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Archive for the ‘Other Medicine’ Category

Monday, May 20th 2013

Financial Toxicity In Cancer Care

I wouldn’t know what to tell patients if they raised the issues of the cost of care. Let me correct that, I don’t know what to tell them. Questions like: “How much will this cost?” or “Are there any resources to help pay for this?” do come up in my patient encounters. I can do little more than shrug ignorantly and suggest a call to the social worker on the floor or in the clinic.

Now some limited research out of Duke looks at how discussions about cost in oncological care impact such,

The people who did talk about financial issues told the researchers it was helpful to do so. “They said it helped decrease their expenses,” Zafar says.

[...]

“I treat colon cancer, and I have the option of giving a drug as an IV or an oral pill,” he says. “If I give the pill form, the patient faces a copay even if they have insurance, and that copay goes away if I give the intravenous version.”

[...]

“We can’t necessarily give the best care to patients unless we address cost,” Zafar says.

Cost and the taboo about discussing such is obviously an obstacle to care. I wish I was better informed on resources for my patients. I’ve grown better over the course of my training but still feel pretty impotent in pointing them in the right direction.

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Monday, May 20th 2013

Your Robotic Surgery Costs More, Doesn’t Get You More

Robotic surgery has been a marketing point for plenty of hospitals across the country. Topping the list is the da Vinci surgical system used primarily in urologic and gynecologic surgeries and some cardiac surgeries. But these systems are expensive, costing nearly 2 million dollars. And the benefits of such, as compared to traditional minimally invasive surgery, such as with laprascopy, is highly questionable.

The surgery is “minimally invasive,” and there is some small evidence, although hardly uniform, that they may be an easier thing to learn than laproscopy. For some procedures, notably prostatectomy, the robot offers the only “minimally invasive” option. But the growth in robotic surgery, and where manufacturer’s are marketing are in procedures with other, cheaper, minimally invasive alternatives.

There is hardly an obstetrician/gynecologist or urologist or general surgeon graduating training in the western world today without extensive laprascopy experience. Heck, after a single year of general surgery, which I’m now well removed from, I almost feel comfortable taking out a gallbladder with a scope. Not that that’s comparative in difficulty to a hysterectomy with a scope (which may be why there hasn’t been a splurge for using the robots from cholecystectomies…yet) but you get the idea. I’m not sure the increased costs associated with robotic surgery can be excused as allowing a subset of older surgeons to easily expand their limited minimally invasive repertoire.

The benefits of robotic surgery have simply not been born out in the literature. See here and here and here.

Robotically assisted and laparoscopic hysterectomy had similar morbidity profiles, but the use of robotic technology resulted in substantially more costs.

The growth in these procedures is being driven largely by marketing. Marketing to providers and directly to consumers. The technology is presented as ideal for “unique” cases. But such obviously is silly. As a patient, my future or your current “unique” case, has been well represented in the studies.

Given my particular health history and current diagnosis, and based on the reading I have done and my consultation with my oncologist, I believe that da Vinci is likely to bring some genuine benefits to my situation. Not only will the surgical incisions be small (minimally invasive), easing my recovery significantly, during the procedure, as this ABC News video shows, the robot’s dexterous mobility and 3D visualization will offer heightened precision. Dr. Irvin has called da Vinci “a quantum leap” forward in treating gynecological malignancies, and that sounds good to me.

Such does little more that contribute to America’s ridiculous health care spending.

I do see a final benefit to this wide adoption. There’s a very legitimate chance that this technology will evolve and improve into systems that truly have benefits. The da vinci may be a precursor to automation or something. Adoption and support obviously make further research and investment possible. But I’m not sure even that’s an adequate excuse for the wide adoption. Maybe skip picking whose going to do your mitral valve replacement based on a billboard for now.

Thursday, May 16th 2013

Your Next Prescription Will Come From A Computer

Vinod Khlosa has already made it clear Silicon Valley will be at the forefront of automating health care. He made waves last year by saying that 80% of what physicians do can be done as well or better by a computer.

I can’t fault the premise that diagnoses and interpretation of studies and prescription of therapies are soon to be carried out better by computers than physicians. Now making headlines is the famous IBM supercomputer Watson. The former Jeopardy champion is being trained at Sloan-Kettering and The Cleveland Clinic.

In Silicon Valley and other centers of innovation, investors and engineers talk casually about machines’ taking the place of doctors, serving as diagnosticians and even surgeons—doing the same work, with better results, for a lot less money. The idea, they say, is no more fanciful than the notion of self-driving cars, experimental versions of which are already cruising California streets.

