DC Medical Malpractice & Patient Safety Blog

Most of the recent media conversation about breast cancer prevention has concerned the topic of screening, and whether and when mammography is routinely appropriate.

Last week, the Institute of Medicine (IOM), a National Academy of Science panel that advises government and the public on issues of health and medicine, garnered front-page headlines with its study about risks for breast cancer. In comparison to most media outlets, which took a “Now Hear This!” approach, the New York Times’ coverage seemed … underwhelming.

“An exhaustive new report meant to address public fears about possible links between breast cancer and the environment,” it began, “finds evidence strong enough to make only a few firm recommendations, most already well known and none with a large proven benefit.”

Where some media framed the report’s conclusion as—if not revelatory, at least significant—The Times was measured. After enumerating the factors that appear to contribute to increased risk of the disease, The Gray Lady suggested that people in search of definitive information about exposure to chemicals, pollution, cosmetics and drinking water would be disappointed. The report, the paper said, “is based largely on a review of existing research, and its limited advice reflects the lack of solid scientific information in many areas of concern to the public.”

Subsidized by $1 million from Susan G. Komen for the Cure, an advocacy group dedicated to eradicating breast cancer, the IOM committee’s chairwoman said it could not “identify a bunch of environmental factors” that might contribute to breast cancer.

According to the report, data did indicate that women could reduce their risk by limiting or avoiding:

• unnecessary medical radiation;


• hormone treatments that combine estrogen and progestin;


• alcohol consumption; and


• weight gain (especially for postmenopausal women).

Weaker evidence, according to the report, suggested that not smoking and increasing exercise lowered risk for breast cancer, and there were a “possible associations” between breast cancer and secondhand smoke, nighttime shift work and exposures to the chemicals benzene, ethylene oxide and 1,3-butadiene (component of car exhaust, gasoline fumes and tobacco smoke).

Even weaker evidence, defined as “biological plausibility,” was identified in certain substances including the chemical bisphenol A (BPA), found in some plastic containers, can liners, food packaging and other products.

In terms of radiation, the report called out the overuse of CT scans, which deliver relatively higher doses of radiation. But it did say that mammograms, which deliver smaller doses, are not of concern.

Cancer in general is a hot medical topic because of its intractability, its invasive and side-effect inducing treatments, its many varieties and the massive amounts of dollars devoted to its treatment and eradication. So any news that seems to be maybe groundbreaking often is translated by the media as definitely groundbreaking.

This news isn’t.

The Times describes why. The disease is difficult to study because suspect chemicals cannot ethically be given to people to see if they cause cancer, and studying people who were exposed in the past yields unreliable information about the dose and timing. Animal studies don’t always apply to humans. And people are exposed to various mixtures of chemicals that may interact differently and with effects that may also vary according to an individual’s genetic makeup.

Also, the panel noted that the effects of various environmental exposures differ depending on someone’s age. Breast tissue may be affected differently in the womb, during childhood, adolescence and adulthood and before and after pregnancy. To state definitively that a certain chemical in a certain environment will pose a certain risk to all breast tissue is false and irresponsible.

The IOC panel noted that even if a woman is scrupulous in eliminating the outlined risks, her risk is subject to the usual vagaries of cancer. “The potential risk reductions from any of these actions for any individual woman will vary and may be modest.”

And some of the behaviors to be avoided might be helpful if someone is facing a different disorder or disease. Moderate drinking might help prevent heart disease; if someone forgoes a CT scan, she might deny herself a valuable diagnostic tool.

As always in the face of breathless medical “news” reporting, before you swallow the message, read the whole story.

No healthy man should get the PSA blood test to screen for prostate cancer, says the influential US Preventive Services Task Force in a new, strongly worded recommendation. As readers of this blog know, this recommendation has been a long time coming.

Prostate removal surgery, even in the most skilled hands, has a high rate of causing incontinence and impotence in the patient. So a test that detects early prostate cancer is valuable only if it prevents early death. The problem is the PSA test can't tell the difference between cancers that are so slow-growing they will never kill a man and those that can be deadly. Hence it directs millions of men to biopsies and extensive operations of uncertain value.

We reported in 2009 that two huge studies were published that year that found zero benefit for PSA testing in one American study and only a tiny benefit, but much more harm, in the European study. Seven lives were saved for every 10,000 men tested, but in the same 10,000, forty-eight were harmed by unnecessary surgery.

Last year, also as we reported, the inventor of the PSA test decried its widespread use and said it should be limited to monitoring men who already have had their prostates removed and need a marker of possible return of the disease.

