Health and Medical News and Resources

General interest items edited by Janice Flahiff

Robotic Surgery Roundup: Take Me Out To The Ballgame and much more

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From the 18 July 2013 article at HealthNewsReview Blog

Robotic surgery systems are spreading so quickly across the US and across the globe that trying to keep up with the news could become a fulltime beat.  Here are just a few nuggets in an attempt to catch up on things you may have missed.

The Reading (PA) Eagle reports, “Fans test surgical robot at baseball game.” Excerpts:

“Fans at FirstEnergy Stadium got the chance to try Reading Hospital’s da Vinci surgical robot before the Fightin Phils game Thursday night. … The hospital has three da Vinci robots, which are used for minimally invasive surgeries, including heart, thoracic, bariatric, urologic, gynecologic, cancer and other procedures.”

We’d seen robotic surgery promotions in shopping malls before, but the ballpark setting was a new one to us.  Maybe Reading readers should also read or watch stories like the next three we profile.

“The use of intensity-modulated radiotherapy (IMRT) and robotic prostatectomy to treat prostate cancer patients at low risk of dying from the disease increased from 32 percent in 2004 to 44 percent in 2009, researchers found in reviewing Medicare patient data. …

“The implementation of these technologies occurred in populations at a time when there was an increase in awareness that some prostate cancers might not warrant treatment,” said study co-author Dr. Brent Hollenbeck, an associate professor of urology and director of the Herbert H. and Grace A. Dow Division of Health Services Research at the University of Michigan….

What’s more, new technologies like IMRT, robotic prostatectomy and proton beam therapy have not been shown to be any more effective in treating prostate cancer or avoiding side effects than established procedures like traditional external beam radiation treatment (EBRT) and open radical prostatectomy. …

Aggressive direct-to-consumer marketing and incentives associated with fee-for-service payment may promote the use of these advanced treatment technologies,” the study authors wrote.”

“The story of the robot is really the story of American medicine: expensive technology, poor evaluation, and little communication with patients about the research and the data about robotic surgery.”

Visit NBCNews.com for breaking news, world news, and news about the economy

And now a brief glimpse of some recent journal articles:

“Overall, robotic thyroid surgery is unlikely to show improved outcomes with typical metrics. It is unlikely to be cost-effective because it involves more equipment and, even in the best of hands, more operating room time. Length of stay is unlikely to be effected because most thyroid surgery patients are in the hospital for less than 24 hours. Robotic thyroid surgery is not minimally invasive; therefore, is there really any expectation of a decreased level of pain during the postoperative period? The implementation of the routine use of robotic technology will depend ultimately on what it means for the patient—the real stakeholder. Comparative efficacy studies have partially addressed the end points of robotic thyroid surgery by focusing only on the risk of complication or oncologic value when compared with conventional or endoscopic surgery, but what about other patient-centered end points? Are the patients happy and satisfied, and are they more satisfied than someone who underwent conventional thyroid surgery? At the end of the day, it will come down to how a third-party payer or health care provider system weighs patient-centered outcomes and whether such surgery would be covered and provided, or whether it would be considered purely cosmetic in nature.

In summation, once you strip away all the blinking blue and green lights, the hundreds of moving parts, and the beeps and occasional error messages, robotic thyroid surgery can be just as elegant, effective, and safe as conventional surgery. It can be efficient. However, to get to this point, the surgeon needs to be committed to this type of surgery and not merely regard it as a hobby or a sideline. It needs to be the focus of a truly dedicated thyroid surgeon who has excellent outcomes with both the standard and robotic approach. Emil Theodor Kocher was not the first surgeon to win the Nobel Prize for nothing. After a century of experience, the new high-profile version of his thyroidectomy may be good, but it is not better than the tried and true.”

“Given the high costs and small scientific evidence, the introduction of robotic surgery has been irresponsibly quick.- Better scientific research of robotic surgery is needed before this technology can be broadly applied in clinical practice.”

