July 24, 2014

Do We Have a Winner in the Overtesting Games?

We’ve seldom seen a more shocking example of overtesting than the one identified by Harriet Hall on ScienceBasedMedicine.org.

In an article called “An Egregious Example of Ordering Unnecessary Tests,” Hall describes the adventures in primary care experienced by a friend’s healthy 21-year-old son who sought a routine physical. He had no complaints, no past history of significant health problems and no family history of disease.

His doctor ordered lab tests, did not explain what they were for and the patient didn’t ask, assuming they were part of the physical. When the insurance Explanation of Benefits arrived, it showed coverage for $13.09 and said he was responsible for the remaining $3,682.98.

Here are the tests that generated that bill:

  • lipids: total cholesterol, LDL-C, HDL-C, Triglycerides, Non-HDL-C

  • lipoprotein particles and apolipoproteins: Apo B, LDL-P, sdLDL-C, %sdLDL-C, Apo A-1, HDL-P, HDL2-C, Apo B: aApo A-1 Ratio, Lp(a) Mass, Lp(a)-P

  • inflammation/oxidation: fibrinogen, hs-CRP, Lp-PLA, myeloperoxidase

  • myocardial structure/stress/function: galectin-3, NT-proBNP

  • platelets: aspirinworks (urine) Ppg/mg of creatinine

  • lipoprotein genetics: CYP2C19*2*3, CYP2C19*17

  • coagulation genetics: factor V leiden, prothrombin mutation, MTHFR (C677T), MTHFR (A1298C)

  • metabolic: 25-hydroxy-vitamin D, uric acid, TSH, homocysteine, vitamin B12

  • renal: cystatin C, estimated glomerular filtration rate, serum creatinine

  • electrolytes: sodium, potassium, chloride, CO2, calcium

  • liver: ALT/GPT, AST/GOT, ALP, total bilirubin

  • renal: creatinine, BUN

  • thyroid: TSH

  • others: albumin, total protein, ferritin

  • omega-3 fatty acids: ALA, DPA, EPA, DHA

  • omega-6 fatty acids: omega-6 total, arachidonic acid, linoleic acid

  • other fatty acids: cis-monosaturated total, saturated total, trans total

You don’t have to know what all that scientific shorthand means to know it’s a lot of investigating for conditions or possibilities that a healthy young man does not present. Suffice to say the tests looked at values for heart, kidney, liver, thyroid and metabolic function in several ways.

In addition, the lab results did not include a couple of blood and diabetes tests — hemoglobin, hematocrit, blood glucose, hemoglobin A1C — but somehow still concluded:

  • Glucose and hemoglobin A1c are in the normal range and are consistent with normoglycemia.

  • There may be some evidence of insulin resistance. There is evidence of adipose tissue insulin resistance.

  • There is evidence of hyperinsulinemia, suggesting beta cell strain. There is evidence of beta cell dysfunction. Elevated Proinsulin to C-peptide ratio has been associated with beta cell failure and beta cell dysfunction.

A routine physical on a 21-year-old male should include blood pressure, weight, updating immunizations, discussion of risk factors and counseling, if appropriate, about lifestyle issues such as safe sex, smoking, alcohol, diet and exercise.

“NO lab tests are recommended except for possibly checking lipids or HIV status,” Hall concludes, “which most guidelines do not advise in the absence of risk factors.

“I will not comment further, as I feel incapable of moderating my language.”

No wonder. (Tip of the hat to HealthNewsReview.org, which drew our attention to Hall’s story.)

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July 23, 2014

Texas Might Decide Radiologic Techs Don’t Need a License

Texas has about 28,000 licensed X-ray technicians, but if the state follows the recommendation of an advisory commission, the piece of paper that certifies that they’re qualified to dose you with radiation won’t be necessary.

The state, according to the Texas Tribune, might decide that radiologic technologists, as well as several other categories of health professionals, no longer need a license to do their jobs. What the members of the Department of State Health Services’ Sunset Advisory Commission don’t seem to understand is that licensing the people with the potential to cause serious harm is a measure of protection against lack of training and ability. (See our backgrounder on radiation overdose injuries.)

The commission, which is charged with identifying inefficiencies in state government, believes licensing is regulatory redundancy because people receive X-rays, MRIs and CT scans in health-care facilities that themselves are highly regulated. By that logic, no hospital that surpasses all oversight measures ever grants practice privileges to a surgeon who — oops! — leaves a sponge inside a patient.

Such medical errors happen, but they’re less likely to occur if practitioners regularly prove they’re worthy of the trust placed in them.