The scourge of cervical cancer -- a leading cancer killer of women in the third world without access to Pap smears and HPV vaccinations -- is being whipped with an unlikely low-tech, low-cost preventive treatment: Ordinary vinegar plus freezing of the cervical warts before they turn cancerous.

The vinegar is brushed on the cervix by a nurse and any areas of abnormality turn white. It's not perfectly accurate -- sometimes spots turn white and they are totally benign. But the treatment of the white spots is low-pain and cheap -- and highly effective: freezing of the white spots with a metal rod dipped in liquid carbon dioxide (available from the nearest Coca Cola plant).

Read more about this public health innovation that was co-invented by American and Indian doctors, and spread in Thailand, in this New York Times article.

Last November, the FDA ruled that tobacco manufacturers must include on their packaging graphic depictions of the horrors smoking can wreak. The new packaging was to take effect in autumn 2012.

Five tobacco companies now have taken the FDA to federal court, challenging the regulations. Among other things, they claim that the depictions:

• would unfairly dissuade adults from using a legal product;


• would cost millions;


• violate the First Amendment;


• “do not further any compelling governmental purpose”; and


• “would have few if any benefits.”

In case you're feeling the slightest twinge of sympathy for the tobacco makers, here's what Dr. Howard K. Koh, writing in the New England Journal of Medicine, says.

“A decade of experience in more than 30 other countries has demonstrated that such graphic warnings lead to an array of public health benefits. The warnings are more likely to be noticed than text-only labels, are viewed as more effective in communicating health risks to smokers and are associated with increased motivation on the part of smokers to quit smoking.”

Dr. Koh is assistant secretary for health in the U.S. Department of Health and Human Services. So he's defending his own decision. But knowing what we know about how tobacco poisons work throughout the human body, is this even a close question?

To see a slide show of the text and images for the new packaging, click here.

And if you want to harken back to the olden days before we had any warnings on cigarette packs, and when the manufacturers liked to use doctors to promote their smoky poisons, check out this tour through nostalgia.

The news that health insurers will be required to cover contraception and related counseling, courtesy of the Affordable Care Act (ACA) passed last year, received a lot of media attention and political blowback.

Because some people find that provision of preventive care for women objectionable, it overshadowed other elements of the new guidelines, which pertain to insurance policies whose plan years begin on or after Aug. 1, 2012. Such policies are referred to as “nongrandfathered” because they represent only new plans; a health plan in effect now cannot be “grandfathered” into this coverage, although some might include it anyway.

As defined by the U.S. Department of Health and Human Services, the mission of the ACA is to promote prevention of health problems in the hope of reducing the need to treat them. It also aims to make care affordable and accessible for everybody by requiring health plans to cover preventive services and eliminating cost sharing.

Although “preventive services” covers a lot of territory that can include marginally appropriate, cost-inflating measures, those required by HHS demonstrate strong scientific evidence of their health benefits, per research conducted by the Institute of Medicine (IOM). Not only must plans cover them, they may not charge a copayment, coinsurance or deductible if the services are delivered by a network provider.

In addition to the birth control measures, from which plans are exempt for certain religious employers, the following preventive services for women are mandatory and must be provided by insurers without cost sharing to policyholders for policies beginning on or after Aug. 1, 2012:

• well-woman visits;


• screening for gestational high blood sugar;


• human papilloma virus (HPV) DNA testing for women 30 and older;


• sexually transmitted disease counseling;


• human immunodeficiency virus (HIV) screening and counseling;


• breastfeeding support, supplies and counseling; and


• family violence screening and counseling.

If your health insurance plan or insurance policy began on or after Sept. 23, 2010, it is also subject to mandatory preventive services for which you are not supposed to be charged a copayment or coinsurance, or for which you must meet your deductible if services are delivered by a network provider. To find out what’s on the list, link here.

Blogger Jim Edwards has a list of "10 Weird Health Theories That Just Won't Go Away."

Many of them flower from the backlash to the medical industrial complex's desire to medicalize, and provide a pill for, all slightly different human behaviors. Others underscore how appropriate skepticism about modern medicine can lead to an over-correction and an endorsement of wrongheaded and dangerous ideas (autism being caused by vaccines as a prominent example).

Here's the list of myths:

• "The so-called obesity epidemic is just a scare tactic to make you feel bad"

• "Human growth hormone is the fountain of youth"

• "Women who don't like sex have female sexual dysfunction"

• "Low-dose naltrexone cures everything"

• "Multiple sclerosis is caused by blocked jugular veins"

• "Taking multivitamins can prevent prostate cancer"

• "High cholesterol is not a health risk" [Note from Malone: This one is complicated.]

