ACP Internist

Thursday, November 19, 2009

Rethink pink: breast cancer screening evidence met politics and lost

The controversy started at exactly 5 p.m. Monday, when the Annals of Internal Medicine lifted its embargo on new breast cancer screening recommendations and the rest of the medical community simultaneously released opposing positions. With lines drawn and positions taken, a furor began ultimately pitted evidence-based medicine against political machinations. So far, medicine has lost.

The recommendations, issued by the U.S. Preventive Services Task Force, suggest that asymptomatic individuals with no family history or other risk factors could wait before starting mammograms and undergo screening every two years instead of annually. They balanced the benefits of less frequent screening against the harms of more frequent screening by reviewing the evidence and creating models.

The recommendations have since been on the pages of every newspaper in America, from the smallest locals to the biggest dailies. The American College of Physicians is tracking "impressions," as they're called, in the millions.

There's always a downside to new knowledge, and it's playing out in week following the announcement. It will take time for physicians to digest the new recommendations. It will take time to explain them to patients. In the meantime, public discourse has been messy.

Experts have told women to talk to their doctors about how evidence-based recommendations apply to individual circumstances. But other medical societies are sticking to their guns on annual screenings at earlier ages, and it's unsettling for patients to see doctors disagree and even more unsettling when shouting matches erupt on television.

But neither the government nor insurers are rushing out to make dramatic changes to existing practice of medicine. To calm fears, HHS Secretary Kathleen Sebelius clarified that the doctors who drafted the recommendations, the U.S. Preventive Services Task Force, comprise an independent body of experts who review evidence but don't set policy. To calm fears, she stated that women should still go to their doctors to discuss their individual needs. Insurers aren't going to change their policies, either.

In short, the recommendations inform the talks between doctors and patients. They give physicians something to consider during the informed consent process. Consider the words of family physician David Baron, MD, who said, "I respect [USPSTF] a great deal. They've got no horse in the race. They are independent experts." Take it from practicing physician Jan Gurley, MD, who summarized in plain language how recommendations should impact encounters between physicians and patients.

This is in contrast to internist and TV commentator Elizabeth Lee Vliet, MD, who went on the attack about a "distant and impersonal 'review of data' from published studies." In an op-ed shopped around to media outlets, she further ranted that, "I am profoundly concerned that government 'experts,' far removed from the daily care of patients, are sitting 'on high' to proclaim that women don't need to start mammograms at age 40."

And of course, Dr. Vliet decried it as a cost cutting measure and as the start of "government-mandated, guideline-based rationing of health care." Those are her poorly chosen words. But she's not alone.

U.S. Rep. Marsha Blackburn of Tennessee bemoaned that, "This is where you start getting a bureaucrat between you and your physician." Rep. Michele Bachmann of Minnesota joined the misinformation brigade, starting her press conference on the task force recommendations by blaming President Obama and Speaker of the House Nancy Pelosi. Watch for yourself.

Hijacking evidence-based recommendations to further partisan debate is a semantic trick. And it's a disgrace.

Labels: cancer, evidence-based medicine, guidelines, health care reform, health policy, patient communication, patient education, women's health

QD: News Every Day--The disconnect of health reform

ACP Internist's daily digest of internal medicine in the news continues with the disconnect on health care reform, a larger analysis of who was hospitalized for H1N1, and more on the primary care shortage.

Health care reform
Americans want health care reform to change, but they don't want to pay for it.

Meanwhile, the Economic Policy Institute, a think tank focused low- and middle-income Americans, points out that Medicaid and the SCHIP held in check the number of children who would have gone without health between 2000 to 2008. Children without insurance dropped 1.7% between 2000 and 2008, while adults less than 65 without insurance rose 3.1%. By contrast, children with public coverage grew 8.8%, compared to a 3.5% increase for the adult population under 65.

H1N1 influenza
Health officials now say that 46% of 1,400 adults hospitalized with H1N1 influenza did not have a chronic underlying condition, according to the largest analysis to date. The study looked at adults and children hospitalized from April through August in 10 states at medical centers participating in a special disease surveillance network. Anne Schuchat, FACP, who heads the CDC's National Center for Immunization and Respiratory Diseases, said the larger analysis looked at underlying conditions not previously examined. Among adults, 26% had asthma, 10% had diabetes, 8% had some other chronic lung disease, 8% had weakened immune systems and 6% were pregnant.

