Book review: A coffee enema for a health writer

UMass Med School pediatrician, Darshak Sanghavi – who also writes a column for Slate –trashes a new book on junk science by a noted New Yorker health writer in tomorrow’s NY Times Book Review.    

(Note that the book was favorably reviewed by another Slate writer)

..(T)here are two ways to deal with scientific illiteracy: take a long, hard look at the forces that repel so many from science, or throw up your hands and write people off as fools.

Michael Specter, a science and public health writer for The New Yorker, shows little interest in the first approach in his pugnacious new book, “Denialism,” which carries the ominous subtitle “How Irrational Thinking Hinders Scientific Progress, Harms the Planet, and Threatens Our Lives.” He devotes chapters to anti-­vaccine zealots, purveyors of organic foods, promoters of alternative medicines and opponents of race-based medicine, accusing each group of turning “away from reality in favor of a more comfortable lie.”

Doesn’t Harvard have an entire department devoted to this? Make sure you read their listing on Source Watch for the full picture of where they might be coming from.  

 

Goodman on mammography: Policyspeak v. pink ribbons

Globe-based national columnist Ellen Goodman writes today about how badly the USPSTF delivered the message on the limits of mammography in women under 50. She agrees with their recommendations. She just thinks the panel was blindsided by extremely angry women who are not willing to reconsider the notion that early detection is key to cancer survival.  Then there was the anti-health reform “guidelines = rationing/death panel”  crowd.

This was never going to be an easy message. The breast cancer research is more complex and controversial than the cervical cancer research that was released just days later with recommendations to delay and reduce pap smears. But nevertheless, this perfect storm created a perfect case on how not to deliver a public health message.

It’s important because – and I say this as someone whose mother, aunt, and sister have all had breast cancer – the task force had a strong story to tell. The benefits of mammography for younger women have been oversold. As Laura Nikolaides of the National Breast Cancer Coalition and a cancer survivor says, “People have been doing mammography as a security blanket: If you have a mammogram, you won’t die of breast cancer. We wish that were true.’’ The biology of the tumor – how aggressively it grows – is now judged more important than the size at which it was discovered. And the terrible reality is that we haven’t done much to change the survival rate of younger women who get this disease.

Tufts doc warns of industry influence on health reform

The pharma watchdogs at Gooz News point out that: 

The latest New England Journal of Medicine contains a scathing perspective denouncing the Senate’s health care reform bill for giving industry too much control over a new comparative effectiveness research (CER) agency, an issue I tried to call attention to in Health Tech Review (Sept. 28, 2009). The Senate bill guarantees at least three of 15 slots on the new CER agency’s board to industry representatives, and would involve those board members in designing studies.

For the uninitiated, comparative effectiveness research (CER) is the study of what works and what doesn’t in health care. So, while industry should have a seat at the table, know that they are likely to take this position — the stuff I sell works. 

One of the authors is Dr. Harry Selker  of Tufts, who “studies the factors that affect clinical care and its outcomes, and develops treatment strategies, decision aids, and computer-based systems for improving care.  He is known for a series of studies of the factors influencing emergency cardiac care, including clinical, socioeconomic and gender issues, and is particularly known for the development of cardiac “clinical predictive instruments.”  These decision aids provide emergency physicians with predictions of their patients’ key outcomes for real-time use in clinical care.”

 So, he knows this stuff and it may have saved you life if you ended up in the New England Medical Center with a heart attack

 Here’s what he says in NEJM.

 If health care reform legislation does not promote CER that is free of the potential taint of commercial and political meddling, the public will have little confidence in the results of such research. This outcome would be extremely unfortunate, since such research has the potential to improve patients’ lives by leading to more effective medical care. The U.S. biomedical research enterprise has a long and storied history that has made it a model for other countries. It would be a tragedy if we were to squander its achievements for political expediency, in the service of short-term commercial interests. The current proposals for controlling CER in a manner unlike anything we have seen in federally sponsored biomedical research therefore should be rejected.

 

Screen baby, screen — News coverage of new mammography guidelines

 BHN is a big fan of the health news blog produced by fellow health writer/journalism prof Gary Schwitzer at the University of Minnesota. And while we hate gratuitous attacks on the so-called ”lamestream” media, there is a lot of really, really bad health reporting out there. Schwitzer follows and rates the coverage and he is always spot on.

So, check out his comments on the coverge of the new mammography guidelines, which brought out the worst in health journalism.  He calls it the “screen, screen, screen mentality.” 

Start with his “10 things that stand out from the mammography week to remember (forget?)”