• "The feds want to microchip you like a pet cat"

• "HIV is not the cause of AIDS"

• "Vaccines cause autism"

Ever since the U.S. Preventive Services Task Force suggested relaxing the rigid schedule for mammography testing in 2009, patients seeking a unified, authoritative voice on the topic have been rewarded with confusion. Probably because the medical community, too, is unresolved about who needs what kind of breast screening and when.

A study published this week in the Annals of Internal Medicine, is the latest participant in the discussion. It articulates as well as any previous research the notion that mammograms are situationally useful, and promotes the idea that such testing should be customized to each patient.

For women with a normal genetic profile, the timing and frequency of a mammogram, the researchers say, depend on the patient's:

• breast density;


• age;


• family history; and


• personal preference.

Age, history and, to a lesser degree, density, are not new factors in the tricky equation of when to have a mammogram, but personal preference? Since when does science ever acknowledge, much less respect, that what's preferable might also be good medicine?

Although the study researchers made clear that, apart from genetic mutation, breast density is the single-most important consideration in determining the suitability of relatively frequent screening, mammograms often result in false positives -- the suspicion that you have cancer when you really don't. That feeds a cycle of anxiety, unnecessary exposure to radiation, expensive follow-up procedures including surgery and physical discomfort. The artful conclusion here is that such a tangle of concern can undermine the utility of the procedure.

Because dense breasts (more muscle tissue, less fat) are the strongest risk factor for cancer, women with that anatomical profile should have mammograms more frequently. But after an initial screening at age 40 to establish a baseline reading and determine breast density, women lacking other risk factors--such as the two genetic mutations known to increase cancer risk--who aren't comfortable with such frequency, might be acceptably excused from it.

The American Cancer Society and the Task Force would disagree. The former recommends
that women screen initially at 40, and repeat the procedure every year or two thereafter. The latter recommended that women begin screening sometime between 40 and 49, depending on risk factors, and every two years after 50.

As usual, the best guidance for women seeking clarity is to establish and maintain an open line of communication with their physicians that results in a mutual decision about their treatment.

Medical mistakes account for between 18 and 45 cents of every health care dollar spent in the U.S., and a medical error or adverse effect occurs in one out of every three hospital admissions, researchers say.

According to studies published in the journal Health Affairs, the single most expensive cause of harm is infection after surgery, with more than 252,000 infections costing $3.36 billion reported in 2008, while pressure ulcers (bedsores) are the most common preventable event, with with nearly 375,000 cases in 2008 costing $3.27 billion.

Following a shocking 1999 report that showed that as many as 98,000 people die annually due to medical mistakes, hospitals have tried to reduce such adverse effects, but serious mistakes persist. In 2006, for instance, medical mistakes contributed to as many as 187,135 deaths and 6.1 million injuries that cost between $393 billion and $958 billion.

“There are some examples of excellence; we have many [intensive-care units] that have eradicated central line infections. But surrounding those examples of excellence we have serious adverse events going on,” said Dr. Mark Chassin, president of the Joint Commission, a nonprofit organization that accredits health care programs. “Every week in the United States, up to 40 patients undergo a procedure meant for somebody else or the wrong body part,” he said.

The costliest medical errors were:

1. Infections after surgery (252,695 in 2008, cost $3.36 billion)

2. Pressure ulcers - Bedsores (374,964 in 2008, cost $3.27 billion)

3. Complications from noncardiac implants and grafts (60,380, cost $1.07 billion)

4. Complications from lower back surgery (113,823, cost $1 billion)

5. Excessive bleeding complicating a procedure (78,216, cost $680 million)

Source: National Journal

You’ll find more information about the Health Affairs studies here.

A new Texas law that mandates insurance coverage for coronary artery calcium scanning and carotid artery ultrasound was “premature” and will have major ramifications for public health, a noted Texas cardiologist says.

In a commentary published in the Archives of Internal Medicine, Dr. Amit Khera, a cardiologist at the University of Texas Southwestern Medical Center in Dallas, says that although some of these tests may be right for some patients, mandating their use via legislation goes far beyond what the evidence to date supports.

"I'm not against this technology – I use it myself," Khera says. "But when you go from an individual doctor and a patient making a decision about a test to a statement like 'we should apply this to an entire population, and the evidence is so strong that we need a law,' I think then you need a much higher level of evidence and a more detailed look at all the ramifications."

