Richard Knox, NPR News, Author at �鶹Ů�� Health News

Doctor Groups Unite Against Unnecessary Tests & Procedures

Richard Knox, NPR News — Thu, 21 Feb 2013 16:33:39 +0000

This story comes from our partner

‘s Shots blog.

Doctors do stuff — tests, procedures, drug regimens and operations. It’s what they’re trained to do, what they’re paid to do and often what they fear not doing.

So it’s pretty significant that a ��is issuing an expanding list of don’ts for physicians.

Don’t induce labor or perform a cesarean section for a baby who’s less than full-term unless there’s a valid medical reason, say the American College of Obstetrics and Gynecology and the American Academy of Family Physicians. (It can increase the risk of learning disabilities and respiratory problems.)

Don’t automatically do a CT scan on a child with a minor head injury, warns the American Academy of Pediatrics. (Currently half of all such children get them, when simple observation is just as good and spares radiation risk.)

Don’t try to normalize blood sugar in most diabetic patients over 65, exhorts the American Geriatrics Society. (It can lead to higher mortality rates.)

And on and on. The latest that are often unnecessary and potentially harmful, compiled by 17 specialty groups representing more than 350,000 doctors.

The list is the second chapter in a campaign called Choosing Wisely sponsored by the Foundation of the American Board of Internal Medicine. Last year the foundation that often do patients no good. That list was endorsed by nine medical specialty organizations.

The new don’ts bring the total to 135.

The idea is to curb unnecessary, wasteful and often harmful care, its sponsors say — not to ration care. As one foundation official , rationing is denial of care that patients need, while the Choosing Wisely campaign aims to reduce care that has no value.

The campaign aims to foster the notion, among patients as well as doctors, “that when it comes to health care, more is not necessarily better,” Dr. ��of the ABIM Foundation says in a statement abut the latest list, to be officially unveiled at a Washington media event Thursday.

The sponsors promise even more lists of don’ts later this year from a dozen more specialty groups, ranging from the American College of Surgeons to the American Headache Society.

Here are some other notable tests, traditions and procedures to skip:

Don’t use feeding tubes in patients��with advanced dementia. Simply assisting such patients to take food by mouth is better.

Don’t perform EEGs��(electroencephalography) on patients with recurrent headaches. It doesn’t improve diagnosis or outcomes and simply increases costs.

Don’t perform routine annual Pap tests��in women between 30 and 65. Every three years is enough.

Don’t hold back on providing hospice care��to relieve pain and distress just because a seriously ill patient is getting treatment aimed at alleviating disease.

Don’t leave an implantable defibrillator turned on��if a patient with incurable disease, or his family decision-makers, have elected to forego resuscitation. Currently there are no formal policies on this issue, and implantable defibrillators often fire in the weeks preceding death, causing pain and distress to dying patients and their families.

Don’t use cough and cold medicines in children under four��suffering from respiratory illness. They offer little benefit, can have serious side effects and risk accidental overdose.

Don’t do repeat bone scans for osteoporosis��more often than every two years. Healthy women over 67 with normal bone mass can go up to 10 years without a repeat bone scan.

Don’t prescribe benzodiazepines, such as Valium, or sedatives and sleep aids to older adults with insomnia, agitation or delirium. They can more than double the risk of motor vehicle accidents, falls, hip fractures and death.

Don’t screen patients routinely for vitamin D deficiency.��Over the counter supplements without laboratory testing is sufficient for most otherwise healthy patients.

Don’t screen for cancer in healthy individuals using CT or PET��scans. The likelihood of finding cancer is around 1 percent, and the scans are likely to ��leading to more tests, biopsies or needless surgery.

�鶹Ů�� Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at �鶹Ů��—an independent source of health policy research, polling, and journalism. Learn more about .

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Study Questions Benefits Of Many Double Mastectomies

Richard Knox, NPR News — Wed, 28 Nov 2012 18:35:20 +0000

This story comes from our partner��

‘s Shots blog.

It’s a startling trend: Many women with cancer in one breast are choosing to have their healthy breast removed, too.

But a��being presented later this week says more than three-quarters of women who opt for double mastectomies are not getting any benefit because their risk of cancer developing in the healthy breast is no greater than in women without cancer.

“People want absolute certainty,” breast surgeon��of Memorial Sloan-Kettering Cancer Center tells Shots. “Unfortunately, even having a double mastectomy doesn’t provide certainty that breast cancer will not recur. So it’s a false sense of security.”

Morrow is a co-author of a paper that will be presented at the American Society of Clinical Oncology’s Quality Care Symposium in San Diego.

Another co-author,��, of the University of Michigan, says double mastectomy “does not make sense” for about three-quarters of the women who are choosing the operation “because having a non-affected breast removed will not reduce the risk of recurrence in the affected breast.”

The researchers looked at nearly 1,500 women who had been treated for early-stage breast cancer. Of those who chose��instead of��, nearly 20 percent opted to have both breasts removed.

But of those who chose double mastectomy, three-quarters had no medical justification, Hawley tells NPR’s Shots blog.

In fact, many women had a diagnosis of��, considered a so-called stage zero breast cancer — a type many say shouldn’t really be considered cancer at all.

The more radical operation makes medical sense, Hawley says, for fewer than 10 percent of women with early breast cancer. Those include the 1.5 percent who have a genetic mutation called��and another 8 percent who have a strong family history, which means two or more immediate relatives who’ve had breast or ovarian cancer.

Double mastectomy rates “have been inching up over the last decade,” Hawley says. There are no guidelines on who should be getting the operation.