“Surgeons must try to avoid marketing operations behind some of the indications of companies producing robotic instrumentation. Otherwise, the first robotic surgery centers will be seen as “a real taste of Hollywood.” …

Robotic surgical procedures’ economic aspect should be analyzed and we have to reconsider whether our countries (Poland, the Czech Republic, Slovakia) are at such an economic level that they are able to compete with more economically developed countries such as Germany. I believe that they are not [1]. Certainly, only a few robotic surgical centers need to be built in each of our countries. They should carry out scientific research, should be supported by other than state funds, and should cooperate with each other so that the whole system does not become just “a taste of Hollywood” for a particular surgeon or center.”

In summary, when thinking about robotic surgery, you could sing “Take Me Out To The BallGame,” but remember the closing lyrics:

“Let me root, root, root for the home team,
If they don’t win it’s a shame.
For it’s one, two, three strikes, you’re out,
At the old ball game.”

ADDENDUM ON JULY 19:  See our next-day post, “FDA warns robotic surgery maker, which complains of ‘negative press’ ”

Related articles (on all sides!!!)

July 22, 2013 Posted by | health care, Uncategorized | , | Leave a comment

Researchers identify 146 contemporary medical practices offering no net benefits

From the 22 July 2013 EurekAlert article
[Please note that I added emphasis to some sentences!]

Study published in Mayo Clinic Proceedings documents reversal of established medical practices in last decade

Rochester, MN — While there is an expectation that newer medical practices improve the standard of care, the history of medicine reveals many instances in which this has not been the case. Reversal of established medical practice occurs when new studies contradict current practice. Reporters may remember hormone replacement therapy as an example of medical reversal. A new analysis published in Mayo Clinic Proceedings documents 146 contemporary medical practices that have subsequently been reversed.

A team of researchers led by Vinay Prasad, MD, Medical Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, reviewed ten years of original articles published in the New England Journal of Medicine testing standard of care.

“The purpose of our investigation was to outline broad trends in medical practice and identify a large number of practices that don’t work,” says Dr. Prasad. “Identifying medical practices that don’t work is necessary because the continued use of such practices wastes resources, jeopardizes patient health, and undermines trust in medicine.”

Dr. Prasad and his investigative team evaluated 1,344 original articles published in the New England Journal of Medicine between 2001 and 2010 that examined a new medical practice or tested an established one. This included assessment of a screening, stratifying, or diagnostic test, a medication, a procedure or surgery, or any change in health care provision systems.

Dr. Prasad and colleagues made several interesting findings. First, only a minority of studies over the last 10 years even tested current medical practices. Dr. Prasad found that only 27% (363/1344) of articles that tested a practice tested an established one. Instead, the vast majority of such studies, 73% (981/1344), tested a new medical practice. Dr. Prasad says, “While the next breakthrough is surely worth pursuing, knowing whether what we are currently doing is right or wrong is equally crucial for sound patient care.”

Dr. Prasad’s major conclusion concerns the 363 articles that test current medical practice — things doctors are doing today. His group determined that 146 (40.2%) found these practices to be ineffective, or medical reversals. Another 138 (38%) reaffirmed the value of current practice, and 79 (21.8%) were inconclusive — unable to render a firm verdict regarding the practice.

Dr. Prasad comments, “A large proportion of current medical practice, 40%, was found to offer no benefits in our survey of 10 years of the New England Journal of Medicine. These 146 practices are medical reversals. They weren’t just practices that once worked, and have now been improved upon; rather, they never worked. They were instituted in error, never helped patients, and have eroded trust in medicine.”

Dr. Prasad adds, “Health care costs now threaten the entire economy. Our investigation suggests that much of what we are doing today simply doesn’t help patients. Eliminating medical reversal may help address the most pressing problem in health care today.”

Key examples of medical reversal include the following:

Stenting for stable coronary artery disease was a multibillion dollar a year industry when it was found to be no better than medical management for most patients with stable coronary artery disease. Hormone therapy for postmenopausal women intended to improve cardiovascular outcomes was found to be worse than no intervention. The routine use of the pulmonary artery catheter in patients in shock was found to be inferior to less invasive management strategies.

