Vol. 193 May 15, 2018 Antibiotics are Beneficial: A Reminder

May 15, 2018

Hub thumbnail 2015

A disease outbreak anywhere is a risk everywhere.”
-Dr. Tom Frieden, Director U.S. CDC

 

We read a lot about the dangers of using too many antibiotics. The popularity of “organic foods” is due in part to their claim to be from “antibiotic-free” animals and plants. Concern about the increasing antibiotic resistance of germs due to antibiotic overuse is real as is frequently described in scientific journals as well as the general press. Why, then, would the New England Journal of Medicine publish an article describing the benefits of random, mass distribution of an oral antibiotic to nearly 100,000 children who had no symptoms or diagnosis! Maybe because that effort reduced the death rate of children aged 1-5 months by 25%!

As you’ll remember in my last blog,  I was impressed by Bill Gate’s knowledge of the medical literature because during his presentation he cited this antibiotic clinical trial which had been published that very same week. Well, full disclosure, he knew about the study because his foundation funded it! This study is the kind of innovative medical study related to global health that the Bill & Melinda Gates Foundation supports. I think it is worthwhile to review the details of the study, if just to remind us that antibiotics are good, that medical science advances on the shoulders of previous work, and that sometimes simple answers, like putting iodine into salt or fluoride into water, can prevent a whole lot of disease.

Previous studies in sub-Saharan Africa showed that blindness caused by trachoma, an infectious disease, could be reduced markedly through the mass distribution of an oral antibiotic, azithromycin. Other studies suggested that the same antibiotic could prevent other infectious deaths like malaria, infectious diarrhea, and pneumonia. It is known that azithromycin affects the transmission of infectious disease, so that treatment of one person might have benefits on others in the same community. The data in two of these studies of trachoma prevention in Ethiopia suggested that mass distribution of azithromycin “might” reduce childhood deaths. Since death (after the neonatal period) is a relatively rare event, even in these settings, the trial had to be conducted in a large population. Hence the need for a large grant to carry it out.

A single dose of oral azithromycin was given to 97,047 children aged from 1 month to 5 years in three African countries during a twice-yearly census. 93,191 children in different communities of the same countries were given a placebo. Over the two-year study the “treated” children received 4 oral doses of azithromycin, each about 6 months apart. Children were identified by the name of the head of the household and GPS coordinates of their location for subsequent censuses. Approval for the study was obtained from 9 ethics committees in 6 countries (3 in the US, 1 in the UK, and 2 in Africa).

The average reduction of annual death rates of children receiving a single dose of the antibiotic every 6 months was 13.5% . Children aged 1 month to 5 months receiving the antibiotic had a mortality rate reduction of 25%. At the conclusion of the trial all the children in the communities of Niger, which has one of the highest child mortality rates in the world and a mortality rate reduction of 18% for all ages in this study, were offered treatment with azithromycin.

This study is a beautiful example of the testing of a simple hypothesis, generated by the results of previous work, using innovative methods, requiring a large population for validity,  and implemented by a multi-national team of medical scientists with a large grant from a private foundation that resulted in clear benefits for better global health.

I, for one, am happy to trumpet some good news about antibiotics and this example of “medical research for all” at its best.

Reference:
Azithromycin to Reduce Childhood Mortality in Sub-Saharan Africa, NEJM 378;17, April 26, 2018

 

 

 

 

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Vol. 128 July 1, 2015 Obamacare is Five Years Old. Can It Walk and Talk?

July 1, 2015

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“From a historical perspective,
5 years is a very short time.
Many of the key insurance provisions have been
in effect only since October 2013.” (1)

Now that the Supreme Court has decided that a key provision in the Affordable Care Act of 2010, the federal subsidy of health insurance for eligible citizens, is legal, the infancy of Obamacare is over. It looks like it is here to stay. How is the toddler doing? What has it done? Luckily, The Commonwealth Fund just published a summary of ACA effects so far. (1)

The Commonwealth Fund is a private foundation formed in 1918 with Harkness family money made from the early oil business, (Shell Oil).

“The Commonwealth Fund has sought to be a catalyst for change by identifying promising practices and contributing to solutions that could help the United States achieve a high-performance health system. The Fund’s role has been to establish a base of scientific evidence on what works, mobilize talented people to transform health care organizations, and collaborate with organizations that share its concerns. The Fund’s work has always focused particularly on the challenges vulnerable populations face in receiving high-quality, safe, compassionate, coordinated, and efficiently delivered care.”