Besides Texas, 10 other states do not require imaging technicians to be licensed, and you have to wonder why. As the vice president of government relations and public policy for the American Society of Radiologic Technologists told The Tribune, “Everyone knows that radiation is a carcinogen. If performed incorrectly, it’s a direct risk to public health and safety,” said Christine Lung.

In addition to administering X-rays, CT scans, MRIs and other kinds of imaging, radiologic technologists also perform interventional procedures, such as injections and IV placement. The procedures measures can deliver high doses of radiation that must be within millimeters of accuracy, and can pose a risk of infection.

“It’s not just point and shoot X-ray,” Lung said.

Along with imaging techs, the commission suggests there’s also no need to license respiratory care practitioners, perfusionists (people who monitor the heart-lung machine during open heart surgeries), dietitians and opticians.

We’re relieved that the commission’s report was met with skepticism by at least some legislators. "Your charge was to make sure that each profession is administered and licensed in a way that is the least burdensome possible," said one state senator, according to The Tribune. "But we've all gotten a lot of phone calls."

But, this is Texas, which often leads the nation in worker fatalities but is the only state that does not require private employers to carry workers’ compensation insurance or a private equivalent. This is Texas, where the political hunger to cut, cut, cut government, even government that protects people from harm, is insatiable. So of course the senator is appointing a subcommittee to devise a modified proposal that "has a realistic chance of passing the Legislature."

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July 22, 2014

Counterfeit Equipment for Spine Surgery Spurs Lawsuits

Some sleazy California surgeons and their enablers, it seems, have pulled a General Motors: They used substandard equipment that caused, if not fatalities, at least several thousand injuries to patients undergoing spinal operations.

The Center for Investigative Reporting (CIR) discovered that the doctors implanted counterfeit screws and rods manufactured in a small machine shop, into injured workers undergoing back surgery. Many have filed lawsuits after suffering adverse outcomes.

The surgeons’ motive, of course, was money: Some who used the fake hardware took kickbacks including cash and private plane rides. Middlemen and hospitals also got a slice of the poison pie by wildly inflating the cost of the screws, according to one of the suits. Some of the screws cost $300 to make but were billed at as much as $12,500 each.

One lawsuit filed last month claims that the bogus spinal implants could cause harm by causing infection or because patients could have an adverse reaction to metal that is not surgical grade. The screws also might loosen or fail.

“It’s probably the worst example where fraud has progressed from being a financial crime to hurting people for profit,” Thomas Fraysse, an attorney on the case told the CIR. “It’s beyond unethical.”

The cases involve spinal fusion surgeries, about which we’ve raised concerns. The procedure implants rods and screws in the patient’s back to relieve pain. In this case, the patients were people who had filed back injury claims for workers’ compensation, a state system that, according to the CIR, used to pay a premium for hardware used in the surgeries until a loophole was closed by recent legislation.

One of the lawsuits says the defendants committed fraud and battery, and that the deficient hardware risked the life of Arthur Golia, who got seven of the counterfeit devices implanted in his spine.

A similar case alleges that David Solomon had medical implants from the mom-and-pop machine shop implanted in 2011. One of the screws broke, requiring Solomon to undergo a second surgery in 2013. He has ongoing pain and loss of movement.

“If you break this down to the core of right and wrong, it really is using people as pieces of meat to make money,” attorney Chris Purcell told the CIR.

A whistle-blower lawsuit charges that many of the patients with fake implants might not have needed surgery in the first place. It alleges they were damaged victims of a massive scheme to defraud insurers that involved the former owner of Pacific Hospital in Long Beach.

Michael Drobot, the owner, admitted to paying doctors kickbacks of as much as $15,000 to use his hospital for the surgeries. He also admitted to paying bribes to former state Sen. Ronald Calderon for supporting a law allowing hospitals to bill insurance providers for the full cost of spinal implants. Calderon has been charged with corruption charges, and Drobot is to be sentenced in December.

Spinal Solutions LLC, is the outfit accused of distributing and inflating the cost of the hardware in some of the lawsuits. Its owner, Roger K. Williams, is accused of passing off the counterfeit rods and screws as FDA-approved even though they were made at a local tool shop. The federal agency sent him a warning letter a couple of years ago, and recalled its products last year.

The lawsuits point up how widespread illegal palm-greasing is when it comes to lucrative spine surgeries.

To understand the risks of back surgeries, and to better assess your treatment options for back trouble, see our newsletter, “Better Care for Your Aching Back.”

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July 21, 2014

Testosterone-Suppressing Drugs Are a Bad Idea for Many Prostate Cancer Patients

For many men diagnosed with early-stage prostate cancer, drugs commonly are prescribed to suppress their production of testosterone. Despite its frequent use, these drugs have not been shown to extend patients’ lives, and they have devastating side effects of what is colloquially termed "chemical castration."

