I took a deposition a few days ago that underlined for me why we need to have public report cards on primary care doctors so that patients can separate the mediocre practitioners from the really good ones. I wrote an article explaining the idea. Read my entire piece on Huffington Post, which I called "One Good Reason to Get Mad About Health Care."
"Amenable mortality" is a body count of unnecessary deaths due to lack of preventive health care. The latest measure is not flattering to the American health care system.
Researchers count these deaths by looking at premature deaths in areas like these:
* Adults who die from breast or colon cancer before age 75, indicating lack of timely mammograms or colon screens or care. * Children who die before age 14 from vaccine-preventable or easily treatable illnesses such as coughs, measles, asthma, and other respiratory problems. * Diabetics who die before age 50 from complications that could easily have been prevented with proper medical management. * People who die from infections or hypertension before age 75, a symptom of lack of preventative and appropriate care, including blood pressure control.
In the mid-1990s, the U.S. ranked 15th out of 19 industrialized nations in its death rate from "amenable mortality." Now the figures have been updated, and America is in last place -- 19th out of the same 19.
France, Japan and Australia do the best in this ranking. The United Kingdom used to be worse than the U.S. but has gotten a lot better.
Consumer Reports has a chart of the latest data here.
Vertebroplasty is a popular surgical technique for treating patients who suffer "crush" fractures of their vertebrae due to osteoporosis, the loss of bone mass that often comes with old age. Two newly published studies suggest that this procedure is going the way of other medical "fads" that showed early promise but failed to show a real benefit after extensive testing.
Both new studies were published in the New England Journal of Medicine in August 2009, and they found that the surgery was no better than doing nothing at relieving the patients' symptoms. Here is how one put it into perspective for an online publication, Medscape Neurology.
Lead investigator of the second trial, Rachelle Buchbinder, PhD, from Monash University in Malvern, Australia, raised similar concerns to Medscape Neurology. "There have been numerous examples of treatments that have looked promising in noncomparative studies but have subsequently been shown to be no better than placebo, a sham procedure, or standard care."
Dr. Buchbinder cites arthroscopy for osteoarthritis of the knee, bone marrow transplantation for breast cancer, embryonic neurons for severe Parkinson's disease, and from her own work, shock-wave therapy for plantar fasciitis. She suggests that each of these looked promising early on, but didn't do well after rigorous study.
It had previously been argued that performing a randomized placebo-controlledtrial of vertebroplasty is unnecessary and unethical in light of the published results of numerous studies that suggest a benefit. But Dr. Buchbinder said that the take-home message from her trial is that vertebroplasty was no better than a sham procedure for improving pain, function, and quality of life after an osteoporotic spinal fracture.
"Both treatment groups improved by about the same amount," she said. "In view of the known potential adverse effects and no benefit, vertebroplasty should not be used in clinical practice."
The bottom line for patients is that this is just another in a long string of popular medical innovations that failed to pan out, so wise patients should be wary about undergoing any new-fangled treatment before it is of proven benefit.
A new series of investigative articles by the Hearst newspapers concludes that errors in medical facilities are still taking some 100,000 lives per year -- a decade after a national report first focused wide attention on the problem. Worse, the reforms that started after that report have been piecemeal and ineffective, according to the authors.
The series concudes:
[T]he federal government and most states have made little or no progress in improving patient safety through accountability mechanisms or other measures. According to the Hearst investigation, special interests worked to ensure that the key recommendations in the report -- most notably a mandatory national reporting system for medical errors -- were never implemented.