This health-care-focussed fund and think tank reports that it is too early to see many benefits of the ACA, but lists some of its immediate, observable effects.

Access to care:

  • 7.0 to 16.4 million young adults from chronically uncovered populations ( hispanics, blacks, and those with low incomes) have gained health insurance coverage since 2010 (different survey methods and timing cause the difference in results).
  • 11.7 million Americans selected a health plan through the health insurance marketplaces established by the ACA. 87% of those people were eligible for federal subsidies of premiums.
  • 10.8 million additional Americans have enrolled in Medicaid since the ACA was passed.
  • 3 million previously uninsured young Americans have gained coverage through the ACA extension of dependent coverage to age 26.
  • 8-12 million Americans have benefitted from the ACA’s regulation that prevents insurers from discriminating against people with preexisting conditions.
  • 75% of those newly insured seeking appointments with primary care or specialist physicians have secured one within 4 weeks or less.

Delivery-System Reform:
“ The law constitutes one of the most aggressive efforts in the history of the nation to address the problems of the health care delivery system through funding many divergent experiments though lacking a coherent strategy.” (1)  The Commonwealth Fund report lumped the efforts into four categories.

1. Changes in Payments:
Reduce readmissions – There are 150,000 per year fewer Medicare hospital readmissions within 30 days of discharge partly attributed to ACA financial penalties to hospitals with higher than expected readmission rates.
Reduce hospital-acquired conditions – ACA financial penalties to hospitals in the highest quarter of avoidable hospital-acquired conditions may have helped the composite rates for those to drop by 17% from 2010 to 2013.
Pay for Performance – ACA payment incentives to hospitals and physicians to improve their performance on various cost and quality measures: “too early to tell”.
Bundled payments – This departure from fee-for-service reimbursement pays the hospital, the physician, and post-hospital services with a single payment for a procedure or condition. 7000 providers have signed up for it, but it is “too early to tell”.

2. Changes in the Organization of Health Care Delivery:
Accountable Care Organizations (ACOs) – An ACO is an organization of physicians and hospitals formed to improve the integration and coordination of ambulatory, inpatient, and post-acute services for a defined population of Medicare beneficiaries. 405 ACOs are participating in a program that allows them to keep a portion of any cost savings they can generate without degrading quality. Although the pilot program of about a dozen Pioneer ACOs “saved” $385 million in the first two years, it is “too early to tell” if the others will have a postive effect.
Primary Care Transformation – A pilot program to reduce costs and improve quality in primary care has shown a $14 per month cost reduction per Medicare enrollee and less emergency room visits and hospitalizations in the 2.5 million patients participating in its first year, but it is “too early to tell”.

3. Changes in Workforce Policy:
The effects of increased primary care reimbursement for Medicaid patient services, increased National Health Service Crops scholarships for practicing in underserved areas, and establishment of a National Health Care Workforce Commission (but remains to be funded by Congress) are all “too early to tell”.

4. Increase Innovation in Health Care Delivery:
The Center for Medicare and Medicaid Innovation (CMMI) was funded at $1 billion a year for 10 years to undertake a wide variety of experiments in improving quality for patients and reducing the 43% share of national health costs now paid by the government.

  • Commonwealth Fund says: CMMI is perhaps the most promising of the ACA efforts, but “way too early to tell”.
  • The CMMI itself reports it has launched 26 “demonstration models” of cost reduction and quality improvement. The Pioneer ACOs mentioned above is the first model “to meet the statutory criteria for expansion”.(2)
  • A separate report from Weil Cornell Medical College Department of Healthcare Policy and Research states that to date the CMMI has spent only one-third of its $10 billion, that it seems to be slow in distributing data from its experiments to participating organizations, and that it is hampered, as most quality improvement efforts are, by the lack of consensus on what constitutes “ improved quality”. So it is “too early to tell” (2)

Wow, that is definitely more than you may have ever wanted to know about the ACA so far!
It is certainly more than I can remember.
It is clear that Obamacare does have a lifetime before it.
As that lifetime unfolds one can only hope that responsible adults will guide it through its future developmental stages.

Bottom line: carry a small laminated copy of this blog in your pocket or purse to pull out when engaged … embroiled, …immersed, …or even entangled in any discussion about Obamacare, which will continue, even if Hilary renames it.

