer — especially
at home where the risk of spreading the germ is highest. Swine flu
also appears to be contagious longer than ordinary seasonal flu,
several experts said.

“This study shows you’re not contagious for a day or 2. You’re
probably contagious for about a week,” said Gaston De Serres, a
scientist at the Institute of Public Health in Quebec. He presented
one of the studies Monday [14 Sep 2009] at an American Society for
Microbiology conference. It is the 1st big meeting of infectious
disease experts since last spring’s emergence of swine flu [influenza
pandemic (H1N1) 2009 virus], which now accounts for nearly all of the
flu cases in the United States. More than one million Americans have
been infected and nearly 600 have died from it, the CDC estimates.

It is unclear whether the new research will lead the CDC to rethink
its advice on how long people with swine flu should hole up. Long
breaks from school and work do not seem worth it for a virus that now
seems to cause mostly mild illness, said the CDC’s flu chief, Nancy
Cox. Swine flu is spreading so widely now that confining the sick does
less good, she said. “We tried to have our guidance balance out all of
these factors,” she said. “It’s just virtually impossible not to have
virus introduced into settings such as schools and universities.”

Doctors know that people can spread ordinary seasonal flu for a couple
of days before and after symptoms start by studying virus that
patients shed in mucus. The 1st such studies of swine flu are just
coming out now, and they imply a longer contagious period for the
novel bug. “It’s probably realistic that this virus sheds much longer
than seasonal flu,” said Dr. Jonathan McCullers, an infectious
diseases specialist at St. Jude Children’s Research Hospital in
Memphis, Tennessee.

Three reports suggest this is so. De Serres and other researchers in
Canada took nose and throat swabs from 43 patients with lab-confirmed
flu and dozens of other sick family members. On the 8th day after
symptoms 1st appeared, 19 to 75 percent showed signs of virus
remaining in their noses, depending on the type of test used. “This
proportion appears to be very big, and it is,” but it’s not clear how
much virus is needed to actually spread flu, so the lower number is
more reliable, he said.

Dr. David C. Lye reported on 70 patients treated at Tan Tock Seng
Hospital in Singapore. Using a very sensitive test to detect virus in
the nose or throat, he found that 80 percent had it 5 days after
symptoms began, and 40 percent 7 days after. Some still harboured
virus as long as 16 days later. How soon they started on antiviral
medicines such as Tamiflu made a difference in how much virus was
found, but not whether virus was present at all.

A 3rd report came from Dr. Guillermo Ruiz-Palacios of the National
Institutes of Medical Science and Nutrition in Mexico, where the 1st
cases of swine flu were detected. Infected people “shed the virus for
a very, very long time,” often for more than a week after the start of
symptoms, he told the conference. This was especially true of obese
people, and patients who started on medicines longer than 2 days after
symptoms 1st appeared.

The new reports suggest a longer contagious period for swine flu, but
how long is not clear, Cox said. Even with it in your nose, “you might
not be shedding enough virus to infect other people,” she said. That
is why signs like coughing may matter more, De Serres said.
“Contagiousness varies, not only with the presence of the virus, but
the other symptoms that would make you transmit,” he said.

Swine flu symptoms can include fever, cough, sore throat, runny or
stuffy nose, body aches, headache, chills and fatigue, and sometimes
diarrhea and vomiting. Young children may be cranky, less playful or
not eat as much as normal, the CDC advises. The agency’s advice to
stay home for a day after fever breaks does not apply to health care
settings. There, confinement for 7 days from the start of symptoms —
or until they go away, whichever is longer — is still advised.

People who have had swine flu should cover their mouths when they
cough or sneeze and wash their hands a lot once they do return to work
and school, the CDC says.

I will give out more information on the vaccine as it becomes available.  One bit of information is that it is free!  Physicians may charge an administrative fee.  The maximum allowed in San antonio is $19.20.

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A Few Thoughts on Health Care Reform

Friday, October 29, 2010 // Uncategorized

9/14/2009 10:47:28 PM

As the debate on health care reform continues, here are a few observations of my own.

I have a patient from England.  He lives in San Antonio a few months of the year and travels extensively.  Though he is 67 he has never been offered a colonoscopy for colon cancer screening from his doctor in England.  He also was not offered a treatment for his elevated cholesterol even though it was 260.

