Over-treatment? There’s an app for that

ss accCritics have knocked the recently updated guidelines  on statins for patients at risk of heart disease. While some heart specialist spent years putting together advice for the high risk, others said the guidelines will result in massive overtreament.

Still, health monitoring apps are hot,. The American College of Cardiology is now offering an iPhone/ iPad risk calculator,  the Globe’s Daily Dose reports. This paragraph from the Boston.com post was cut off the print version of the story.

The app does instruct doctors to have a discussion about the risks and benefits of statins and to consider patient preferences; whether busy primary care providers will make the time to have that discussion, rather than simply prescribing the drugs, remains to be seen. 

The headlines were different as well. 

Print: App Calculates Heart Disease

Boston.com: Heart disease risk app may increase statin prescriptions

Don’t like the ACC app? There are already a handful of others.

NEJM: 80% of arthroscopic partial meniscectomy procedures do little for the knees

Note: Consider BMC for your next knee surgery. You may not need it.

From The New York Times:

A popular surgical procedure worked no better than fake operations in helping people with one type of common knee problem, suggesting that thousands of people may be undergoing unnecessary surgery, a new study in The New England Journal of Medicine reports.

The Finnish study does not indicate that surgery never helps; there is consensus that it should be performed in some circumstances, especially for younger patients and for tears from acute sports injuries. But about 80 percent of tears develop from wear and aging, and some researchers believe surgery in those cases should be significantly limited.

“Those who do research have been gradually showing that this popular operation is not of very much value,” said Dr. David Felson, a professor of medicine and epidemiology at Boston University. This study “provides information beautifully about whether the surgery that the orthopedist thinks he or she is doing is accomplishing anything. I think often the answer is no.”

Globe: BWH surgeon sues BWH over wife’s post-#hysterectomy #cancer diagnosis

The Globe’s play on this story should say something — Metro front rather than 1A.  Malpractice stories are tricky– serious charges and a response penned by a lawyer, not a doctor.  (At 8 a.m., a complete version of the story was lingering on White Coat Notes, outside the paywall.)

Note the Brigham’s carefully worded statement on the link between cancer and  morcellation, the procedure used during a minimally invasive hysterectomy.

The Brigham said in a statement that “while it’s not possible to know what impact the procedure will ultimately have on Dr. Reed’s health, we do know that literature suggests morcellation of malignant tumors increases the chances of mortality. 

Here’s the lead

A Boston surgeon and his wife, an anesthesiologist, are pushing to stop a widespread surgical technique used on thousands of women during hysterectomies, which they say caused her undetected cancer to dangerously spread.

The she said/she said suggest that

Dr. Barbara Goff  president of the Society of Gynecologic Oncology and director of the Division of Gynecologic Oncology at the University of Washington in Seattle says “Morcellation allows many women to have safer hysterectomies with better outcomes than full abdominal surgery, including less blood loss, smaller wounds, and a quicker overall recovery.”

“You try to balance cost and outcomes and doing the best you can for an entire population of women,” Goff said.

But Dr. Bobbie Gostout, chairwoman of obstetrics and gynecology at the Mayo Clinic, said more women should be given the option of a vaginal hysterectomy, where the uterus can often be taken out intact through the vagina, especially because morcellation “is a questionable practice.”

She said morcellating devices are not yet good at capturing tissue or protecting other sensitive organs from rotating blades.

“I don’t want to see [morcellation] go away, but I would like to see it kept in perspective and occupy its necessary place,” she said. “Morcellation is still so far off what it ought to be.”

A round-up: The new and maybe-not-improved statin guidelines

See NYTimes to catch up on the debate over new guidelines from the American Heart Association that would vastly expand the use of cholesterol-lowering statins.  Here’s a Nov. 25 update. 