Primary care shortage
A financial advisor chimes in with his analysis of why primary care doesn't pay, including input from his own internist. The doctor says, "The average income of a primary care doctor in Massachusetts is about $86,000. Why do I do it? Because I love it."

The medical home
Profiles of practices trying the patient-centered medical home include Greenhouse Internists in Mt. Airy, Pa. and the Adirondack Regional Medical Home Pilot, which also an effort to stop the loss of primary care practitioners in the region. And for a lighter note, don't miss ACP Internist's own Stacey Butterfield's report from the MGMA meeting in Denver.

In case you missed it ...
In Minnesota, the Vitality Project prompted one town to build sidewalks and bike trails; restaurants, groceries and schools to push healthier foods; and employers to give workers time to exercise. The experiment added an average 3.1 years to the longevity of about 2,300 residents who calculated their lifespans by answering 36 lifestyle questions.

Labels: diet, exercise, flu, H1N1, health care reform, health insurance, health policy, patient-centered medical home, primary care shortage, QD

Will taxes make us skinny?

Probably not, concedes an article in the NEJM calling for a tax on sugar-sweetened beverages. Efforts to discourage people from drinking caloric beverages have usually not resulted in significant weight loss, their analysis of the literature concludes. But a soda tax is still worthwhile, in their opinion, because it can reduce the degree of weight gain and provide funding for other public health efforts. Think of it like the tobacco tax. Will drinking a Coke soon carry the cost and stigma as toting pack of cigs?

Not if the soft drink manufacturers have anything to do with it, reports the New York Times. Obama may like the idea but it's going to be a hard sell, given the level of organized opposition. The opponents of the soda tax are calling themselves "Americans Against Food Taxes," the NYT says. The group's name might hint at the difference in understanding that has led to this conflict--do they really think that soda is a food?

Labels: health policy, taxes, weight loss

There are still other health policy issues.

With the media and political attention focused on the health insurance coverage debate, it may be hard to get anyone in the U.S. to think about other policy issues that affect health. But a group of prominent docs, including ACP president Joseph Stubbs, are giving it a try. They published a letter in BMJ and The Lancet urging politicians to take strong action on climate change. (ACP Internist has covered the likely human health effects of climate change before.) As the Washigton Post reports, the issue will come to a head when the United Nations meets in December to replace the Kyoto treaty. Maybe with a push from the medical community, the U.S. can do better than last time (when we failed to ever ratify the protocol).

Labels: climate change, health policy

A totally different vision of health reform

Often the phrase "consumer-driven health care" is a cue to hold on to your pockets because there's an unexpected bill headed your way. But in the cover story of this month's issue of the Atlantic, David Goldhill makes an interesting argument about the benefits that a truly consumer-driven system could provide. Or, at least, he's pretty convincing on the idea that it couldn't be any worse than things are now. His plan's not going to be enacted anytime soon and has some flaws (boy, does he hate hospitals), but it's definitely an interesting read.

Labels: health care reform, health insurance, health policy

Is prevention more politically effective than cost effective?

Last week, a study in BMJ pointed out that cervical cancer screening may be overused in young women. According to the researchers, there's probably no need to screen women under 25. They also suggested that women who are screened and have abnormal results don't necessarily benefit from immediate colposcopies.

I'm guessing that most members of Congress were too busy arguing about health reform to catch that journal article, but there may be a valuable lesson in it for them. Preventive health care has been a popular talking point for politicians--it was one of the few things President Obama and Senator McCain agreed on. But does preventive care actually have any relevance to cost-cutting?

No, but that won't stop Congress from making preventive coverage a major part of health care reform, according to new article from Kaiser Health News. "Under the House plan, patients could receive free an initial physical exam, diabetes screening tests, blood tests for heart disease, mammography, pap smears, bone mass measurements, flu and pneumonia vaccines, screenings for colon and rectal cancer, and ultrasound screenings for abdominal aortic aneurysm."

Not to say that covering screenings is a bad thing, but it does seem like a little attention to their effectiveness (cost and outcome-wise) might be worthwhile. After all, just because a pap smear's free doesn't mean it's fun.

Labels: health policy, screenings

One more thing to learn

As part of ACP Internist's standard profile feature, we ask physicians "What's one thing you wish you had learned in medical school?" Their answers are usually something about communicating with patients or accepting people's inability to change.

