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Through a Scanner Darkly: Three Health Care Trends for 2013

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By DAVID SHAYWITZ, MD

As we anticipate a new year characterized by unprecedented interest in healthcare innovation, pay particular attention to the following three emerging tensions in the space.

Tension 1: Preventive Health vs Excessive Medicalization

A core tenet of medicine is that it’s better to prevent a disease (or at least catch it early) than to treat it after it has firmly taken hold.   This is the rationale for both our interest in screening exams (such as mammography) as well as the focus on risk factor reduction (e.g. treating high blood pressure and high cholesterol to prevent heart attacks).

The problem, however, is that intervention itself carries a risk, which is sometimes well-characterized (e.g. in the case of a low-dose aspirin for some patients with a history of heart disease) but more often incompletely understood.

As both Eric Topol and Nassim Taleb have argued, there’s a powerful tendency to underestimate the risk associated with interventions.  Topol, for example, has highlighted the potential risk of using statins to treat patients who have never had heart disease (i.e. primary prevention), a danger he worries may exceed the “relatively small benefit that can be derived.”  (Other cardiologists disagree – see this piece by colleague Matt Herper).

In his new book Antifragile, Taleb focuses extensively on iatrogenics, arguing “we should not take risks with near-healthy people” though he adds “we should take a lot, a lot more, with those deemed in danger.”

Both Topol and Taleb are right that we tend to underestimate iatrogenicity in general, and often fail to factor in the small but real possibility of potential harm.

At the same time, I also worry about external experts deciding categorically what sort of risk is or isn’t “worth it” for an individual patient – a particular problem in oncology, where it now seems  fashionable to declare the possibility of a few more months of life a marginal or insignificant benefit.

Even less dramatically, a treatment benefit that some might view as trivial (for hemorrhoids, say) might be life-altering for others.  For these sufferers, a theoretical risk that some (like Taleb) find prohibitive might be worth the likelihood of symptom relief.  Ideally, this decision would ultimately belong to patients, not experts asserting to act on patients’ behalf.

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A Well-Armed and Regulated Citizenry, Led by Heavily-Armed Teachers in Body Armor …

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By PETER UBEL, MD

Gun rights advocates are correct: a well armed principal might have reduced the death toll from the tragic elementary school shootings in Connecticut last week.

Gun carrying citizens might also have been able to take down the shooters in Aurora and Virginia Tech. To most people, after all, guns are about self-defense, not about committing crimes. As the old saying goes: “There has never been a mass shooting at a gun show.”

On the other hand, gun control advocates are correct to point out that mentally disturbed people like Adam Lanza would not be able to commit massacres if they were prevented from getting their hands on high-powered, semiautomatic weapons. They are also correct to point out that Americans have staggeringly easy access to weapons that far exceed what any sportsmanlike hunter would use during deer season.

In other words, figuring out what to do in the wake of the Connecticut massacre means recognizing the truth in both of these views. It means considering the possibility that the answer to reducing gun violence is a matter of both having more guns and less.

To understand what I mean by “both more and less,” I offer two analogies: a straightforward one about airport security, and a more unexpected one about breast cancer screening.

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Can We Stop Dementia Before It Starts?

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By E. Loren Buhle

Few diseases invoke more fear in patients and families than dementia (e.g., Alzheimer’s Disease (AD), progressive multiple sclerosis, Pick’s Disease). Surveys have shown the fear of dementia—especially AD—far outweighs concerns of a diagnosis of cancer, stroke, or cardiovascular disease.

Perhaps this fear arises from two concerns: (1) dementia robs us of what makes us human—memory, reasoning, emotions, language—and (2) in most cases there are no effective treatments to cure or palliate the disease. While diagnostics for certain forms of dementia are progressing—allowing us to sort out the reversible causes of dementia, such as hydrocephalus, electrolyte or blood sugar imbalances, brain tumors, and brain injuries—once the diagnosis of AD or Pick’s disease is made, there is little we can do aside from manage the comfort and safety of the patient and family.

What if we could prevent or delay dementia?

In the mid-1960s, the incidence of heart attacks and stroke were increasing at an alarming rate. Great strides were made in treating existing cardiovascular disease, followed by programs at preventing the disease in the first place. These prevention methods included exercise, diet, and the tracking of key incidence indicators such as blood pressure, body mass index, and cholesterol levels to maintain a quantifiable physical health.

Could we use similar prevention methods for preventing or delaying dementia?

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Now Is Not the Time to Talk About Gun Control

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By David Katz, MD

Yesterday was.

There are two reasons not to talk about gun control in the immediate aftermath of the Newtown atrocity, and opposition by the NRA and its adherents is neither of them.

The first is that addressing gun control right after innocents are shot might in some way seem exploitative. The second is that no imaginable degree of stringent gun control could fully exclude the possibility of an unhinged adult shooting a kindergartener.