Neither screening test has been proven in adequately powered trials to lead to diagnoses or preventive measures that translate into reduced adverse cardiovascular events. There is also no real consensus as to which patients might benefit from screening, what level of baseline risk would warrant further screening or what steps should be taken as a result of any given finding.

In terms of calcium screenings alone, Khera calculates that approximately 285,000 individuals in Texas who would be eligible for insurance coverage of screening based on criteria set out in the bill would be found to have calcium scores over 400, and many of these people would already have another indication for taking statin therapy. And, he notes, a one-time screen could be expected to result in 190 new cancers and find 190,000 incidental findings of "minimal consequence" that would inevitably be followed with further, possibly unnecessary tests.

In an editorial note accompanying Dr. Khera’s commentary, Archives editor Dr Rita Redberg commented that “at a time when states are facing crises in health insurance spending and cutting lifesaving treatments, and when Texas leads the nation in the percentage of residents without health insurance, it is remarkable that Texas has chosen this path."

A new bill modeled on the Texas legislation is also set for consideration in Florida.

Source: TheHeart.org

You can read an extract of Dr. Khera's original commentary in the Archives of Internal Medicine here.

The number of bloodstream infections in intensive care units (ICUs) caused by tubes inserted into major blood vessels decreased significantly between 2001 to 2009, but unacceptably high rates of infection are still occurring for patients in other hospital units and for dialysis patients, government researchers say.

Central lines are tubes that are usually placed in the large veins of the neck or chest to deliver medicines and nutrition. Infections of these lines, which are largely preventable, can become serious problems, with death rates of 12-25%.

An estimated 18,000 ICU central-line infections were recorded in 2009, down from 43,000 in 2001, according to a report by the Centers for Disease Control and Prevention (CDC). This 58% decrease means that in 2009, between 3,000 and 6,000 deaths were prevented and as much as $414 million saved. And if the decrease in these ICU infections was steady from 2001 to 2009, as many as 27,000 lives and as much as $1.8 billion may have been saved.

(Note: These numbers are rough estimates. The 2001 figure of 43,000 infections could have been as low as 27,000 and as high as 67,000.)

According to the CDC, much of the decrease resulted from campaigns to improve techniques for managing the lines in ICUs, where they are most frequently used. Infections involving bacteria such as staphylococcus can be avoided with simple measures like washing hands, wearing sterile gowns and drapes, and following the proper techniques for inserting and maintaining the lines.

However, researchers noted that central line infections still occurred far too often, affecting 80,000 patients a year and killing at least 10,000. In addition, of the 350,000 patients who received dialysis in the U.S. in 2008, about 37,000 suffered central-line infections. Such infections are the second leading cause of hospital stays and death in people on dialysis after cardiovascular problems.

Peter Pronovost, MD of Johns Hopkins Hospital, a pioneer in patient safety, developed the simple "checklist" for using central lines in ICU patients, which was proven in a landmark study in the New England Journal of Medicine to cut the infection risk to close to zero.

Source: The New York Times

You can read an abstract of the study here.

One thing you won't see mentioned much in the new U.S. Dietary Guidelines: red meat.

Nutrition experts know that to fight back against our national epidemic of obesity, it's important that we eat red meat only sparingly. But the guidelines, a product of the U.S. Department of Health and Human Services and the U.S. Department of Agriculture, show the heavy hand of the food industry in what they say, and more importantly, what they leave out.

That's the criticism from the Harvard School of Public Health, which has a new article on the subject in its latest newsletter.

Other criticisms of the dietary guidelines from the Harvard folks:

* Too lax on refined grains -- white bread, white pasta, white rice.

* Too much dairy.

* Too little Vitamin D. Most Americans need 1,000 milligrams a day, which is hard to get from food alone.

* Too easy on sodium. Most Americans should only consume 1,500 milligrams -- a teaspoon and a half -- per day, but the guidelines allow 2,300 milligrams for everyone but "high risk" groups.

You can read the full dietary guidelines here, and the Harvard critique here.

Go here to see the Healthy Eating Pyramid, Harvard's alternative advice on good diet.

An excerpt of the key advice from the Harvard School of Public Health:

Go with plants. Eating a plant-based diet is healthiest. Choose plenty of vegetables, fruits, whole grains, and healthy fats, like olive and canola oil.

Cut way back on American staples. Red meat and processed meat, refined grains, potatoes, sugary drinks, and salty snacks are part of American culture, but they’re also really unhealthy. Go for a plant-based diet rich in non-starchy vegetables, fruits, and whole grains. And if you eat meat, fish and poultry are the best choices.