I have another patient who is from Canada  and who injured his knee in an exercise class.  It didn’t respond to rest, ice, elevation and anti-inflamatory medication.  He had an MRI, was found to have a cyst which was apirated and injected.  He was told that in Vancouver he would have to wait a year for an MRI.

The population of the United States is about 300 million.  Last year, about 50 million CAT scans were performed.  Not only is more medicine not better medicine, the cumulative effect of all these CAT scans will be felt in the years to come as cancer rates may increase due to the radiation exposure.  Some people would say that the number of CAT scans done is related to concerns by physicians about liability.   Texas has enacted some of the most dramatic tort reforms in the country.  This has resulted in an influx of new physicians into the state, lower malpractice insurance rates, but I’ve been unable to locate information that documents any  cost savings to consumers.

There must be a middle ground.

Anyone who has ever had dealings with Medicare is not in favor of a “public option”.

There can be no reform of the health care system without increasing the number of primary care physicians.  At present, doctors in the United States are paid to do, not to think.

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September Flu Update

Friday, October 29, 2010 // Uncategorized

9/12/2009 1:30:09 PM

Seasonal flu vaccine is plentiful this year.  Usually, we like to give it in October and November.  This year, faced with having to give an additional vaccine, we decided to start giving it as soon as it was available.  There is a lot of H1N1 flu circulating.  It’s mainly being reported in universities.  It doesn’t seem to be any worse than usual flu viruses and most people get well within a few days.  I don’t encourage people to take Tamiflu as this doesn’t seem to have dramatic effects.  If we use too much Tamiflu there is a concern that it will cause widespread resistance which may be incorporated into other more severe flu viruses like Avian flu.  Rest, Advil, fluids and times cures most of these individuals.  A sudden rise in temperature during the recovery period may indicate a secondary infection which we treat with antibiotics.

There is good news about the H1N1 vaccine:

H1N1 Update: Early Results on Vaccine Indicate One Dose May Be Sufficient for Most Groups
Preliminary studies of two vaccines against 2009 H1N1 virus reported online in the New England Journal of Medicine are “reassuring.”
Using a variety of dosages and schedules, the industry-supported studies, done in Australia and the U.K., comprised some 300 healthy adults and evaluated the immunogenicity of the vaccines 3 weeks after administration. (One vaccine, derived from viruses grown in cell culture and not hens’ eggs, contained adjuvant, which is not expected to be licensed for use in the U.S. this year.)
The immune response to a single 15-μg dose of unadjuvanted vaccine was rated as “robust” by researchers. Both vaccines showed good immunogenicity. The journal’s editorialist says the data suggest that the single 15-μg dose “should be immunogenic” in the groups prioritized for vaccination; however, younger children will probably still require two shots. Side effects included tenderness at the injection site and pain.
The editorialist observes: “It is reassuring that the manufacturing process for these vaccines is identical to that used for seasonal vaccines, which have a strong record of safety.”

When the vaccine becomes available at the end of October we will try to immunize high risk individuals first.  These key populations include pregnant women, people who live with or care for children younger than 6 months of age, healthcare and emergency medical services personnel, persons between the ages of 6 months and 24 years old, and people ages of 25 through 64 years of age who are at higher risk for novel H1N1 because of chronic health disorders or compromised immune systems.

Stay tuned for more flu information.

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Two Articles on Health Care Reform

Friday, October 29, 2010 // Uncategorized

9/3/2009 8:16:02 AM

My patients are always asking me what I think about health care reform.  Of course, I’ve been thinking about this for a long time.  I’m putting my thoughts together and that will be the subject of a future post.  In the meantime, here are a couple of articles of interest from the Wall Street Journal.

Fixing Health Care Is Good for Business

How many aspiring entrepreneurs are stuck in dead-end jobs because of health concerns?

You have probably heard the horror stories about President Barack Obama’s health-care proposals leading to rationed care and bankrupt businesses and governments. Those claims are flat wrong. The real horror story is not what health-care reform will bring. It’s what’s already happening.

There has been a lot of talk about the 47 million Americans who do not have health insurance. But health-care reform is just as important to the majority of Americans who have health insurance now. Absent reform, the price of an average family’s insurance will nearly double over the next decade—to $25,000 from $13,000.

