Good News, Cancer Rates and Health Care Costs Decreasing

http://www.kaiserhealthnews.org/Daily-Reports/2010/August/30/Medical-Imaging.aspx

AUG 30, 2010

"Part of the explosion in medical imaging over the past two decades may be attributable to overuse, and steps need to be taken to cut back," according to a study in the journal Radiology, MedPage Today/ABC News reports.

"Initiatives include rewriting the fee-for-service system, curbing physician self-referral practices, and creating appropriateness criteria for imaging, according to William R. Hendee of the Medical College of Wisconsin in Milwaukee and colleagues. … Imaging services and their costs have grown at about twice the rate of other technologies in healthcare including lab procedures and pharmaceuticals, Hendee and colleagues wrote." Overuse of imaging "also exposes the public to unnecessary radiation." The authors "called for a national effort to develop evidence-based appropriateness criteria for imaging, so that physicians can make greater use of practice guidelines in requesting and conducting imaging studies" (Fiore, 8/29).

This is part of Kaiser Health News' Daily Report - a summary of health policy coverage from more than 300 news organizations. The full summary of the day's news can be found here and you can sign up for e-mail subscriptions to the Daily Report here. In addition, our staff of reporters and correspondents file original stories each day, which you can find on our home page.

http://www.kaiserhealthnews.org/Stories/2010/August/23/imaging-tests-health-risks-sidebar.aspx?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+khn%2Ffulltext+%28All+Kaiser+Health+News+%28Full+Text%29%29

Several recent studies show the risk of cancer associated with CT scans appears to be greater than previously believed.

Related Content

Health Law Changes Rules For Docs With In-House Imaging Machines

A study published last year in the Archives of Internal Medicine projected that 29,000 future cancers will be directly attributable to the 57 million CT scans performed in the United States in 2007.

Another study last year by the National Council on Radiation Protection and Measurements found medical imaging was responsible for about half the total radiation exposure to the typical U.S. resident, up from just 20 percent in the 1980s. The council was chartered by Congress to recommend ways to limit radiation exposure.

A 2007 study published in The New England Journal of Medicine estimated that 0.4 percent of all cancers in the country may be attributable to the radiation from CT studies. By adjusting this estimate for current CT use, this estimate might now be as high as 2 percent.

"By definition, an unnecessary exam that uses radiation, such as a CT scan, is an unnecessary exposure to radiation and, in self-referring facilities, perhaps an inordinately high radiation dose since many of them are not properly accredited," said John Patti, chairman of the American College of Radiology’s board of chancellors.

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To have something in the journal Radiology that calls for evidence-based guidelines for when to order a CT.......  Leaves me speechless.

This combined with the decreases in screening mammograms will decrease cancer rates noticeably and cut a major source of revenue for hospitals and specialists.   Health care expenditures are going to decrease because of this.   That's not good news for the larger institutions' bottom line.  

So let's summarize:

Less cancer + less expensive health care =  financial hardship for radiologists,  oncologists and hospitals

That's a recipe for disaster,  having the incentives between patients and institutions clash so completely.


Let's see if I find a copy of the journal articles themselves.

Happy Birthday to Me

So way back on May 8th I got this cake in the mail.   My artist friend from Bellingham makes treats and sends them through the mail.  

 



She actually designed her own little business around it on flickr.  











She also takes incredible pictures which end up in the northwest newspapers.





So if you want custom made confectioneries just let Juline know.




http://www.flickr.com/photos/julescakewalk



And her pictures are here http://www.flickr.com/photos/julineb/


But most importantly,   those of you with flickr accounts (and you automatically have one if you have aYahoo mail account)  please favorite this picture of the cake and/or comment on it.


http://www.flickr.com/photos/julineb/4580632440/in/set-72157622526233311/




It's for a good cause.   

Just in time for summer

http://www.cnn.com/2010/TECH/innovation/06/09/technology.prize.window/index.html?hpt=Sbin

A professor who invented low-cost solar cells that may be incorporated into energy-producing windows has been awarded the Millennium Technology Prize.

Overtreatment in the news

http://news.yahoo.com/s/ap/20100607/ap_on_bi_ge/us_med_overtreated

Overtreatment means someone could have fared as well or better with a lesser test or therapy, or maybe even none at all. Avoiding it is less about knowing when to say no, than knowing when to say, "Wait, doc, I need more information!"