It was supposed to be a moment of triumph. An august committee had for the first time relied only on the most rigorous scientific evidence to formulate guidelines to prevent heart attacks and strokes, which kill one out of every three Americans. The group had worked for five years, unpaid, to develop them. Then, at the annual meeting of the American Heart Association, it all went horribly awry.

Many leading cardiologists now say the credibility of the guidelines, released Nov. 14, is shattered. And the troubled effort to devise them has raised broader questions about what kind of evidence should be used to direct medical practice, how changes should be introduced and even which guidelines to believe.

The critics of guidelines are Brigham researchers. The initial coverage by Todd Neale at MedPage Today talks about Dr. Ridker’s background conducting clinical trial on one statins and researching the biomarker C-reactive protein as a “marker of subclinical atherosclerosis.”

The NYTimes

Less than a week after the American Heart Assn. and the nation’s cardiologists issued guidelines that would greatly expand the number of Americans taking a statin medication, the guidelines have been faulted for overestimating patients’ risk of heart attack or stroke.

Few authors of the new recommendations had even returned to their clinical practices before learning that an influential Harvard cardiologist and his biostatistician collaborator had taken the guidelines to task, arguing they use unreliable data on Americans’ health to calculate which patients would benefit from taking the medication. 

Dr. Paul Ridker and Dr. Nancy Cook, both professors at Harvard Medical School, estimate that between 13 and 16 million of the 33 million middle-aged adults targeted by the new guidelines for statin therapy do not have sufficiently high odds of having a heart attack or stroke over the next decade to warrant statins’ use.

Gary Schwitzer offers a  round-up within a round-up. His looks at conflicts of interest and link to a very funny cartoon from the Daily Kos, which also ran in the NYTimes week in review.

Some more coverage:

LA Times

In the summer of 2012, two Brigham and Women’s Hospital researchers were asked to review a draft of a major cholesterol treatment guideline. They sent back a pointed critique, declaring that the authors should abandon a proposed heart-disease risk calculator because it overestimated patients’ chances of getting sick.

So they were shocked when they saw the final guideline, which was issued last week by two leading heart groups. The risk calculator remained an integral part of the document and would be responsible for millions more Americans being put on cholesterol-lowering statin drugs to prevent heart attacks and strokes.

“I’m a strong advocate for statin therapy,” said Brigham cardiologist Dr. Paul Ridker. “I just want to see the right patients get treated.”

More from:

Medpage Today

The Lancet

Medscape

Obesity surgeon — with support from colleagues — kept practicing despite complaints, via Boston Globe

randallAnother reason to subscribe to the Globe: This Sunday story about how hard it is to get the knives out of the hands of potentially dangerous surgeons. The piece talks about  the state medical licensing board’s slow process for reviewing complaints against practitioners like high-profile obesity doc Dr. Sheldon Randall. The story is behind the pay wall, but here’s the nut.

Two months ago, the panel suspended Randall’s medical license, accusing him of a pattern of negligence and declaring him an “immediate and serious threat’’ to the public. Investigators charge that he did not recognize and treat post-surgery complications quickly enough in four patients, two of whom died.

Randall, 61, denies the allegations and has appealed the suspension, enlisting a team of experts who said he provided perfectly fine care for those patients. Four prominent Harvard physicians also have written letters to the board supporting him.

Click here is you have a subscription and are signed in. If not, find Sunday’s paper in the library.
Seems like the Globe  should have had this story in August. From the state:

FOR IMMEDIATE RELEASE:                                                                  

Tuesday, August 20, 2013

STATE BOARD OF MEDICINE TAKES DISCIPLINARY ACTION

WAKEFIELD: At its meeting on August 16, 2013, the state Board of Registration in Medicine took disciplinary action against the medical license of Sheldon Randall, M.D.

The Board summarily suspended Dr. Randall’s medical license, finding him an immediate and serious threat to the public health, safety or welfare. The Board based its decision on allegations that Dr. Randall’s treatment of four patients failed to meet the standard of care. Dr. Randall is a 1978 graduate of the Centro de Estudios Universitarios Xochicalco and was first licensed to practice medicine in Massachusetts in 1985.  He practiced general surgery in Medford and Natick.

