[Reblog] Saying No to “Know Your Numbers” campaigns – Health News Watchdog blog

Saying No to “Know Your Numbers” campaigns – Health News Watchdog blog.

Saying No to “Know Your Numbers” campaigns

Posted by Gary Schwitzer in Health care journalism, Risk communication

4 COMMENTS

“Know Your Numbers” campaigns can serve a useful purpose.

But they can also be guilty of non-evidence-based fear-mongering.  They can fuel obsessions with numbers that fully-informed people might just as soon not know anything about. There can be harm living our lives worrying about numbers, test results – making ourselves sick when we are, in fact, healthy.

Here’s a screenshot of just a tiny part of a Google search result of “Know Your Numbers” campaigns.  The list goes on and on and on.

The most recent that I saw was in the January 2014 edition of Prevention magazine.  It’s entitled, “Know Your Numbers: The 5 Health Stats You Should Know.”

While we acknowledge the prestige of the Cleveland Clinic and its chief wellness officer, we point out that there is a lot of debate in medical science circles about what is laid out in this Preventionmagazine piece. For example:

• The Eighth Joint National Committee (JNC 8) recently published evidence-based guidelines for managing high blood pressure in adults. They wrote:

“There is strong evidence to support treating hypertensive persons aged 60 years or older to a BP goal of less than 150/90 mm Hg and hypertensive persons 30 through 59 years of age to a diastolic goal of less than 90 mm Hg; however, there is insufficient evidence in hypertensive persons younger than 60 years for a systolic goal, or in those younger than 30 years for a diastolic goal, so the panel recommends a BP of less than 140/90 mm Hg for those groups based on expert opinion”

So if 140/90 is where this group starts thinking about treatment, and if even the American Heart Association says normal is “less than 120/80,” what we have with an announcement that 115/75 is “ideal” is mission creep, medicalizing normal blood pressure, or disease-mongering. Where does this “ideal” come from?  It may only be a few points of difference, but with a few points, thousands of Americans suddenly become “less than ideal”…or, as we often call them, patients. One minute they’re healthy.  And then – voila – with a prestigious organization’s spokesman proclaiming a new “ideal” – they’re sick, abnormal, patients.

• Cholesterol.  Hmmm.  Let’s see what the Cleveland Clinic website says about LDL and HDL. The Clinic’s own website says the LDL goal value should be less than 130 for people who don’t have heart or blood vessel disease or high risk.  And since a Prevention magazine article reaches a broad audience, that’s the crowd we’re talking about. And the Clinic website says HDL goal value should be greater than 45.  So the Prevention magazine targets of LDL under 100 and HDL over 50 are again mission creep, medicalizing normal blood tests, or disease-mongering.  Please note:  we could (but won’t herein) write volumes about much broader questions about being obsessed over LDL or HDL numbers, which are surrogate markers that don’t tell people everything they need to know.

• This is the one that bugs me the most.  The article lists C-reactive protein as one of the “5 health stats you should know.”  What you should know is that the US Preventive Services Task Force does not share in that endorsement.  The USPSTF states that “the current evidence is insufficient to assess the balance of benefits and harms of using the (the test) to screen asymptomatic men and women with no history of coronary heart disease (CHD) to prevent CHD events.” Even a brief look at other guidelines by other groups shows that the promotion of this test as a “stat you should know” is not as simple and uncomplicated as the Prevention magazine article makes it out to be.

Please note that almost exactly 2 years ago we wrote, “Cleveland Clinic’s Top 5 Tests for 2012 clash with many guidelines.” C-reactive protein was on that list as well.

And you may be interested in some of my past articles about “Know Your Numbers” campaigns:

• TV station should stop promoting questionable screening tests at MN State Fair
• Star Tribune is wrong about experts recommending annual physicals

Comments

Laurence Alter posted on January 13, 2014 at 10:00 am

Dear Gary & Staff:

1. “Live by the numbers; die by the numbers”
2. “The facts speak for themselves”

Live by the first expression or idiom; die by the second one.

Fine physicians give subtlety and nuance behind “the numbers.”

Laurence Alter

Reply

Gary Schwitzer posted on January 13, 2014 at 12:06 pm

Laurence,

Thanks for your note, but for the umpteenth time, there is no staff.

There wasn’t even any staff when we had funding. So there certainly isn’t any staff in the unfunded era.

Whereas I once had help from as many as almost 40 different part-time contributors, they were not staff, just very limited part-time contributors.

It’s just me, flying solo these days.

Reply

Gwyneth Olwyn posted on January 14, 2014 at 10:50 pm

Dear Gary By Himself:

1. Live by the numbers, die anyway.
2. Unequivocally one death per person.

There is no subtlety or nuance to be had for fine physicians in an era of standard of care and fear of litigation from failing to screen aggressively for potential disease.