As reported last week in the New York Times, “androgen deprivation therapy” was studied for 15 years by researchers, whose results were published by JAMA Internal Medicine. The study’s lead author, Dr. Grace L. Lu-Yao from the Rutgers Cancer Institute of New Jersey, told The Times, “There are so many side effects associated with this therapy, and really little evidence to support its use. I would say that for the majority of patients with localized prostate cancer, this is not a good option.”

Patients usually are put on the drugs for life. Among the side effects of this “chemical castration” are:

  • impotence

  • diabetes

  • bone loss (leading to fractures and sometimes disability)

  • heart disease

  • hot flashes

Lu-Yao’s team studied tens of thousands of men with early prostate cancer for as long as 15 years. Those who received androgen deprivation therapy lived no longer on average than those who didn’t get the drugs. The study is only the latest to indicate that many men with early prostate cancer are better off not taking testosterone-suppressing medicine.

Still, as Dr. James M. McKiernan, the acting chairman of urology at New York-Presbyterian Hospital/Columbia University Medical Center, observed, many doctors recommend the treatment. Many of the patients who follow that advice have experienced negative consequences beyond the medical, such as deteriorating marriages.

About 250,000 new cases of prostate cancer are diagnosed in the U.S. every year. More than 9 in 10 of these patients have an early form of the disease in which the cancer has not spread and is classified as low-risk. In many cases, as we’ve pointed out in previous prostate cancer blogs, these men will die of something else besides their slow-growing, essentially nonlife-threatening cancer.

Drugs that suppress the hormone testosterone can be appropriate for men with more advanced or aggressive cancers; they can shrink tumors or retard their growth, which can improve outcomes, especially when the drugs are combined with radiation or other treatments.

In the 1990s, according to The Times, use of the drugs rose sharply for patients of all ages and stages of the disease, especially older people. It’s estimated that at least 1 in 4 of all patients older than 75 are chemically castrated.

Lu-Yao’s study involved more than 66,700 men at least 66 years old with prostate cancer. Researchers compared men living where the drugs were frequently prescribed with men living where they used less often. They found the drugs were not associated with greater long-term survival.

A large, randomized trial of Europeans found that the hormone treatments improved survival only for men with a more aggressive form of the disease.

If you or a loved one is diagnosed with early-stage prostate cancer, and your doctor prescribes hormone-suppressing therapy, it’s time for a second opinion. And maybe a new doctor.

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July 17, 2014

Legal Remedies for Patients Harmed by Unsafe Injection Practices

“Law as a Tool to Promote Healthcare Safety,” an article recently published in Clinical Governance: An International Journal, discusses how the legal system can punish health-care providers who engage in unsafe injection practices, and deter them, and others, from putting future patients at risk.

As we wrote in our blog “Safe Injection Practices Are not a Shot in the Dark,” tens of thousands of people are harmed every year from infections caused by sloppy injection procedures that are completely preventable, and that the Centers for Disease Control and Prevention (CDC) has addressed.

Practices that compromise patient safety include using needles on more than one person, using single-dose or single-use medications for more than one patient and failing to use proper hygiene when handling, preparing and storing meds and injection.

The Clinical Governance paper reviewed legal theory and precedents, and identified several ways, from the administrative to the criminal, in which the law can address disputes about unsafe injection practices, including:

  • holding doctors or facilities responsible for preventing harms;

  • using state civil courts in malpractice lawsuits to compensate victims for the harms they suffer;

  • prosecuting defendants as criminals in order to deter practices that cause disability or death.

To review guidelines for safe injection practices devised by the CDC, link here.

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July 15, 2014

How to Shop Smartly for a Plastic Surgeon

When a celebrity “has work done” and the job goes wrong, it’s splashed all over the tabloids. When it happens to you, it doesn’t make the news, but the results are equally devastating.

Dr. Patrick Hsu, a plastic surgeon, recently wrote on KevinMD.com that the number of people having plastic surgery is increasing, and that the number of bad outcomes is increasing right along with them. Hsu wants potential patients for plastic surgery, whether the procedure is elective or medical, to know how to find the right surgeon.

As always, it’s best to get more than one opinion about a nonemergency medical procedure, and plastic surgery is no different. To enhance your chances of getting the best outcome, Hsu advises all patients to ask prospective plastic surgeons these questions:

  • Are you board certified?

    Confirm that your surgeon is board certified by either the American Board of Plastic Surgery or the Royal College of Physicians and Surgeons of Canada. Such certification proves that he or she has spent five years training and has passed multiple examinations. Each board’s website lists surgeons that are certified by them.