The Massachusetts Board of Registration in Medicine licenses more than 40,000 physicians, osteopaths and acupuncturists. The Board was created in 1894 to protect the public health and safety by setting standards for the practice of medicine and ensuring that doctors who practice in the Commonwealth are appropriately qualified and competent. The Board investigates complaints, holds hearings and determines sanctions. More information is available at www.mass.gov/massmedboard.

Data, health, news contest draws applications from Bostonians

How to get most of the city’s health writers in the same room as a bunch of app developers? A health-themed meet-up of the local Hacks and Hackers group might do it. But last week, a good number of us gathered a WBUR for a presentation on the Knight News Challenge. (WBUR has won in the past for a court-related project.)  The media innovation project has drawn 650 entries,  including one based on  BHN’s ongoing HealthDecider project.  The handful of winners gets money and support for a project designed to answer the following question: How can we harness data and information for the health of communities?

May the best projects win.  Here’s mine.

Here are some others from Boston or with a big local footprint.  Great ideas and stiff competition. (WBUR has its own list with lots of overlap.)

Unlocking the Potential of Patient Blogs To create the first searchable repository of health blogs, giving patients a chance to connect to others with similar medical problems and better understand what it’s like to live with their health issues.

Big Data to Big Story leverages academic medicine’s foremost health-record data-mining tool to allow the public to gain critical, previously unavailable answers about medical treatments and their outcomes.

Gimme My DAM Data This crowdsourced web site will assign a letter grade to each hospital or app privacy policy, thereby encouraging data holders to participate in the health data commons. (This on links to one of Ross Martin’s health policy music videos from The American College of Medical Informatimusicology

Increasing Patient Buy-In to a Statewide Health Data Sharing Effort We will educate consumers about the benefits of sharing their personal medical information in the statewide data-sharing network while also informing them of their rights and gathering input about their concerns, which we will share with decisionmakers at the Massachusetts Executive Office of Health and Human Services to lead to an improved data-sharing system.

Data to Table: A Healthy Recipe for Urban Agriculture The Data to Table website will visualize the details of Boston’s new rezoning ordinance for urban farming, making the information transparent and accessible for those interested in fostering healthy communities through local agriculture.

 Nothing to Hide: Tracking patient harm and hospital efforts to prevent errors We aim to help consumers wisely choose the safest hospitals by building a website that tracks incidents of patient harm at Massachusetts hospitals

 HealthNewsReview.org & Crowdsourcing: We will improve the public dialogue about health care by providing patients and health care consumers a proven platform for telling media messengers what they’re doing well, and where they’re missing the mark with the health care news and information they deliver. 

 

Race, Place and Health: Notes from a Martha’s Vineyard meeting

Click here or on the image below for a Storify on “Take Two Aspirin: Race, Place and Health in the 21st Century,” and event that took place last week, August 14 the Martha’s Vineyard Regional High School in Oak Bluffs.

storify ss

“Life and Death in Assisted Living”: A Frontline/ProPublica investigation

downloadDealing with the housing and care issues that come with aging and disability is, at best, discouraging. When assisted living came along, those who could afford a spot found a comfortable, dignified place to age. These homes look more like hotels than hospitals and offer care for those who need help, but don’t need a nursing home.

But, long-term care is a challenge for both residents and owners. And when the owner is an off-site corporation, efforts to contain costs can lead to poor care for residents.

That’s what the  investigative reporters at Frontline and ProPublica found when they started digging. The FRONTLINE series — starts tonight, Tuesday, and the ProPublica series is running this week on the group’s website. Here’s what they found:

imagesWith America’s population of seniors growing faster and living longer than ever before, more and more families are turning to assisted living facilities to help their loved ones age in comfort and safety.