Other instances pertain to the use of the drug aprotinin in cardiac surgery, use of a primary rhythm control strategy for patients with atrial fibrillation, use of cyclooxygenase 2 inhibitors, early myringotomy procedures, and application of recommended glycemic targets for patients with diabetes.

Says Dr. Prasad, “To our knowledge, this is the largest and most comprehensive study of medical reversal. The reversals we have identified by no means represent the final word for any of these practices. But, the reversals we have identified, at the very least, call these practices into question.”

In an accompanying editorial, John P. A. Ioannidis, MD, DSc, of the Stanford Prevention Research Center, Department of Medicine and the Department of Health Research and Policy at Stanford University School of Medicine, comments on the work of Prasad and his team and evaluates it within a broader context.

“The 146 medical reversals that they have assembled are, in a sense, examples of success stories that can inspire the astute clinician and clinical investigator to challenge the status quo and realize that doing less is more,” notes Dr. Ioannidis. “If we learn from them, these seemingly disappointing results may be extremely helpful in curtailing harms to patients and cost to the health care system.”

According to Dr. Ioannidis, it is just as important to promote and disseminate knowledge about ineffective practices that should be reversed and abandoned. Given the widespread attention that practice guidelines typically receive, particularly when published by authoritative individuals or groups, he questions whether a generally higher level of evidence should be required before these guidelines are recommended and can impact clinical practice.

“Finally, are there incentives and anything else we can do to promote testing of seemingly established practices and identification of more practices that need to be abandoned? Obviously, such an undertaking will require commitment to a rigorous clinical research agenda in a time of restricted budgets,” concludes Dr. Ioannidis. “However, it is clear that carefully designed trials on expensive practices may have a very favorable value of information, and they would be excellent investments toward curtailing the irrational cost of ineffective health care.”

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July 22, 2013 Posted by | health care | , , , , , , , , | Leave a comment

The Math of State Medicaid Expansion

English: President Barack Obama's signature on...

English: President Barack Obama’s signature on the health insurance reform bill at the White House, March 23, 2010. The President signed the bill with 22 different pens. (Photo credit: Wikipedia)

 

Excerpts from the Rand Report

 

In June 2012, the Supreme Court ruled on the constitutionality of key components of the Affordable Care Act; and foremost among these were the individual mandate and Medicaid expansion. The Court judged the former to be constitutional but allowed states to “opt out” of the Medicaid expansion and some states have indicated that they will exercise this option. How might state choices affect health care coverage and costs?

The Patient Protection and Affordable Care Act (ACA) provides for three basic ways to increase health insurance coverage: the expansion of Medicaid to cover the poorest population; the provision of subsidies for those with low or medium incomes to purchase coverage on the new health insurance exchanges; and the institution of an individual mandate requiring everyone to have insurance. Taken as a whole, the ACA is highly controversial. However, Medicaid expansion and the individual mandate are particularly contentious issues, and the constitutionality of both was challenged, ultimately landing on the docket of the Supreme Court.

In June 2012, the Court ruled that the individual mandate was constitutional but gave states the option of not participating in the Medicaid expansion slated to begin in 2014. As of the spring of 2013, governors from 14 states had indicated publicly that they will choose to opt out.

Medicaid Expansion by StateThe state-by-state breakdown as of spring, 2013. States where governors have stated they will not expand Medicaid are indicated in white, states that are leaning toward opting out or seeking alternative options are indicated in gray, and the remainder are red.

Source: The Advisory Board Company

What does Medicaid expansion offer states?

  • More federal Medicaid funds: Under the ACA, the federal government will pay 100 percent of the coverage costs for those newly insured under Medicaid expansion. After 2016, the federal share gradually shrinks to 90 percent, substantially more than the 57 percent they currently pay on average.
  • Greater access to care for the poor: Medicaid expansion makes health care more accessible to the poorest segment of the population — those earning less than 138 percent of the federal poverty level (this amounts to an income of about $16,000 for a single person or $32,000 for a family of four in 2013).
  • Reduced outlays for uncompensated care: Providing insurance to the very poor reduces uncompensated costs of treatment for this group — an estimated $80 billion in 2016. Currently, about one-third of these expenditures come from state coffers.
  • Reduces financial risk for the lowest-income Americans: Analysis of Oregon’s Medicaid experiment found that the financial hardship associated with medical coverage was dramatically reduced.