Remember, Medicare was just as controversial when first passed. One governor that opposed Medicare actually mobilized his state’s National Guard the day Medicare was passed in fear of the hordes of newly insured people that he expected to overwhelm emergency room departments.

References:
1. NEJM June 18, 2015;  The Affordable Care Act at Five Years
2. NEJM May 21, 2015;  Assessing the CMS Innovation Center


Vol.111 October 1, 2014 ; How Does Your Doctor Rate?

October 1, 2014

hubI think this is actually a trick question. I know very few people who have only one doctor. They have several, spanning different specialities.

 “Doctor Rating” sems to be  a thriving business. Consumer Reports Magazine (October 2014) lists six websites that present some sort of doctor ratings that go beyond the basic info provided by the AMA, Medicare, and state Boards of Registration in Medicine and state medical societies.

I examined these websites to see what I could learn how each one rated some primary care doctors that I know in my own vicinity. What I found was not particularly helpful nor illuminating for a variety of reasons.

The websites usually used two sets of criteria for ratings, one for the office (“ease of making appointment, friendly reception, etc.”) and one for the physician (“bedside manner, waiting time, clarity of discussion”,etc.”). Most used a rating of 1-5 stars, but one used “A-F”. Physician groups were rated, but to learn about individual doctors within the groups I had to scroll through individual patient text comments.  All of the websites had errors such as listing physicians who were dead, retired, back in India, or now in New Zealand.

I searched under “internists” and often also got dentists, obstetricians, cardiologists, oncologists, and even “lice doctors”. There seemed to be no rhyme nor reason to the sequence in which doctors were listed, except for the one website that highlighted the “Top 10” (apparently “patient satisfaction” was the sole criteria). Some websites forced me to scroll through all the names alphabetically to find the one name I was looking for. Some allowed me to search by individual name. Despite entering my zip code as a clue I got lists of doctors from many miles away. Some websites listed nurse-practitioners (NP) in the list which is not bad, might even be helpful, but it was not always clear with which physician(s) the NP was affiliated.

In the instances that I was able to find physicians about whom I had my own rating opinion, I did find that the website ratings generally matched my own bias. In the few instances that I could find the same physicians on different websites, the website ratings agreed.

Here are comments on my experience with specific websites:

Angieslist.com    “A to F”    Access to doctors’ rating for a year costs you $20.($16 if you use PayPal)
Gives number of reviews used to decide the rating (usually single digits); Have to click and scroll individual patient comments to identify individual physician rating in a group; three“A” reviews plus one “F” review created a “B” rating (4 reviews).

Healthgrades.com      1-5 Stars   Free Listed
177 internists near me, but listed only alphabetically; the first dozen or so listed would fit my “marginal” category; gives number of reviews used to decide the rating, but no patient comments/reviews presented; also included cardiologists and ophthalmologists.

Vitals.com    “Where doctors are examined.” 1-4 Stars   Free
136 internists near me, but the highest number of dead, moved, or wrong specialty doctors; had search “filters” to help me narrow my list, and the “patients’ choice” was the most helpful; you can choose a video that presents the ratings in a pleasing, non-revealing, fourth-grade-educational-level cartoon.

RateMDs.com     1-5 Stars     Free
Can search by name or “find a doctor by locale”; lists a “top 10” presumably based on patient satisfaction, but my doctor was NOT listed even though he is “the BEST doctor in the world” because no patients had submitted reviews.

Yelp.com   1-5 Stars   Free
The worst mix of wrong specialities and very few physicians listed; I suspect that doctors have to enter their own offices to this website or even pay for a listing, but I am not certain.

CastleConnolly.com   “Lists America’s Top Doctors”  An annual List and Book
Doctors are nominated, reviewed, and screened by a professional staff for this list founded by two men (neither one a physician) on the Board of Trustees of NYU Medical School; list is heavily weighted to academics in the NY metropolitan area.

Whosmydoctor.com    A work in progress; “not yet ready for prime time”
Leana Wen, MD, Rhodes Scholar, Director of patient-centered research at George Washington University, and a recent TEDMED presenter surveyed patients about what they wanted to know about their doctors. Almost everyone wanted to know that their doctors were competent, certified, and free to make evidenced-based medical decisions uninfluenced by whom they were paid. No surprise there. BUT, she also found that patients wanted to know something about the doctor’s values; what the doctors held dear to their heart!