No less troubling are the stories I hear from CEOs, entrepreneurs and workers. Rising health-care costs are crushing American companies—particularly small businesses that are the source of much of our economic vitality.

In 1960, U.S. firms spent 1.2% of their payroll on health insurance. In 2006, they spent 9.9%. Costs rising at this rate are unsustainable and put U.S. firms at a competitive disadvantage to foreign companies that almost universally have lighter health-care burdens. It also destroys U.S. jobs.

Last month, the nonpartisan Rand Corporation released a study that looked at 37 industries from 1987 to 2005 and concluded that excess health-care costs were causing significant job losses as well as revenue and output losses for many American industries. After controlling for other factors, sectors with the highest percentage of employer-sponsored health care (such as the automotive industry) had worse performances than industries in which employer health coverage is uncommon.

These escalating costs have been passed on to the middle class in the form of higher prices and flat wages. Money that would have gone to raises has instead been spent on health-care premiums that have doubled over the past nine years.

The cost pressure is particularly acute for small businesses, which, on average, pay 18% more per worker than large firms for the same health-insurance policies. They pay more because they have a smaller risk pool and have to absorb higher broker fees and administrative costs per worker. As a result, many small businesses don’t offer health coverage. Just 49% of firms with three to nine workers and 78% of firms with 10 to 24 workers offered health plans in 2008, while 99% of firms with over 200 workers did.

It’s hard to know how much health-care costs affect small businesses. But it is clear that rising costs don’t help them. In the third quarter of 2008, half of all private-sector job losses occurred in companies with fewer than 20 employees.

The pernicious price of runaway health-care costs also has a dampening effect on entrepreneurship.

How many aspiring owners of businesses are locked in jobs they don’t like for fear that striking out on their own would cause them to lose their health insurance? The Small Business Majority, a national advocacy group, estimates there are as many as 1.6 million.

In the short term, health-care costs pose a major problem for companies and their employees. In the medium and long-term, these costs pose serious challenges to our economy. This year, health-care expenditures are expected to account for about 18% of our GDP. Without reform, that share is projected to rise to 28% in 2030 and to 34% in 2040. When one out of every three dollars is spent on health care, we will face a situation in which companies can no longer provide insurance. At the same time, if we don’t address rising federal health-care costs, we will likely face either much higher taxes or unsustainable deficits that could spike interest rates and threaten capital formation.

Neither option is a future any of us wants to contemplate.

It is clear that demographic and structural trends are leading us toward worse health care and higher costs for employers, workers and governments. But America has a chance to avoid that fate. President Obama has articulated three broad criteria for reform. Reduce costs, protect Americans’ choice of doctors and insurance plans, and assure quality and affordable health care for any American who wants it.

The bills working through Congress are moving in the right direction, and despite some setbacks, this nation is closer to fundamental health-care reform than we have ever been.

We must keep moving forward. We are in a twilight period, that precious moment before a problem becomes a crisis. What we do in the coming months will play a big role in determining America’s competitiveness and prosperity for decades to come. There is a path toward a more sustainable and prosperous future for America. It’s imperative that we take it. The alternative is frightening.

Mr. Locke is U.S. secretary of Commerce.

Sorting Fact From Fiction on Health Care

Current congressional proposals would significantly change your relationship with your doctor.

In recent town-hall meetings, President Barack Obama has called for a national debate on health-care reform based on facts. It is fact that more than 40 million Americans lack coverage and spiraling costs are a burden on individuals, families and our economy. There is broad consensus that these problems must be addressed. But the public is skeptical that their current clinical care is substandard and that no government bureaucrat will come between them and their doctor. Americans have good reason for their doubts—key assertions about gaps in care are flawed and reform proposals to oversee care could sharply shift decisions away from patients and their physicians.

Consider these myths and mantras of the current debate:

Americans only receive 55% of recommended care. This would be a frightening statistic, if it were true. It is not. Yet it was presented as fact to the Senate Health and Finance Committees, which are writing reform bills, in March 2009 by the Agency for Healthcare Research and Quality (the federal body that sets priorities to improve the nation’s health care).

The statistic comes from a flawed study published in 2003 by the Rand Corporation. That study was supposed to be based on telephone interviews with 13,000 Americans in 12 metropolitan areas followed up by a review of each person’s medical records and then matched against 439 indicators of quality health practices. But two-thirds of the people contacted declined to participate, making the study biased, by Rand’s own admission. To make matters worse, Rand had incomplete medical records on many of those who participated and could not accurately document the care that these patients received.