When the researchers surveyed women about their choice of therapy, not surprisingly they found the main factor was fear that cancer would “spread” to the healthy breast — even though, Morrow says, “it’s a misunderstanding that cancer spreads from breast to breast.”

“One of the biggest fears when you get a cancer diagnosis is, if I go through this treatment, can I be done, can I go on and live my life and not have to worry about it coming back?” Hawley says.

“I have seen young women who leave the office having signed up for lumpectomy,” Morrow says, “and they call back the next day and say, ‘Well, I was on the Internet or I was talking to my friends and they said I’m a young mother, don’t I want to do everything I can to be there for my child? I think I want a double mastectomy.’ “

But there’s a flaw in that approach. “Unfortunately, that’s just fuzzy reasoning.”

There’s another reason cited by many — the belief that a double mastectomy plus breast reconstruction will give a better, more symmetrical cosmetic result.

“We would have thought that concerns about body image would lead women away from double mastectomy,” Hawley says. “But it may be almost the inverse.”

Morrow says there’s no evidence that reconstruction after double mastectomy will lead to a better cosmetic result and there are other ways to achieve symmetry.

She says there’s��among breast cancer specialists about the trend toward double mastectomy.

The evidence, Morrow says, is that the trend is driven by consumers — not surgeons. She finds that ironic.

“I’m old enough to remember the days when surgeons were considered to be horrible mutilators of women when they did one mastectomy, no less two,” Morrow says. It took years of pressure from the then-nascent patients’ rights movement, along with the evidence from controversial research studies, to establish breast-conserving lumpectomy as a valid alternative to mastectomy.

“The two operations really are equal — not just in survival but in the risk of cancer recurrence,” Morrow says. “That wasn’t true 30 years ago. We’ve gotten better at lumpectomy; we understand more about the biology of breast cancer.

“So at a time when we can decrease the intensity of surgical therapy,” she continues, “instead what we’re seeing is patients who want to be ‘safe’ choosing the bigger surgery, even though in fact it’s no safer for them.”

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With Routine Mammograms, Some Breast Cancers May Be Overtreated

Richard Knox, NPR News — Wed, 21 Nov 2012 17:56:41 +0000

This story comes from our partner ‘s Shots blog.

The endless debate over routine mammograms is getting another kick from��that sharply questions whether the test really does what it’s supposed to.

�ٰ�.��, coauthor of the analysis of mammography’s impact, which was just published in the��New England Journal of Medicine, tell Shots that the aim was to “get down to a very basic question.”

That is, do annual mammograms among women over 40 discover early-stage breast cancers that can be treated so that they never become deadlier late-stage tumors?

Over the last three decades, diagnoses of early-stage breast cancers soared, largely due to routine mammogram screening. But the incidence of late-stage cancers declined only slightly. That leads some to question whether mammograms are really doing what they’re supposed to — catching early cancers before they progress (Chart by Alyson Hurt/NPR)

Welch, of Dartmouth Medical School, and coauthor �ٰ�.��of the Oregon Health and Science University, analyzed 30 years of data on breast cancer incidence.

“And what we see is a dramatic increase — a doubling — in the amount of early-stage cancer,” Welch says. “But we don’t see a corresponding decrease in the amount of late-stage cancer.”

They say this means mammography isn’t catching many advanced breast cancers — even though it’s very good at catching early tumors.

Too good, perhaps. The duo says many of the early tumors revealed by mammography don’t need to be treated at all. Doctors call that “over-diagnosis.”

Welch says more than a million women have been over-diagnosed with breast cancer over the past 30 years. And the problem continues.

“Seventy thousand women a year are over-diagnosed and treated unnecessarily for breast cancer,” Welch says.

This all may come as a shock to many women — and their doctors. No other diagnostic test has been more aggressively promoted than mammography — or, lately, been so controversial, with the possible exception of��

“Whenever I see a paper like this, I say, ‘Oh, boy, here we go again!'” says Dr., a breast imaging specialist at Memorial Sloan-Kettering Cancer Center in New York City.

Lee is on the communications committee of the��, whose members often do mammograms. The group, in a��, says the new analysis “is simply wrong.”

The ACR statement’s main criticism is that Welch and Bleyer don’t account for what the radiologists say was a steady increase in the incidence of invasive breast cancer. They say that can explain why mammography didn’t lower the incidence of advanced breast cancer more.

Welch rejects that claim. “Why was breast cancer incidence so stable in the late ’70s, only to shoot up in the 1980s – the very time mammography was introduced?” he writes in an email. “Why didn’t incidence rise dramatically in women under 40 — those not exposed to screening?”

Welch is no newcomer to debates over the benefits and harms of diagnostic screening tests. In fact, he’s a well-known iconoclast, who last year published the popular��Overdiagnosed: Making People Sick in the Pursuit of Health.

“He has a preexisting bias, just as those of us in the breast imaging community have a preexisting bias,” Lee says. “The truth probably lies somewhere in between.”

Still, Lee finds it hard to believe that 70,000 women a year are diagnosed with breast cancer that would not have progressed. And she says the debate isn’t very helpful to most women.

“What my friends in Connecticut want to know is, ‘Should I have a screening mammogram?’ And … this kind of study sometimes raises more questions than it answers,” Lee says.

San Francisco breast surgeon��agrees that women are tortured by these endless debates. But she sees a way out of the dilemma.

“Our concept of cancer has got to change,” she tells Shots. “We now recognize that there isn’t just one pathway — it’s not cancer, yes or no.” And doctors know now that cancer doesn’t always lead to death.