Of course, it will be a generational shift to accept such automation without significant human interface. But such will come. Such is coming. As well, I feel pretty safe that my job as a surgeon as safe for a while longer.

Monday, May 6th 2013

Like All Insurance, Medicaid’s Role In Health Debated

Last week you could watch liberals scramble in response to a New England Journal of Medicine published study.

In 2008 Oregon found resources within the state budget to expand Medicaid. There were far more eligible for the expansion than funds available. Oregon held a lottery to enroll 10,000 new people onto the Medicaid rolls. Harvard, MIT and RAND have a group who saw that lottery as a great playground for studies. The first of these studies has now published its results. The study followed approximately 6,000 people who got Medicaid in 2008 and 6,000 who didn’t and looked at how their blood pressure, cholesterol, diabetes and depression did post randomization. Here’s the important quote from the conclusion that has so many talking,

This randomized, controlled study showed that Medicaid coverage generated no significant improvements in measured physical health outcomes in the first 2 years

As the Affordable Care Act promises the greatest increase in covering the uninsured by Medicaid expansion, if states take it, the study is important.

I linked to Mother Jones above. Here’s what Kevin Drum had to say,

It’s more likely that access to Medicaid did improve health outcomes than that it had zero or negative effects. It’s just that the study was too small to say that with certainty. For laymen, as opposed to stat geeks, the headline result of the Oregon study was “Possibly positive but inconclusive,” not “Had no effect.”

Here’s Jonathan Cohn at The New Republic,

Of course, even if Medicaid isn’t improving health, it’s certainly not making health worse, as some critics have claimed. Meanwhile, it’s improving mental health and providing economic security to some of the most economically vulnerable people in the country.

Justin Wolfers resorted to hypotheticals,


And, as a final example, here’s Matt Yglesias,


There are many nuances that need to be realized about the this study. The measures in the Oregon study where all surrogates for long term health. Admittedly hardly definitive quantities. And it “trended” towards significance in those measures. And we don’t know what the study’s power was.

I concede that significance is a relative crude tool in research. See here for a good explanation of such. But I think that fact plays poorly for this study. The reality is that asking to find a significance defined as a p <0.05, depending on pre-test probabilities, is not asking a lot.

Even without knowing the power with specificity, if this study couldn’t find signifigance at that level then to raise policy questions based on this study is not unreasonable. The beneficial effects of Medicaid on these quantities must be small if they’re real.

And so, only Kevin Drum in hindsight realized the real question this study raises,

Even if they’re real, are these results worth the money spent? That’s a different question, and there’s just no way to answer it with this study. That would require a much larger, longer-term research project.

I strongly disagree with the assertion this study doesn’t help answer that question.

The fact that most proponents of the Affordable Care Act are loathe to discuss, in my limited experience, is the fact that insurance status is not a terribly strong influencer of health. Sure, it influences health utilization and some surrogate markers. But I’m with the studies that imply its effect on major things like mortality is negligible conceding that such is debated.

The Institute of Medicine’s estimate that lack of insurance leads to 18,000 excess deaths each year is almost certainly incorrect. It is not possible to draw firm causal inferences from the results of observational analyses, but there is little evidence to suggest that extending insurance coverage to all adults would have a large effect on the number of deaths in the United States.

The link in the quote is my own.

There are two associations that stunningly are a matter of debate.

The first is the association between insurance status and health care access. Especially with the Medicaid population there are other impressive obstacles to utilizing health care. Those include education and understanding of health issues, time constraints, literacy rates, angst at interacting with providers of different socioeconomic status amongst others. No matter their insurance status those of lower socioeconomic status utilize less health care and have poorer health.

The second is even more stunning, the association between health care access and health. It is true access to care is sometimes associated with secondary measures of health – some of the same measures in the Oregon study and others – but its association with the big quantities such as life expectancy is hardly unequivocal.

I find that personally a little bit shocking.

No doubt health care saves lives and improves health. Our own anecdotes tell us that. But it may very well be doing that on the margins. On a population level how much it effects such, especially as compared to things we might label under the umbrella ‘public health’ is questionable. And so we’re expanding Medicaid at considerable costs and for, perhaps, limited benefit. To what such limited benefit this study may help elucidate. And that is certainly something worthy of policy debate.

The issue is complex. There are cost savings and cost shifting in expansion and there are benefits to consider other than large population based health measures. But to pretend that such doesn’t deserve debate and that this Oregon study doesn’t inform that debate is silly.

The Oregon study is a blow to the logic behind Medicaid expansion.