“One after another, our respondents told us that the doctor-patient relationship is a very intimate one, that to show their doctors their bodies and share their deepest secrets, they want to first understand their doctor’s values.”

Dr. Wen set up a website “Who is My Doctor?” in which doctors could voluntarily state their feelings about reproductive medicine, alternative medicine, and end-of-life-decisions. This information, obviously beyond competency and source of compensation information, would be accessible to all patients and potential patients in an effort toward “total transparency”. The website and Dr. Wen apparently ran into a hailstorm of resistance from some physicians who did not believe that “total transparency” was a good thing. The website is currently just collecting signatures of those who support the concept, 387 to date.

Bottom line:
Doctor rating lists are not very helpful if you are blindly doctor-shopping in your area. If you do the usual thing and get some names of “good docs” from your friends and neighbors, then the rating websites could help you check out the opinions of other patients. None of these websites are as illuminating nor as complete as Trip Advisor…yet.


Vol. 73 September 1, 2012 Two American Medical Care System Miracles

September 1, 2012

Yesterday a friend told me about his own recent medical care “miracle”.

He and his family were finishing up their last day of a two-week vacation on a remote New Hampshire pond (the one, I believe, where the fish called Walter once resided). He was designated to perform an essential rite of passage at the end of their annual visit, the trip to the dump. The dump, of course, is at the outer limits of their township, more remote than their cabin and out of cell phone range.

When he returned to the cabin from the dump he felt the first chest pains. Over the next few minutes they increased, and he didn’t feel or look well. In response to their 911 call the local ambulance raced out on the dirt road and whisked him off to the hospital in Plymouth, NH.

A few minutes after arriving in the ER he received an intravenous “clot-buster” medication and suffered a cardiac arrest! CPR was started immediately, during which he had a seizure. Resuscitation was successful, and a helicopter was called in from a Manchester, NH regional referral hospital. He barely remembers the helicopter ride, but thinks he heard the helicopter pilot getting “clearance to land in 23 minutes” even though the air space was restricted for President Obama’s visit. My friend is a certified pilot and not a supporter of Obama, so, of course, he WOULD remember that.

In the Manchester hospital an immediate cardiac angiogram showed one coronary artery with two narrowed segments, one after the other with a normal segment in between. A stent spanning the two narrowed segments was inserted via his radial artery.

Five hours after the onset of his chest pain and about four hours after his cardiac arrest, he was sitting up comfortably in his hospital bed, fully awake and hungry with a very sore chest from the CPR.

The next day his echocardiogram was normal, he passed his treadmill stress test with flying colors, and he was discharged home.

A week later his chest was still sore as he humbly showed his “before” and “after” angiograms to close friends and colleagues.

What a marvel of electronic communication, modern transportation, presence of trained clinical personnel, and access to state-of-the-art diagnostic and therapeutic equipment and processes.

What superb medical care.

My friend is over 65 years old and is covered by Medicare. He probably won’t even see a bill.

He is the father of three, the grandfather of five, a founding elder of a community church, the medical director of a clinical research center, a retired general surgeon, a member of several non-profit boards of directors, and a so-so pool player. What is the gain in quality-adjusted life years (QALYs) of this event? How could you even begin to calculate it?

How could anyone be against making this kind of medical care available to all Americans?

I heard this story Sunday night as an “oh, by the way” when my friend called to ask my help in arranging a second opinion with a pediatric neurologist for a visiting family.  Their five-year old child had been evaluated elsewhere for left-sided weakness and incoordination. The parents had his medical records, CT scans, and MRIs in hand, and they were looking for a second opinion about prognosis. The only problem was that they were visiting from the U.K. and were returning there in two days.

During my  phone calls to a pediatric neurologist I knew, the Urgent Appointment clinic for pediatric neurology at Boston Children’s Hospital, and the Pediatric Neurology Department at Boston Children’s hospital, I related the short story behind this request for an “urgent” second opinion, and left a few phone messages.. The best I could get, not surprisingly, was a referral to the International Medical Care office of Boston Children’s Hospital for an intake process and a future “second opinion” appointment in a month or two.

I reported this result to my friend on Monday afternoon and remarked how difficult this request would be to fill on such short notice. Later that day he got a call from the BCH Department of Pediatric Neurology with a request for more clinical details. The caller left her cell phone number to call that night after hours, since the family was not then available. The net result: the family went up tp Boston Tuesday afternoon, and received a thorough, reaffirming, and comforting second opinion about their son’s condition from a senior pediatric neurologist. They left for England the next day.

