DrMatt: I'm worried about the death panels...seriously...

Over at DailyKos, DrMatt has collected a nice selection of anecdotes for my collection.

I have some more from Doctors for Amercia I'll try to post later today...

I will be on KDKA Radio Pittsburgh tonight (Thursday Aug 13) at 9 PM with conservative talker Mike Pintek.

You can listen live at www.kdkaradio.com

Cheers,

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IBD, Stephen Hawking and Nice

You have by now all read of the very funny folks at Investors Business Daily thought England's NHS was so awful that a poor soul like Stephen Hawking would be long dead had he to depend on those slugs in England for his care.

Just in case you missed it, here's the correction:

Editor's Note: This version corrects the original editorial which implied that physicist Stephen Hawking, a professor at the University of Cambridge, did not live in the UK.

But, enough hilarity. If you read the rest of IBD's editorial, you might notice their attack on England's National Institute for Health and Clinical Excellence (NICE), an arm of the NHS, for its ruthless analysis of the cost and effectiveness of drugs. The bastards!

Anyway, the editorial contains this sentence, "In March, NICE ruled against the use of two drugs, Lapatinib and Sutent, that prolong the life of those with certain forms of breast and stomach cancer." This is interestingly the exact same sentence that appeared in a WSJ op-ed on July 7th. But it's a beautiful sentence. Who can blame IBD?

IBD also has this gem: "The British are praised for spending half as much per capita on medical care. How they do it is another matter. The NICE people say that Britain cannot afford to spend $20,000 to extend a life by six months. So if care will cost $1 more, you get to curl up in a corner and die."

I can just see the clinicians and scientists at their final meeting, throwing patients under the bus for that dollar/pound. Bastards! The corollary to this, when you think about it, is the pharmaceutical company not lowering the price for the wonder drug by this apocryphal dollar. Bastards!

But what about these heartless beasts at NICE and these wonder drugs the British public is being denied.

From the NICE report on Lapatinab for breast cancer:

Clinical Benefit Rate
Using the independent assessment a greater proportion of subjects in the lapatinib + capecitabine group (29%) than in the capecitabine group (17%) achieved clinical benefit (odds ratio: 2.0, 95% CI: 1.2, 3.3, two-sided p-value: 0.008; cut-off date 3 April 2006). Using the investigator assessment of the clinical benefit response rate a greater proportion of subjects in the lapatinib+capecitabine group (37%) than in the capecitabine group (21%) achieved clinical benefit (two-sided p-value: 0.001).

Duration of Response
For subjects who responded to treatment, the median duration of response was 32.1 weeks in the lapatinib+capecitabine group and 30.6 weeks in the capecitabine group.

Get that? They are being denied a drug that increases the median duration of response by a staggering 1.5 weeks for the additional 12% who had some response to treatment!

The same paper included an analysis of a study on brain metastases that showed no significant difference in outcomes there, either.

Don't get me wrong. I am all for research and pushing the envelope. Continuing to study these drugs is fine, as long as all the appropriate ethical guidelines are followed, particularly with regards to real informed consent. But arguing on the basis of a study as described above that this should be placed into mainstream use is ridiculous.

My other pet peeve about these types of treatments is the cruel, false hope given to so many patients as they are offered "the next" chemotherapy regimen, intensive care, and so on.

I also have no objection to choosing to continue these treatments to the bitter end, as long as one understands the choice. I often get patients on "salvage" chemotherapy, palliative chemotherapy or palliative radiation treatments who don't understand what those terms mean. Maybe they were too rattled when the discussion took place and simply don't remember. But my experience with these patients and their families is that the discussion never took place in earnest.

Being told that the cancer has come back or spread to your brain or whatever and that here's what we can do next is far different than having a really hard conversation about your prognosis and all of your options.

Maybe your options are 2 or 4 or 6 months with "salvage" chemo if things go well (or a much more abrupt end if they don't!) versus 1 or 3 or 5 months without, but at home, having your symptoms aggressively managed by a palliative care specialist and working with hospice for a peaceful dignified end. And more than likely the 2 or 4 or 6 months with aggressive treatment means a lot of that time spent in the hospital, dying in an intensive care unit, hooked up to life support until someone finally tells you, too late, the hard truth.

Let's not kid ourselves about this disturbing side of American medicine: our often mindless devotion to doing "everything" up until the nails are being hammered into the coffin is, more often than not, in stark contrast to doing "the best things" for our patients.