But are some in the loosely regulated, multibillion-dollar assisted living industry putting the lives of those loved ones at risk?

From the Texas assisted living resident who froze to death on Christmas morning to the Hall of Fame football player who drank unsecured toxic dishwashing liquid and died 11 days later, this major investigation raises questions about fatal lapses in care and a quest for profits at one of America’s best known assisted living companies.

Here in Massachusetts, assisted living facilities have to be certified by the state Office of Elder Affairs. State law requires the homes to have:

  • One or two bedroom units with entry doors that lock
  • Private bathrooms for each unit in newly constructed ALRs
  • Private kitchenettes or access to cooking facilities
  • At least one meal a day
  • For all residents who need it, assistance with bathing, dressing, ambulation and supervision of or reminders to take prescribed medications.
  • 24 hour a day on-site staff
  • Emergency response systems to signal on-site staff
  • Individualized service plans
  • Residency agreements (lease/contract) which detail what the home will provide to the resident, including the rights and responsibilities of both the home and the resident.

The home staff members are not allowed to deliver medical care and the homes are barred from accepting residents who need “skilled nursing care” unless that care is provided by an “employee of a Certified Provider of Ancillary Health Services.  Those caregivers can include physician, pharmacist, restorative therapist, podiatrist  hospice and home health aides.

In other words, assisted living is housing, not health care. This series did not look at homes here. But a former aide at a Massachusetts assisted living program makes some serious charges in the comment section of the ProPublica story.

Is DCIS cancer? New National Cancer Institute panel says no, get “carcinoma” out of the name

download8/29: Globe weighs in on new new study on how women perceive the DCIS diagnosis 

Via JAMA  

This seems huge, although the questions about the overdiagnosis of cancer have been bubbling up for a while.

Here’s the NYTimes Well blog take on it.

A group of experts advising the nation’s premier cancer research institution has recommended sweeping changes in the approach to cancer detection and treatment, including changes in the very definition of cancer and eliminating the word entirely from some common diagnoses.

The recommendations, from a working group of the National Cancer Institute, were published on Monday in the Journal of the American Medical Association. They say, for instance, that some premalignant conditions, like one that affects the breast called ductal carcinoma in situ, which many doctors agree is not cancer, should be renamed to exclude the word carcinoma so that patients are less frightened and less likely to seek what may be unneeded and potentially harmful treatments that can include the surgical removal of the breast.

 

More here:

The “Susan G Komen for the Cure” take is quite a  bit different:

Ductal carcinoma in situ (DCIS) is a non-invasive breast cancer. In DCIS, abnormal cells are contained in the milk ducts. It is called “in situ” (which means “in place”) because the cells have not left the milk ducts to invade nearby breast tissue. …. You may also hear the terms “pre-invasive” or “pre-cancerous” to describe DCIS.

 

A primer on using data to stay healthy and get well

medicare compare ss

9/8: COMING SOON: HealthDecider.com

How do you choose a new doctor or a nursing home? Get information on toxins in your neighborhood.? Search an index of reliable, up-to-date medical findings? Ask friends, do a web search or brave an impenetrable government database?  The HealthDecider data links to the left are designed to help.

Most are national, but some are local to Boston. Most are easy to use. However, the Medicare fee database is not consumer-friendly. More on that below.

A few general tips on how to use them:

  •  Always cross reference. Different  sources may rank the same hospital differently
  • Pay attention to sources of information.
  • Look for most recent data.
  • Learn a little about spread sheets to keep track of your research and to    crunch your own numbers.
  • Comment here on the usefulness of this data.
  • Talk to your doctor about “shared decision making.



medicare-ss

The Medicare fee database is rather complex. One way to make sense of it is to simply search on the hospital or provider name. It will then give you a list of procedures you can click on.  We include it here because it contains valuable information. Do know that this is not a consumer database. You  need to know a bit about payer jargon and databases to make sense of it.

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