For example, Rand found that only 15% of the patients had received a flu vaccine based on available medical records. But when asked directly, 85% of the patients said that they had been vaccinated. Most importantly, there were no data that indicated whether following the best practices defined by Rand’s experts made any difference in the health of the patients.

In March 2007, a team of Harvard researchers published a study in the New England Journal of Medicine that looked at nearly 10,000 patients at community health centers and assessed whether implementing similar quality measures would improve the health of patients with three costly disorders: diabetes, asthma and hypertension. It found that there was no improvement in any of these three maladies.

David Gothard

groopman

groopman

Dr. Rodney Hayward, a respected health-services professor at the University of Michigan, wrote about this negative result, “It sounds terrible when we hear that 50 percent of recommended care is not received, but much of the care recommended by subspecialty groups is of a modest or unproven value, and mandating adherence to these recommendations is not necessarily in the best interest of patients or society.”

The World Health Organization ranks the U.S. 37th In the world in quality. This is another frightening statistic. It is also not accurate. Yet the head of the National Committee for Quality Assurance, a powerful organization influencing both the government and private insurers in defining quality of care, has stated this as fact.

The World Health Organization ranks the U.S. No. 1 among all countries in “responsiveness.” Responsiveness has two components: respect for persons (including dignity, confidentiality and autonomy of individuals and families to make decisions about their own care), and client orientation (including prompt attention, access to social support networks during care, quality of basic amenities and choice of provider). This is what Americans rightly understand as quality care and worry will be lost in the upheaval of reform. Our country’s composite score fell to 37 primarily because we lack universal coverage and care is a financial burden for many citizens.

We need to implement “best practices.” Mr. Obama and his advisers believe in implementing “best practices” that physicians and hospitals should follow. A federal commission would identify these practices.

On June 24, 2009, the president appeared on “Good Morning America” with Diane Sawyer. When Ms. Sawyer asked whether “best practices” would be implemented by “encouragement” or “by law,” the president did not answer directly. He said that he was confident doctors “want to engage in best practices” and “patients are going to insist on it.” The president also said there should be financial incentives to “allow doctors to do the right thing.”

There are domains of medicine where a patient has no control and depends on the physician and the hospital to provide best practices. Strict protocols have been developed to prevent infections during procedures and to reduce the risk of surgical mishaps. There are also emergency situations like a patient arriving in the midst of a heart attack where standardized advanced treatments save many lives.

But once we leave safety measures and emergency therapies where patients have scant say, what is “the right thing”? Data from clinical studies provide averages from populations and may not apply to individual patients. Clinical studies routinely exclude patients with more than one medical condition and often the elderly or people on multiple medications. Conclusions about what works and what doesn’t work change much too quickly for policy makers to dictate clinical practice.

An analysis from the Ottawa Health Research Institute published in the Annals of Internal Medicine in 2007 reveals how long it takes for conclusions derived from clinical studies about drugs, devices and procedures to become outdated. Within one year, 15 of 100 recommendations based on the “best evidence” had to be significantly reversed; within two years, 23 were reversed, and at 5 1/2 years, half were contradicted. Americans have witnessed these reversals firsthand as firm “expert” recommendations about the benefits of estrogen replacement therapy for postmenopausal women, low fat diets for obesity, and tight control of blood sugar were overturned.

Even when experts examine the same data, they can come to different conclusions. For example, millions of Americans have elevated cholesterol levels and no heart disease. Guidelines developed in the U.S. about whom to treat with cholesterol-lowering drugs are much more aggressive than guidelines in the European Union or the United Kingdom, even though experts here and abroad are extrapolating from the same scientific studies. An illuminating publication from researchers in Munich, Germany, published in March 2003 in the Journal of General Internal Medicine showed that of 100 consecutive patients seen in their clinic with high cholesterol, 52% would be treated with a statin drug in the U.S. based on our guidelines while only 26% would be prescribed statins in Germany and 35% in the U.K. So, different experts define “best practice” differently. Many prominent American cardiologists and specialists in preventive medicine believe the U.S. guidelines lead to overtreatment and the Europeans are more sensible. After hearing of this controversy, some patients will still want to take the drug and some will not.