Article first published as New Dietary Guidelines May Be Overly Influenced by Agribusiness on Technorati.

One of the main arguments made by proponents of malpractice reform is that physicians would order fewer medical tests if patients could receive only a limited amount of money in a potential lawsuit. But that assumption may not be true, according to a recent study published in the journal Health Affairs. In that study, researchers from the University of Iowa found that not only does reducing malpractice costs not make physicians less concerned about being sued, it also doesn't necessarily result in them ordering fewer tests.

The study evaluated physicians’ perceptions about malpractice claims in states where more objective indicators of malpractice risk, such as malpractice premiums, varied considerably. It found high levels of malpractice concern among both generalists and specialists in states where objective measures of malpractice risk were low. The study also found relatively modest differences in physicians’ concerns across states with and without common tort reforms. These results suggest that many policies aimed at controlling malpractice costs may have a limited effect on physicians’ malpractice concerns.

Proponents of malpractice reform, including lawmakers, assume that physicians order unnecessary tests because they fear being sued, and this so-called "defensive medicine" is one of the main factors driving up health care spending.

However, opponents of malpractice reform argue that although some physicians request unneeded tests to avoid potential lawsuits, in many cases, physicians order tests because they're trying to do a thorough job with patients, while others order tests to exploit the “fee-for-service” system, which allows physicians to bill more when they perform more services or provide more care.

Source: Des Moines Register editorial

You can read the abstract of the University of Iowa study here.

The news this week from the Centers for Disease Control and Prevention that as many as 48 million U.S. adults have high levels of bad cholesterol, and aren’t doing enough to control it, left out one conspicuous controversy: Should lots more Americans be taking statin drugs, or would it be a huge waste of money?

Statins like Crestor and Lipitor lower cholesterol in the blood by decreasing cholesterol synthesis in the liver. Since plaques in coronary arteries are mostly composed of cholesterol, lowering cholesterol cuts the rate of formation of plaque, and in some cases, even shrinks it.

For people with diagnosed heart disease, statins are mainstream, non-controversial medical treatment. But for patients who just have high cholesterol, but no known heart disease yet, the drugs have modest if any benefit. And this is the group that is the main target of drug manufacturers for expanding sales of statins.

A cautionary statement about the questionable role of statin drugs in "primary prevention" of heart disease was recently released by the British-based Cochrane Collaboration, which conducts rigorous reviews of medical studies to see how the evidence measures up.

The authors of the new Cochrane review criticized much of the studies sponsored by drug manufacturers for leaving out key data. They concluded:

Only limited evidence showed that primary prevention with statins may be cost effective and improve patient quality of life. Caution should be taken in prescribing statins for primary prevention among people at low cardiovascular risk.

Doctors who are slow to turn healthy people into medical patients are careful about whom they prescribe statins for. For example, Dr. Robert Lemmon, a South Carolina family practice doctor and medical blogger, wrote an analysis of the published studies and concluded that statins were "overrated" and did not much help people who don't have heart disease. Noting that other cautious reviewers had reached the same conclusion, even though it cuts against drug manufacturer hype, he wrote: "This post is blasphemy. Fortunately I am in good company."

The CDC report also talks about improving diet and exercise habits as strategies to cut cholesterol. That can work in individuals very well, but as a public health strategy, education campaigns also fall short in making any notable impact. That's why public health advocates reach for systemic changes that would expose people to less temptation by strategies such as bans on use of certain bad fats in restaurants and fast food manufacturers. A provocative article on this topic was published in PLoS Medicine.

Article first published as Government Reports Millions of Americans Have Untreated High Cholesterol — But What Treatment Works? on Technorati.

Today's news has two reminders of why statisticians are our friends and allies when it comes to getting the right health care and avoiding dangerous and over-hyped treatments.

The headlines:

* Hormone replacement therapy after menopause not only increases the risk of getting breast cancer, but also makes the cancer more deadly. Details here.

* Taking a daily fish oil supplement in pregnancy doesn't make babies any smarter. Details here.

The arc of both stories is similar, and that's no coincidence.

Act One: Medical scientists develop a new treatment that, based on then current knowledge, should work.

In hormone therapy, the idea was that estrogen protected women from heart and blood vessel disease. This was based on a statistical notion -- since proven false -- that there was a big jump in heart attacks and similar disease after menopause, which must mean (so it was thought) that the drying up of estrogen in the body with menopause was depriving the body of a natural protectant.