 

The report goes on to explain

  • Without Medicaid expansion, the poorest population could fall through a coverage gap.
  • What could be done about the coverage gap for low-income populations?
  • The bottom line.

 

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July 22, 2013 Posted by | health care | , , , , , , | 1 Comment

U.S. Health in International Perspective: Shorter Lives, Poorer Health

From the summary at the Institute on Medicine

The United States is among the wealthiest nations in the world, but it is far from the healthiest. For many years, Americans have been dying at younger ages than people in almost all other high-income countries. This health disadvantage prevails even though the U.S. spends far more per person on health care than any other nation. To gain a better understanding of this problem, the NIH asked the National Research Council and the IOM to investigate potential reasons for the U.S. health disadvantage and to assess its larger implications. 

 

No single factor can fully explain the U.S. health disadvantage. It likely has multiple causes and involves some combination of inadequate health care, unhealthy behaviors, adverse economic and social conditions, and environmental factors, as well as public policies and social values that shape those conditions. Without action to reverse current trends, the health of Americans will probably continue to fall behind that of people in other high-income countries. The tragedy is not that the U.S. is losing a contest with other countries, but that Americans are dying and suffering from illness and injury at rates that are demonstrably unnecessary.

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“The poorer outcomes in the United States are reflected in measures as varied as infant mortality, the rate of teen pregnancy, traffic fatalities, and heart disease. Even those with health insurance, high incomes, college educations, and healthy lifestyles appear to be sicker than their counterparts in other wealthy countries. The U.S. Council on Foreign Relations, a nonpartisan think tank, described the report as “a catalog of horrors.”

Findings that prompted this reaction include the fact that the rate of premature births in the United States is the highest among the comparison countries and more closely resembles those of sub-Saharan Africa. Premature birth is the most frequent cause of infant death in the United States, and the cost to the health care system is estimated to top $26 billion a year.

As distressing as all this is, much less attention has been given to the obvious question: Why is the United States so unwell? The answer, it turns out, is simple and yet deceptively complex: It’s almost everything.

Our health depends on much more than just medical care. Behaviors such as diet, physical activity, and even how fast we drive all have profound effects. So do the environments that expose us to health risks or discourage healthy living, as well as social determinants of health, such as education, income, and poverty.

The United States fares poorly in almost all of these. In addition to many millions of people lacking health insurance, financial barriers to care, and a lack of primary care providers compared with other rich countries, people in the United States consume more calories, are more sedentary, abuse more drugs, and shoot one another more often. The United States also lags behind on many measures of education, has higher child poverty and income inequality, and lower social mobility than most other advanced democracies.

The breadth of these causal factors, and the scope of the U.S. health disadvantage they produce, raises some fundamental questions about U.S. society. As the NRC/IOM report noted, solutions exist for many of these health problems, but there is “limited political support among both the public and policymakers to enact the policies and commit the necessary resources.”

One major impediment is that the United States, which emphasizes self-reliance, individualism, and free markets, is resistant to anything that even appears to hint at socialism. …”

July 22, 2013 Posted by | Public Health | , , , , , , , | Leave a comment

Life Expectancy Shortest In Southern ‘Poverty Belt’ (INFOGRAPHIC)

From the 19 July post at HuffPost

Living in a high-poverty area often means a lifetime of struggle with underperforming public schools, limited job opportunities, higher crime rates, and poor nutrition, health care and housing — all of which can add up to a shorter, sicker retirement.

Americans who live in the South can expect to live fewer healthy years past 65 than those who live in other parts of the country, according to a new report from the CDC. Health disparities among seniors in their final years align closely with profound geographical differences in poverty. The region where more than 30 percent of people live in high-poverty areas — dubbed the “poverty belt” by The Atlantic’s Richard Florida, falls right over the states with the lowest healthy life expectancies. As inequality in the U.S. climbs steadily, this public health crisis may only expand.