Sunday, May 5th 2013

Post Spinal Tap Headaches Can Be A Real Problem


You can imagine that if the pressure inside of your head is high you might, amongst other things, have a headache. Your skull is a closed box and the contents of the box are relatively fixed with a certain amount of blood, cerebrospinal fluid and brain. Adding additional contents to the box such as blood or cerebrospinal fluid, such as in hydrocephalus or pseudotumor cerebri, or more brain, such as in some tumors, increases the contents without increasing the volume which necessarily increases the pressure.

What’s interesting is that you can also get terrible headaches if the pressure is too low. Such appears to have happened to Chicago Bulls forward Luol Deng.

Your spinal cord, and the nerves that run to your legs, bowel and bladder, are protected by a tough sheath known as dura. The spinal cord and the nerves are bathed in a fluid your body makes, known as cerebrospinal fluid, which is contained within the dura as well. Some diseases require sampling the cerebrospinal fluid to help diagnose them. Examples of such include hydrocephalus, to see if the pressure is high, or meningitis or multiple sclerosis.

In Luol Deng’s case he apparently had symptoms that made the ER physicians concerned that he might have meningitis and so he had a lumbar puncture. This is a procedure wherein a needle is inserted into the back, between the vertebrae, and through the dura to get a sample of cerebrospinal fluid.

In most cases the hole the needle makes in the dura heals up easily by itself. However sometimes the durotomy does not heal and cerebrospinal fluid can continue to leak through the hole after the lumbar puncture is done.

The image above is technically post operative, involving a surgery where the dura had to be opened. However the idea is similar, you can see the cerebrospinal fluid (and actually the nerves themselves) are leaking out of the dura. Because the cerebrospinal fluid in your back is continuous with the cerebrospinal fluid in your head and around your brain, a persistent leakage of cerebrospinal fluid can actually lower the pressure inside your head. Low intracranial pressure can lead to headaches as well.

The initial treatment for cerebrospinal fluid leaks from small holes in the dura, such as typically caused with a lumbar puncture, is to have the patient lay flat for several days. The idea is that cerebrospinal fluid is more likely to leak when you’re upright and gravity is pulling the fluid down towards the hole. If you’re flat and prevent a continuous leak the dura can heal itself. If that fails then often a blood patch will be attempted. Here blood is drawn from a patient’s vein and then injected into the area right around the durotomy to try to produce a clot that seals the leak. Failing that, and incredibly rarely, patients may have to go to the operating room to have surgery to close the leak.

It sounds as if Luol Deng may be feeling better. I wish him the best. As I write this his teammates are winning Game 7 of their second round matchup with the Brooklyn Nets.

Sunday, May 5th 2013

Facing The Truth On Cancer

You need to read this piece in Salon by Mary Elizabeth Williams who is living with widely metastatic melanoma.

[T]he fate of people with metastatic cancer is the same as everybody else’s – to go on living until life ends

It raises important issues, and links to posts from others on the same subject, about how the end of life with cancer makes even cancer patients and cancer support groups and cancer researchers uncomfortable.

Sunday, April 28th 2013

The Government Telling You What Drugs You Can Take Is A Balancing Act

What’s the substantial difference between hydrocodone or dihydromorphone or diacetylmorphine? Beyond their manmade designations. Their potential risks versus their potential benefits are difficult things to quantify. In some studies diacetylmorphine is a better analgesic than morphine; nowadays, at least in the United States, only the criminal can tell us anecdotally. The various governments of our federal republic nominally weigh the risk versus reward of all controlled substances in determining under what conditions they will allow them.

It is true that government regulatory behavior appears to influence clinical providers utilization of opiates. But considering physicians can’t even agree on the appropriate use of the opiates the government does lend them to use,

It is unlikely these standards will be developed until there is a consensus among pain specialists about opioid use for nonmalignant pain because boards/agencies have no consistent, reliable source of expert information: Pain specialists should initiate efforts to develop this consensus.

Long term opiates for nonmalignant chronic conditions remain a controversial subject. I say that despite their wide use. Many factors including many psychological and social and financial factors that favor benefit from opiates play into any improvement (or lack thereof) in such pain. And the long term benefit from opiates in a condition like chronic back pain is questionable at best despite the fact such drugs may be the only thing that seems to make your loved friend or family functional. To be fair, not as dubious as surgery itself often.

Nor, as above, is the utilization of opiates, even amongst pain specialists, standardized for such conditions. It is remarkable both the variations amongst clinicians in opiate use for nonmalignant pain and the factors that influence such use. So a belief your personal health care providers know best for your pain may be an inadequate argument against government regulation of opiates.