  • How many times have you done this procedure?

    You don’t want a surgeon who’s new on the job. He or she should have done at least 100 or more of the procedure you’re having, per year, for many years. Do not agree to the surgery under the knife of someone learning to master the skill.

  • What are the risks and complications of this procedure?

    Long before the surgery, discuss with your doctor of choice all the risks and complications your procedure might present. You can’t adjust to a less than perfect outcome if you have no idea that such a thing could occur. Ask how often such risks occur, and what to do if they happen to you. Remember: No surgery is risk-free.

    The most common risks of plastic surgery are scarring, bleeding and infection.

  • May I see some before-and-after photos of people you have performed this surgery on?

    A surgeon with nothing to hide has no problem showing you his or her work. Insist on seeing photos not only for quality assurance, but to see if you like the transformation. Still, your outcome could be different. But this sort of review is the most visual sense of what’s likely to happen.

“By making sure that you ask the right questions, not only your surgery will be worry-free,” Hsu says, “but your recovery as well.”

We’re not sure any medical procedure is worry-free, but preparation goes a long way toward minimizing the concern.

To learn more about cosmetic procedures, see our blogs and our backgrounder on the topic.

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July 13, 2014

Some Hospitals Are a Big Source of Bad Medical Advice

Like other businesses, hospitals rely on promotions to generate customers. But when the customer is buying health care, an ill-advised promotion can do irreparable harm.

Public Citizen, a consumer advocacy organization, has embarked on a campaign to stop 20 different 20 hospital systems from partnering with companies that offer low-cost screenings for heart disease and stroke risk because the exams can do more harm than good, which the advocates say is “unethical.”

We, too, have advised against hospitals hooking up with mobile screening operations because the branding opportunity for them too often makes people who aren’t ill afraid of getting ill.

Public Citizen sent letters to hospitals in eight states and Washington, D.C., seeking to stop their screening promotions.

Hospitals pair up with testing outfits to raise their profiles and boost referrals, but that’s not what they tell consumers. That message is that, for a reasonable cost, you, too, will benefit because you can find out if you have a higher risk for heart problems or stroke in time to make changes and seek treatment to reduce your risks!

According to Public Citizen, as reported by KaiserHealthNews.org, “the promotions rely on fear mongering and erroneously suggest that for most adults in the general population, these screening tests are useful in the prevention of several potentially life-threatening cardiovascular illnesses.”

These “check it out” appeals appear on websites, in newspapers or through direct mail.

Screenings — often performed in specially equipped mobile units whose signage changes according to the affiliated hospital — often include ultrasound tests for artery blockages and elasticity, weaknesses in the abdominal aorta and a resting electrocardiogram (ECG), in which the heart’s electrical activity is mapped on paper.

The promotions, of course, don’t mention that best practice generally does not include such routine testing for people without risk factors or symptoms. The promotions don’t mention that such widespread screening can lead to misleading results, unneeded and expensive additional tests and maybe even unnecessary surgery. Not to mention that such overuse contributes to increasing health-care spending.

We’re not optimistic that the hospitals approached by Public Citizen will acknowledge the bogus motivation behind their promotions, but if the effort contributes to a greater understanding among consumers about when and why to be tested, that’s valuable.

To learn more about how to strike the right treatment balance, see our blog, “The Right Amount of Care.”

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July 10, 2014

Why Medical Providers Ignore Disabled Patients

People with physical or mental disabilities have disadvantages the rest of us can only imagine, and when it comes to the delivery of health care, the insult is compounded. Disabled patients have a harder time than other people in finding a doctor, and when they do, they receive inferior health care, less information about prevention and fewer screening tests.

According to a recent post on the NPR health blog, about 1 in 5 Americans has a physical or mental disability, and not even 1 in 5 U.S. medical schools teaches students how to talk with a disabled patient about his or her needs. In May, we blogged about a single-state study showing that disabled patients receive inferior care in many ways.

More than half of medical school deans say that their students aren't competent to treat people with disabilities, and about the same percentage of graduates agree. Agencies that accredit and license practitioners have no requirements for clinicians to demonstrate competence treating patients with disabilities.

Dr. Leana Wen, who wrote the NPR blog, is an attending physician and director of patient-centered care research in the Department of Emergency Medicine at George Washington University. One day in the ER, eight patients had presented within minutes of each other. The junior resident, two interns and a medical student signed up for all of them … except the guy in his 20s complaining of back pain.

The middle-aged man with chest pain, the old woman with a broken wrist, the teenager with a sore throat all were seen. Len saw one medical student read the chart for the man with back pain, and replace it in the rack. Nurses avoided his room.