From the US Centers for Disease Control and Prevention site

Screen Shot 2013-07-22 at 1.34.43 PM

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July 22, 2013 Posted by | Health Statistics | , , , | Leave a comment

A Constitutional Right to Health Care: Many Countries Have It, but Not the U.S.

From the 19th July 2013 article at Science Daily

Uruguay has it. So does Latvia, and Senegal. In fact, more than half of the world’s countries have some degree of a guaranteed, specific right to public health and medical care for their citizens written into their national constitutions.

July 19, 2013 — Uruguay has it. So does Latvia, and Senegal. In fact, more than half of the world’s countries have some degree of a guaranteed, specific right to public health and medical care for their citizens written into their national constitutions.

The United States is one of 86 countries whose constitutions do not guarantee their citizens any kind of health protection. That’s the finding of a new study from the UCLA Fielding School of Public Health that examined the level and scope of constitutional protection of specific rights to public health and medical care, as well as the broad right to health.

The study examined the constitutions of all United Nations member states and found the results to be mixed, despite the fact that all U.N. members have universally recognized the right to health, which is written into the original foundational document establishing the international body in 1948.The researchers reviewed the constitutions of all the member states as amended to two points in time: August 2007 and June 2011.

The report appears in the July issue of the journal Global Public Health.

The study also calls for regular and long-term monitoring of all countries’ protection of health rights, whether or not such rights are written into specific country’s constitutions.

That’s because a constitutional definition of what health protection actually is varies widely between nations. Further, how such protections have been implemented varies widely, said the study’s first author, Dr. Jody Heymann, dean of the Fielding School of Public Health.

“With respect to specific rights to health, the status of the world’s constitutions can be described as either half empty or half full,” Heymann said.

The study found that 73 U.N. member countries (38 percent) guaranteed the right to medical care services, while 27 (14 percent) aspired to protect this right in 2011. When it came to guaranteeing public health, the global performance was even poorer: Only 27 countries (14 percent) guaranteed this right, and 21 (11 percent) aspired to it.

But doing the math doesn’t provide a comprehensive picture, said Heymann.

“There also exists gaps between individual countries that may have strong constitutional protections but poor records of implementing health rights on the ground,” she said. “On the other hand, there are countries that lack constitutional provisions that have excellent health care systems in place.”

The latter is particularly true in the case of older constitutions that have not been significantly amended since constitutional rights to health became common, she noted.

The good news, Heymann said, is the clear trend toward greater constitutional protection of health rights overtime……..

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July 22, 2013 Posted by | health care | , , , , | Leave a comment

‘The View’, Jenny McCarthy, and a public health nightmare

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The Anti-Vaccine  Argument – good essay placing vaccines in an evolutionary context

David L. Katz, MD, MPH

David L. Katz, MD, MPH, Director, Yale University Prevention Research Center

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You Think You Know

There’s been a lot in the news recently about the decision to hire Jenny McCarthy to replace Elizabeth Hasselback on “The View”.  I cant say that I’m particularly sad to see Hasselback go, as I was never a fan of her conservative “values” but the hiring of Jenny McCarthy – as has been pointed out by many – amounts to a public health nightmare.

For those of you who don’t know, McCarthy is a staunch believer that vaccines caused her son to have autism.  Furthermore, she is an outspoken advocate for not vaccinating children and both encourages and supports parents who choose not to do so.  McCarthy is a strong supporter of UK physician Andrew Wakefield, who published a study in 1998 showing that the measles, mumps, and rubella vaccine causes autism.  That very study has been discredited as a fraud, and follow up studies have disproved Wakefield’s claim.  Despite…

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July 22, 2013 Posted by | Consumer Health, health care | , , , , , , , , , , | 2 Comments

NLM Director’s Comments Transcript Force Feeding Guantanamo Detainees Criticized

The NLM Director showed some courage in commenting on the force feeding of prisoners in Guantanamo.
This is indeed a health issue, because we are indeed responsible for the health (including mental health) of these detainees.