It's great this is in the news but again the way overtreatment is framed leaves people without a clear picture of the harms.  They do mention a risk of cancer with excessive CT scans but they refer only to the "limitations" of PSA screening.   They don't mention the harms of screening mammograms at all.  They don't mention the blockbuster (expensive) vaccines gardasil and prevnar which have more evidence of harm than benefit.  


They mention a couple medications which are overprescribed such as Nexium and antibiotics but they again leave the magnitude of harm vague.  


It's interesting to watch the system attempt to retreat slightly and reduce the overtreatment burden slightly with guidelines and payment incentives for physicians to counsel more and test/over treat less.  


Amend and reform,  amend and reform.   


But what if the core of the system is rotten?  


What if the fundamentals of health care incentivize overtreatment?  How are some guidelines going to counteract the massive marketing power of pharmaceutical companies?  


See it's times like these that "lip stick on a pig" would be appropriate but our friend Sarah P ruined that gem for us all.   


Oh well.  


But this article does sample a pretty large chunk of the super-sized american health care experience.  It's a superficial view of the harms from all this over testing, over treating.   It doesn't make the connection between overtreatment and marketing.  It doesn't make the connection between over everything and lack of coverage via high costs.  


It doesn't talk about how overtreatment and over testing are the same things as economic growth in the so called health care industry.  


IF


IF we somehow reverse this trend toward more and more unnecessary/harmful health care,  then what will it do to the economy?  I mean other than the military and other government spending, health care has been one of the few consistent sources of economic growth.   Do we really have a system that punishes society with yet another bursting bubble (dot com followed by housing followed now by health care) because society finally figures out that more is less?


Because as we break this mindless cycle of excessive treatment and testing and reduce the harms that go with it all,  some mighty powerful industries will be forced to shrink and good, hardworking people will be out of a job.   


The stuff about low back pain in the article reminds me of a local phenomenon.   Here in Yakima one of the few highly lucrative health care institutions is the pain clinic.   The pain clinic functions as a kind of deep injection factory.  Nerve blocks,  epidurals,  spinals.  These deep injections often under xray guidance pay very well.  The benefits are almost always short-lived and the potential harms remain vague in most minds but the financial incentives to do more tests and more procedures are painfully evident at the pain clinic.  


And now that the ER has a fancy new MRI scanner,  there's even more opportunity to find common disc abnormalities that can be harvested at the pain clinic.  


But almost all of their business at the pain clinic is discretionary spending.  Most of the patients walking in their doors will either get better on their own and/or not benefit from the procedures preformed.  


It's not that we don't need specialists who can do nerve blocks well.   It's just that the incentive to do more procedures,  advertise and repeat runs counter to the best interests of the average patient in pain.  


Put another way:   If most people with low back pain will get better just as rapidly with certain treatments as without,  then most people are harmed in some fashion by said treatments. 


It's pretty grotesque but almost every popular AKA lucrative treatment and test in medicine is over applied.  It just makes sense,  if you limit interventions to just the people who need them, you are missing out on a larger market.   The goal, financially, of any medical intervention is to apply something studied in a limited population of patients to the general population.  


Like with acid blockers like Nexium.   If it works well in people with ulcers then focus on the symptoms that are most common in the general population and get people used to treating the symptoms.   There are thousands of times more potential customers who have occasional heartburn versus the rare individual with stomach ulcers.  


Interesting times  

Stress

http://www.yesmagazine.org/happiness/want-the-good-life-your-neighbors-need-it-too

....It's not the inferior housing that gives you heart disease, it's the stress, the hopelessness, the anxiety, the depression you feel around that. The psychosocial effects of inequality affect the quality of human relationships. Because we are social beings, it's the social environment and social relationships that are the most important stressors. For individuals, of course, if you're going to lose your home, or if you're terribly in debt, those can be more powerful stressors. But amongst the population as a whole, it looks as if these social factors are the biggest stressors because so many people are exposed to them.




...


If you grow up in an unequal society, your actual experience of human relationships is different. Your idea of human nature changes. If you grow up in a consumerist society, you think of human beings as self-interested. In fact, consumerism is so powerful because we're so highly social. It's not that we actually have an overwhelming desire to accumulate property, it's that we're concerned with how we're seen all the time. So actually, we're misunderstanding consumerism. It's not material self-interest, it's that we're so sensitive. We experience ourselves through each other's eyes—and that's the reason for the labels and the clothes and the cars.