In fish oil, the idea came from observations that DHA, a key fish oil ingredient, is naturally transmitted to a fetus in the last half of pregnancy and is important to brain development. And premature babies, born with low supplies of DHA, did better in some studies if they received DHA supplements in the first few months of life.

Act Two: Hopeful "observational" studies are published. These involve dozens to hundreds of patients and have very favorable results for the treatment in question.

Act Three: Manufacturers make big bucks pumping the treatment in question.

Act Four: Medical scientists do the hard work of large-scale studies where patients are "randomized" to the real treatment versus a dummy (placebo) treatment.

This takes years of carefully following patients and comparing outcomes.

Act Five: Enter the statisticians.

They come in, crunch the numbers and discover: It doesn't work (see today's fish oil study) or worse, it causes a lot of harm too (today's hormone story).

What's the lesson for the rest of us? As I wrote a few days ago on this blog, it pays to be skeptical of medical research findings, particularly when hyped by commercial interests.

Most people hear about research in the Act One, Two or Three stages.

If you wait till the story plays out in Acts Four and Five, you'll be less disillusioned, and safer and wiser too.

It was nearly a year ago that the U.S. Preventive Services Task Force caused a huge uproar with the mildest imaginable recommendation about mammograms, and now two physician researchers say it might be time to point out that certain emperors are wearing no clothes.

In their Sounding Board article in the New England Journal of Medicine, Drs. Kerianne Quanstrum and Rodney Hayward note that some of the harshest cries against the Preventive Services Task Force came from those doctors with the highest vested self-interest in maintaining the importance of mammograms: radiologists with the Society for Breast Imaging. Yet nobody seemed to notice the obvious conflict of interest.

As the authors note:

When a given service is successfully extended to more people with more intensity, the profession providing that service tends to grow in importance and profitability. In the United States, where medical specialists often enjoy an exalted status in the minds of the public, if experts shout loudly that every woman 40 years of age or older must be screened annually for breast cancer, then breast cancer must be important, screening must be a basic human right, and doctors who provide this service must have great value and authority.

But what if those experts are basing their recommendations on more than the interest of patients alone? In any other industry, we accept the idea as natural that those providing a service or product hold their own and their shareholders' interests as a primary objective. Why have we failed to acknowledge that the same phenomenon occurs in health care? Although it is true that individual medical providers care deeply about their patients, the guild of health care professionals — including their specialty societies — has a primary responsibility to promote its members' interests. Now, self-interest is not in itself a bad thing; indeed, it is a force for productivity and efficiency in a well-functioning market. But it is a fool's dream to expect the guild of any service industry to harness its self-interest and to act according to beneficence alone — to compete on true value when the opportunity to inflate perceived value is readily available.

The objective facts, as Quanstrum and Hayward point out, are that the well known economics law of diminishing marginal returns applies in health care as much as anywhere. In mammograms, as the rareness of the tested condition increases, the hidden costs of the test goes up and the value goes down.

So for women between ages 60 and 69, you can save one life by subjecting only 400 women to mammogram screening (in the process of 5,000 screening visits and 400 false alarms in the same group over 13 years of follow-up). That's enough of a benefit to encourage everybody in the age group to get annual screening.

But in women between ages 40 and 49, the data show that to save a single life, you need to subject 1,900 women to screening and endure 20,000 screening exams with 2,000 false alarm tests during eleven years of follow-up. That puts the risk-benefit equation in more of a gray area where you cannot say definitely that no one should have it, or that no one should not have the screening.

And that was exactly the point of the Preventive Services' recommendation: To put the issue into the hands of individual doctors and patients and let them decide if family history or individual anxiety are enough to make the patient want to have the test. That's not a cop-out, it's a prudent bow to individual self-determination.

Here's another quote from Drs. Quanstrum and Hayward:

We must acknowledge that just as in any other profession or industry, self-interest is unavoidably at work in health care. Rather than even acknowledging practice guidelines offered by vested experts, we ought to borrow from the wisdom of sound governance and implement a system of checks and balances when it comes to the interpretation and application of medical evidence. At the same time, we need to recognize that these two tasks are distinct. Although the interpretation of medical evidence is (or ought to be) a scientific exercise, the application of that evidence, as in guideline formation, is ultimately a social exercise.

Decisions regarding practice guidelines can, and certainly should, be informed by evidence. But they will always require value judgments regarding how much evidence is sufficient to dictate care, for example, or whether and to what degree costs should be considered. By separating the processes of evidence review and guideline formation, fair disagreements about the quality or substance of the evidence can occur separately from, and before, disagreements about the implications for clinical care.