Therefore a person needs to know ahead of getting his or her numbers checked whether he or she is ready to inadvertently become a patient based on numbers and that the treatments to change those numbers may have little to no evidence to support them.

Reply

shaun nerbas posted on January 20, 2014 at 3:01 pm

It seems that the patient must look out for themselves, ask questions, and not just accept the standard script of medical people. I had an MI 4 years ago (stent placed in the LAD which was nearly 100% blocked ) , but in the 2.5 months before that I saw 4 different doctors who told me nothing was wrong. I had normal LDL and total cholesterol,but I did have low HDL, which I had recently raised up to a ” nearly normal ” value using niacin. I walked for 1.5 hours a day, but in that 2.5 month period before the MI, while walking, I started to get increasing shortness of breath, indigestion, and a pain in my upper back, between the shoulder blades. My doctor gave me Nexium . My doctor didn’t think it was my heart. He based that on having two relatives of his with heart disease, my normal ECG, and my normal cholesterol numbers. I saw other doctors, as my shortness of breath got worse, but again, they didn’t think it was my heart. Then one day I got the symptoms while eating lunch. I went to the local hospital,who after being in communication with a larger specialized hospital, sent me to that larger center, which put the stent in. I eventually learned that over 62% of MIs happen to people with ” normal cholesterol ” . How is it possible that the cholesterol numbers used by lay doctors are so useless for diagnosis ? Does heart disease have multiple causes or do we just not have a good understanding of how do diagnose and track it ? I almost never see this inadequacy discussed by the experts ! Subsequent to my MI I became a vegan to improve my diet to remove saturated fat, which along with a grandmother who had a heart problem, were, in my mind, the reasons for my heart disease. My cardiologist acted as if I was misguided with the vegan approach, which he felt was a path almost nobody could follow.. ….. just take the statins. Maybe Cardiology is a very lucrative occupation that keeps us coming back…..see you next time ! Sorry for being so cynical, but that’s how I feel.

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Preventing disease is a problem for the health industry

By ROB LAMBERTS, MD | PHYSICIAN | OCTOBER 3, 2013, at KevinMD.com

……

People come to me for answers, and my profession pitches doctors as the ones with answers.  We fix problems.

This, of course, is not true — a fact that I have come to see as a core problem in the practice of medicine in America, and a reality that (as everything seems to do) comes largely from the way we pay for medicine.  We are paid to fix problems.  How do we fix problems?  With procedures.

The best evidence for this are the things at the heart of health care: codes.   There are three types of codes that dominate the financial and clinical lives of anyone in health care:

• ICD codes: codes for medical problems
• CPT codes: codes for medical procedures
• E/M codes: codes used by doctors who don’t do procedures so they can get paid for office visits

What this encourages from the medical profession is predictable: lots of problems treated by lots of procedures.  This is good for doctors who do procedures, especially ones that are cutting-edge (like robotic surgery) or ones that seem particularly dramatic and/or heroic (open heart surgery, heart stents).  These are the things the headline consuming public is most hungry for.  Just like it grabs more headlines to catch a terrorist plot just before it has its horrible effect than to prevent it early in the process, it’s a lot sexier to do a procedure to treat heart disease than to simply prevent the disease in the first place.  Which is the better outcome?  Preventing heart disease.  Which is paid more?  Not even close.

The problem with problems

A more subtle (and perhaps more significant) effect of this mindset is the way in which everything is labeled as “problems” or “diseases.”  A recent ruling of the AMA that obesity is a “disease” stirred up quite a bit of controversy. The AMA ruling does nothing to change the nature of obesity, and clearly is more a discussion of semantics, politics, and funding, than it is a true medical question.  In reality, I used to not be able to bill the ICD-9 code for obesity and get paid, but now I guess I could (if I did that kind of thing any more).  I suspect this opens the door for more procedures to be paid for by insurers, as the response to any problem is always a procedure in our system.

There is pressure now to respond to each “problem” with a procedure, or at least a thing to eliminate it as a problem.  Examples:

• Sinus infections are routinely treated with antibiotics despite no evidence that it actually helps.  Having marketed our profession as problem-fixers, we are met with patients expecting a fix to their problem.  They are disappointed (and even angry) when we don’t “do something” for a “problem” that will resolve on its own, even if the intervention probably causes more harm than benefit.  Problem: sinusitis.  Procedure: antibiotic.  Check.
• Cholesterol treatment is another example of this.  High cholesterol, be it LDL, total, or triglyceride is seen as a “problem,” even in people who are not at risk for heart disease.  I’ve seen many low-risk patients come to my practice on cholesterol medication that does little more than improve their numbers.  The evidence shows that certain high-risk people benefit from being on certain medications which lower the cholesterol.  For folks outside of those high-risk groups, the medications simply make numbers look better (at best) and potentially harm them (at worst).  Problem: High cholesterol.  Procedure: cholesterol drug.  Check.
• Depression and anxiety are normal emotions.  Life is painful and unsure.  There only are two ways to avoid these emotions: die or get stoned.  My personal experience (some fairly recent) is that the times of life most marked by anxiety and depression are accompanied by significant personal growth.  Before everyone gets mad at me for saying these aren’t diseases, I must add that there are cases of both of these emotions that are terribly destructive and potentially fatal if not treated.  But we physicians have lowered the price of admission to treatment, including people going through hard times as those who have clinical depression.  Responding to TV ads about “that pill that will make me happy,” we are met with patients expecting us to “fix their problem” — a problem that is not really a problem; it’s life.  Problem: anxious and depressed people.  Procedure: medication.  Check.