.....

The gift in a sense is a symbol that you and I don't compete for the necessities of life. We don't need to fight each other for them. You feel a sense of indebtedness and you reciprocate the gift, which anthropologists have suggested is a sort of basic social contract. That symbolism is still really important: You invite your friends over, sit around the same table, and share food, the basic necessity of life. The symbolism is also there in religious services and communion—these things are very fundamental, very deep.

Inequality is a reflection of how strong hierarchies are, how much we share or how much we don't. It shows us which part of our potential we're developing. What game do I play? Have I got to fend for myself? Or have I got to get people to trust me and cooperate with me? Is my survival dependent on good relationships? Are you my rival? Are you going to steal from me? Have I got to keep what I've got, defend it? Or can we share? Human beings can do both. We've lived in the most egalitarian and the most awful, hierarchical, tyrannical societies. It's very interesting that we can measure how unequal societies are and how that can elicit more of certain kinds of behavior. 

Blow Back

http://www.yesmagazine.org/issues/water-solutions/real-people-v.-corporate-people-the-fight-is-on

Real People v. Corporate “People”: The Fight Is On

The Supreme Court says corporations can spend as much money as they want on political advertising. Millions of Americans say they've had it.

http://movetoamend.org/learn-more

Hard to add anything to that so I won't.

Jama Article about shenanigans and a loose tangent on a new vaccine

http://jama.ama-assn.org/cgi/content/short/303/20/2058


So of the articles reporting on clinical trials that didn't reach statistical significance 40% contained some "spin".  Spin being a fancy way to say lie.   Distract,  trick, deceive .... Whatever

They say in the comment section of the article (which isn't free online):

Our results are consistent with those of other related studies showing a positive relation between financial ties and favorable conclusions stated in trial reports.   Other studies assessed discrepancies between results and their interpretations in the Conclusions sections.....
The publication process in biomedical research tends to favor statistically significant results and to be responsible for "optimism bias" (ie, unwarranted belief in the efficacy of a new therapy).  Reports of RTCs with statistically significant results for outcomes are published more often and more rapidly than are those of trials with statistically nonsignificant results.  Good evidence exists of selective reporting of statistically significant results for outcomes in published articles.  




So,  not only are clinical trials showing a positive effect from a new med or treatment more likely to be published and published faster than those showing negative effects or lack of benefit but also trials get published spinning a lack of effect into benefit?  

It's not really a surprise then when medications proven to increase suicidal thinking in teens and children get marketed as safe and effective depression treatments.

Of course the same JAMA has an entire section called "from the centers for disease control and prevention".   This issue has basically an Ad for Prevnar 13.    The CDC editorial note points out that "Overall,  rates of IPD have remained stable at 22-25 cases per 100,000 since 2002."

IPD is invasive pneumococcal disease.  It means the bacteria pneumococcus got in the ear fluid, blood, lungs,  spinal fluid.   Prevnar came out in 2000 and wasn't widely available because of production problems for at least 2 years.  If Prevnar made a big impact,  then why didn't the rates drop more?

Oh but the CDC looks at a subgroup for us, children less than 5 years old,  it shows that in 2007 black children had a rate of 35.8 per 100,000 while other races was 30.7 and white children 18.4

Prevnar was famous for how it was going to eliminate the racial disparity of the infectious diseases caused by pneumococcus.

This new vaccine, Prevnar 13,  covers approximately 64% of the serotypes that cause IPD in 2007.  The previous prevnar covered about 80%.   There's no worry about testing the effectiveness of the new vaccine.   They just did some antibody studies and then backpedaled on how they measured success of that when 3 serotype-specific antibodies didn't reach target levels after 3 shots.   After 4 shots one serotype (6) still wasn't reaching the target antibody levels.

Who knows how this will translate to clinical cases of IPD.  MAYBE we will get lucky and drive the rate down further from 22-25 per 100,000.  And maybe we'll get lucky and not cause another serotype like 19A which currently tends to be multidrug resistant and difficult to cure.  And maybe the MRSA spike in children wasn't related to the effects the 1st Prevnar had on the normal nasal flora of children.

I guess we're going to find out as the experiment rolls on.

Unless the 24% uptake of the swine flu shot is any indication of the state of trust in organizations like the CDC.