Many of us might rather move on and end all of the discussion about the US Preventive Task Force’s mammography recommendations last week. But I think it’s essential that we reflect on ten things that stand out from last week:

1. Many in the general public (most of those quoted in news stories) are not prepared for evidence to be used in making health care recommendations. They haven’t been prepared by the health care industry, by their physicians, or by the news media. 

 
2. Many in health care (many of those quoted in news stories) are too invested in their own preferences to allow evidence to make a difference in their practices.

3. There is an undeniable and clear bias in many news stories, reporters and news organizations for promoting screening – evidence be damned. I’ve reported on this before and last week provided overwhelming new evidence. (Mind you – I said “many”, not “all.”)

4. The USPSTF, which is a collection of independent experts, has no public relations arm. They simply review the evidence and publish their recommendations.

5. The public relations machinery of the American Cancer Society, the American College of Obstetrics and Gynecology - and other groups that opposed the USPSTF recommendations – helped the anti-USPSTF message rule the media all of last week.

6. Politicians chimed in – sometimes distorting the evidence beyond all recognition. The clash between politics and science at such times is predictable and disgusting.

7. The rhetoric used to oppose the USPSTF recommendations was the ugliest and most ill-founded I can remember.

8. There was some excellent journalism done on the issue last week, but it was overwhelmed by and drowned out by the drumbeat of dreck shoveled out by many news organizations – including in much (not all) of what was provided on network TV.

9. The week may have caused harm to the nation’s discussion of health care reform.

10. The week was certainly a setback for the nation’s understanding of science, of evaluation of evidence, of the potential harms of screening tests.

Single-payer supporters, Harvard Med on the Senate reform bill

The president of Harvard Med School doesn’t like the reform will, he says in the Wall Street Journal. He refers to the Mass global payments plan with the dirty word “capitation.”

 Single-payer supporters at MassCare offer their opinion in an email that  arrrived before Sunday’s vote to open debate on the bill. No link yet so here’s the whole thing:

 Senate Majority Leader Harry Reid has released a bill that he will try and get introduced to the floor of the Senate shortly. It weighs in at over 2000 pages, but many of the details appear to be similar to the bill passed by the House last week, with a couple of critical exceptions. We are working hard to put together a table that compares all of the important details of the House and Senate bills: public subsidies to low-income people, the individual mandate and who will be required to purchase insurance, the public options proposed and their limitations, how the bills are paid for, immigrant access, employer responsibility, abortion access, insurance market reforms, small business subsidies, and Medicare reforms. For the time being, however, here is a very brief summary of what Senator Reid has proposed:

Like the House bill, the Senate proposal would expand Medicaid, and would give sliding scale subsidies for people up to 400% of the poverty line. Most uninsured people would be required to purchase coverage. None of these provisions in the Senate bill begin until 2014.

Market reforms would begin in the first year of implementation, including a ban on lifetime and most annual insurance caps, no canceling policies after you get sick, and expanded dependent coverage under family plans up to age 25. Beginning in 2014 the Senate bill would also prevent insurance companies from charging different premium rates based on anything except whether the plan is for an individual or a family, geographic area, age, and tobacco use: insurers could not charge more than 3 times more to the oldest enrollee than they do the youngest, or more than 1.5 times more to smokers than to non-smokers. They would also be required to accept any business or individual applying, and guarantee renewability.

None of the above provisions would have much impact on Massachusetts, where we already have a mandate, subsidies, and stricter regulations on insurers than most states. The bill would also try to facilitate co-operative insurance plans (defined in the bill essentially as non-profit insurers, which we already have in Massachusetts) through loans and grants, and would set up a public option (called the “Community Health Insurance Option”). The public option would not be available until 2014, and then only to uninsured individuals and small businesses with 50 or fewer employees; expanding to include employers with up to 100 employees in 2016. Starting in 2017 each state would then have the choice of expanding the option to larger employers. The Senate bill borrowed language from the House stating that the public option would have to negotiate its own rates with providers, and would not be using Medicare rates.

TWO KEY DIFFERENCES between this Senate bill and what emerged out of the

House:

First: the House paid for its bill largely through a tax on the highest income earners in the country. The Senate bill instead contains a very high tax on the most expensive insurance plans. These are being called “cadillac” plans and the press are assuming that it will affect the most comprehensive insurance coverage, but in reality the most expensive plans are those that cover older people and people with higher risk of illness, and those purchased by individuals and small businesses with less ability to negotiate low premium rates. This version of the bill raised the threshold at which such plans would be taxed, but this completely misses the point.