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AMNews: May 14, 2007. Battle over futile care erupts in Texas ... American Medical News

AMNews: May 14, 2007. Battle over futile care erupts in Texas ... American Medical News:

Disability rights and pro-life activists are pushing for changes in Texas law that would force physicians and hospitals to provide life-sustaining treatment indefinitely in medically futile cases.
Under an advance directives law hammered out by medical, disability and pro-life groups in 1999, the families or proxies of patients on life support have 10 days after hospital officials formally notify them that they plan to withdraw treatment to find another facility to care for the patient.
But the Terri Schiavo controversy and a number of heavily publicized cases in which Texas families scrambled to transfer their loved ones and sued hospitals to continue treatment have taken place since then. Bills now being considered in the Texas Legislature would eliminate that 10-day time limit. A measure in the 150-member House has garnered 80 co-sponsors.
The Texas Medical Assn. argues that these so-called treat-until-transfer bills would force doctors to continue treatment in cases when it's medically inappropriate and that further intervention inflicts pain on patients without any corresponding medical benefit.
The Texas law, which applies only to terminally ill patients with an irreversible condition who are unable to make their own health care decisions, is also unusual because it requires the hospital's ethics committee to review any medical futility case before the 10-day clock starts ticking. While hospitals in other states usually review any decision to withdraw care, such procedures are not legally required. Virginia is the only other state to place a time limit, 14 days, on how long an effort to transfer the patient must continue before life support is withdrawn.
Texas hospitals have used their state's advance directives law 27 times to withdraw treatment over family objections, said Robert L. Fine, MD, one of the 1999 law's architects.

Although, as the article points out, AMA ethics policy is consistent with this approach, I am surprised that it has ben used so often in Texas. But then, this is the death penalty state, and so, I suppose we shold not be surprised.

I can't see doing this, personally, but I can tell you that the irrationality of some families is impenetrable, and the strain on ICU staff - which should count for something - in engaging in what most of us would consider behavior tantamount to cruelty leads to early burnout of some very fine individuals for no benefit other than the acquiescence to this irrationality.

BTW, the law was not updated and stands as it was.

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The Associated Press: Long lines as free health care offered in LA area

The Associated Press: Long lines as free health care offered in LA area:

The Los Angeles event marks the first time Remote Area Medical has provided such medical care in a major urban area. The medical group typically serves patients in rural parts of the United States and travels to underdeveloped countries.

The piercing sound of teeth being drilled and scraped echoed up to the rafters where the Los Angeles Lakers once played to the roar of capacity crowds. Mobile health trucks provided other medical examinations, and tables full of donated eyeglasses were available to those who had eye examinations done.

Since 2000, The Forum has been owned by Faithful Central Bible Church, which donated the use of the facility for a week. The medical professionals volunteered their time and covered their own liability. Cash and services were donated by local hospitals, health systems and charitable groups.

Tennessee-based RAM's founder Stan Brock said he helps organize 30 to 40 such health care events a year, with a total of 567 events held to date, adding: 'We just wish we could do more.'

'This need has existed in this country for decades and decades,' said Brock. 'The people coming here are here because they are in pain.'
The event came at a time when the national debate over President Barack Obama's health reform plan has boiled over at town hall meetings, with opponents sometimes shouting down Democratic members of Congress who favor the program.
Rep. Maxine Waters, D-Calif., told a cheering crowd of volunteers and medical professionals at The Forum that she would continue to advocate for health care reform because 'we can do a better job of providing health care to those who desperately need it.

Let's see, 567 events times maybe 500 people each, how many anecdotes is that?

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A reality check on that Canadian "Brain Tumor" story

A reality check on a reality check:

Still, I found Holmes tale both compelling and troubling. So I decided to check a little further. On the Mayo Clinic's website, Shona Holmes is a success story. But it's somewhat different story than all the headlines might have implied. Holmes' 'brain tumour' was actually a Rathke's Cleft Cyst on her pituitary gland. To quote an American source, the John Wayne Cancer Center, 'Rathke's Cleft Cysts are not true tumors or neoplasms; instead they are benign cysts.'
There's no doubt Holmes had a problem that needed treatment, and she was given appointments with the appropriate specialists in Ontario. She chose not to wait the few months to see them. But it's a far cry from the life-or-death picture portrayed by Holmes on the TV ads or by McConnell in his attacks.
In Senator McConnell's home state of Kentucky, one out of three people under age 65 do not have any health insurance. They don't have to worry about wait times for hip or knee replacement or cancer surgery -- they can't get care. The median household income in Kentucky is $37,186 -- not quite enough for the $97,000 bill at the Mayo Clinic. CNN didn't mention that in its 'Reality Check.'"