After 30 minutes, Wen assigned a team to care for him. The chosen nurse said, “"We drew the short straw here.” The resident said, "I already ordered labs and an X-ray. It's going to take too long to examine him, so let's just get this started."

The man wasn’t being difficult, he didn’t smell bad, he wasn’t drunk or contagious. He was in a wheelchair.

The reason for his disability was paralysis from the waist down, which had been his plight since a car accident five years earlier. He told Wen that he was used to waiting, to being the patient patient, because caregivers always avoided him.

As it turned out, his back pain was the result of a kidney infection, and his treatment amounted to being given an antibiotic.

Medical offices often have people who can interpret for patients who don’t speak English. Medical schools teach students about diseases so rare most will never see a case if they practice for 40 years. “Yet,” writes Wen, “there's been only halting progress in the care of tens of millions of Americans with disabilities.”

Per the Americans with Disabilities Act, it’s against the law to discriminate on the basis of disability; the act guarantees equal opportunities for individuals with disabilities in employment, transportation, public accommodations, state and local government services and telecommunications. But it doesn’t spell out that equal treatment in a medical setting is a disabled person’s civil right.

Medical professionals often deliver substandard care to the disabled because of mistaken assumptions; they’re often surprised, for example, to learn that they are obliged to discuss risks and benefits with patients who are cognitively impaired. Some are surprised to learn that they should ask a patient with a physical disability about sexual activity, just like they would anyone else.

In a study last year published in the Annals of Internal Medicine, researchers telephoned doctors' offices in four U.S. cities to make an appointment for a fake patient who was obese and used a wheelchair.

The study was fairly small — 256 practices representing endocrinology, gynecology, orthopedic surgery, rheumatology, urology, ophthalmology, otolaryngology and psychiatry.

But more than 1 in 5 offices refused to see the patient for reasons including a lack of trained staff, a lack of equipment and/or personnel to help patients onto an examining table and lack of access to the building. The highest rate of refusal was among gynecology practices, at 44 in 100.

Some medical schools have pilot programs to teach students about patients with disabilities. Some schools encourage students to rotate through rehabilitation centers, and incorporate interdisciplinary learning with occupational and physical therapists.

That’s nice, but it’s a paltry effort to address a significant patient demographic. We agree with Wen: “Disabilities education needs to be a central part of medical training in the same way that learning to care for people from different cultural backgrounds is now.”

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July 8, 2014

Pet Health Insurance Is Far Easier to Understand than Policies for People

A family rescued a dog from a local shelter, took him to the vet to treat a minor ear problem and learned a profound lesson: “It tells you everything you need to know about the U.S. health-care system that you can get more comprehensive coverage for a dog than you can for a human being.”

That was the conclusion of David Lazarus, a consumer business columnist for the Los Angeles Times. After taking care of Teddy’s ear, Lazarus looked into the whole animal insurance market and found out that there are about 1 million pet-insurance policies in the U.S. and Canada, mostly covering dogs, and that there’s an industry group called the North American Pet Health Insurance Assn.

It’s a $600 million market that addresses our fears that our pets will succumb to bacteria, viruses, cars, fights, snake bites and who knows what else. Beyond worrying about the animals, we also should worry about the financial cost of some of these perils. "Your dog gets hit by a car. He needs $7,000 worth of work. It's that simple," said one vet.

Lazarus interviewed one animal insurance company founder who observed that health insurance for people is too complicated. “I'd rather have animal insurance for myself than people insurance,” he said.

Pet insurances falls into three kinds of policies:

  • accidents only

  • accidents and illness

  • accidents, illness and wellness

Most people who insure their pets — more than 9 in 10 — choose accidents-and-illness plans.

The average premium last year for accidents-only plans was $166.25 for dogs and $136.26 for cats. Accidents and illness premiums averaged $456.98 a year for dogs and $289.99 for cats. Comprehensive coverage cost $1,178.13 for dogs and $743.11 for cats.

Lazarus discovered things that people seeking to cover their own species, as well as their four-footed friends, should know. “There are some obvious differences between pet insurance and people insurance,” he writes. “For example, Anthem Blue Cross isn't going to want to know your breed when deciding rates.

“But shopping for both forms of coverage can be very similar.”

Here are his tips for animal insurance shoppers:

  • Shop around. About a dozen leading providers offer pet insurance in the U.S., and each has different types of coverage for different prices limitations. “As with human health insurance,” says Lazarus, “it's not one size fits all.”