But both of these objections are as porous as the sands of our shores battered by Hurricane Sandy. And a consideration of those shores readily reveals why.

With regard to exploitation, there was no thought of it as post-Sandy ruminations turned to how we might best prevent or at least mitigate the next such catastrophe. It was not exploitative to look around the world at strategies used to interrupt storm surges, divert floodwaters, or defend infrastructure. Those reflections continue.

Similarly, it’s not exploitative when my clinical colleagues and I speak to our patients in the aftermath of a heart attack or stroke about what it will take to prevent another one. In fact, these exchanges have a well-established designation in preventive medicine: the teachable moment.

It is opportunistic, but in a positive way: There is an opportunity to do what needs to be done. Admittedly, it’s better to talk about preventing heart disease, or the drowning of Staten Island, or of New Orleans, or the shooting of children, before ever these things happen. But the trouble tends to be: Nobody is listening then.

We are constitutionally better at crisis response than crisis prevention.

We’ll get back to the Constitution shortly.

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The Only Way Out of the Health Care Wilderness

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By William Bestermann, MD

The landmark 2001 document from the Institute of Medicine’s (IOM), Crossing the Quality Chasm, should have guided us out of the healthcare cost-quality crisis. It argued that the root cause of our difficulties has been a failure to meet the needs of patients with chronic disease. We have not solved this crisis because we have almost entirely ignored the recommendations for reform found in that document.

The claim that we have the best healthcare in the world is correct only if you have an acute condition. If you are having an event, such as a heart attack, our system can provide an emergency stent — for as much as $50,000 — that will open the blocked artery, immediately relieving the pain and saving your life. We are really good at rescue medicine-crisis medicine.

But acute conditions generate enormous costs only because we have not addressed the chronic condition earlier, interrupting the disease progression that produces the acute events. Since most healthcare cost growth over the past 2 decades has been related to patients with 4 or more chronic conditions, this should be recognized as the foremost issue in healthcare reform.

In fact, the IOM charged that, despite the central role of chronic disease in most pain, disability, death, and cost, care continues to be designed around the needs of providers and institutions, and most patients with chronic conditions do not receive the care they need. A 17-year lag in implementing new scientific findings results in highly variable care.

That cardiologists favor coronary stenting over optimal medical therapy — that is, managing vascular disease using $4 drugs and recommended lifestyle changes — provides a powerful case in point.

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Can Too Much Preventive Care Be Hazardous to Your Health?

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By AL LEWIS

Politicians and pundits everywhere call for more disease prevention as a way to reduce healthcare costs. Certainly you cannot argue with the logic that “an ounce of prevention is worth a pound of cure.”

Or can you? It turns out that you can not only argue against that so-called logic, but – just as with cancer detection, which may have been done to excess in some protocols — you can mathematically prove that, at least for asthma, it takes a pound of prevention to avoid an ounce of cure.

The database of the Disease Management Purchasing Consortium Inc. (www.dismgmt.com) tracks both asthma drugs and visits to the emergency room (ER) and hospital stays associated with asthma. The average cost of an attack requiring an ER visit or inpatient stay is about $2000. The average cost to fill a prescription to prevent or recover from an asthma attack is about $100. It turns out that asthma attacks serious enough to send someone to the ER or hospital are rare indeed. In the commercially insured population, these attacks happen only about 3-4 times a year for every thousand people. (The rate is much greater for children insured by Medicaid; additional resources spent on prevention could very well be cost-effective for them.)

For a million-member health plan, that might be 3000 or 4000 attacks Yet that same million-member health plan is paying for hundreds of thousands of prescriptions designed to prevent or recover from asthma attacks. Depending on the health plan, the ratio of drugs prescribed to asthma events serious enough to generate an ER or hospital claim ranges from 60-to-1 to 133-to-1. Using those statistics of $2000 per event and $100 per prescription, a health plan would pay, on average, anywhere from $6000 to $13,300 to prescribe enough incremental drugs to enough incremental people to prevent a $2000 attack.

Averages lump together people at all risk levels. Surely some of those people really are at high enough risk of an attack that they are already inhaling their drugs regularly to prevent one, and have a “rescue inhaler” nearby. By definition their risk of attack is much greater than for low-risk people. Assume, very conservatively, that low-risk patients have a risk of attack which is half that of the average patient. This means that putting most low-risk patients on drugs costs $12,000 to $26,600 for every $2000 attack prevented.

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How to Stop a Future Cancer Epidemic

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By Paul Levy

The theory of preventative care, including inoculations, is that we spend a little money now to offset big expenses later in life.  But sometimes behavioral friction keeps this from happening, even when the technologies and approaches are proven.  We are witnessing such a failure right now with regard to Human Papilloma Virus (HPV).