Esserman thinks mammography screening should be done more selectively. Women at lower risk of breast cancer — because they don’t have close relatives who’ve had it or have a genetic predisposition for it — may not need to be screened so often.

Second, she says women and their doctors have to get out of the mind-set that any breast cancer should be treated maximally. For instance, doctors now routinely deploy surgery, hormones and radiation to treat a condition called��.

“We can watch a lot of those things and most of them turn out to be just fine,” she says.

But this is a long way from how either mammography or breast cancer treatment is practiced right now.

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Tax Breaks For Organ Donors Aren’t Boosting Transplant Supply

Richard Knox, NPR News — Fri, 31 Aug 2012 13:16:49 +0000

This story comes from our partner��

‘s Shots blog.

Seventeen states offer tax incentives to people who donate a kidney, a portion of their liver or bone marrow for transplantation. But a study��these sweeteners aren’t working.

Researchers looked at what happened in the years before and after these tax incentives were passed and found no increase in organ donation rates.

It’s the latest contribution to a debate about how to increase the supply of organs for transplantation at a time when more than 100,000 people are on waiting lists and donations have been flat for several years.

A recent NPR-Thomson Reuters Health Poll��that 60 percent of Americans support some kind of financial incentive to organ donors that could be applied to health care needs.

But the new report raises a caution about how much to expect from financial incentives.

“It may be that this particular form of altruistic behavior is unrelated to finances,”��and his colleagues write in this month’s��American Journal of Transplantation.��“Individuals who want to donate will commit to that regardless of cost, especially if they know and care for the recipient.”

But there may be other reasons why the tax breaks aren’t working, they say. For one thing, they may just be too small.

Typically states offer a deduction of up to $10,000 from taxable income. For a typical family that translates to less than $1,000 in reduced taxes. But the financial burden for a living kidney donor can range from $907 to $3,089, according to��.

The tax incentives are intended to defray the organ donor’s cost in medical care, travel and lost wages. By federal statute, it’s illegal to pay someone for the organ itself.

Authors of the new study suggest increasing the value of the tax deductions or converting them into a tax credit, which would lower the donor’s tax bill on a dollar-for-dollar basis. So far only Iowa offers donors a tax credit.

There’s also reason to think that few people in states with tax credits know about them. Study authors found that even organ donation advocate groups were unaware. So were people being evaluated as living donors, including even the most educated and informed prospective donors.

Maybe states that have enacted organ donor tax incentives were already progressive enough to have done other things to increase donation. So they have tapped out the potential.

Finally, maybe it just takes longer for changes in tax law to have an effect. The study looked at donation rates within two years after passage.

Whatever the reason, the study authors aren’t saying the tax breaks should be abandoned. “These tax incentives cost the states very little, so there is no real reason to do away with them,” says Venkataramani, a Massachusetts General Hospital resident who led the study. “Instead we should focus on improving them.”

The states that offer organ donor tax breaks are Arkansas, Georgia, Idaho, Iowa, Louisiana, Maryland, Massachusetts, Minnesota, Mississippi, New Mexico, North Dakota, Ohio, Oklahoma, South Carolina, Utah, Virginia and Wisconsin.

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Health Care In Massachusetts: ‘Abject Failure’ Or Work In Progress?

Richard Knox, NPR News — Mon, 13 Feb 2012 11:51:00 +0000

This story comes from our partner

Voters are hearing a lot about health care this year. Republicans want to make the 2012 elections a referendum on the health care law that President Obama signed two years ago.

That law was largely based on one that then-Gov. Mitt Romney signed into law nearly six years ago in Massachusetts.

Romney is now a GOP presidential contender, and that has made the Massachusetts universal health care law a political football. Romney’s rival Rick Santorum recently called it “an abject failure.”

But “Romneycare,” as Santorum and others call it, isn’t controversial in its home state. And a lot of people there don’t call it Romneycare because it took the support of a lot of other people — Democratic legislators, business leaders, insurers, hospitals and doctors, consumer groups — to get it passed.

Analyzing Romney’s Leadership On Health Care

But it’s true that Romney got the ball rolling. When I interviewed him in 2006, Romney said he got the idea from talking to Massachusetts business leaders.

“The key insight was this: People who don’t have insurance nonetheless receive health care — and it’s expensive,” Romney said.

Romney saw a state fund set up to provide free care — paid for by a growing surcharge on private insurance premiums — was spending a billion dollars a year.

“My question was, could we take that billion dollars and help the poor purchase health insurance — let them pay what they could afford? We’d subsidize what they can’t,” Romney said.

And he proposed a requirement that people buy private health insurance if they’re able. That’s the “individual mandate” that has become a curse word in Republican politics these days.

“We’re going to say, ‘Folks, if you can afford health care, then, gosh, you’d better go get it,’ ” Romney said back in 2006. ” ‘Otherwise you’re just passing on your expenses to someone else.’ That’s not Republican, that’s not Democratic, that’s not Libertarian — that’s just wrong.”

Flash forward to 2012. Romney’s successor, Democrat Deval Patrick, says the health plan Romney launched is no abject failure — it’s working.

“I think it’s just been a terrific success,” Patrick said in an interview. “And [it’s] a statement of value — about our values here, about how people aren’t all on their own, that we are in this together.”

Patrick says no state can match Massachusetts’ record of getting more than 98 percent of its citizens insured for health care — and virtually every last child. And, he boasts, “It has cost the state about 1 percent in additional new state spending.”