  • Read the fine print. Unlike people policies that adhere to the provisions of the Affordable Care Act (ACA), most pet-insurance policies don't cover pre-existing conditions. Some don’t cover congenital problems (those present from birth) and hereditary problems. Also in a departure from the ACA, they cap how much can be paid out in a single year.

  • Explore your options before you choose a pet. Some pet insurers impose rates according to breed — English bulldogs, for example, can cost more to insure because they’re known for having certain medical issues other breeds don’t. And often, rates vary for animals of different ages.

Like medical care for humans, wellness and preventive treatment that might seem optional can save money over the long term. Ask about policies that cover routine visits to the vet.

Also like human coverage that comes with lower rates if you cover your home, car and life, some pet insurers drop the cost for covering more than one animal.

The leading provider of pet insurance is Veterinary Pet Insurance (VPI). It's more than 30 years old, and — fun fact! — issued its first policy for the dog who played Lassie on TV. VPI accounts for more than half of all policies written. Keep in mind that its benefit schedule, according to Lazarus, limits reimbursements for various treatments. So some vet bills might exceed the company's claim levels.

Policies offered by Healthy Paws invite you to choose among three options for reimbursement and deductible — 90%, 80% or 70% of medical costs, for yearly deductibles of $100, $250 or $500. Different combinations will give you different quotes, and everything is covered except pre-existing conditions and routine checkups.

PetPartners, (not to be confused with the nonprofit organization Pet Partners, which supports animal therapy programs to improve human health), excludes a long list of specific medical problems, including diabetes, osteoarthritis and hip dysplasia, a common ailments among larger breeds of dogs. But the exclusions are spelled out on the website.

Petshealth promotes itself as the "strategic partner" of the American Society for the Prevention of Cruelty to Animals.

But tons of companies offer policies to cover your pet, and we’re not in a position to recommend or disapprove of any of them. To learn more about the wisdom of buying insurance for Fido, read Consumer Reports’ analysis of pet insurance coverage and costs. Another examination is offered by MSN’s money site.

Review the information provided by the North American Pet Health Association, which promises to set high standards for the industry, coverage and transparency.

“[P]eople insurance is often a minefield of exclusions and sneaky provisions,” Lazarus concludes, “and insurers typically come off as reluctant partners, at best, in a policyholder's well-being.”

When it comes to pets, however, that doesn’t seem to be the prevailing industry attitude.

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July 6, 2014

Can Doctors Avoid Conflicts of Interest?

As editor-in-chief of JAMA for 11 years, Dr. Catherine DeAngelis was known for her outspoken views about the deficiencies of U.S. health care and the drug industry. Her recent commentary, “Conflicts of Interest in Medical Practice and Their Costs to the Nation's Health and Health Care System,” continues her campaign to expose what’s wrong with our medical care.

“Many, if not most physicians practicing today have, or have had, conflicts of interest that clearly do not result in their patients’ best interest,” she writes in the Milbank Quarterly, a health policy journal. She defines conflicts of interest as “a conflict between the private interests and the official responsibilities of an individual in a position of trust.”

That sorry situation, as summarized by MinnPost.com, has become widespread over the last couple of decades, largely driven by pharmaceutical companies whose marketing and scientific divisions seem to be one and the same.

We’ve blogged about the slimy intersection of these two forces, and their harmful effect on patient safety. DeAngelis traces their roots back to medical school, with “the free black bags, instruments or books given to medical students by a pharmaceutical company, or even the doughnuts, coffee, soft drinks and free lunches provided at teaching conferences.”

It’s not long before those … kindnesses … escalate to “the free food, tickets to sporting and other events, sponsored trips to resort locales and the shower of other gifts given to physicians by the pharmaceutical representatives assigned to them,” says DeAngelis.

Often, the recipients of this largess claim that their clinical and prescribing practices are not influenced by it, but if that were true, DeAngelis wonders, “[W]hy would pharmaceutical companies spend billions of dollars on these items, and why would they partially reimburse their marketing representatives according to the number of prescriptions written by the physicians to whom they are assigned?”

Sunlight is spreading over this smarmy practice of drug and device manufacturers showering practitioners with attention and treats — ProPublica’s Dollars for Docs is one site where you can track how the industry greases practitioners’ palms — but DeAngelis explains how much more disinfectant is required to clean up the mess.

“What about the free drug samples provided to physicians for their patients?” she asks. Some people say free samples help patients who otherwise can’t afford the drugs they need. If so, she asks, “[W]hy are the vast majority of these free samples for new (meaning those still under patent protection) and expensive drugs that are almost exclusively for illnesses that require the drug’s frequent or continued use?”