This is how doctors and patients make shared decisions—by considering expert guidelines, weighing why other experts may disagree with the guidelines, and then customizing the therapy to the individual. With respect to “best practices,” prudent doctors think, not just follow, and informed patients consider and then choose, not just comply.

No government bureaucrat will come between you and your doctor. The president has repeatedly stated this in town-hall meetings. But his proposal to provide financial incentives to “allow doctors to do the right thing” could undermine this promise. If doctors and hospitals are rewarded for complying with government mandated treatment measures or penalized if they do not comply, clearly federal bureaucrats are directing health decisions.

Further, at the AMA convention in June 2009, the president proposed linking protection for physicians from malpractice lawsuits if they strictly adhered to government-sponsored treatment guidelines. We need tort reform, but this is misconceived and again clearly inserts the bureaucrat directly into clinical decision making. If doctors are legally protected when they follow government mandates, the converse is that doctors risk lawsuits if they deviate from federal guidelines—even if they believe the government mandate is not in the patient’s best interest. With this kind of legislation, physicians might well pressure the patient to comply with treatments even if the therapy clashes with the individual’s values and preferences.

The devil is in the regulations. Federal legislation is written with general principles and imperatives. The current House bill H.R. 3200 in title IV, part D has very broad language about identifying and implementing best practices in the delivery of health care. It rightly sets initial priorities around measures to protect patient safety. But the bill does not set limits on what “best practices” federal officials can implement. If it becomes law, bureaucrats could well write regulations mandating treatment measures that violate patient autonomy.

Private insurers are already doing this, and both physicians and patients are chafing at their arbitrary intervention. As Congress works to extend coverage and contain costs, any legislation must clearly codify the promise to preserve for Americans the principle of control over their health-care decisions.

Dr. Groopman, a staff writer for the New Yorker, and Dr. Hartzband are on the staff of Beth Israel Deaconess Medical Center in Boston and on the faculty of Harvard Medical School.

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August Flu Update

Friday, October 29, 2010 // Uncategorized

8/25/2009 9:56:56 PM

I started this off initially with the title “Fall Flu Update”.  That was wishful thinking.  Fall is a long way off.

We have received our first shipment of SEASONAL flu vaccine.  Patients wishing to receive it may get it if they have an appointment this fall or may call the office to set up an appointment.  WE PREFER THAT PATIENTS NOT DROP IN.  Scheduling an appointment minimizes wait time.

I have registered to receive H1N1 vaccine.  This will be available some time in the fall.  It will require two doses three weeks apart, we think.  It will be given to high risk patients first.   CDC’s Advisory Committee on Immunization Practices (ACIP) has recommended that certain groups of the population receive the novel H1N1 vaccine when it first becomes available. These key populations include pregnant women, people who live with or care for children younger than 6 months of age, healthcare and emergency medical services personnel, persons between the ages of 6 months and 24 years old, and people ages of 25 through 64 years of age who are at higher risk for novel H1N1 because of chronic health disorders or compromised immune systems.

We do not expect that there will be a shortage of novel H1N1 vaccine, but availability and demand can be unpredictable. There is some possibility that initially the vaccine will be available in limited quantities. In this setting, the committee recommended that the following groups receive the vaccine before others: pregnant women, people who live with or care for children younger than 6 months of age, health care and emergency medical services personnel with direct patient contact, children 6 months through 4 years of age, and children 5 through 18 years of age who have chronic medical conditions.

For people who come down with flu like symptoms, who should be treated?

Antiviral Treatment for Novel (H1N1) Influenza

For antiviral treatment of novel influenza (H1N1) virus infection, either oseltamivir or zanamivir are recommended. Recommendations for use of antivirals may change as data on antiviral effectiveness, clinical spectrum of illness, adverse events from antiviral use, and antiviral susceptibility data become available.

Clinical judgment is an important factor in treatment decisions. Persons with suspected novel H1N1 influenza who present with an uncomplicated febrile illness typically do not require treatment unless they are at higher risk for influenza complications, and in areas with limited antiviral mediation availability, local public health authorities might provide additional guidance about prioritizing treatment within groups at higher risk for infection.

Treatment is recommended for:

  1. All hospitalized patients with confirmed, probable or suspected novel influenza (H1N1).
  2. Patients who are at higher risk for seasonal influenza complications (see above).