QED: The second American medical care system “miracle” of the week.


Vol. 71 July 15, 2012 When “Yes” Becomes “No” in Medicine

July 18, 2012

 

“PRIMUM NON NOCERE” – First, do no harm.

This quotation is considered to be the first rule for physicians, but it has a somewhat uncertain origin and a changing definition. The original definition of “harm” became more complicated and variable as medicine accepted the concepts of “risk vs. benefit” and “cost benefit analysis”. Since the values in these concepts are variable, the definition of “harm” has become more variable, more complex, and sometimes more relective of the bias of the definer.

Medicine is both an art and a science, and science, as we know, considers all of its “truths” as tentative. As new data is obtained these truths can change. Here are some recent examples of changes in medical recommendations based on new data AND new elements in“”cost benefit analysis” AND possible bias of the maker of the recommendation.

Men should not be screened for elevated PSA (Prostate Specific Antigen)
The initial excitement about this test for the early (“before symptoms appeared”) diagnosis of prostate cancer has been dissipated by data showing that positive tests (elevated levels of PSA) led to lots of referrals to urologist specialists, lots of biopsies, and lots of invasive surgical and radiation treatment which did NOT result in a reduced death rate or lessened disease burden from prostate cancer. Also, the interventions were associated with a bunch of serious complications.

Prostate cancer is usually an indolent disease. If a man lives long enough it will eventually appear in his body, but will rarely cause death or a heavy disease burden. PSA screening of asymptomatic men who have a normal digital (digital, as in finger) rectal exam and a negative test for occult fecal blood is now considered to cost more (in money, patient inconvenience, and medical complications) than its benefits. The PSA does not identify the less common case of aggressive prostatic cancer at a time that makes earlier treatment more effective.

Women under 50 don’t have to get an annual mammogram.
This 2009 recommendation caused a great deal of controversy because of the long term investments of several “stakeholders” in the mantra “get an annual mammogram to save your life.” But, by 2009, data conclusively showed that in order to save the life of one woman in her 40s from breast cancer, 1,904 women would have to be screened every year for up to 20 years. Because the U.S. Preventive Services Task Force judged that the risks of harm from false positives mammograms, subsequent biopsies, and overly aggressive treatment of indolent lesions that resulted from annual screening outweighed its benefits. Hence, the USPSTF panel’s recommendation that most women ages 40 to 49 need NOT get a routine annual mammogram.

Statins do not prevent fatal heart attacks in healthy people.
Studies in 1999 indicated that lowering cholesterol by taking statins (Lipitor, Zocor, etc.) in people who had had a heart attack reduced subsequent cardiac deaths in those people by 30% and reduced subsequent symptomatic coronary artery disease by 25-60%. This dramatic protective effect of statins in these high-risk patients was extrapolated to people without heart disease or risk factors and by 2008 half of U.S. men between the ages of 65-74 were taking statins. Last year a meta-analysis (a research analysis of a large number of studies) failed to show a reduction of death rates in healthy people taking statins.  “Only limited evidence showed that primary prevention with statins may be cost effective and improve patient quality of life.” (1)  More recent studies documenting the complications and side effects of statin use have also contributed to the change in this recommendation.

Colonoscopy for the prevention of death from colon cancer is no better than, and may be inferior to, flexible sigmoidoscopy.
Not so many years ago your primary physician would perform a screening examination of your lower colon with a flexible sigmoidoscope in his/her office, with just light sedation, no biopsy, and no annoying, rigorous bowel preparation. The reimbursement was modest. Since then, the norm for screening for colon cancer has become a colonoscopy, performed by a gastroenterologist or general surgeon in a hospital or an ambulatory surgical center with sedation heavy enough to warrant the presence of an anthesiologist and associated with an interpretation of the inevitable biopsy by a pathologist. The reimbursement all around is much more substantial.