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The Health Care Blog: How to Rein in Medical Costs, RIGHT NOW

The Health Care Blog: How to Rein in Medical Costs, RIGHT NOW
From Dr. George Lundberg...

"So, what can we in the USA do RIGHT NOW to begin to cut health care costs?

An alliance of informed patients and physicians can widely apply recently learned comparative effectiveness science to big ticket items, saving vast sums while improving quality of care.

1. Intensive medical therapy should be substituted for coronary artery bypass grafting (currently around 500,000 procedures annually) for many patients with established coronary artery disease, saving many billions of dollars annually.

2. The same for invasive angioplasty and stenting (currently around 1,000,000 procedures per year) saving tens of billions of dollars annually.

3. Most non-indicated PSA screening for prostate cancer should be stopped. Radical surgery as the usual treatment for most prostate cancers should cease since it causes more harm than good. Billions saved here.

4. Screening mammography in women under 50 who have no clinical indication should be stopped and for those over 50 sharply curtailed, since it now seems to lead to at least as much harm as good. More billions saved.

5. CAT scans and MRIs are impressive art forms and can be useful clinically. However, their use is unnecessary much of the time to guide correct therapeutic decisions. Such expensive diagnostic tests should not be paid for on a case by case basis but grouped along with other diagnostic tests, by some capitated or packaged method that is use-neutral. More billions saved.

6. We must stop paying huge sums to clinical oncologists and their institutions for administering chemotherapeutic false hope, along with real suffering from adverse effects, to patients with widespread metastatic cancer. More billions saved.

7. Death, which comes to us all, should be as dignified and free from pain and suffering as possible. We should stop paying physicians and institutions to prolong dying with false hope, bravado, and intensive therapy which only adds to their profit margin. Such behavior is almost unthinkable and yet is commonplace. More billions saved."

My personal opinion is that all of these issues are not solely driven by economics, but just as often by being the path of least resisitance. It is generally easier to do the "next thing," rather than having difficult conversations about a CABG or intervention or chemo regimen or whatever, and the real risks and benefits to the patient in front of you. So rewarding patient care and outcomes and time spent or simply not rewarding so generously all of these procedures could go a long way as Dr. Lundberg suggests.

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The Best Medical Care In The U.S.

The Best Medical Care In The U.S.:

Every day some 1,400 patients pass through the Buffalo VA's unprepossessing entrance, into what many might assume is a hellish health-care world,
understaffed, underfunded, and uncaring. They couldn't be more wrong. According to the nation's hospital-accreditation panel, the VA outpaces every other hospital in the Buffalo region. 'The care here is excellent,' says Roemer. 'I couldn't be happier, and my friends in the POW group I belong to all feel the same.'

LOWER COSTS, HIGHER QUALITY
Roemer seems to have stepped through the looking glass into an alternative universe, one where a nationwide health system that is run and financed by the federal government provides the best medical care in America. But it's true -- if you want to be sure of top-notch care, join the military. The 154 hospitals and 875 clinics run by the Veterans Affairs Dept. have been ranked best-in-class by a number of independent groups on a broad range of measures, from chronic care to heart disease
treatment to percentage of members who receive flu shots. It offers all the same services, and sometimes more, than private sector providers.

According to a Rand Corp. study, the VA system provides two-thirds of the care recommended by such standards bodies as the Agency for Healthcare Research & Quality. Far from perfect, granted -- but the nation's private-sector hospitals provide only 50%. And while studies show that 3% to 8% of the nation's prescriptions are filled erroneously, the VA's prescription accuracy rate is greater than 99.997%,
a level most hospitals only dream about. That's largely because the VA has by far the most advanced computerized medical-records system in the U.S. And for the past six years the VA has outranked private-sector hospitals on patient satisfaction...

read on...

When I talk about the VA, I always make this qualification: I know that they are struggling to deal with the epidemic of PTSD and the influx of Veterans from the past seven years, and they need the help of us as taxpayers. Go show IAVA that you care.

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