If a patient is not in a high-risk group or is not hospitalized, healthcare providers should use clinical judgment to guide treatment decisions, and when evaluating children should be aware that the risk for severe complications from seasonal influenza among children younger than 5 years old is highest among children younger than 2 years old. Many patients who have had novel influenza (H1N1) virus infection, but who are not in a high-risk group have had a self-limited respiratory illness similar to typical seasonal influenza. For most of these patients, the benefits of using antivirals may be modest. Therefore, testing, treatment and chemoprophylaxis efforts should be directed primarily at persons who are hospitalized or at higher risk for influenza complications.

Once the decision to administer antiviral treatment is made, treatment with zanamivir or oseltamivir should be initiated as soon as possible after the onset of symptoms. Evidence for benefits from antiviral treatment in studies of seasonal influenza is strongest when treatment is started within 48 hours of illness onset. However, some studies of oseltamivir treatment of hospitalized patients with seasonal influenza have indicated benefit, including reductions in mortality or duration of hospitalization even for patients whose treatment was started more than 48 hours after illness onset. Recommended duration of treatment is five days. Antiviral doses recommended for treatment of novel H1N1 influenza virus infection in adults or children 1 year of age or older are the same as those recommended for seasonal influenza . Oseltamivir use for children <1 year old was recently approved by the U.S. Food and Drug Administration (FDA) under an Emergency Use Authorization (EUA), and dosing for these children is age-based.

Note: Areas that continue to have seasonal influenza activity, especially those with circulation of oseltamivir-resistant seasonal human influenza A (H1N1) viruses, might prefer to use either zanamivir or a combination of oseltamivir and rimantadine or amantadine to provide adequate empiric treatment or chemoprophylaxis for patients who might have seasonal human influenza A (H1N1) virus infection.

Want more information?  The CDC has a lot of information for you.  Start here.  http://www.cdc.gov/h1n1flu/

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More on CAT Scans and Cancer

Friday, October 29, 2010 // Uncategorized

8/18/2009 10:13:21 PM

Coronary calcium scoring has been advocated by some as a screening test for patients at risk for coronary artery disease.

Prognostic Value of Absence of Coronary Calcium

The absence of coronary calcium was associated with low event rates, especially in asymptomatic patients.

Elevated coronary calcium scores are associated with greater burden of atherosclerotic disease. To determine whether the absence of calcium as identified by computed tomography identifies a population at low risk for adverse cardiac events, U.S. investigators conducted a meta-analysis of 49 articles in which the diagnostic and prognostic values of coronary artery calcification were addressed.

In 13 studies that involved 65,000 asymptomatic patients, 25,903 did not have coronary artery calcification; only 146 of such patients (0.6%) experienced adverse cardiac events during a mean follow-up of 51 months. In seven studies in symptomatic cohorts, 17 of 921 patients (1.8%) without coronary artery calcification had adverse cardiac events during a mean follow-up of 42 months.

Comment: In this large meta-analysis, the absence of coronary calcium was associated with low event rates, especially among asymptomatic patients. Unsurprisingly, event rates in symptomatic patients were somewhat higher. However, editorialists remind us that more data are needed to determine when scans such as these add incremental prognostic value to standard assessments and whether calcium scoring will lead to improved treatment and outcomes.

Kirsten E. Fleischmann, MD, MPH

Published in Journal Watch General Medicine July 28, 2009

It’s not clear from this what the risk factors for the populations studied were.  It doesn’t make sense to do on everyone, but it may make sense to do on patients with multiple risk factors in whom aggressive lipid/blood pressure lowering is being considered.

The test is not completely without risk as can be seen from the following article.

Cancer Risk from Coronary Artery Calcium Screening

Researchers estimate that radiation exposure from coronary CT could lead to excess lifetime cancer risk.

Recently, multidetector computed tomography scanners have become the modality of choice for assessing coronary artery calcium (CAC). In this study, researchers estimated risk for developing cancer from CAC screening with CT scanners. Because no standardized CAC screening protocol exists, researchers reviewed protocols that were used in cardiac studies. Cancer risk was estimated primarily from data on Japanese atomic bomb survivors.