Both procedures reduce the incidence and mortality of colon cancer, but “as reimbursement moves from fee-for-service to bundled payments for episodes of care, there will be a renewed focus on delivering evidence-based interventions in a manner that optimizes resource use.” (2)

Daily low-dose aspirin does not reduce cardiovascular deaths in healthy people.
Use of aspirin to prevent a subsequent heart attack in people who have already had one DOES reduce their death rate from another heart attack. Extrapolation of this widely accepted fact has prompted many  healthy people with no history of heart disease to take low dose aspirin daily. In yet another meta-analysis of over 100,000 people “at risk for” but not having coronary artery disease, daily aspirin did NOT lower the rate of fatal heart attacks. The rate of non-fatal heart attacks was reduced by 20%, but more importantly the use of aspirin INCREASED the rate of non-trivial bleeding (GI bleeding, stroke, hematuria, and nose bleeding) by 31%, ie. the risks of daily aspirin use outweighed its benefits.
SPOILER ALERT: The study recommends that physicians and patients should decide on a case-by-case basis about whether to continue daily aspirin if you are already taking it. My own physician noted that in several of the international studies in this meta-analysis the dose of aspirin was up to 300 mg a day (one adult aspirin) but that in the U.S. the usual recommended aspirin “low” dose is 81 mg. ( a baby aspirin) daily The higher the dose of aspirin the more likely it is to cause bleeding.

DEET insect repellent is safe to use on anyone over the age of two months.
“The American Academy of Pediatrics states that insect repellents with DEET are safe to use on children as young as two months old.” Apply only once a day, but you can use any concentration from 7% to 25%. The higher concentration isn’t any more effective, but its protection lasts longer. DEET protects against tick bites too.

Statistics NEVER lie, … or can they?
Published medical research produces data that meets statistical standards of “significance” which reassures the reader that the findings are “true”. Meta-analysis studies ( a technique of comparing data results from different studies and treating them as if they are all from the same study) are the current epitome of statistical correlations. The interpretation of statistics, however, is not standardized, and epidemiology (the science of statistics applied to large populations) has been called by some cynics as “the art of lying on a grand scale.”  Here’s an example of the potential pitfalls in interpreting statistics:

700,000 physicians “cause” 120,000 accidental deaths per year for a rate of
.171% accidental deaths per physician per year

There are 1,500 accidental gun deaths per year and 80 million (yes, million) U.S. gun owners for a rate of .0000188% accidental gun deaths per gun owner per year.

THEREFORE, statistically, doctors are approximately
9,000 times more dangerous than gun owners.

We withheld the statistics on ….Lawyers !
for fear the shock would cause people to panic and seek medical attention! (3)

References:
1. Arch Int Med June 2010:170:1024
2. NEJM 366;25 June 21, 2012, pg. 2421
3.  thanks to Bob Harrington for picking this pearl off the web
4. Overdiagnosed: Making People Sick in the Pursuit of Health
H. Gilbert Welch, MD, Lisa M. Schwartz, MD, Steven Woloshin, MD
http://www.beacon.org/


Vol. 59 January 15, 2012 “Good” Things That Aren’t So Good.

January 16, 2012

Oft expectation fails, and most oft where most it promises;
and oft it hits where hope is coldest; and despair most sits.
~William Shakespeare

.

Screening asymptomatic men for PSA (prostate specific antigen) does more harm than good.

Ten years of screening healthy men for PSA (prostate specific antigen) as a marker for prostatic cancer has not reduced the death rate from cancer of the prostate (still very low).  This single blood test has resulted in a lot of money and time spent for diagnostic tests (biopsies and their complications which “are not trivial”),  physician office visits, and aggressive therapy which have been of little benefit to patients.. Even when a biopsy confirms the presence of prostate cancer in a  high-PSA patient, there is very little evidence that there is any benefit in treating the patient that has a normal physical exam (digital rectal examination) and normal prostatic volume by ultrasound. While still controversial, recommendations from the U.S. Preventative Service Task Force include “just wait and see” if there is a bump in your annual PSA. If you as a patient can’t tolerate that, it is probably better to ask your physician to skip the blood test.

Screening for lung cancer with an annual chest x-ray doesn’t help either.

A thirteen year study of 155,000 people showed no difference in mortality rates between those who got annual chest x-rays and those who did not. In fact, 95% of the people with “positive findings” on x-ray did NOT have lung cancer. Low-dose CAT scanning of the lung may be a better screening tool, but the jury is still out on that.

What about the screening blood test (CA 125) for often-silent and frequently lethal ovarian cancer?

In a twelve and a half-year study of 68,000 U.S. women screened for ovarian cancer with a CA 125 blood level and vaginal ultrasound the women who were screened did no better in terms of earlier diagnosis, reduction in mortality, or increased longevity after diagnosis than those who were not screened. Serial measurement of CA 125  can be helpful in monitoring tumor activity in patients already diagnosed and treated for ovarian cancer, but it is of no benefit as a screening tool for ovarian cancer. Large scale clinical trials outside the U.S. are currently seeking confirmation or refuting of this viewpoint.