The Massachusetts law has had strong and steady support — and little opposition. Last year, an attempt to repeal the “individual mandate” — the part that requires most people to have insurance — couldn’t get enough signatures. Last week, only 39 people had “liked” its Facebook page.

To get an idea of how it’s working at the ground level, I stopped by the office of Dieufort Fleurissaint, a self-employed Haitian-American businessman. He has a tax prep and insurance business. He’s also an evangelical minister who worked with the group Greater Boston Interfaith Organization, which helped get the health law passed.

“Close to 500,000 people didn’t have health insurance,” Fleurissaint says. “Now, because of the passing of the law, they have health insurance.”

And one of them, it turns out, is Fleurissaint. He used to be a mortgage broker, but his business crashed in 2008. He couldn’t pay his health insurance premiums.

But under the new law, Fleurissaint qualified for state-subsidized insurance.

“My premium … dropped from $1,200 on a monthly basis [to] $770 for the same coverage for the same family of four,” he says. And when his income dropped again during the recession, so did his health insurance costs.

“The law has been extremely good for me,” he says, but he admits that not all his business colleagues like the law.

“They complained that they were forced, basically obligated to purchase health insurance,” Fluerissaint says. “So I explained to them that it’s much better to have health insurance than not having it.”

In fact, despite some initial grumbling, more Massachusetts businesses of all sizes have begun offering insurance.

When I called the Massachusetts Restaurant Association, it said it didn’t know of any members that don’t offer coverage. That was surprising, since restaurant owners have been among the most opposed to health laws like this one.

Similarly, Bill Vernon, who heads the Massachusetts office of the National Federation of Independent Businesses, says the law “works for Massachusetts.” The NFIB is a plaintiff in one of the lawsuits challenging the constitutionality of the Obama health plan that will be argued later this month before the U.S. Supreme Court.

But in Massachusetts, Vernon says, “my guess is that we would probably be pretty much split on the issue of whether to repeal the law or not. That suggests repeal is not something we would favor. And I don’t think it’s politically realistic, either.”

Likewise, the individual mandate has not met with nearly the resistance that many predicted.

“The sky did not fall,” says Andrew Dreyfus, president of Blue Cross Blue Shield of Massachusetts, the state’s largest insurer. “And by the way, we have much stronger penalties around the individual mandate than the national law has, and despite that, the sky did not fall.”

The penalty for not buying insurance can be on the order of $1,200 a year for a 37-year-old single person in Boston. But only about 1 percent of taxpayers end up paying any penalty.

Meanwhile, a new study in the journal Health Affairs shows that more Massachusetts citizens are seeing a doctor regularly, fewer are going to emergency rooms for care, and the percentage who rate their own health as “good” or “excellent” is going up.

But that doesn’t mean everything about Massachusetts health care is wonderful.

The 2006 law didn’t do anything about controlling the state’s health costs, which were already among the nation’s highest.

So now the conversation in Massachusetts has turned to cost control. And some very interesting things are beginning to happen.

They didn’t happen overnight. When Patrick took over the governor’s office in 2007, he called together top insurers, hospital executives and doctors to talk about controlling costs. He says it was an exercise in frustration.

“I finally lost my patience,” Patrick says. “Because they’d sit around the table and everyone would start their response the same way — ‘Well, governor,’ they’d say, ‘it’s complicated.’ “

Patrick says the insurers would point to the hospitals, the hospitals would point to the doctors, the doctors would say it’s malpractice suits or red tape or the imaging center down the street.

Patrick says he got fed up. “I understand it is complicated,” he says. “But the point is, we have to stop being defeated by that complexity.”

So, two years ago, the governor directed his insurance commissioner to exercise a little-used power to turn down a requested rate increase because it was excessive. Not every state has this power.

Insurance companies were outraged. But Dreyfus of Blue Cross Blue Shield now says it was a pivotal point.

“It sent a message to the entire health care community and the business community that we had to change,” Dreyfus says.

And change seems to be happening. Insurers have torn up their contracts with hospitals calling for annual reimbursement increases of 8 percent and 10 percent, and negotiated agreements providing for 3 percent, 2 percent and even zero percent increases.

Blue Cross Blue Shield has persuaded some of the state’s biggest hospitals, and thousands of doctors, to accept a new kind of payment. Instead of getting paid every time they do something — a venerable system called fee-for-service that encourages them to provide more and more services — they’re paid a fixed amount each month for each patient.

That was tried in the 1990s, and it failed, largely because of backlash over its incentive to stint on care. The new wrinkle is that this time hospitals and doctors have to meet 60-some different quality measures to show they’re not cutting back on care.

Dreyfus says a third of his company’s 2.8 million subscribers are now on these so-called “global payment” plans, and he’s hopeful that most of the state will be on this kind of reimbursement within the next two to three years.

The various steps seem to be working to moderate Massachusetts’ historically high health care inflation rates. “We’ve got some more work to do here,” the governor says, “but average premium increases were almost 17 percent two years ago. They are less than 2 percent right now.”

But he doesn’t trust that it will automatically go on that way. Patrick and many others, inside and out of government, say Massachusetts now needs some legislation to lock in these changes and go further — cut down on administrative costs, reform the malpractice system and other innovations.

The big idea you often hear these days is to hold total Massachusetts health spending to a target tied to the state’s overall economic growth.

“I want to assure … that it’s sustainable,” Patrick says, “that we don’t continue to have increases above the rate of growth in the economy.” Otherwise, he says, health care will “eat up everything else.”