I’m not a fan of government regulation of opiates whether in a medical setting

My wife suffers from chronic pain…she…requires daily narcotic pain medication to manage her pain.

[...]

My wife is not the criminal. Colorado and the DEA are forcing her to live in pain as they restrict her legal access to pain relief. No one should have to watch the person they love suffer in unimaginable pain just because of bureaucratic hurdles put in place to slow illegal drug use.

…or for personal treatment or other reasons. The point of this post is the distinction is smaller than you may imagine. “[I]llegal drug use” is whatever the government says. Philosophically is there much difference between restricting the hours when you can get morphine from a pharmacy and making the very possession of heroin out of the lab illegal?

Friday, April 26th 2013

Why You May Have Less To Fear From Superbugs Than You Think

Infectious disease is the most hyperbolic of all medical fields, at least when the media gets ahold of such. Right now we are to fear a new avian influenza virus. Previously there was another avian influenza strain whose outbreak threatened the world and of course SARS and, more distantly, the ebola virus and the threat of bioterrorism. And on the periphery, as these acute threats come and go, is the persistent threat of super bugs; bacteria resistant to multiple antibiotics. Sometimes all antibiotics.

I remember my pharmacology professor in medical school claiming that within our practice lives we would reach the useful end of antibiotics. A claim, literally, that physicians would no longer have any use for antibiotics by the time I reached the end of my career.


via The Hamilton Project

Scary stuff but evidence that such outrageousness sells pharmacology in a classroom as much as it does magazines on a news stand. Time magazine a post called “The End of Antibiotics?” referencing a Guardian article along the same lines. This followed a similar 2009 scare article in Time.

And recently in the New York Times, this,

Scientists all over the globe are in a race with evolution, scrambling to understand the underlying mechanisms of antibiotic resistance and to discover new ways to fight bacteria. We must diversify our methods for treating bacterial infections and simultaneously reduce the amount of antibiotics we use, says Brad Spellberg, an infectious-disease specialist at U.C.L.A. This has led to a renewed interest in treatments from a world before penicillin.

In the United Kingdom tabloids took to tracking down individual MRSA victims and sensationalizing their stories, prompting this response from the BMJ,

Raising public awareness can be helpful, but the creation of a climate of fear among patients entering hospital is more likely to increase newspaper sales than to provide a solution.

And while that is part of the issue of the hysteria around antibiotic resistant infections, obviously media is not the sole driver of such. The director of the World Health Organization said antibiotic resistance meant “an end to modern medicine as we know it.” The Infectious Disease Society of America has this publication called, “Bad Bugs, No Drugs.” Sensational quotes.

In 2007 multiantibiotic resistant bacteria were attributed as the cause of 25,000 United Kingdom deaths a year. In the United States the CDC estimates that 90,000 people die from hospital acquired infections every year, a significant portion of those likely from multiantibiotic resistant bacteria. Terrible numbers, but even if they’re on the rise, they continue to pale in comparison to other health care risks and this more than 5 decades after the first great superbug came into the mainstream consciousness.

Infection continues to register weakly as a cause of mortality in the United States compared to heart disease or cancer or chronic respiratory disease or trauma or suicide even. Even when you add all the infections up; the majority of them hardly attributable to multiantibiotic resistant bacteria.

I know we spend much time focussing on the risk factors for cardiac disease and lung disease and the public health issues of such. And the media aids such, but certainly not on the order of magnitude more you might imagine such would demand considering the true risks these non-communicable diseases pose for you and me. And not with the hysteria with which media covers infectious diseases.

This is a serious problem but one that despite its growth will long pale in comparison to other public health issues. And it is not an insurmountable issue. Old therapies, new therapies, prevention are all reasonable strategies for checking the threat of multiantibiotic resistant bacteria. Any public disaster that can be anticipated with any permeance of common knowledge and with any foresight can be stopped.

To be fair, media coverage serves the purpose of informing an important step in fixing any problem but, perhaps, with some measure to the coverage.

Monday, April 22nd 2013

The Two Thousand Dollar CABG

I remember reading a profil of Devi Shetty and dismissing his dream of cheap surgery as unreproducible in the West. His Narayana Hrudayalaya hospital in Bangalore India supposedly does the most heart operations in the world. He contracts with fabric companies to make his own low cost suture, trains families to perform the duties of western nurses (although such is the way in much of the world), is aided by India’s lax recognition of pharmaceutical patents and uses his huge volume to drive a bargain on medical equipment he cannot replicate in cheaper form. All of such is done on the cheap for patients with a tiered progressive pricing system that has the truly poor pay nothing and those that can afford it pay on a scale and for more comfortable accommodations.

