News News News
PSYCHOACTIVE DRUGS LINKED TO METABOLIC AND CARDIOVASCULAR RISK IN CHILDREN
Children treated with antidepressants, “mood stabilizers”, and antipsychotics are two to three times more likely to develop obesity, type 2 diabetes and cardiovascular conditions. Antipsychotics in the study included aripiprazole, ziprasidone, quetiapine, risperidone, olazapine, haloperidol, and fluphenazine.
Cardiovascular disorders included enlargement of the heart, fast heart rates, irregular heart rates and loss of blood pressure while standing. Girls, adolescents, and patients on combination therapy were at highest risk of these adverse effects. (Arch. Pediatr.Adolesc. Med. 2008; 162:929-35)
CLOSTRIDIA EVEN WITHOUT PRIOR ANTIBIOTICS INCREASING, MORE DEADLY THAN EVER
A McGill University (Montreal) review published in October 2008 indicated more than half of patients with clostridia difficile infection had not been exposed to antibiotics in the 45 days before their hospitalization. Different clostridia bacteria are responsible for gas gangrene and botulism poisoning and, of course, as a source for Botox®.
C. difficile is difficult to treat and persistent once an infection has developed, causing diarrhea and other disorders of the gut. Canadian researchers found that infection rate per 100,000 had increased more than 10,000% from 1997 to 2004, and the fatality rate is also increasing. (American Medical News October 27, 2008)
METHICILLIN RESISTANT STAPHLOCOCCUS AUREUS SINUS INFECTIONS INCREASING
From 2001 to 2003 staph infections were isolated in 8 per cent of acute sinusitis and 30 per cent of these were MRSA. In 2004 to 2006, staph was found in 10% of patients and 69% were MRSA. A similar trend was seen in chronic sinusitis, increasing from 16% who had staph infections, 27% of which were MRSA, to 20% staph infections of which 61% were MRSA.
Recent treatment with antibiotics was a strong predictor of MRSA associated sinusitis. Unfortunately, definitive diagnosis requires endoscopy or puncture of the sinus with a needle. (Family Practice News November 15, 2008 p. 1)
ANOTHER NAIL IN THE COFFIN FOR PRIMARY CARE
Presently, medical practices waste hundreds of hours of time translating English diagnoses into a numerical format for the sole benefit of bureaucrats. These codes, which are a major source of income to organized medicine, are known as the “international classification of disease code set”, or ICD-9. The ICD-10 version, slated for 2011, will increase the number of possible codes tenfold.
These codes provide no proven benefit to patients or physicians, and in fact reduce efficiency and increase costs. Ten times the complexity will not improve diagnosis or treatment, but will, of course create endless fodder for bureaucrats as codes are added and deleted. Inaccurate, invalid or obsolete codes are grounds for nonpayment, so making a system that is Byzantine, unpredictable, and obscure benefits the insurance industry in every way.
Baltimore-based Nachimson Advisors estimate that the upgrade itself will cost $83,290 for the average small practice (3 doctors), a medium practice $285,195 (10 doctors) and $2.7 million for a large practice (100 physicians). These prices will drive many smaller practices out of business and reduce the attractiveness of primary care medicine. (see below) (American Academy of Family Physicians)
More than 14% of health care costs are wasted by the process of billing for third party payments. Beyond that, 3-7% of correct billing is denied without justification, and 13-38% of payments are less than the insurers’ own pay scales allow. Appealing and correcting these errors wastes personnel time and further increases overhead. (AMA News November 3, 2008 p 19)
JUPITER: A GAS GIANT OF A STUDY; HOW MUCH IS HOT AIR?
The JUPITER trial of rosuvastatin in “seemingly healthy” people with normal LDL levels and elevated c-reactive protein was suspended two years early because the researchers felt the results were so positive that not treating the placebo group would be unethical. Over this period, death, heart attack and other events requiring angioplasty were reduced by 44%, non fatal heart attack was reduced 55%, and non fatal stroke was reduced 48%.