She’s concerned as well about academics who conduct research and/or write practice guidelines or review papers who are subsidized by Big Pharma. “Most Americans are surprised to learn that the clinical research funded by Big Pharma dwarfs the annual investment by the National Institutes of Health. Moreover, much of this industry-sponsored research is tainted by bias that is not always clearly stated.”

If you’re not happy to name the members of your team, doesn’t that suggest there’s something sordid about the game you’re playing?

DeAngelis decries the practice of physicians, biomedical and health-care researchers working for a pharmaceutical company’s marketing division instead of its scientific division. One example is “expert physicians” serving as industry-sponsored speakers using data provided by the pharmaceutical company. “Invariably” she writes, “such ‘chaperoned’ presentations accentuate the positive and downplay the negative (including price differentiation) aspects of the drug being promoted.”

Then there’s the common but illegal habit of promoting a drug for off-label use. DeAngelis describes how insidious drug companies and their willing medical partners operate in this arena:

Imagine the following and, unfortunately, common scenario: At a major clinical or health-related lecture, a physician paid by the pharmaceutical company is “planted” in the audience. The “plant” raises his or her hand and supposedly innocently asks the presenter if he or she has ever used the drug for an illness for which the drug has not been approved by the … FDA. The presenter then discusses off-label uses of the drug for this or that illness or symptom. Remember that physicians in the United States can write prescriptions for any drug, whether or not it has been approved by the FDA for that illness. So why not add a few more uses, which can translate into multiple sales and millions of dollars in unexpected revenue?

Later this year, as we’ve noted, the Physician Payment Sunshine Act, a provision of the Affordable Care Act, requires drug and medical device manufacturers to report what they pay individual physician on a website accessible to consumers.

Will that public disclosure persuade physicians to uphold their Hippocratic oath to do no harm, to always act in the best interest of their patients and reject the free meals and trips, the lucrative speaking and consulting fees Big Pharma offers?

Says DeAngelis, “We can only hope.”

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July 3, 2014

Your Toothbrush — An Essential Health Tool, a Potential Threat

We all brush our teeth every day, sometimes several times. But most of us remain unaware that the humble toothbrush can carry a medical textbook’s worth of nasty bugs.

A toothbrush can play host to Staphylococci (commonly from mucus membranes and skin), yeasts, intestinal bacteria and even fecal germs. But instead of tossing it into a vat of boiling bleach, the School of Dentistry at the University of Alabama, Birmingham invites you to learn a bit more and practice a few habits.

“The oral cavity is home to hundreds of different types of microorganisms, which can be transferred to a toothbrush during use,” according to Dr. Maria L. Geisinger in a report on the university’s website. She’s a professor of periodontology at UA.

“Furthermore,” Geisinger said, “most toothbrushes are stored in bathrooms, which exposes them to gastrointestinal microorganisms that may be transferred via a fecal-oral route. The number of microorganisms can vary wildly from undetectable to 1 million…. Proper handling and care of your toothbrush is important to your overall health.”

This Q&A, excerpted from the one with Geisinger, explains the proper care and handling of your toothbrush:

Q. How do bacteria from the toilet reach your toothbrush?

A. Enteric bacteria, which mostly occur in the intestines, can transfer to toothbrushes through inadequate hand washing or via microscopic droplets expelled during a toilet flush. In a recent episode of Discovery Channel’s “Mythbusters,” 24 toothbrushes were tested. All of them bore microorganisms — even the ones that hadn’t been stored in the bathroom. Toothbrushes can be contaminated with bacteria right out of the box, because packaging requirements don’t include a sterile process.

Q. What is the proper way to clean a toothbrush?

A. After brushing, thoroughly rinse toothbrushes with potable tap water to remove remaining toothpaste and debris. Soaking toothbrushes in an antibacterial mouth rinse has been shown to lower the level of bacteria growing on a toothbrush.

Q. How do you store a toothbrush to avoid germ and bacteria buildup?

A. Don’t store it in a closed container or routinely cover it — a damp environment invites the growth of microorganisms. Store it upright, and allow it to air dry until the next use, if possible. If toothbrushes are stored together, keeping them separate helps prevent cross-contamination.

Q. Should you brush your teeth when you’re sick?

A. Sure. But if you’re ill with anything that can be transmitted through body fluids, keep your toothbrush separate from anybody else’s. Replace it when you’re feeling better.

Q. How often should a toothbrush be replaced?

A. At least every three to four months, or when bristles become frayed and worn, whichever comes first.

Take these steps for additional protection against contaminating toothbrushes and for better oral health generally:

  • Use antimicrobial mouth rinse before brushing. This can decrease the bacterial load in your mouth and might reduce the number of microorganisms that end up on the toothbrush after brushing.