Here’s the story, from MGH’s James Michaelson, PH.D., arguably one of the most thoughtful, trustworthy, and sensible researchers in the field of analysis of cancer survival.  Jim and his team develop sophisticated mathematical methods for predicting the risk of local, regional, and distant recurrence.  He says:

There are a couple of good papers about Human Papilloma Virus (HPV), and the coming epidemic (yes, an overused term, but truly applicable here) of head and neck cancer. As Chaturvedi et al say in a recent paper: “If recent incidence trends continue, the annual number of HPV-positive oropharyngeal cancers is expected to surpass the annual number of cervical cancers by the year 2020.”

I get to see this problem from two angles: From my work as the the manager of the MGH/MEEI Head and Neck Cancer Database, and  from my experiments in using computer telephone messages to get patients in for preventive health services, such as the fabulous HPV Vaccines: Cervarix (from GlaxoSmithKline) and Gardasil (from Merck). The vaccines are incredibly underutilized. Only about 1% of eligible boys and only 50% of eligible girls get one shot.  Only about 25% of girls get all three shots.

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Stop Cancer Research?

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By James Salwitz, MD

Now here is a novel idea to save lives and stop the cancer plague; stop trying!  Sounds as crazy to me, as it does to you, but this idea actually may have merit.  Some smart people are saying that we have spent too much money for little gain, thus it is time to give up and by retreating win more battles in the war on cancer, than by charging ahead.

The Cancer Prevention and Research Institute of Texas (CPRIT) is the second largest cancer research agency in the United States, after the National Cancer Institute, controlling a pot of $3 billion dollars, most of which funds basic science and clinical research.  At recent hearings, university scientists and leaders in biotech proposed that CPRIT cut back on the money it is pouring into laboratories.  As Professor John Hagan of the University of Texas proclaimed, “If people didn’t get cancer in the first place, CPRIT would accomplish much of its mission.”

This radical idea was echoed in a scary article in the September issue of Lancet Oncology, entitled “First do no harm: counting the cost of chasing drug efficacy.” This editorial reviewed data, which shows that between 2000 and 2010 many new cancer drugs produced marginal extensions in survival and simultaneously increased risk of treatment associated death and side effects. The Lancet authors emphasized the vital need as we develop new therapies to carefully measure both benefit and harm before FDA approval and for careful post-marketing follow up after drugs are released to the general population.

Now in reality no one is saying that we should shut down cancer research labs and simply hope for the best.  Eventually we will completely cure this disease and basic science, as well as the development of new therapies, is key to that future. Perhaps what we should hear from these words is an idea about a different balance in health and healthcare.

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Rational Rationing vs. Irrational Rationing

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By David Katz, MD

Massachusetts has a long track record of making headlines in the area of health care reform, whether or not Mitt Romney likes to talk about it.

In 2008, Massachusetts released results of its initiative requiring virtually all of its citizens to acquire health insurance. In short order, nearly three-quarters of Massachusetts’ 600,000 formerly uninsured acquired health insurance, most of them private insurance that did not run up the tab for taxpayers. The use of hospitals and emergency rooms for primary care fell dramatically, translating into an annual savings of nearly $70 million.

But that’s pocket change in the scheme of things, so the other shoe had to drop — and now it has. Massachusetts made news recently, this time for passing legislation that aims to impose a cap on overall health care spending. That ambition implies, even if it doesn’t quite manage to say, a very provocative word: rationing.

Health care rationing is something everyone loves to hate. Images of sweet, little old ladies being shoved out the doors of ERs that have met some quota readily populate our macabre fantasies.

But laying aside such melodrama, here is the stark reality: Health care is, always was, and always will be rationed. However much people hate the idea, it’s a fact, not a choice. The only choice we have is to ration it rationally, or irrationally. At present, we ration it — and everything it affects — irrationally.

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What’s the Real Emergency Room?

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By David Allen

My summer job before I left for college in 1965 was the night admitting clerk in the emergency room in the Huntsville, Alabama county hospital – a facility built to support a few thousand in a small rural community but now taxed with serving hundreds of thousands, brought to town by the new Apollo missile program.  Saturday nights in the small emergency room were often pure chaos, with auto wreck victims lined up on gurneys in the hallway. Those shifts passed the quickest for me, and I slept the best, afterwards.

Crisis promotes a kind of serenity. Why do people commonly tend get into their “zone” then? It’s because of what the situation demands: appropriate engagement. Think about the last time you were in such a circumstance. What were the fundamental components of your experience and behavior? Immediate integration of potentially meaningful inputs; clear definition of desired outcomes; trust in your intuitive judgment; decisions about specific next actions and physical movement on the most critical; consistent recalibration of all factors as required; acceptance of what can’t and needn’t be done at that moment. Those are all core elements of triage, and, actually, appropriate engagement with anything. Put together they’ll get you into your “zone.”

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