Many physicians will see this study as a reason to increase prescription of this drug, and statins in general. But Eric Topol, M.D., Dean of the Scripps School of Medicine, La Jolla, points out that the results may not justify widespread prescription, as many of these seemingly healthy participants had significant risk factors: many were overweight, 40% had metabolic syndrome, 15% were smokers, and 10% had positive family histories for coronary artery disease.
Dr. Topol also points out that the absolute risk reduction is small, calculating that “Only 1 person [would be] helped out of 120 treated for a 2 year period”.
Expense and adverse effects for the other 119 patients are a concern, especially as adverse effects in studies tend to increase as the trial continues; “Drug companies love to stop studies early because there are considerably more side effects the longer the studies go. The side effects from statins can be very serious, including a higher incidence of diabetes, crippling muscle problems, kidney disease, and malignant heart rhythms. Stopping this study early conveniently reduces the evidence for evaluating these side effects” noted Dana Ullman MPH.
One out of 200 rosuvastatin patients developed diabetes, a “far greater incidence” than in the placebo group.
Dr. Ross Walker, a cardiologist in Sydney, Australia is also concerned about long term adverse effects: “In clinical trials, the adverse event rates always appear to be very low, and typically rather close to placebo. In the real world these adverse events are much higher. I have been practicing cardiology for over twenty years, and I can assure you that a significant number of patients taking statins over a long period will experience either some subtle issue or at times a serious problem that signicantly affects the quality of their lives.”
He said muscle weakness, myalgias, liver abnormalities and neuropsychiatric problems are the most common, and he believes he is also seeing some unexpected cancers.
Given the cost of about $3.65 per pill, treating the estimated 7.4 million Americans who fit the JUPITER patient profile would cost about 9 billion dollars a year. (Holistic Primary Care, Winter 2008, page 1)
MALE CIRCUMCISION REDUCES HIV RISK
Male circumcision has been found to reduce the risk of contracting HIV by 60%. The South African study recruited 3274 heterosexual men aged 18 to 24 who were considering circumcision and randomly divided them into two equal groups. One group was circumcised and the other acted as controls.
So dramatic were the findings at 21 months in terms of relative HIV infection that the study was halted on ethical grounds. However the study raised concern among other scientists who warned that circumcision should not lull men into a false sense of security and that practicing safe sex was essential to avoid contracting HIV. (PLoS Medicine Vol. 2, No. 11, e298 DOI: 10.1371/journal.pmed.0020298)
FISH & THE BRAIN
As P.G. Wodehouse’s Bertie Wooster was wont to marvel, “The legendary fish-fuelled brain is as sharp as ever, Jeeves.'' This traditional association of fish-eating and good brain function is borne out by a recent study of over 3000 people 65 or older. Those who ate fish once a week were found to have a 10% slower annual decline in thinking, rising to 13% for those who ate fish twice a week. (Arch Neurol. 2005;62:1849-1853).
WEAK AT THE KNEES
Women who play sports suffer a two to eight times greater risk of injuring their knees than sports-playing men, and knee injury in women, especially to the anterior cruciate ligament, has been described as being of epidemic proportions. ‘Pivot’ sports – involving fast stops, twisting and turning, are particularly damaging to women.
Although the root cause is unknown, the study did find that women have much lower levels of rotational knee stiffness (representing the level of protection offered by the knee muscles) than men, despite carrying out the same training routines. In a previous study by the same author it was found that women athletes are more likely to injure their knee during the ovulatory phase of their menstrual cycle. (Journal of Bone and Joint Surgery, Volume 84-A, Number 1)
ACUPUNCTURE & IVF
In a Danish study to investigate the benefits of acupuncture in assisted reproduction (IVF and ICSI), women were randomly assigned to three groups. One received acupuncture only on the day of embryo transfer (immediately before and immediately after transfer), one received additional acupuncture two days later, and a control group received no acupuncture.