Legislators, who are wary of tampering with a health sector that accounts for 20 percent of the state’s economy, are expected to come up with their own proposals this spring.

But significantly, no one is talking about repealing the 2006 law. Not even businessmen like Fred Difinis, who runs a small business selling parts for playground equipment. He’s unhappy with the Massachusetts health plan because it requires him to buy coverage for prescription drugs, which he says he doesn’t need.

“I’m not sure I necessarily want to see the law repealed,” he says. “What I want to see is some balance on the cost side of the equation.”

If Massachusetts can do that, it might become a national model — again.

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In U.S., Hospital Round Trips More Common For Heart Attack Patients

Richard Knox, NPR News — Wed, 04 Jan 2012 18:01:00 +0000

This story comes from our partner ‘s Shots blog.

If a heart attack sends you to an American hospital, you’ll probably go home after only two or three nights. That’s faster than virtually anyplace else in the world.

Photo by Tucuman Arde via Flickr

But your chances of needing to go back into the hospital within the next month are also higher than they are for heart attack patients in 16 other countries. That’s the finding from a Duke University-led in this week’s JAMA, the Journal of the American Medical Association.

On the face of it, the results suggest that hurry-up hospital care for U.S. heart attack patients may be pushing them home too quickly.

But, not so fast, says , a cardiologist and the senior author of the study, which may be the first to compare international rates of hospital readmission after heart attacks.

“We certainly haven’t shown in this study that U.S. heart attack patients need to be in the hospital longer,” Patel told Shots. Rather, he says, the study raises questions about how other countries do post-heart-attack care — both in the hospital and beyond — that results in fewer return stays.

We’ll come back to those questions. But first, consider the study’s main findings. They involve so-called . The acronym stands for ST-segment Elevation Myocardial Infarction. Around 1 in 3 heart attacks is a STEMI, and they pose the gravest risk to victims.

The study looked at nearly 5,600 heart attack survivors in 17 nations, including the United States, Canada, Australia, New Zealand and 13 European nations.

Everywhere but the U.S., about 10 percent of the survivors had to be readmitted to the hospital within 30 days of their heart attack. But in this country, the readmission rate was 15 percent.

The higher U.S. rate wasn’t due to differences in age or the presence of other illnesses.

Some of the higher U.S. readmission rate was from patients who were brought back to the hospital on an non-emergency basis to ream out other clogged arteries discovered at the time of the first admission. Many heart specialists hope that will lessen the chances of a subsequent heart attack, although the evidence for that isn’t clear, Patel says.

But even when these elective hospitalizations are taken out, the U.S. still has the highest rate of post-heart attack readmissions.

Since the U.S. has the shortest hospital lengths-of-stay, it would be tempting to conclude that the pressure to cut costs here has compromised quality. Early readmission is considered a marker of poor quality of care.

Readmission also imposes an additional cost burden, so policymakers also consider it a red flag for inefficient care.

But Patel says it’s simplistic to blame high U.S. readmission rates on short U.S. lengths-of-stay. As a case in point, he cites Canada — perhaps the closest comparison with U.S. medical culture.

“In the U.S., the 30-day readmission rate was 14.4 percent. In Canada it’s in the 5 percent range,” Patel notes. “The U.S. length-of-stay is three days, in Canada it’s five.”

But in all of Canada there are only 45 hospitals that provide the kind of acute heart attack care available in hundreds of U.S. centers — clearing of the clogged coronary artery within hours, followed by placement of a metal stent to keep it open.

“In Canada,” Patel says, “patients are often transferred back to the hospital from where they were initially referred, and then they’re linked up with their primary care physicians and local cardiologists so their rehabilitation can start.”

He says the U.S. often falls down on that post-hospital coordination.

“I think we both do very well from when the patient has chest pain to getting the clogged artery open,” Patel says. “But it looks like Canada does better in going from the hospital to home.”

That involves things like making sure the patient knows all the things he or she needs to do to prevent a subsequent heart attack, such as stopping smoking; setting up a followup visit with a primary care physician who has access to the hospital records; and ensuring the patient knows what to do if new cardiac symptoms arise.

Importantly, the study found no difference in 30-day death rates following STEMI heart attacks between the United States and the 16 other developed countries.

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Why Observing Prostate Cancers Is Gaining Ground On Surgery

Richard Knox, NPR News — Thu, 08 Dec 2011 18:39:41 +0000

This story comes from our partner ‘s Shots blog.

A federally convened panel of experts says most men with newly diagnosed prostate cancer should be offered the chance to put off treatment in favor of medical monitoring of their condition.

In fact, the panel went so far as to say doctors should stop calling most of these low-risk tumors cancer at all.

“Strong consideration should be given to removing the anxiety-provoking term ‘cancer’ for this condition,” the 13-member panel says in its , which were produced after two days of presentation and debate.

Some think these tumors should be rebranded as something else, such as idle tumors, to reflect the fact that they’re not all that threatening and don’t necessarily need to be treated. The analogy, though imperfect, is that some early skin cancers are called “actinic keratoses” and early cervical cancers are termed “dysplasias.”

This week’s�� made clear there isn’t much evidence to show whether deferring surgery and radiation for low-risk prostate cancer gives a man as good a shot at surviving the disease as immediate treatment.

But surprisingly, the panel says there’s no need to do a big study that randomly assigns men with newly diagnosed low-risk tumors to observation or treatment, if their life expectancy is less than 20 years. Such a study would have to be very big and very long to pick up a mortality difference.