 Second: there is no language in Reid’s bill that outright prevents plans receiving federal funding from offering abortion services. It does not allow federal funds to pay for abortion, which is the current practice, but it does allow plans that are federally subsidized to cover abortion services so long as this is paid for through state or private contributions. The Senate bill appears to allow states to have the final word on what can and can’t be offered, or what must be offered, in the new insurance Exchanges. The Stupak amendment, which was added to the House bill, stated that none of the public subsidies “may be used to pay for any abortion or to cover any part of the costs of any health plan that includes coverage of abortion” under the Exchanges.

 We will provide a more detailed analysis of the two bills on our web-site, and send you all a link, hopefully by next week.

_______________________________________________

Mass-Care: The Massachusetts Campaign for Single Payer Health Care

 

New DPH report: Flu cases on the decline

The state reports that that “although ILI (influenza like illness) activity seems to have peaked and is on a decline, activity is still at a level that is significantly higher than what was seen at the same time during the last two years.”

From DPH: Confirmed Influenza cases in Massachusetts, October 4, 2009  – November 19, 2009

	H1N1: Age group (N)	H1N1: Pregnant (N)	H1N1: Hospitalized (N)	H1N1: Deaths (N)	Seasonal and Untyped Influenza by Age Group (N)
0-4 years	58	0	30	1	459
5-12 years	87	0	43	0	1105
13-18 years	59	0	20	0	717
19-25 years	60	2	7	0	397
26-44 years	39	2	10	1	581
45-64 years	38	0	17	2	386
65+ years	9	0	4	1	83
Unknown	0	0	0	0	24
TOTAL	350	4	131	5	3752

 

More on mammography for women under 50

11/19 KHN has a round up of the reaction to the news guidelines.

Now comes another reversal in the mammography debate. (See ACS flap.) On Monday, a U.S. government agency backed away from a more aggressive approach and concluded that, in the balance,  women in their 40s get no net benefit from mammography. The U.S. Preventative Services Task Force (USPSTF), which studies the effectiveness of screening programs, concluded that even women in their 50s don’t need them annually.

Ann Grady Ready: Full mastectomy in the '80s. Died from allergies later.

The USPSTF found fair evidence that women who have screening mammography die of breast cancer less frequently than women who do not have it, but the benefits minus harms are small for women aged 40 to 49 years. Benefits increase as women age and their risk for breast cancer increases. However, there are relatively few studies of mammography for women aged 75 years or older. The potential harms of mammography include anxiety, procedures, and costs due to false-positive results and receiving a diagnosis and treatment of cancer that never would have surfaced on its own within a woman’s natural life time. They found that the benefit of mammography every 2 years is nearly the same as that of doing it every year, but the harms are likely to be half as common. They found no evidence that self- or clinical examination reduces breast cancer death rates.

Some Boston doctors reject this idea in the Globe story:

The new guidelines, published in the Annals of Internal Medicine, stoked unusually harsh responses for the clubby world of academic medicine. Some prominent specialists branded the recommendations as flat-out wrong, with one Boston radiologist, Dr. Daniel B. Kopans of Massachusetts General Hospital Cancer Center, predicting the guidelines “will condemn women ages 40-49 to unnecessary deaths from breast cancer.’’

And while many mainstream breast cancer advocacy groups will agree, others don’t.   The National Women’s Health Network – a Washington D.C.-based group that grew out of the feminist health movement of the 1970s — says their members “don’t want overly optimistic information or simplistic messages that are better at motivating than educating.” The network, like other women’s health advocates, pushed for access to the mammography in the ’70 and ’80s, but eventually began to question the test. 

            So, they offer their members a collection of recommendations from like-minded activists and researchers. One comes from Dr. Susan Love, who has made a career out of offering advice on breast cancer: “Even in older women, mammography is far from a perfect screening tool. It may help you find your cancer early, but finding a cancer “early” is not a guarantee that your life will be saved.” The evidence-scrutinizing Center for Medical Consumers says “Mammography-detected breast cancers have the best outlook. The screening test also leads to the detection and treatment of breast cancers that would never become life-threatening. Mammography’s role in the nation’s declining breast cancer death rate remains unclear.”  Breast Cancer Action – a feisty Bay-area group that prefers boycotts to pink ribbons — says: “The quality of mammography screening varies widely. Mammography is an imperfect test. The benefit of routine mammograms for healthy pre-menopausal women is unproven.”

DPH: More H1N1 vaccine arrives in state, still not enough

From the DPH

As of this past weekend, the state has received just over 1 million doses of the H1N1 vaccine. However, this is still less than one third of the total amount of vaccine we have ordered. Each week we receive tens of thousands of vaccine doses in our state but we need hundreds of thousands, and eventually millions, to fully address the need.  According to the latest projections from the federal government, we will see a significant increase in the volume of doses in our vaccine shipments by the second week in December. 