Clinical and ongoing pregnancy rates were significantly higher in the acupuncture groups than the controls, but the additional treatment given two days after transfer appeared to confer no additional benefit. (Westergaard LG et al. Acupuncture on the day of embryo transfer significantly improves the reproductive outcome in infertile women: a prospective, randomized trial. Fertil Steril. 2006 May;85(5):1341-6)
MORE ON ACUPUNCTURE & IVF
Over a period of three years in a private practice 22 patients entering assisted reproduction therapy were given acupuncture. Treatment was given, usually weekly, during the IVF cycle and immediately before and after embryo transfer. Treatment during the cycle emphasized points such as Baihui DU-20, Taichong LIV-3, Sanyinjiao SP-6, Zusanli ST-36, Neiguan P-6, Guilai ST-29 and Hegu L.I.-4 and ear points Shenmen, Neifenmi, Zhigong and Naodian.
Pre-transfer treatment was Baihui DU-20, Taichong LIV-3, Diji SP-8, Neiguan P-6, Guilai ST-29 and the four ear points. Post-transfer treatment was Sanyinjiao SP-6, Xuehai SP-10, Zusanli ST-36, Hegu L.I.-4 and the four ear points. The success rate was 57.7% compared to 45.3% for patients in the IVF unit not treated with acupuncture. (Johnson D. Acupuncture prior to and at embryo transfer in an assisted conception unit – a case series. Acupuncture in Medicine (2006) 24; 1: 23-28)
ORGANIC BEST FOR BIRDS AND INSECTS
Organic farms in the UK contain almost twice as many plant species, and more spiders (17%), birds (5%) and bats (33%). (Biology Letters, 2005; 1(4): 431-434)
HEART BYPASS WITH ACUPUNCTURE ANESTHESIA
Surgeons at the Shanghai Renji Hospital in China have reported the country’s first successful heart by-pass operation using acupuncture anesthesia. The surgical team performed electro-acupuncture using six needles placed in the chest and wrist of the 78-year-old patient. A small amount of intravenous medication was given to maintain the effects of the anesthetic. The doctors claim that the acupuncture method shortens recovery time, limits postoperative complications and is less expensive than conventional anesthesia. (www.shanghaidaily.com, December 26, 2007)
PACIFIERS & SUDDEN INFANT DEATH SYNDROME
The use of a pacifier while sleeping appears to be associated with a reduced risk of sudden infant death syndrome (SIDS, cot death) says a study that compared 185 babies who had died in this way with 312 matched controls. (BMJ 2006;332)
SWEET FOODS ASSOCIATED WITH BREAST CANCER RISK
An Italian study of over 5000 women suggests that a higher consumption of sweet foods (including biscuits, cakes, ice cream, honey and chocolate) is associated with a significantly higher risk of developing breast cancer, and indeed may account for 12% of cancer cases within the group studied. (BMJ 2005;331:1102)
ACUPUNCTURE & TINNITUS
Six patients treated for ringing in the ear (ten treatments over a two-week period) reported varying degrees of reduction in volume and pitch of the tinnitus, and consistent improvements in number of waking hours affected and quality of sleep. (Jackson A. Acupuncture for tinnitus: A series of six n=1 controlled trials. Complementary Therapies in Medicine (2006) 14, 39046)
CHINESE MEDICINE IN SPACE
Chinese astronauts have been using traditional Chinese medicine to prevent and counteract space motion sickness. According to the director of the China Astronaut Research and Training Centre, the astronauts take medicines before going to space to enhance their ability to maintain balance and improve their immune system. Chinese herbs, tuina and acupuncture are also used as part of the astronauts’ everyday training. China’s space agency is also co-operating with the Chinese University of Hong Kong to find ways to prevent the loss of calcium in bones during zero-gravity. (Xinhua News Agency)
CHINESE HERBS FOR CANCER
Hosni Mubarak ordered a global search for effective lung cancer treatments after his favorite actor died of the disease. This has led to the announcement of a phase-111 trial of a traditional Chinese herbal medicine formula at Cairo University Hospital. The formula (Sanyang Kangtai, also known as Jiangjie Buxue Heji) has already been trialled at Beijing City Tumor Hospital and seven other Chinese hospitals.