For men expected to live longer than two decades, the panel does call for a randomized study. It will be interesting to see whether more men volunteer for such a study than were willing back in 1994, when the only such US study on this issue had a lot of trouble persuading men to be randomized.

That study, called PIVOT, figured heavily in the panel’s deliberations. The�� were presented at an American Urological Association meeting in May. The results haven’t been published in a peer-reviewed journal yet.

More about PIVOT in a sec, but first some perspective.

The great majority of the 240,000 US men diagnosed with prostate cancer each year have low-risk disease, as defined by a Gleason score of 6 or less. (Gleason scores combine how many cancerous cells are seen in a needle-biopsy tissue sample, and how aggressive the cells appear to be.)

More than half of all prostate cancers get a Gleason score of 6, the lowest score usually given. In fact, the panel notes that as many as 70 percent of prostate cancers these days are Gleason 6s, and thus low-grade. Why is that? Widespread PSA testing is catching very early cancers.

Think about that for a minute: The great majority of prostate cancers are low-risk. These cancers aren’t likely to kill them. And yet only 1 in 10 men diagnosed with prostate cancer defers immediate treatment that aims to cure the condition in favor of observation.

Observation takes two different forms. There’s “active surveillance,” which aims to pick up signs that a low-risk tumor is becoming more aggressive. That means regular PSA tests, digital rectal exams and periodic needle biopsies. The hope is that a progressing cancer can be identified in time to cure it. The other approach is “watchful waiting.” Doctors wait for symptoms to appear, which indicates the cancer has advanced.

The panel says these observational strategies are “under-utilized…for reasons that are not fully understood.” It strongly implies that many doctors, and especially urologic surgeons, present observational approaches “in a negative way…as ‘doing nothing.’ “

But by choosing immediate treatment, men with low-risk prostate tumors are subjecting themselves — perhaps unnecessarily — to high rates of urinary and bowel incontinence and impotence, and many of these side effects don’t go away.

Of patients who do choose to defer treatment, a quarter will change their minds within two to three years, and perhaps a half by five years. “The reasons for leaving active surveillance are often unclear,” the panel says.

The best evidence for considering active surveillance or watchful waiting is that the , which compared 731 men with prostate cancer randomly assigned to surgical removal of their prostate or observation.

After an average of 10 years of followup, about half the patients had died. But only 7 percent died of prostate cancer (as far as the researchers could determine), and the risk of dying (from prostate cancer or any cause) was not significantly different between the “treatment” and “observation” groups – if the tumor was initially deemed low-risk.

An earlier Scandinavian study did find that men who underwent immediate treatment had lower risk of dying than those who underwent watchful waiting. But that was back in the days when prostate cancer was typically more advanced at the time of diagnosis, and observation of untreated patients may have been less likely to pick up progressing cancers.

It remains to be seen, of course, how much influence the NIH panel’s statement will have on the real-world practice of prostate cancer treatment, and the choices of patients.

The panel heard from one man, Catholic University law professor David Lipton, who said he deliberately rejected active surveillance three years ago, even though he had a low-risk tumor. And he’d do it again.

“Ultimately…the decision was very visceral and personal,” Lipton says. “I did not want to wake up each morning wondering if the previous night was the night that a cancer cell ‘flew’ from my prostate and invaded other reaches of my body.”

The fact that he no longer has a prostate that might seed a fatal metastasis “gives me some comfort, even though a number of studies suggest it should not,” Lipton says.

His decision might be different, Lipton says, if scientists develop reliable tests that predict if a prostate tumor really is indolent or aggressive, and if future data indicates that men who get treated after a period of observation do as well as those who get treated up-front.

As with any expert panel, this one did recommend, urgently, a number of studies, in addition to the big trial comparing treatment and observation among younger men with low-risk tumors. Much remains to be done, it said, to define just what observation means, to make sure men labeled low-risk really are, to come up with better ways to tell if a low-risk tumor has progressed, and so on.

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Shortages Lead Doctors To Ration Critical Drugs

Richard Knox, NPR News — Mon, 03 Oct 2011 14:00:42 +0000

This story comes from our partner ‘s Shots blog.

Drug shortages mean a growing number of Americans aren’t getting the medications they need. That’s causing drug companies and doctors to ration available medications in some cases.

Source: University of Utah Drug Information Service

“We’re now at 213 shortages for this year,” says�� of the University of Utah, who tracks national drug shortages. “That surpasses last year’s total of 211. And it doesn’t seem like there’s an end in sight.”

The�� involve a wide range of medications: cancer chemotherapy agents, anesthetics, antibiotics, electrolytes needed for nutrient solutions, and dozens more. One drug currently in short supply is used in critically ill patients to bring down soaring blood pressure.

“We know this is a dire public health situation,” Assistant Secretary of Health and Human Services�� told NPR, “and there have been delays in care.”

According to those who are tracking drug shortages, there have been more than delays. Some patients have died.

That’s what the American Society of Health-System Pharmacists found when they did an anonymous survey of members. Last week the Associated Press�� that at least 15 people have died as a result of drug shortages.

And last spring, nine Alabama patients died and 10 others got seriously ill after getting bacteria-contaminated intravenous feeding solutions made by local pharmacies. In a�� on that episode, the Institute for Safe Medication Practices notes that hospitals are relying more on such “batch” suppliers “due to an unprecedented escalation in shortages” of IV nutrient fluids from pharmaceutical companies.