A better way

I think there’s a better way to look at things.  I’ve said this before, but I am coming to grasp just how radical this approach is and just how much it undermines our health care system.  There is something far more important than problems:

Risk.

When someone comes to my office with chest pain, my thoughts do not go to the question: “what is going on?”  A more important problem comes first: “is this a dangerous situation?”  I want to know if the person is ready to die from a heart attack or other serious problem.  This is true in nearly every decision I make as a doctor when faced with a condition.  Could that cough be latent lung cancer?  Could that headache be a brain tumor?  Could the depressed man kill himself?

Risk reduction also rules how I approach disease.  I treat cholesterol and hypertension, not because they themselves are problems, but because they can lead to heart disease, stroke, and other problems.  High cholesterol is not, in my opinion, a “disease” for most people; it is a risk factor.  I treat diabetes mainly to prevent the complications.  Do I care if a 90-year-old has an A1c of 8?  No way.  It doesn’t increase their risk enough to matter.

This does not mean we approach “prevention” like the system presently does: throwing procedures at it.  The health care system doesn’t reward having healthy patients, it rewards doing procedures reported to prevent problems.  Yet the system is not addressing the true goal of prevention: risk reduction. We are “rewarded” by ordering tests, whether or not they reduce risk.  PSA testing is a perfect example of this, as are many other misguided attempts to treat prevention as another problem to  fix with a procedure.

The problem with this, of course, is that it far more to the financial benefit of doctors (and drug companies) for us to address every problem and show we are giving “good care” by checking off the box next to each problem.  In the bigger picture, risk reduction makes the jobs of future cardiovascular surgeons (and drug companies) much less secure.  It attacks the revenue stream of most doctors and hospitals (and drug companies) right where it counts: you can’t make nearly as much money off of healthy people as you can people with “problems.”

This is why, I believe, any system that profits more from people with “problems” than those without is destined to collapse.  Our system is opposed to the goal of every person I see: to stay healthy and stay on as few drugs, have as few procedures, and avoid as many doctors (and drug companies) as possible.

What would happen if we prevented disease?  What would happen if people didn’t have medical problems?  For society it would be great.  For the health care industry it would be a huge problem.

Rob Lamberts is an internal medicine-pediatrics physician who blogs at More Musings (of a Distractible Kind).

Read the entire article here

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Some “Good” Cholesterol May Be Bad For Heart

Fr0m the 20 May 2012 article at Medical News Today

It appears that in some cases, high-density lipoprotein (HDL) cholesterol, the so-called “good” cholesterol, does not protect againstheart disease, and may even be harmful. A new study suggests a subclass of HDL that carries a particular protein is bad for the heart.

Previous studies have shown that high levels of HDL cholesterol are strongly linked to low risk of heart disease. But trials where people have been given drugs to increase their levels of HDL cholesterol have yielded inconsistent results: leading to the idea that HDL cholesterol may actually have protective and non-protective elements.

Now, researchers at the Harvard School of Public Health (HSPH) have found that when the surface of HDL cholesterol bears a small protein called apolipoprotein C-III (apoC-III), there is an increase in the risk of heart disease, and when it is absent, HDL cholesterol is especially heart protective….

Related articles

• HDL ‘Good Cholesterol’ Found Not to Cut Heart Risk – NYTimes.com (policyabcs.wordpress.com)
• ‘Good’ cholesterol’s heart benefits challenged (cbc.ca)
• Some ‘good’ cholesterol unable to protect heart (news.bioscholar.com)
• Will high HDL level lower the risk of heart attack? (thehindu.com)
• Some HDL, or ‘good’ cholesterol, may not protect against heart disease (eurekalert.org)
• “Good” HDL Cholesterol May Not Protect Heart After All, Study Suggests (wibw.com)
• HDL Won’t Protect Against Heart Disease, Says Study Proving ‘Good’ Cholesterol Is Wishful Thinking (blisstree.com)
• HDL ‘Good Cholesterol’ Found Not to Cut Heart Risk – NYTimes.com (fitnessgroan.me)
• ‘Good’ cholesterol doctrine may be flawed: study (news.yahoo.com)