Since it first became available in small amounts in early October, most of the vaccine has been sent to clinical settings.   But because there are thousands of clinical settings that share these shipments, none of them receive enough.  In general, the size of the shipment that a clinical site receives each week is a reflection of the number of patients in the targeted priority groups that it cares for.  However, this varies somewhat based upon the type of vaccine that becomes available each week.  For instance, pregnant women can’t take nasal flu vaccine sprays: so if the only vaccine available is the nasal spray, we cannot send that new quantity to OB/GYNs.  It can however, be administered to healthy children, and would therefore be sent to pediatricians. Regrettably, given the changeability of the production processes we don’t know what amounts or what formulations of vaccine doses will become available ahead of time.  This makes it very difficult for clinical practices to plan ahead or to notify their patients of what to expect.

En Espanol: Disponibilidade da vacina H1N1 em Massachusetts

 

Is Fox-Boston passing off Beth Israel PR as news?

This from the Association of Health Care Journalists.

Hospital says it gives content to short-staffed media

Nov. 12th, 2009 by Pia Christensen

Lindsey Miller of Ragan Communications Inc., a publisher of corporate communications, writes that Boston’s Beth Israel Deaconess Medical Center has found a way to “spread its message“ – by providing content to the area’s short-staffed television stations.

The (BIDMC) hospital’s director of marketing communications says she has flipped the problem of reduced local medical reporting due to layoffs to her advantage by providing features and experts to help fill the gap, particularly at TV stations such as Boston’s Fox affiliate.

Swine flu peaking? Not last week. New Massachusetts flu numbers

Check here from vaccine latest clinics: From Masspro.org

Nov. 12: WBUR asks: Has Swine Flu Peaked in Mass? The NYTimes had a story in September predicting it would peak in October. The state’s new numbers say it was still going up last week.

2009 H1N1 influenza

As of November 12, 2009, 1,659 confirmed cases of H1N1 have been reported throughout Massachusetts since April of 2009. The 2009-2010 influenza season officially started on October 4, 2009.  Table 3 below represents H1N1 cases that have been confirmed in MA since October 4, 2009; the final column of this table is the number of cases of seasonal flu and influenza of unknown type, also since October 4.  Table 4 shows the cumulative H1N1 cases that have been confirmed in MA since April 26, 2009.  Both tables are updated weekly. The Centers for Disease Control and Prevention (CDC) is no longer reporting the national total of confirmed cases of H1N1 and is instead focusing on hospitalized cases and deaths. Nationally, influenza-like illness (ILI) continues to be reported as widespread.  Please visit the CDC’s website for up-to-date information (www.cdc.gov/h1n1).

Table 3. Confirmed Influenza cases in Massachusetts, October 4, 2009  – November 12, 2009

	H1N1: Age group (N)	H1N1: Pregnant (N)	H1N1: Hospitalized (N)	H1N1: Deaths (N)	Seasonal and Untyped Influenza by Age Group (N)
0-4 years	31	0	7	0	308
5-12 years	66	0	24	0	882
13-18 years	46	0	8	0	568
19-25 years	47	1	4	0	284
26-44 years	27	2	6	1	386
45-64 years	20	0	7	1	249
65+ years	4	0	2	1	49
Unknown	0	0	0	0	19
TOTAL	241	3	58	3	2745

Table 4. Confirmed H1N1 cases in Massachusetts, April 26, 2009 – November 12, 2009

 

	Age group (N)	Age group (%)	Female (%)	Pregnant (N)	Hospitalized (N)	Hospitalized (%)	Deaths (N)
0-4 years	232	14	38.36	0	42	18.10	0
5-12 years	462	27.8	40.26	0	56	12.12	0
13-18 years	337	20.3	47.77	6	27	8.01	1
19-25 years	189	11.4	65.08	19	21	11.11	2
26-44 years	255	15.4	67.06	32	37	14.51	4
45-64 years	162	9.76	61.73	0	41	25.31	6
65+ years	21	1.27	71.43	0	11	52.38	2
Unknown	1	0.06	0	0	0	0	0
TOTAL	1659	~~	50.93	57	235	14.17	15

As shown in Table 4 above, school-aged individuals (5-18 years) have been primarily affected by H1N1, with over 62% of cases age 18 or younger.  The median age of cases is 14 and cases ranged from 0 to 92 years.  To date, males and females have been equally impacted by H1N1. Overall, 235 cases have been hospitalized (14%), which is similar to the national hospitalization rate of 11% as of July 10, and 15 cases have died. Of the 15 deaths, 11 had underlying conditions.