‘Robbing Peter To Pay Paul’ With Calcium

Fifteen-year-old Kevin Zakhar of Bethel, Conn., is one among thousands of patients affected by a months-long shortage of electrolytes — minerals such as calcium, phosphorus and magnesium necessary for normal metabolism.

Zakhar can’t eat at all. A year ago, his small intestine suddenly kinked, cutting off its blood supply. Surgeons had to remove the entire small bowel, which is where nutrients in food get absorbed. So he must depend on daily intravenous feeding.

“The solution has all of his calories, all of his minerals, all the vitamins that he needs,” says his mother, Laura, who hooks him up to an IV pump every afternoon. “It’s everything that you and I would get by eating.”

But in August, a pharmacist phoned Laura Zakhar to say a necessary nutrient called calcium gluconate wouldn’t be in that week’s supply due to a national shortage.

“My first words to the pharmacist were, ‘Who do I call? Who do I write? What can I do?'” Zakhar said. “And he said, ‘Hopefully, it will just be a short period of time, and I don’t really know what you can do.'”

Checking around, Zakhar found the shortage of IV calcium had been brewing since April, when one of the nation’s two suppliers shut down due to contamination on their manufacturing lines. She hadn’t known about it because pharmacists had been trying to protect Kevin’s supply as long as they could.

“My son was one of the last patients they took it from because of his circumstance — he can’t take anything by mouth,” Zakhar says.

One reason that Kevin Zakhar hasn’t been able to get the calcium solution he needs is that hospitals have been reserving it for patients who need it even more desperately than he does.

Kathy Gura, a pharmacist at Children’s Hospital in Boston, points to one of those patients, a tiny infant born only 23 weeks past conception, as premature as a baby can be and still survive. And he wouldn’t have survived without the same kind of IV feeding that Kevin Zahkar gets.

Gura and caregivers at other hospitals say they have had to divert scarce electrolytes from other children and adults to save the lives of fragile preemies. Gura calls it “robbing Peter to pay Paul.”

More Shortages At A Hospital

Across town at the Massachusetts General Hospital, New England’s largest, pharmacist Paul Arpino says drug shortages were once rare. Now they’re routine.

Source: FDA

Arpino often gets calls in the middle of the night from desperate doctors and nurses. “We try to react as quickly as possible to these shortages,” he says. “Sometimes there’s not a lot of notice. But when we’re informed of the shortage, we really get all hands on deck.”

He says drug shortages plague every corner of Mass General, from the emergency department to operating rooms to intensive care.

Currently, for example, intensive care doctors are coping with a shortage of a drug called that’s used to treat patients whose blood pressure is going through the roof. Labetalol is so scarce that the hospital recently decided to reserve it only for patients having a brain hemorrhage.

Dr. Taylor Thompson, medical director of the Mass General’s medical ICU, calls it rationing – something most people think happens only in socialized medical systems or developing nations, not in America. But experts say the problem has been building over the past decade, and has accelerated since 2006.

“It’s really no way to run an integrated health care delivery system, to take cornerstone drugs and have to do without and find alternatives monthly,” Thompson says.

Doctors and nurses do find work-arounds. They try different drugs or combinations. But that increases the risk of a dangerous medical error.

“It would be a bit like a pilot coming to Logan Airport in the morning and (being told), ‘We’re out of Airbuses, you’re going to have to fly a 727. And oh, by the way, you’re taking off in 10 minutes.’ “

Are Generics To Blame?

Thompson isn’t quite sure why drug shortages are happening so often. “My understanding is it appears that the major problem is business decisions around generic drugs,” he says.

Most drugs in short supply have been older generic drugs, which are generally less profitable. Hospitals are most affected, because many scarce drugs are intravenous forms, not pills dispensed in bottles.

But actually, officials at the Food and Drug Administration say only 11 percent of shortages happen because a company decides to stop making an unprofitable drug. Most shortages, they say, occur because something goes wrong in the manufacturing process that halts production.

The problem today is there are fewer companies making essential drugs. So when one manufacturer stops producing, there may be only one other supplier – and it can’t keep up with demand. This is what happened with calcium gluconate, the missing ingredient in Kevin Zakhar’s IV nutrient mix. (Last Friday, one of the two manufacturers told NPR that it was resuming shipments and Zakhar should have a steady supply beginning this week.)

Whatever the tangled causes, all those involved believe drug shortages are the new normal in U.S. medical care.

That’s why the Mass General recently formed a task force on drug shortages. Its chairman, surgical oncologist Annekathryn Goodman, says next month the group will begin to confront the agonizing questions of how to decide who gets the available drug when there’s not enough to go around.

“If it ever gets to a place where you have to choose one patient over another,” Goodman says, “that is a very tough, ethical, existential, emotional issue — for us, for the people receiving the care.”

Goodman is currently grappling with a problem that foreshadows such difficult choices. A drug called Doxil, which is highly effective in treatment some advanced ovarian cancers, is being�� right now.

Betsy Neisner, the consumer representative on the new drug shortage task force, is a patient of Goodman’s who had been getting Doxil.

“I was getting it monthly, responding superbly, until July of this year, when I went into the hospital to have my infusion and the cupboard was bare,” Neisner says. “They didn’t have it. There was a nationwide shortage.”

She had to switch to an older drug that caused months of terrible nausea and fatigue, and damaged the nerves in her feet. Last Friday she started getting Doxil again after her turn came on the manufacturer’s waiting list.

“It’s really astonishing and terrifying,” Neisner says, “because you assume that if there’s something that we’ve invented, that we’ve made available, it will stay available. And that’s not true anymore.”