But an article on Slate.com makes the argument that what's missing from medical education is health policy. The authors report on how some schools are trying change the system, so that students actually know what a "third-party payer" is by the time they graduate.

The article may exaggerate students' ignorance a little. I've certainly seen a lot of med students/policy activists at ACP's Leadership Day. But spreading the knowledge more widely sounds like a good thing. Only one problem: what classes will these health policy lessons replace? Maybe, to be more useful, we should rephrase our profile question. What do you wish you hadn't learned in med school?

Labels: health policy, medical education

The honeymoon's over

Obama's out collecting love from the rest of world, but back home he's earned his first negative press release from a health organization. The AIDS Healthcare Foundation today expressed "deep disappointment" at Obama's proposed domestic spending on AIDS awareness--$45 million. The foundation wants to see $200 million spent on testing to combat recent dramatic increases in CDC-estimated infections. Someone was bound to be disappointed sooner or later; hopefully, this isn't an indicator of underwhelming funding coming for other health initiatives.

The president did make a move likely to gain support among the fake doctors of America. Kal Penn, who had a role on the TV show House but is best known as stoner/would-be med student Kumar (of Harold and Kumar Go to White Castle), is now going to the White House as a liason between the administration and arts groups, news organizations reported today. Makes us wonder--has anyone considered Neil Patrick Harris (aka Doogie Howser, MD) for the open surgeon general slot?

Labels: health policy, HIV/AIDS

And how are you finding your stent, sir?

It used to be that only teachers and critics gave grades and reviews. Now Netflix asks you to rate every movie you watch and even Kmart receipts ask for your opinion. Two news items out this week show how far the trend has moved into health care.

First, Zagat announced their expansion from restaurant-rating to doctor-rating. According to the NY Times, patients insured by WellPoint (in certain areas) will be invited to rate and comment on their doctors through a Zagat site (viewable only by other WellPoint insureds). Not surprisingly, the announcement didn't attract a lot of positive feedback from physicians. Who wouldn't rather take their job pass/fail?

More likely to please docs was the news that Obama's stimulus bill includes funding for comparative effectiveness research. Up to 15 employees and $1.1 billion will be allocated to reviewing existing research and conducting new comparison trials of various treatment options. Sounds like some grades that could be pretty useful, although critics worry that it's the first step toward rationing health care by cost. For more on the stimulus bill's impact on medicine, check out the The ACP Advocate blog.

Labels: health care ratings, health policy

Is health care the new Hummer?

Rationing is in. First, we learned that we all need to cut back on our carbon output, then it was discretionary spending that had to be restricted. Now, some health care analysts are pointing out the painful truth that the only affordable, equitable way to provide health care may be to ration it.

Daniel Callahan of the Hastings Center has recently stirred controversy on the issue, with a New York Times blog post describing his rationing plan. Basically, he suggests that Medicare coverage for very expensive therapies (like open-heart surgery) be cut off once patients hit age 80. By the way, it seems important to note that Dr. Callahan himself is 78. "Our society can not, and should not, promise open-ended, progress-driven medical care that is indifferent to costs," he concluded.

Sound outlandish? Not to the Brits, who are already doing something along these lines. Another NYT article discusses NICE, the British government institute that decides whether a therapy is cost-effective enough to be covered. Their cut-point right now for life-extending cancer drugs is about $22,000 for per 6 months of life gained. The policy raises a whole heap of protest from pharma companies (who the article pretty well puts through the ringer) and patient advocates. Even so, numerous other countries are looking at the British example to deal with their ballooning health care costs, the NYT says.

"What price is life?" asks a woman in the article whose husband was denied an expensive drug. It's a tough question, but one which bureaucrats, health experts and politicians might soon have to answer. Is rationing the only solution?

Labels: drug companies, health care reform, health policy

Obama should read the NEJM

There's no shortage of advice available to President-elect Obama on how to reform health care. If there's a health policy analyst out there who hasn't thrown her 2 cents in yet, I'd be surprised. But the experts writing in this week's New England Journal have an extra argument on their side: history. They analyze the last successful piece of federal health reform--the creation of Medicare.

In their account, the passage of the plan was in large part due to LBJ's political skills. We know Obama is talented in that department, but a couple of the authors' key suggestions may prove difficult for him to follow.