He continues to push boundaries by opening facilities across India and one in the Cayman Islands. In a new profile, he compares his ambitions to health care in the western world,

“Near Stanford (in the US), they are building a 200-300 bed hospital. They are likely to spend over 600 million dollars,” [Devi Shetty] said.

“There is a hospital coming up in London. They are likely to spend over a billion pounds,” added the father of four, who has a large print of mother Teresa on his wall — one of his most famous patients.

“Our target is to build and equip a hospital for six million dollars and build it in six months.”

There may indeed be things to take away from Dr. Shetty’s work. Ideas about continuous operations and large volumes and standardization of processes. Here is his talk on such things to an NHS trust. But it is not wholly replicable. And isn’t merely a matter of entrenched interests or unnecessary regulation. Certainly such are major obstacles. The biggest obstacle and a foolish obstacle.

But even if such didn’t exist in western health care there are other more inherent considerations. At least one of which is that I think much of what Dr. Shetty has done has benefited from costs borne by western health care.

India and Africa and the Cayman Islands didn’t bear the development costs of those dialysis machines or heart valves that Dr. Shetty’s company is now buying in bulk. And they can’t. The technology in fifty years or a hundred years that is going to make all of Dr. Shetty’s valve replacement operations obsolete isn’t going to come from the still developing world.

That’s not to completely justify the massive difference in costs between what Dr. Shetty is doing and America. Like I said, there is much to learn from him. I agree in the specialization of physicians as technicians, of tertiarization of specialized care, of volume and of operating closer to capacity and with greater efficiency. There is probably amazing savings for western health care there. But the idea of the two thousand dollar CABG in England or France or Canada is infeasible and, to be honest, I’m not sure desirable.

Friday, April 19th 2013

The Studies Are All Bad

One of my fellow residents might be a Ben Goldacre disciple except amongst all his citations in conversation I’ve never heard him reference the English Physician. I’ll call Dr. Goldacre the ‘Bill Nye’ or the ‘Neil Degrasse Tyson’ of the antagonistic medical epidemiology circle. But it’s a growing group. Amongst them as well the Greek epidemiologist, John Ioannidis.

There is a horrific set of facts about what we know in medicine.

1) Most medical research is so poorly designed that conclusions you can draw from it are…limited

2) The medical research we are conducting is low yield

3) Most medical research performed never comes to light because it fails to meet the hypothesis of those who conducted it

4) There is strong incentive to falsify results

Ioannidis has a famous paper entitled “Why Most Published Research Findings Are False,”

[T]he majority of modern biomedical research is operating in areas with very low pre- and post-study probability for true findings. Let us suppose that in a research field there are no true findings at all to be discovered.

A Huffington Post article by Dr. Ida Sim,

About 80 percent of clinical trials are funded by the commercial sector, but the commercial sector disproportionately studies drugs, and understudies behavioral treatments or older treatments that can’t be patented or profited from. When 75 percent of our medical costs are for chronic diseases that are largely due to poor lifestyle habits, where are the studies on prevention? On behavior? On effective patient-doctor or public health strategies? Where are the studies that examine the balance of benefits and harms, that guide patients and doctors on side effects and cost-effectiveness?

In England a researcher working for Aptuit is set to serve a prison sentence for falsifying lab results for a cancer drug.

Steven Eaton, from Cambridgeshire, has become the first person in the UK to be jailed under scientific safety laws.

[...]

Sheriff Michael O’Grady said: “I feel that my sentencing powers in this are wholly inadequate. You failed to test the drugs properly – you could have caused cancer patients unquestionable harm.

“Why someone who is as highly educated and as experienced as you would embark on such a course of conduct is inexplicable.”

Speaking after the case, Gerald Heddell, the Medicines and Healthcare Products Regulatory Agency’s director of inspection, enforcement and standards, said he welcomed the conviction.

He added: “This conviction sends a message that we will not hesitate to prosecute those whose actions have the potential to harm public health.”

Biomedical research is difficult to call science. What you can assume your doctor or surgeon knows about your condition is surprisingly less than you think. They will certainly act like they know and truly believe that they do but such knowledge is based on a limited amount of reliable data. In Dr. Ionnaidis’ essay there are some suggestions on making medical research better. And of course as Dr. Goldacre calls for all results of all medical research should be public. Even if that disincentivizes some research we may not be missing out on much.