More wrenching decisions may be just around the corner for patients with ovarian and breast cancer. A critical drug called Taxol is now on the FDA’s shortage list.

And Mass General’s pharmacists say they have less than a month’s supply of Taxol on hand.

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Female Docs Fall Further Behind On Pay

Richard Knox, NPR News — Thu, 03 Feb 2011 15:00:00 +0000

This story comes from ‘s health blog .

Women are playing a greater and greater role in medicine. But when it comes to salaries, they’re actually losing ground.

A provocative in the current issue of the journal Health Affairs finds female physicians’ average starting salaries earned nearly $17,000 less than their male counterparts’ in 2008, once researchers took into account gender differences in hours clocked, choice of specialty, and other factors.

And, strikingly, the trend for female doctors seems to be heading in the wrong direction. Back in 1999 the gender gap in starting salaries was $3,600 – more than $13,000 less than the most recent discrepancy.

The data come from a 10-year analysis of data from New York. Study authors think that’s a good proxy for what’s happening nationally, since New York leads the nation in number of residency training programs.

They also think starting salary is a good metric, because it avoids possible differences in productivity that emerge later in doctors’ careers – due to time off for child-rearing, for instance.

Well, you may be thinking, , such as pediatrics, family practice and general internal medicine. So of course their average pay would be less. But it turns out that doesn’t explain their recent slide in starting salaries.

In fact, the new study finds women are now no more likely to go into primary care jobs than newly minted male doctors. And those who choose high-paying sub-specialties such as cardiology, heart surgery, radiology, ob-gyn and anesthesiology all start at salaries thousands of dollars below comparable men.

Consider this: Starting cardiologists in 2008 raked in $228,188 if they were male, $204,671 if they were female. For radiologists, men made $250,709 and women got $244,532. And so on.

The $17,000 average gender gap is “unexplained,” say , a professor of economics at the University of Illinois, and his coauthors. That is, it “cannot be explained by specialty choice, practice setting, work hours or other characteristics.”

For instance, it wasn’t because women physicians are more likely to get paid a salary while men work on a piecemeal, fee-for-service basis, which can generate more income. Nor because women might be more likely to join a group practice while men might prefer working solo.

The trend is all the more striking because women are on track, finally, to reach parity in medicine. Now of all medical students are women, up from only 9 percent in the mid-60s. Recent trends about 1 in 3 U.S. doctors is now a woman, with further gains on the way.

So, could there be a backlash going on here? That is, as women become more prominent in medicine, could they be encountering more old-fashioned gender discrimination in the labor market?

The study’s authors say they can’t prove it, but they don’t think so. Instead, they think the influx of women into the profession is leading employers to offer greater flexibility in hours and other family-friendly policies “that are more appealing to female practitioners, but that come at the price of commensurately lower pay.”

It’s also possible, they say, that women aren’t as skilled at negotiating their starting salaries as men. But they think it’s unlikely that women have gotten worse at negotiating over the past 10 years.

But even if women doctors are willing to trade off job flexibility for considerably lower pay, the authors think the trend deserves a closer look. For one thing, if the new Affordable Care Act survives in some form and millions more Americans get health coverage, the need for more doctors “will place a brighter spotlight on physician compensation,” the study authors say.

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Researchers Say Common Test For Prostate Cancer May Not Work

Richard Knox, NPR News — Mon, 22 Nov 2010 23:31:02 +0000

This story comes from NPR’s health blog .

More bad news on the prostate cancer front: A widely used ��that’s supposed to help doctors and patients predict the outcome of most prostate cancers is basically worthless.

That’s according to a study just published in the journal CANCER.

The new discrediting the test, coupled with about how useful prostate screening is for most men anyway, add up to a whole lot of discussion points patients should take to their doctors.

The test in question is called “clinical staging.” It relies on certain signs doctors use to classify how advanced an individual patient’s cancer is that is, what stage it’s in. It includes criteria like whether the doctor can feel a nodule through rectal examination, and whether a tumor is detected through a test called trans-rectal ultrasound.

Ten years ago, the American College of Surgeons decreed that doctors should use these types of clinical staging tests to help decide how to treat cancers.

“Our findings question the utility of our current staging system for localized prostate cancer,” says Dr. Adam Reese of the University of California at San Francisco, lead author of the study.

To begin with, doctors err in using this prostate test 35 percent of the time. When these errors occur, the study says, doctors most often conclude the cancer is less serious than it really is.

But even when researchers allowed for these errors, they found the test doesn’t predict how patients ultimately do.

Dr. Gerald Andriole of Washington University, who was not involved in the study, told Shots he wasn’t surprised by the results. Recently, he says, urologists “have begun to realize these criteria are not adequate. But this is the first study that quantifies the magnitude of the inadequacy.”

Even so, Andriole says, the findings may not make too much difference in the real world. Before treatment recommendations are made, doctors put most prostate tumors through other tests, too, like the Gleason score, and they look at the percentage of biopsies that are positive for cancer cells.

“I use all those parameters to tell a patient what his chances of a good outcome are,” Andriole says.

Still, both study author Reese and Andriole say the new study may serve as a wakeup call to those who are over-relying on the clinical staging system.

They say what’s really needed is a set of tests that classify prostate tumors by what genes are turned on or off in the cells.

Once this is sorted out, doctors treating prostate cancer will be less like the blind men who try to guess what kind of creature they’re dealing with when they grasp the elephant’s trunk or tail.

This is one of KHN’s “Short Takes” – brief items in the news. For the latest from KHN, check out our News section.

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