Among the key findings of the Hearst investigation:
• 20 states have no medical error reporting at all, five states have voluntary reporting systems and five are developing reporting systems;
• Of the 20 states that require medical error reporting, hospitals report only a tiny percentage of their mistakes, standards vary wildly and enforcement is often nonexistent;
• In terms of public disclosure, 45 states currently do not release hospital-specific information;
• Only 17 states have systematic adverse-event reporting systems that are transparent enough to be useful to consumers;
• The national patient-safety center is underfunded and has fallen far short of expectations;
• Congress approved legislation for "Patient Safety Organizations" as a voluntary system for hospitals to report and learn from errors, but the new organizations are devoid of meaningful oversight and further exclude the public;
• Hearst journalists interviewed 20 of the 21 living authors of "To Err is Human" -- 16 believe that the U.S. hasn't come close to reducing medical errors by half, the primary stated goal of the report;
• New York's reporting system has run out of money and staff -- its last public report is four years old;
• The law mandating reporting in Texas expired in 2007, and funding ran out -- a new reporting law has been passed, but no funds have been allocated;
• Washington State requires reporting, but doesn't enforce that requirement -- and the legislature failed to provide funds to analyze the results.
If there is a silver lining in this cloud, it is that safety experts now know a lot more about how patients can keep themselves safe and secure in the health care system. I report their recommendations in my book, "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst."
That question was asked in a New York Times column by Dr. Pauline Chen, and her column prompted a number of thoughtful comments by both doctors and patients. Clear communication is a critical element to good diagnosis, and that puts burdens on both doctors and patients.
Some of the comments on the column which I found most helpful:
I think the most important thing to avoid missed diagnosis is to improve the communication between doctors and their patients. It is especially important to encourage patients to be pro-active and be involved in their care. For example, I give my patients copies of all their test results when they come to visit and encourage them to read them and ask questions if they do not understand specific terms (and they frequently do). I tell all my patients not to assume anything; “If you call to find about test results and no one return your call, do not assume that they are ok. Please call again and make sure that you speak to someone.”
As a cancer specialist in a referring center, many of my patients ask whether they had their cancer for a long time, and whether an early diagnosis was missed. I perfectly understand the concerns. However, it is my experience that patients who are involved in their own health care and are well informed, usually have less chance of having missed diagnosis than those who blindly trust the system and passively participate. Blaming never resolves any problems. It is more tragic if one (patients or doctors) did not learn from their mistakes.
— Anas Younes, M.D.
And this one from a doctor in training:
I appreciate the 2nd half of the article, particularly highlighting the social characteristics of the patients most likely to not follow up with something they should have. However, in contrast to the comments above, I believe that it is always the physician’s responsibility to make sure that he/she and the patient are on the same page. I say this as a physician-in-training, and as a patient as well.
Patients are sick, scared, and, for the most part, worked pretty hard to get through the clinic door. it is the physician’s responsibility to understand the patient’s perspective, and act accordingly. We need to understand their disease as they understand it, even if we don’t agree with it.
All too often, we ignore or fail to appreciate the power differential latent within the patient-physician relationship. If a physician authoritatively tells a patient to schedule a mammogram or colonoscopy, it takes a strong patient to go against that edict. However, when the patient doesn’t follow up in the way we want him/her, it is our fault for failing to understand their position. Within each encounter, we need to strive for a truly shared decision-making model. If we solicit the patient’s thoughts, feelings and concerns about the plan we have for them, they will be on board with the plan, because it’s their plan too.
Granted, this is a tall order, However, it is our responsiblity as physicians to ensure that the patients we see are on board with us. Now certainly there are some patients and some reasons why a person may not follow-up when they say they will, but, from my experiences, a patient chooses not to follow-up when he/she hasn’t been part of the decision-making process.
Patients who want to communicate effectively with their physicians and be joint participants in the care plan should take a look at my system for going to the doctor's office, in Chapter 3 of my book, "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst." The system is "Make a List, Leave a List, Take a List," and it involves putting in writing all our worrisome symptoms before the visit, leaving that list with the doctor, and making sure to take home a list of the action plan. This helps focus both you and the doctor on what is important and helps cut way back on the potential for miscommunication which is the source of so much misdiagnosis and missed opportunities for cure.