Results from those trials showed that 77% of 62 patients with middle and advanced stage lung cancer, who were also receiving chemotherapy, experienced complete or partial recovery compared to a control group receiving chemotherapy plus granulocyte colony-stimulating factor. (The Journal of Complementary Medicine (2006) 5; 1).
ASTRAGALUS COMBINES WELL WITH CHEMOTHERAPY
The combination of Huang Qi (Astragali Radix)-based Chinese herbal medicine and platinum-based chemotherapy is more effective in the treatment of non-small cell lung cancer than the chemotherapy alone. An analysis of data from 34 published clinical trials suggests that at 12 months the mortality rate was reduced by 33% among those treated with the dual therapy.
The Astragalus may work by stimulating macrophage and natural killer cell activity. (McCulloch M et al. Astragalus-Based Chinese Herbs and Platinum-Based Chemotherapy for Advanced Non–Small-Cell Lung Cancer: Meta-Analysis of Randomized Trials. J Clin Oncol. Jan 20 2006: 419-430)
"What Were They Thinking?" Department
A HOUSE IS NOT A HOME, PART TWO
Last month, an analysis of the first half of the Joint Principles of the Medical Home (JPOTMH), was presented. Consistent with past creations of an out-of-touch organized medicine bureaucracy, these unworkable and unrealistic recommendations exemplify precisely how commitments to centralized planning and top down regulation has resulted in an overpriced, unworkable and inefficient system of medical care. Worse, it has stifled innovation and driven talented practitioners and prospective students away from the path of medicine.
Unfortunately, this proposal is another feckless response by medical bureaucrats that does not address any of the pressing issues facing modern medicine, but is more akin to rearranging the deckchairs on the Titanic.
The second half of these proposed “principles” will be the subject of this month’s commentary:
Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staff.
The false premise that underlies this particular fantasy is that professional level services can be provided without any cost. Of course, that also means that they can be “expanded” without any cost, also. But, outside of think tanks, the time of the physician, the staff, and the cost of infrastructure required to “expand hours” or “communicate” does not appear magically.
Staff must be paid for and supervised if hours of work are increased. Heat, water, electricity, telephones and internet services during these expanded hours are another expense. Capital expense must be invested into computer and billing systems. Any doctor or staff member who reads, analyzes, and replies to emails must of necessity take time away from direct patient care. Except for the very most simple problems, office visits will still be necessary for most problems: "Communication" without an exam is a proven risk for error and potential malpractice.
Expanding services without a commensurate increase in charges is a recipe for failure. The present system of payment, where income is controlled but overhead is not, is already pushing primary care physicians out of practice or into megaclinics. Salaried bureaucrats and academic physicians expect and are accustomed to taxpayer subsidized staff and infrastructure, and have no experience in being responsible for overhead, taxes and payroll. In the front lines of medicine, however, increasing the costs and workload of primary care doctors will contribute to the exodus of physicians from this activity.
Where is the “enhanced access” for many elderly and disabled patients, who may not be healthy or mobile enough to travel to a doctor’s office? Requiring the most medication, supervision and high technology care, the needs of these patients are not fulfilled by six-visit-an-hour industrial medicine at a megaclinic. A visit to the patient’s residence isn’t even on the horizon for the visionaries of the brave new world of “medical homes”.
Proposing “enhanced access” is fraudulent when patients are unable to even find a doctor who can provide entry level primary medical care. Furthermore, access in of itself does not imply outcome: “Access” to a distracted, overworked, inattentive, or inept practitioner will solve nothing. Substituting “physician extenders” will add to the present trend of devaluing the work of physicians and will contribute to already basement level morale, as detailed in Part One.
Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home. The payment structure should be based on the following framework:
It should reflect the value of physician and non-physician staff patient-centered care management work that falls outside of the face-to-face visit.
It should pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources.
It should support adoption and use of health information technology for quality improvement;
It should support provision of enhanced communication access such as secure e-mail and telephone consultation;
It should recognize the value of physician work associated with remote monitoring of clinical data using technology.
It should allow for separate fee-for-service payments for face-to-face visits. (Payments for care management services that fall outside of the face-to-face visit, as described above, should not result in a reduction in the payments for face-to-face visits).
It should recognize case mix differences in the patient population being treated within the practice.
It should allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting.
It should allow for additional payments for achieving measurable and continuous quality improvements.
The unpleasant truth is that no realistic suggestions on how to provide for the costs of the present system of primary care has come from "organized medicine", much less for the “enhanced”, “added value” of the medical home concept. At a time when face-to-face visits are inadequately paid for, a proposal to pay doctors for administrative work strains credulity: In fact, none of the items listed under this section are presently paid for at all.
What is worth paying for is a much more important question than who will pay for it. Much more significant than how much will be paid for something is determining how much something is worth. Sadly, the vast majority of present debate concerns solely who will pay.
Cleverly embedded in the demands for what “should” be in the JPOTMH are unproven assumptions that advance the agendas of the medical-industrial complex. The benefits of “health information technology” are vague and unproven; the costs are enormous. Assertions by our newest president (as well as the last holder of that office) that “digitalizing” medical records will improve the health of patients makes as much sense as the proposal that “digitalizing” libraries will improve literacy.
Another embedded false premise is the “savings” realized from establishing a “medical home” practice. Even more fantastic is the idea that any such funds will somehow trickle back to the physician instead of filling the coffers of fat cats. This premise doesn’t bear much close scrutiny, as everything in the JPOTMH increases costs and workloads. At a time when real income for primary care practitioners has decreased for a decade, this suggestion is akin to throwing a rubber bone to a starving dog. (apologies to Linus)
Ultimately, one can find no evidence that there will be any “added value” should the medical home concept become “reality”. Will suffering be decreased? Will illness or death be reduced? Will patients even be able to find a primary care doctor? The medical bureaucrats don’t know. They don’t address these questions because they don’t have the answers. What they do have is a burning desire to obtain grants and taxpayer funds to “study” the concept or operate “demonstration” projects. Bureaucrats can always work out the details at resort conferences.
Primary care practitioners themselves would be the best resource for correcting the conditions which have driven many of their colleagues out of practice, and presently dissuade the majority of medical students from considering primary care. But, the elitists of “organized medicine” have never accepted the leadership of the physicians who actually work on the front lines of medicine. It is far easier to produce pie in the sky daydreams of how things could be if cost was no object and every primary care doctor could be transformed into a kindly Hollywood archetype (who is also a master of all subjects and technologies).
And, lest we forget the efforts of our elected “representatives”;
In much the same way as they have manipulated and destroyed trillions of dollars of savings and wealth, the elitists are now girding to destroy what’s left of the medical system and drive the few remaining primary care practitioners in the United States out of practice.
Individuals within the legislative and executive branch with no experience or track record of success are presently proposing expensive and vague answers to the financial tsunami American is now experiencing. The events of the past few months are clear confirmation that allowing our governing elite carte blanche has been a catastrophe. Much more accountability is in order, as well as clear and detailed proposals. Simply exclaiming “trust me, we need the money with no strings attached”, astonishingly, worked once. I hope that America has learned a lesson from that experience.
Allowing fat cats and bureaucrats free reign to manipulate the financial health of our nation has in fact been a very expensive failure so far. Risking the nation’s corporeal health along with even more astonishing financial losses on the grandiose delusions of wigeting medicine into any kind of “universal” structure is nothing short of suicidal.