The vaccine against shingles (herpes zoster) is about 50% effective.

A large observational study of people who received the zoster vaccine confirmed that in the “real world”, as in the laboratory, about one-half of vaccine recipients were protected from developing the condition. In the natural course of shingles without the vaccine about 6% of people who have had shingles in the past have a recurrence within 8 years. Presumably the vaccination of someone who has had shingles in the past could reduce the recurrence rate by half to 3%.  As with all medical statistics, of course, if you get shingles it is 100% for you.

If you get a mammogram every year for 10 years the chances of having a “false positive” finding is 50%.

During ten years of study of 160,000 women receiving either annual or biennial mammograms about half of the women during the 10 year period had at least one false positive finding; a non-cancerous abnormality that led to additional imaging without a biopsy. The probability that a false positive finding during the 10 years of annual testing led to a biopsy was about 7%.

Lowering cholesterol levels in the elderly can increase their mortality rate.

A 14-year study of nearly 6000 men with an average age of 69 showed that those with higher cholesterol had LESS non-cardiovascular and less cancer-associated deaths. There was NO association between a higher cholesterol and increased cardiovascular death rates in those men between 55 and 84 years of age.  In those over 85 years old a HIGHER cholesterol level was associated with a LOWER death rate from cardiovascular disease. This means that cholesterol lowering medications (statins) are unnecessary for elderly with low coronary risk factors. So, if you or a family members are over 70 and have high cholesterol, just live with it and don’t take statins. You may live longer.

MRIs give lots of false positives in people with non-specific low back or shoulder pain.

A 1994 study of 98 normal people without back pain showed that 2/3 of them had significant and “potentially serious” findings suggesting back pain on their MRIs. But, they had no pain or other back symptoms. A more recent study of 31 professional baseball pitchers revealed that 90% had abnormal cartilage by MRI in their pitching shoulder; findings considered indications for surgery. But, none of the pitchers had shoulder symptoms, and all were in excellent health.

Lyme blood tests are misleading a lot of the time.

Guidelines for diagnosing Lyme disease by laboratory test requires a positive test of the same blood sample using two different techniques, one an “enzyme assay” (ELISA) and one an “immune blot”. The laboratory diagnosis of Lyme disease requires a positive test with both techniques. A Dutch study of 89 patients with suspected Lyme, syphilis, or mycoplasma pneumonia revealed a significant amount of cross reactivity (falsely positive Lyme test in those that had syphilis or mycoplasma pneumonia). Many samples from suspected Lyme patients had a positive ELISA test with only one of the eight commercial labs providing the test. Some tested negative on ELISA but had positive immune blot tests, and visa versa. Only 16 of the 89 had positive ELISA tests with all 8 laboratories.  This inconsistency of results confirms the opinion of infectious disease clinicians that the diagnosis of Lyme disease is a clinical judgement, not a laboratory one. Reassuringly, all healthy people tested in this study had negative Lyme test results.

References:
1. Three PAS viewpoints, NEJM Nov. 24, 2011 and Year in Review 2011, Journal Watch Gen Med, pg.4 Jan 1, 2012.
2. Chest X-rays for lung cancer, NEJM Aug. 4, 2011 and JAMA Nov. 2, 2011 and Year in Review, Jour Watch Gen Med, pg.5 Jan. 1, 2012.
3. CA 125 in Ovarian Cancer, JAMA June 8, 2011.
4. Shingles vaccine, JAMA Jan 12, 2011 and Mayo Clin Proc February 2011
5. Mammogram false positives, Ann Int Med 2009; 151:716
6. High Cholesterol, J Am Geriatric Soc, Oct 2011
7. MRIs false positives, Wired, January 2012, pg.108
8. Lyme tests, Eur J Clin Microbiol Inf Dis, Aug 2011


Vol. 57 December 15, 2011 Four Ways To Speed Up Your Emergency Room Visit.

December 16, 2011

BLESSED ARE THE SQUEAKY WHEELS,
FOR THEY SHALL RECEIVE THE OIL. *

*Re-learned and confirmed by my recent 8AM – 4PM sojourn on a Monday in a community hospital ER helping a friend who had become unhinged and needed psychiatric help. 