A new report from Public Citizen proposes 10 cost-cutting, patient safety measures that would save an estimated 85,000 lives and $35 billion a year. The report, "Back to Basics," analyzed the results of scientific studies of treatment protocols for chronically recurring, avoidable medical errors.
In contrast to the high-tech tests and procedures that many experts blame for staggering increases in the nation’s health care costs, most of the reforms in Public Citizen’s report involve fundamentals as simple as practitioners consistently washing their hands, sufficiently tending to patients to prevent bed sores, and following simple safety checklists to prevent infections and complications stemming from operations.
Many of the proposals on Public Citizen's list are the same that I discuss in my book, "The Life You Save." The only difference is that I believe patients and families can do their own health care reform at home to implement many of these safety measures. I discuss examples of things patient advocates can do at the bedside to help prevent pressure ulcers (bed sores), injuries from falls, blood clots, infections and medication errors. See Chapter 12: "Your Personal Advocate, in the Hospital and Out," and Chapter 13: "The Scandal of Infections in Hospitals and Other Health-Care Facilities, and What You Can Do."
Here is more from Public Citizen's news release announcing their new report.
Aside from the tragedy of needless deaths and injuries, the financial toll of failing to follow accepted safety procedures is astounding. Severe pressure ulcers cost an average of $70,000 apiece to treat. A catheter infection costs $45,000. Each instance of ventilator-associated pneumonia costs $5,800. Collectively, avoidable surgical errors cost an estimated $20 billion a year, bed sores $11 billion and preventable adverse drug reactions $3.5 billion.
"There are many incentives to order expensive tests and procedures and too few rewards for providing basic, sensible care," said David Arkush, director of Public Citizen’s Congress Watch division. "As the largest investor in the nation’s health care system, the federal government should ensure that fulfilling basic patient safety standards is a condition of receiving federal reimbursements. And the government should pay providers for doing the right thing. It will save money in the long run."
Public Citizen proposes that health care providers:
• Use a checklist to reduce avoidable deaths and injuries resulting from surgical procedures (saves $20 billion a year);
• Use best practices to prevent ventilator-associated pneumonia (saves 32,000 lives and $900 million a year);
• Use best practices to prevent pressure ulcers (saves 14,071 lives and $5.5 billion a year);
• Implement safeguards and quality control measures to reduce medication errors (saves 4,620 lives and $2.3 billion a year);
• Use best practices to prevent patient falls in health care facilities (saves $1.5 billion a year);
• Use a checklist to prevent catheter infections (saves 15,680 lives and $1.3 billion a year);
• Modestly improve nurse staffing ratios (saves 5,000 lives and $242 million a year);
• Permit standing orders to increase flu and pneumococcal vaccinations in the elderly (saves 9,250 lives and $545 million a year);
• Use beta-blockers after heart attacks (saves 3,600 lives and $900,000 a year); and
• Increase use of advanced care planning (saves $3.2 billion a year).
Swine flu testing is the latest example of an important issue for informed patients. Patients need to understand that some medical tests are valuable if there is a "positive" finding, but not much good at all if they are "negative." The problem is that the test is "insensitive," which means a negative result can miss the disease that's really there -- a "broken alarm."
For swine flu, in every 100 patients who actually have flu, the various brands of "rapid flu" tests will have a "positive" result (meaning the patient has the flu bug) for as few as ten of the 100 patients, or as many as 69 of the 100 patients. Even with the higher accuracy, that means that a lot of patients are being missed by these "rapid flu" tests. These statistics come from a New York Times article quoting newly published studies and experts in the field including the Centers for Disease Control and Prevention.
A CDC official told the Times:
“We’re saying you need to understand the limitations of these tests,” Dr. Timothy M. Uyeki, an author of the C.D.C. guidance, said in an interview. “The clinician should not base a decision to treat or not treat on the basis of a negative result.”