The use of rapid response teams could be masking underlying patient care problems in hospitals, according to a patient safety expert writing in the Journal of the American Medical Association.

Rapid Response Teams (RRTs) are teams of doctors and nurses assigned to provide rapid bedside care for patients who are in critical condition.

The co-author of the article, Peter Pronovost, MD, PhD, a professor of anesthesiology and critical care medicine at Johns Hopkins University School of Medicine, says hospitals should focus more on why patients are deteriorating in the first place, instead of waiting until they crash.

Pronovost argues that the use of rapid response teams illustrates that the way hospitals manage patient flow can have an impact on patient health. For example, overcrowding can lead hospital managers to move patients who still need intensive care out of the ICU to free beds for even sicker patients. When patients are moved out of the ICU, they fail to receive the care they need, leading their conditions to deteriorate, and sometimes to a crash, at which point, a rapid response team takes over.

The main problem, however, isn’t lack of beds but rather how hospitals manage patient flow. For instance, many hospitals schedule all their surgeries during the beginning of the day and week; therefore, the ICU becomes overcrowded in the middle of the day and the middle of the week.

Pronovost worries that hospitals are using RRTs as a crutch. Instead, he says, hospitals need to better manage these conditions so as to prevent patients from worsening so that they don’t need to appeal to the use of rapid response teams, which, he says, only look good because patients are allowed to get so bad.

Source: RT Magazine online

You can read the original article in JAMA here (registration required)
J

When a 44-year-old male friend dropped dead the other day from a massive heart attack -- no prior symptoms, no warning of any kind -- I wondered if modern medicine could have done anything to prevent the tragedy. The answer I learned is that low-tech still beats high-tech hands down in preventing America's No. 1 killer.

Low-tech means getting regular exercise, eating right and paying attention to cholesterol, blood pressure and the other risk factors for heart disease, and it also means moving fast to get to a medical facility with any symptoms whatsoever that might be signaling heart attack. Those are the proven ways to lengthen your life span and avoid early death.

But my friend didn't have any symptoms or risk factors. What could he have done? That's where high tech comes in, but the answers are not encouraging. The available treatments are expensive and not very effective for people without symptoms.

He could have had the gold-standard test for narrowed arteries in the heart: an angiogram. That's an X-ray movie of the arteries that involves putting a tube into the groin, threading it up to the surface of the heart, and squirting dye through the tube to outline the inside of the blood vessels as high-speed multiple X-rays are taken. I've watched these movies for some of my medical malpractice lawsuits, and they are eerily fascinating: the dye looks like smoke as it pushes out of the tube and mingles with the blood in the arteries, which suddenly light up as if a switch has been turned on, with the heart quivering all the while behind the arteries.

The problem is that most of the time, angiograms on people without chest pain symptoms show nothing. Even when there are some symptoms, the angiogram is just as likely to turn up clean as a whistle, or with only minor narrowing, as it is to show serious disease.

A new study in the New England Journal of Medicine of 400,000 patients found that the odds of finding operation-worthy heart disease in patients getting a first-time angiogram without any known heart disease was only four in ten -- which means that the $2,500 procedure was wasted on six of every ten patients.

Now, you might think that the angiogram can still be worthwhile if it shows some blockages that can be cleaned out. But that's true ONLY IF those blockages are causing symptoms. The usual technique to unblock arteries -- with a balloon and a wire scaffolding (stent) to hold open the artery -- has been shown to work to relieve symptoms of chest pain, but it does NOT extend life in symptom-free patients. In those patients, it's thought that the heart has already learned how to deal with the blockage by shifting blood from another supply.

Here is a very good article from Harvard Medical School on who should get the balloon treatment -- called angioplasty -- and who shouldn't.

The bottom line: Angioplasty can save your life during a heart attack if it can be done fast enough to open the artery before permanent damage is caused to the heart muscle. But for symptom-free patients, angioplasty is worthless and exposes patients to the risk of dying from a complication of having wires and tubes poked into your heart. And for patients with non-debilitating chest pain, angioplasty doesn't work any better than taking drugs and making lifestyle changes.

People who get chest pain and learn they have heart disease should think of the pain as a gift from on high: It's given them a chance for a new lease on life. But for people like my friend whose first symptom is a fatal heart attack, there's not much that medicine can do. We're all fated to die at some time, and we haven't learned how to defeat fate. We can and should pay close heed to getting plenty of exercise, eating right and doing other things to lower our risk. But the risk will always be there.