Some excerpts from the comments, full text may be found here.

A candid and stimulating editorial, recently published in the New England Journal of Medicine, strongly suggests physicians at the Guantanamo Bay detainment camp in Cuba should not force feed detainees who are on a hunger strike. The editorial’s three authors argue the force feeding of some Guantanamo prisoners is medically unethical — and the practice warrants more criticism from health care professionals.

A news story about the editorial published in the U.K. Guardian reports the Guantanamo Bay camp currently houses about 166 prisoners (most of whom are held for alleged terrorist activities). Many of these detainees or prisoners have been held at Guantanamo Bay (a U.S. military base in Cuba) in an era that began with the destruction of the World Trade Center in New York City on September 11, 2001. At the time the editorial was published, the Guardian reported 104 prisoners were on a hunger strike and 43 detainees received forced feeding.

The editorial’s authors (who are highly respected senior faculty at Boston University’s Schools of Public Health and Medicine) write [and we quote]: ‘Guantanamo is not just going to fade away, and neither is the stain on medical ethics it represents’ (end of quote).

The editorial’s authors explain the ethical principle to not force feed prisoners initially was advanced by the World Medical Association’s Declaration of Helsinki after World War II. The authors cite the declaration that says (and we quote): ‘forcible feeding (of mentally competent hunger strikers) is never ethically acceptable’ (end of quote). The authors add forced feeding (and we quote): ‘is a form of inhumane and degrading treatment’ (end of quote).

The editorial’s authors note a U.S. Department of Defense’s 2006 directive on force feeding detainees says (and we quote): ‘In the case of a hunger strike, attempted suicide, or other attempted serious self-harm, medical treatment or intervention may be directed without the consent of the detainee to prevent death or serious harm’ (end of quote).

However, the authors explain a hunger strike is not an attempt to commit suicide. They discern the goal of the hunger strikers (and we quote): ‘is not to die but to have perceived injustices addressed’ (end of quote).

In addition, the authors suggest physicians abdicate their professional responsibilities to make individual and independent medical assessments when they participate in penological decisions that maintain prison order by force feeding detainees. The authors write (and we quote): ‘physicians who participate in this nonmedical practice become weapons for maintaining prison order’ (end of quote).

The editorial’s authors also imply a sense of frustration with the dearth of criticism among physicians regarding Guantanamo’s forced feeding efforts.

The authors conclude (and we quote): ‘As (Guantanamo) increasingly becomes a medical ethics-free zone, we believe it’s time for the medical profession to take constructive political action to try to heal the damage and ensure that civilian and military physicians follow the same medical ethics principles’ (end of quote).

We should add it is rare to see such a frank and critical editorial in one of the world’s leading medical journals. The editorial is a reminder of the field of medical ethics’ capacity to illuminate health and social issues.

Meanwhile, a helpful overview of the legal and ethical issues in health care (provided by Merck and Co. Inc) is provided in the ‘overviews’ section of MedlinePlus.gov’s medical ethics health topic page.

A link to information about the nutritional needs of end-of-life patients is available within the introduction of MedlinePlus.gov’s medical ethics health topic page. MedlinePlus.gov’s medical ethics health topic page also provides updated, comprehensive, evidence-based information about diverse healthcare ethics issues such as: genetic and prenatal testing, birth control, organ donation, and patient rights.

MedlinePlus.gov’s medical ethics health topic page additionally contains links to the latest pertinent journal research articles, which are available in the ‘journal articles’ section. From the medical ethics health topic page, you can sign up to receive email updates with links to new information as it becomes available on MedlinePlus.

To find MedlinePlus.gov’s medical ethics health topic page, just type ‘medical ethics’ in the search box at the top of MedlinePlus.gov’s home page. Then, click on ‘Medical ethics (National Library of Medicine).’ MedlinePlus.gov also has a health topic page devoted to nutrition and health.

 

July 22, 2013 Posted by | health care, Psychiatry, Psychology | , , , , , , , , | Leave a comment

   

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