The effective radiation dose delivered from a single CAC screening study ranged from 0.8 to 10.5 millisieverts (mSv) across the different scanning protocols. For the median dose of 2.3 mSv, a single screening at age 55 would result in a lifetime excess cancer risk of 8 cases per 100,000 men (lung cancer would account for 6 cases) and 20 excess cancer cases per 100,000 women (lung cancer would account for 14 cases and breast cancer for 4 cases).

Comment: Current technology allows CAC screening at a substantially lower dose (approximately 1 mSv) than the dose used in this analysis (2.3 mSv). In contrast, a mammogram delivers approximately 0.5 mSv of radiation, and an abdomen and pelvis CT scan delivers approximately 10 mSv. The American Heart Association considers CAC screening to be reasonable in intermediate-risk patients (class IIB recommendation) but not in low- or high-risk patients. The U.S. Preventive Services Task Force recommends against routine screening for CAC. Imaging sites should use protocols that deliver the lowest possible radiation dose; otherwise, CAC screening should not be performed.

Jamaluddin Moloo, MD, MPH

Published in Journal Watch General Medicine August 18, 2009

As pointed out, these screens can be done at a radiation dose that is approximately twice that of a screening mammogram.  A CTA or CAT scan angiogram involves contrast or dye and involves a substantially higher radiation dose.  It delineates the arteries and is more sensitive at detecting plaques than a calcium score which just detects calcium deposits in longstanding plaques.  The other potential risk is the detection of “incidentalomas”.  These are unexpected findings which are probably innocous, but require further testing to insure that they are.  This involves risk from additional radiation or complications of a biopsy.

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Diet, Exercise and Dementia

Friday, October 29, 2010 // Uncategorized

8/17/2009 10:46:07 PM

Most people’s concept of The Mediterranean Diet is to substitute olive oil for butter.

This is a more detailed description of the concept.

“Mediterranean diet — There is no single Mediterranean diet, but such diets are typically high in fruits, vegetables, whole grains, beans, nuts, and seeds and include olive oil as an important source of fat. There are typically low to moderate amounts of fish, poultry, and dairy products, and there is little red meat.”

“Little red meat” means about two servings a month.

A recent study suggests that adhering to this type of diet along with exercise can reduce the risk of developing dementia.  Diet, alone, may not confer a benefit.  At least,according to the second study, if you’re French.  This is a summary of the studies from Journal Watch.

Mediterranean Diet, Physical Activity, and Risk for Dementia

Both diet and exercise are beneficial, but the combination seems particularly advantageous.

A Mediterranean diet (high intake of fruits, vegetables, and olive oil, and low intake of saturated fats, dairy products, and meats) is associated with lowered risks for cardiovascular disease and stroke and might also protect against cognitive decline. In two studies, researchers assessed this relation; in one, investigators also assessed the value of physical activity.

In an extension of the original prospective cohort study that showed a relation between a Mediterranean diet and lowered risk for Alzheimer disease (AD; Ann Neurol 2006; 59:912), diet and exercise were assessed in 1880 older New York City residents (mean age, 77). During mean follow-up of about 5 years, 282 participants developed AD. In adjusted analyses, both high physical activity and high adherence to a Mediterranean diet were associated with lower risk for developing AD. Absolute risk for developing AD was 19% in people with low physical activity and low diet adherence, compared with 12% in those who reported high levels of both behaviors.

In a prospective French cohort study that was designed to replicate the New York study, diet, cognitive function, and a wide range of clinical factors were assessed regularly in 1410 older adults (mean age, 76) during a mean follow-up of 5 years. No association was noted between degree of adherence to a Mediterranean diet and four standardized cognitive tests, except for a statistically significant but clinically modest effect on the Mini-Mental Status Examination (0.7 points during 5 years). No relation between diet and the incidence of dementia was observed in an analysis that was controlled for a wide range of clinical factors.

Comment: Although the protective benefit of physical activity on risk for AD seems clear in the New York study, the relation still should be studied in other populations. The benefit of a Mediterranean diet is less clear. Randomized trials that might prove that diet and exercise prevent cognitive decline are unlikely to be done. For now, clinicians can recommend both physical activity and the Mediterranean diet, particularly together, for preventing cardiovascular disease and stroke, with possible additional benefits for preventing cognitive decline and AD.

Thomas L. Schwenk, MD

Published in Journal Watch General Medicine August 13, 2009

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