More and more women with cancer in one breast are now opting to have the other healthy breast removed as well, even though the statistics show survival odds don't improve by having both breasts removed and most patients end up with chests that are numb to sensation.

Peace of mind is cited by many of these cancer patients for their decision.

A new report by Tara Parker-Pope in the New York Times details this trend, and the Times' "Well" blog has a number of interesting comments from women and cancer experts.

As many as three in ten breast cancer surgeries in large urban cancer centers are for preventive removal of the healthy breast, the Times reported.

But what is prevented, exactly?

The only women who get a very slight survival bump from having their healthy breast removed are patients under age 50 who have estrogen-negative cancers that don't respond to drugs like Tamoxifen. For everyone else, there is no real advantage in having the second breast removed. When the second breast gets cancer, as happens sometimes, that is not "spread" from the original cancer but is a new, unrelated cancer.

The real risk that women face from the original cancer is that it has already spread beyond the breast, but removal of the second breast doesn't help that risk.

The most striking evidence of how afraid of cancer women are is with DCIS: ductal carcinoma in situ, which is not even considered true cancer by many experts because it either disappears or never progresses in two-thirds of women. Yet still many women with DCIS are electing to have not just the one breast removed, but both.

Ultimately, this is an intensely personal decision. But it helps to get the true facts first.

The man who discovered the PSA test for prostate cancer now says the test is so overused it has become a public health disaster with an annual price tag of $3 billion in wasted testing.

Dr. Richard Ablin writes an op-ed piece in the New York Times calling for the test to be abandoned for routine cancer screening for men over age 50. At most the test is useful in men with a family history of prostate cancer and also useful to detect cancer coming back in men who have already has their prostates removed for cancer.

Dr. Ablin notes that the appropriate use of the test is a tiny portion of the amount of testing now occurring, driven by those who profit from use of the test. He concludes:

I never dreamed that my discovery four decades ago would lead to such a profit-driven public health disaster. The medical community must confront reality and stop the inappropriate use of P.S.A. screening. Doing so would save billions of dollars and rescue millions of men from unnecessary, debilitating treatments.

As this blog noted in an entry a year ago, large studies have been published showing that the PSA test saves very few, if any lives, when used for routine screening, and it causes many men to undergo unnecessary, painful and potentially harmful biopsies and surgery.

Deaths from preventable medical error kill as many people in the nation's capital as guns, and far more than motor vehicle crashes, according to a new report from the D.C. Department of Health.

The report, the first of its kind in the District of Columbia, analyzed the 5,168 total deaths reported to health officials in 2007. It determined that fully half of the deaths could have been prevented. Among the leading causes of preventable death:

1. Tobacco: 860 deaths
2. Poor diet and physical inactivity: 780 deaths
3. Infections (not counting HIV): 240
4. Alcohol abuse: 150
5. Firearms: 140
6. Medical errors: 140
7. Poisons (and pollution): 110 deaths

DC Motor vehicle deaths were a distant 10th place on the list of leading preventable causes of death, with 30 deaths in 2007, according to the Health Department.

Another interesting number: The Department estimates that as many people died from lack of health insurance -- which discourages access to medical care -- as motor vehicles -- 30 people in 2007.

The estimate of deaths from lack of health insurance is based on the number of uninsured people in D.C. and uses methodology from a report by the Kaiser Family Foundation. The estimate of deaths from medical error was made by applying D.C. population numbers to estimates that were made in 2000 by the Institute of Medicine, part of the National Academy of Sciences.

Memorize the name of this antiseptic wash and make sure your hospital uses it: chlorhexidine.

Research continues to pile up that diligent but inexpensive efforts by hospital staff can greatly cut the annual toll of an estimated 100,000 lives lost to hospital infections. The latest simple step involves greater use of the antiseptic chlorhexidine to wash patients before surgery.

In two studies reported in the New England Journal of Medicine, post-surgical infections were cut dramatically when either of two steps were taken:

* Disinfect the patient's skin just before surgery with a chlorhexidine-alcohol rub -- instead of the usual iodine prep.

* Have the patient shower for several days before surgery with a chlorhexidine-based soap, like Hibiclens.

Read more on this antiseptic at Wikipedia.

See Pam Belluck's article in the New York Times for more details on the new studies.

My book, "The Life You Save," lists simple ways patients can help reduce their risk of getting infections in the hospital, including chlorhexidine soap. So the latest studies are only confirming the wisdom of this advice. But because many hospitals don't yet do this, you should ask questions and make sure they have plenty of chlorhexidine on board.

"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.