  • Get routine dental care. Seeing the hygienist and dentist regularly can reduce the bacteria count in your mouth, and the types of bacteria present. It’s especially important for people with gum disease, because the oral bacteria present in their mouths can enter the bloodstream during the performance of everyday activities, including eating, chewing gum and tooth-brushing.

  • Wash your hands. Reduce the likelihood of fecal-oral contamination by washing up after using the toilet and before brushing your teeth.

  • Do not share toothbrushes. Duh. Still, lots of people do this — we’re talking to you, spouses and lovers, parents and children. Sharing a toothbrush is sharing bacteria, including the ones that cause dental decay and periodontal disease — the two major dental diseases in adults.

To develop good oral hygiene habits with your children, see our blog “Good Oral Health Starts in Infancy.”

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July 2, 2014

Rapist Who Got His Medical License Is Accused of Assaulting a Patient

Last year, Maryland lawmakers declined to pass a bill promoting background checks for health-care providers. Had they acted differently, maybe a man who had been convicted of rape wouldn’t have been granted his Maryland medical license. Maybe he wouldn’t be facing charges of assaulting a patient in April.

As explained by the Baltimore Sun, the case of Dr. William Dando has renewed discussion about reforming Maryland law. It’s one of 13 states that does not conduct background checks on physicians.

Dando practiced medicine in Maryland for nearly 20 years before anyone knew he had been convicted of raping a woman at gunpoint in Florida. Now that he’s facing trial, his medical license has been suspended. He has pleaded not guilty.

Some legislators are keen to submit new bills, and the Maryland Board of Physicians also is expected to submit a proposal after discussing policy and taking feedback from public health advocates this summer.

Lisa McGiffert, director of the Safe Patient Project at Consumers Union, welcomes any action that offers consumers more information about their doctors' criminal records. "The pattern usually is something very egregious like this happens, and that's what makes legislators take action," she told The Sun. "Most consumers would want to know if the physician they're going to had a felony conviction in their background."

Previous efforts to ensure doctors weren’t creeps, or felons, were rather tepid. In 2007, 31 recommendations were given to the state Board of Physicians for evaluating their own. One was that it be required to conduct criminal background checks of licensure applicants.

But what happened instead is about as forceful as butterfly in a boxing glove — applicants are asked to volunteer information about any arrests, guilty pleas or convictions related to crimes of "moral turpitude." Board officials say they investigate any that are disclosed.

But, really, if you’re a scumbag who wants a medical license, are you likely to say, “Hey, I’m a scumbag who wants to practice medicine — how about an assist?”

Legislation to reform the board was passed in 2007, and again in 2012 and 2013. But none of those measures required physician background checks. They were organizational, not substantive changes, including making the board chairmanship a gubernatorial appointment and establishing dual disciplinary panels to speed processing of complaints against doctors.

The legislation in 2013 was proposed at the request of state health department employees who oversee health occupation boards. It was intended to give the physicians’ board and various other licensing boards the power to conduct background checks of applicants.

The legislation was withdrawn after the attorney general's office said stronger language would be needed. To gain access to a national FBI database of criminal records, the boards needed statutory muscle for the background checks; so the reforms died over the linguistic difference between "may" and "shall" in the legislation, which wasn’t reintroduced.

The legislators who were pushing the measure said they got little support from state licensing boards, including the Board of Physicians.

Nine witnesses initially spoke in favor of the measure, and none opposed it. The physicians board did not participate. But MedChi, the medical society that advocates for Maryland physicians, and the Maryland Hospital Association spoke in favor of the bill, as did representatives from state boards responsible for licensing physical therapists and dentists.

Because the bill had broad support and no opposition, state health officials didn't add its voice to the “yes” side. They were surprised when the legislation foundered.

Now comes Dando. Details about his criminal past emerged after his indictment in May. He had been practicing medicine in Maryland since 1996, despite a 1987 conviction in Florida for sexual battery with the threat of a deadly weapon.

In that case, he followed a woman home after a night of drinking at a strip club, broke into her house and raped her at gunpoint. He pleaded guilty, was sentenced to 10 years in prison and was released after serving four.

The Board of Physicians suspended Dando's license June 5. State health officials launched an investigation to determine how he got a medical license at all, given that when he applied, he told the board he "assaulted someone."

As The Sun reports, “It is not clear if — or to what extent — the board investigated Dando after that admission.”

To make register your feelings about requiring background checks as a condition of receiving a medical license, contact your state legislators (locate them here) and register your opinion with the state Department of Health and Mental Hygiene via email (dhmh.healthmd@maryland.gov) or telephone (877-463-3464), and the Maryland Board of Physicians.

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