Another classic example of an "insensitive" test is the "hemoccult" test for hidden blood in the stool. If it's positive, you need further workup. If it's negative, it doesn't give you a clean bill of health for colon cancer. That's why the standard screening test for colon cancer is a colonoscopy, which looks at the entire length of the colon with a video camera.
My book "The Life You Save" has a chapter about understanding medical testing and why you cannot necessarily rely on a negative test result.
The point is: A negative result doesn't mean you have a clean bill of health. Sometimes you have to pay attention to other signs and symptoms.
Whether or not a patient should get an expensive imaging scan or some other elaborate and expensive test is not always clearcut. But what should be clearcut is that doctors should not have a thumb on the scale when they're balancing harms versus benefits. The balancing ought to be focused entirely on what's in the patient's best interest. The news story about what happened when a group of urologists in Iowa ordered a new CT scanner for their office sheds light on this conflict of interest issue.
According to the article by Shankar Vedantam in the Washington Post, the doctors at Urological Associates in Iowa were ordering fewer than one dozen CT scans per month for their insured patients in the months before their office bought its own CT scanning machine. That number jumped to 55 scans per month soon after the doctors got their own machine and started getting direct insurance payments for its use.
Defenders of the doctor-owned machines say it's more convenient for patients not to have to go to some other building for their scan. That's no doubt true -- if the scan is really needed in the first place. The problem is that self-interest colors the doctor's calculation, whether subtly or blatantly.
You might say "so what," but no test is without its downside, and excessive radiation from unnecessary CT scans can ultimately cause cancer in some patients -- as many as one in one hundred cancers are traced to radiation exposure. Not to mention bankrupting our health care system in the meantime.
Congress is considering outlawing the practice of what is called "self-referral," referring the patient to a test on a machine that the doctor owns. At the least, Congress should make it mandatory that doctors disclose any self-interest they have in testing, so that patients can take it into account in deciding whether they want the test.
I discuss doctor conflicts of interest in Chapter 9 of my new book, "The Life You Save." Chapter 9 is called "The Second Opinion: Always Your First Choice." It explains why you the patient need to understand if your doctor may have some ulterior influence on his or her thinking, and how it's always a good idea to get a second opinion before undergoing any major procedure.
Another reason for careful patients to be skeptical about overly hyped prescription drugs came this week with news about the extent to which articles in important medical journals are "ghost-written" by drug manufacturers.
According to an article in the New York Times by Natasha Singer, newly released papers from lawsuits involving Wyeth's hormone replacement drugs Premarin and Prempro show that over several years, Wyeth repeatedly hired ghost writers who placed 26 articles in 18 prestigious medical journals, all promoting the drugs in the guise of objective analysis by medical experts:
The court documents provide a detailed paper trail showing how Wyeth contracted with a medical communications company to outline articles, draft them and then solicit top physicians to sign their names, even though many of the doctors contributed little or no writing. The documents suggest the practice went well beyond the case of Wyeth and hormone therapy, involving numerous drugs from other pharmaceutical companies.
The Times article made an interesting comparison to professional baseball's steroids scandal.
“It’s almost like steroids and baseball,” said Dr. Joseph S. Ross, an assistant professor of geriatrics at Mount Sinai School of Medicine in New York, who has conducted research on ghostwriting. “You don’t know who was using and who wasn’t; you don’t know which articles are tainted and which aren’t.”
Because physicians rely on medical literature, the concern about ghostwriting is that doctors might change their prescribing habits after reading certain articles, unaware they were commissioned by a drug company.
“The filter is missing when the reader does not know that the germ of an article came from the manufacturer,” said James Szaller, a lawyer in Cleveland who has spent four years going through the ghostwriting documents on behalf of hormone therapy plaintiffs.
The same concern about ghostwriting applies to patients who read literature on the Internet. People can be easily misled if they think an article is truly objective.
Some top medical journals like the Journal of the AMA now require authors to fill out detailed forms describing exactly how much input they had into the writing of an article. But many do not have such requirements. Consumer, beware.