First, they say that to be successful, health care reform must be tackled immediately (if not sooner). Yet, it seems likely that dealing with the disaster that is the economy will take most of Obama's attention after inauguration. Can he really launch a huge, new spending plan when pleas for money are coming from every direction? (See governors' meeting taking place today.)

The authors also recommend letting Congress manage the specifics of reform. But Obama's already got problems with Congressional Democrats straying way off the health care reservation. (e.g., Sen. Baucus is now proposing to mess with employer-sponsored coverage--an idea that Obama campaigned hard against during the election.) Also, can what has come to be known as our do-nothing branch be trusted to get something effective passed on this issue?

There is one recommendation that it seems like it shouldn't be too hard for Obama to follow. LBJ got Medicare enacted because he didn't worry too much about the future costs, the authors say. (Explains a lot about the mess it is now.) And as AIG, Citi and the rest of the bunch can attest, if there were ever a time when it was publicly acceptable for the government to spend money it doesn't have, that time is now.

Labels: health care reform, health policy

He's not done yet.

Before leaving office, President Bush is trying to push through one last health-related policy change. The proposed rule would prohibit federally funded institutions from discriminating against health care providers who have religious and moral objections to certain procedures/activities (i.e., abortion, emergency contraception). The idea's raised a storm of protest from health experts, including the AMA, AHA and pharmacists' groups, and President-elect Obama has already promised to reverse it when he takes office. Which makes you wonder, especially given the disagreement over this within the administration, why bother?

If you want to put your two cents in, here's an email address for the Office of Information and Regulatory Affairs.

Labels: health policy

Election results

You may have heard already that the candidate who favors universal health care, Barack Obama, won the election. But there were some other, less-publicized votes on health issues decided yesterday.

In Michigan, voters supported medical marijuana by a huge margin (63% to 37%) as well as approving the expansion of stem-cell research (allowing researchers to use embryos that were created but not used for in-vitro fertilization).

Proposed abortion bans in Colorado and South Dakota were shot down, as was a parental notification proposal in California.

Washington state residents legalized physician-assisted suicide for terminally ill patients. Under the referendum, physicians can prescribe, but not administer, lethal medication for patients who are not depressed and expected to live less than six months.

An Arizona proposal that would have made it illegal for the state to require people to have health insurance looks like it was narrowly defeated but the preliminary numbers are extremely close (867,101 no votes vs. 864,964 yeses, according to the Arizona Republic this morning).

Labels: health policy

ACP Internist hosted Grand Rounds on June 16, wrapping up the best of the medical blogosphere. Click here for the complete wrap-up.

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Blog log

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

db's Medical Rants
Robert M. Centor, FACP, contributes short essays contemplating medicine and the health care system.

Everything Health
EverythingHealth is designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

Getting Better with Dr. Val
Getting Better is the continuation of Dr. Val Jones' previous blog at Revolution Health. It is devoted to helping people understand health issues from a balanced, scientifically sound perspective.

HealthHombre
A roundup of health policy news drawn from a database of hundreds of Web sites.

Interact MD
Michael Benjamin, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

Kevin, MD
The alter ego of Kevin Pho, ACP Member, is the closest thing to royalty in the medical blog world.

LSUHSC-S Medical Library Evidence Alert
Major guidelines, systematic reviews, meta-analyses and/or major reviews by national and international organizations.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by a doctor.

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ACP Internist

Thursday, November 19, 2009

Rethink pink: breast cancer screening evidence met politics and lost

Wednesday, October 14, 2009

QD: News Every Day--The disconnect of health reform

Thursday, September 17, 2009

Will taxes make us skinny?

Wednesday, September 16, 2009

There are still other health policy issues.

Friday, August 28, 2009

A totally different vision of health reform

Wednesday, August 5, 2009

Is prevention more politically effective than cost effective?

Wednesday, June 24, 2009

One more thing to learn

Tuesday, April 7, 2009

The honeymoon's over

Tuesday, February 17, 2009

And how are you finding your stent, sir?

Thursday, December 4, 2008

Is health care the new Hummer?

Wednesday, December 3, 2008

Obama should read the NEJM

Tuesday, November 18, 2008

He's not done yet.

Wednesday, November 5, 2008

Election results

Contact ACP Internist

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