.

.1. Ask for and write down the name of any physician, physician assistant, or nurse practitioner who treats you in the Emergency Room..

These are the only ER staff who can write the orders for your tests or treatments. If later you ask a tech, a nurse, a social worker, or a care manager why something hasn’t been done yet, they may ask you “who said you were getting that?”. Answering with a specific name gets you past that particular speed bump.

These people often come and go in the ER repeatedly during their shift as they deal with multiple patients in multiple areas, so knowing their names can help you reconnect with them if they are not visible. Usually you can spot your ER nurse(s) and hail them directly or point to them if someone asks you “who told you that”. When desperate for info or action you can also ask the nurse to page the physician, physician assistant, or nurse practitioner by name.

2. If you don’t know why you are waiting for something, ask anybody who comes near you: “Why I am waiting, or what am I waiting for?”. Ask every half hour, but increase the rate to every 15 minutes if you have been waiting for more than three hours. If nobody comes near enough to you to ask, push the call button and ask whomever responds; same frequency.

Even if the person you ask doesn’t know the answer, he or she will find someone who does if you keep asking. ERs are busy and most of the staff are caring for multiple patients simultaneously, so sometimes you need to reclaim their attention to move along.

3. If you are waiting for a decision or a service of any kind and the time is close to 6:30 AM, 2:30 PM, or 10:30 PM start asking for clarification or expediting every 10 minutes until the next hour arrives.

Nurses change shift normally at 7 AM, 3 PM, and 11 PM and when the nurse that has been working with you for the past few hours leaves, that change can result in a reduction of a sense of direction or urgency that you have been working hard to establish. So, push for decisions and/or disposition before the shift change. Social workers and  care managers usually work 9 to 5. Physicians work all kinds of shifts, so don’t be afraid to ask him or her when they go off, and push for decisions and/or disposition before they do.

4. If you are in the ER as a patient or as an advocate for a patient seeking behavioral or mental health services, do NOT be quiet, cooperative, and docile. The noisy, agitated “mental” patient gets faster treatment and disposition (or at least a quieter, more removed room to wait in)

One has to be moderate about using this last technique, but it is worth being more noticeable.  If you are perceived as a very cooperative patient or as a polite, passive  patient advocate you may be enabling a slower pace of action. This could be even more of a factor when several patients are awaiting psychiatric referral, evaluation, or placement. However, you don’t want to push this behavior to the point where they call Security or consider injectable medication.

For more details read on:

THE PROCESS: Inefficient, time-consuming, tiring and somewhat irritating to the patient and advocate, but probably “better than usual”.
8AM arrive in ER.
9:15 AM Social worker interviews patient for 10 minutes, and says she will ask the team intake person to evaluate
10:30 AM Team intake nurse interviews patient for 30 minutes. She says patient needs placement and someone will come to evaluate him.
11:30 AM Psychiatric Nurse Practitioner speaks to patient for 5 minutes. She says he needs to stay in the hospital, and they will start looking for a bed.
1:30 PM Patient’s advocate (me) goes to social worker desk to ask about progress in looking for bed. (See above for her response.) Discharge planner at the same desk seems to be hearing this news for the first time.
2:00 PM Patient’s advocate asks for update from discharge planner. Response: a possible bed at facility A 50 miles away.
2:30 PM Patient’s advocate asks for another update. (see above for critical timing). Response: No bed at facility A but possible bed at facility B 90 miles away.
3:00 PM Patient’s advocate reports to discharge planner that patient is getting restless and that the advocate has to leave. (More than a slight exaggeration for effect) Response: Let us know when you leave because “we will have to institute a one-on-one staff observation on him at that time”. (An expensive inconvenience for the nursing staff) Patient advocate requests a move of the patient to the quieter Psych holding area to get him out of the increasingly crowded and noisy ER before the advocate has to leave. Response: There is no room in the holding area.
3:30 PM  ER nurse reports that a bed has been found in facility A, and that patient will be moved out of the ER into the Psych holding area awaiting transport. Patient is taken into the Psych holding area where 3 out of 4 beds are empty.
4:00 PM Local private ambulance company comes to the Psych holding area and packs patient up in 5 minutes to go to facility A.

THE OUTCOME: Excellent
The patient is placed in an appropriate Geriatric Psychiatry Unit with a good reputation in a community hospital 50 miles from home.


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