The Antidote

Improving dementia-care homes in the UK

2009-12-09T07:26:00.002-05:00

Today, after watching last evening this rather moving program in which someone called Gerry Robinson visits and tries to fix dementia care in the UK, I found out that Mr Robinson (actually Sir Gerry) was a businessman. That might explain why he just threw up his hands when confronted with pretty clear evidence that one of these homes was owned and run by two people who couldn't see past making a profit to the well-being of the residents (or the staff, for that matter). Robinson just wasn't ready to admit that capitalism might not always be a sustainable model for the provision of dementia care.

But that's what we have, for now. Measuring and improving quality of care for dementia is, according to the program, in its infancy, but developing measures and benchmarks based on quality of life would be a big step forward.

Tamiflu evidence questioned

2009-12-08T15:16:00.002-05:00

Cochrane reviewers have concluded in yesterday's British Medical Journal that there is little evidence that antiviral drug oseltamivir, or Tamiflu, stops flu complications in otherwise healthy people. The BMJ has a number of related articles as well.

BBC News today had a great investigative piece on the story behind the evidence; there is one crucial, oft-cited dataset belonging to Tamiflu manufacturer Roche, which Roche has not released to the Cochrane reviewers. The BBC has not yet posted a link to the story but I'll up date this when it's available. Meanwhile, the Guardian has also covered the story.
flu
Tamiflu
health news
Cochrane

Post cartoon sums up resistance to health reform

2009-11-30T06:07:00.002-05:00

Check out this Tom Toles cartoon.

Breast cancer screening - more politics

2009-11-26T08:19:00.002-05:00

Contrast the conciliatory tone of this editorial co-authored by Eric Winer, MD, Medical Director of the Susan G. Komen Breast Cancer Foundation with the gloom and doom expressed by Komen's president Nancy Brinker, as quoted in this op ed piece by Washington Post writer Dana Milbank.

Per Winer:

Fourth, we must be careful not to send a message that screening and early detection are of no value: there is no doubt that early detection of breast cancer can save lives. We are particularly concerned about the perceptions of women who are members of disadvantaged minority groups and those who lack education and health insurance. It would be lamentable if progress made in breast-cancer awareness were reversed as a result of this debate. Efforts to educate the public about breast cancer must be maintained and, in some areas, increased.

and Brinker:

The recommendations "have taken a tremendous toll, and I believe they set us back," Brinker told reporters at the National Press Club on Monday afternoon. "The women I have heard from, thousands and thousands and thousands, are justifiably outraged and worried and angry."

Oh, and here's a quote from a statement by Winer on Komen's website:

Susan G. Komen for the Cure wants to eliminate any impediments to regular mammography screening for women age 40 and older. While there is no question that mammograms save lives for women over 50 and women 40–49, there is enough uncertainty about the age at which mammography should begin and the frequency of screening that we would not want to see a change in policy for screening mammography at this time.

What do you think? Are the substance of what Winer and Brinker said similar enough that Winer will keep his job? (Note that Milbank himself is probably just as angry as Brinker, yet he claims he has no problem with the science, just in the way the recommendations were rolled out.) Does Winer's official Komen statement waffly enough to accommodate both his view of the uncertainty of the science and Komen's aggressive pro-screening stance? And will women reading the recommendations - or more importantly the docs who are recommending screening - really take home the message that mammography screening is useless?

I'd love to hear the behind-the-scenes discussions at Komen as they proceed.

Another new evidence blog...

2009-11-25T04:38:00.001-05:00

this one from Michael Power, one of my colleagues from a great evidence-based-medicine listserv out of Oxford University.

New evidence blog

2009-11-24T09:28:00.002-05:00

David Rind, an academic physician in Boston, has started a blog called Evidence in Medicine. Rind has a clear, persuasive, honest yet non-sanctimonious writing style. Here's hoping he doesn't get bored or overwhelmed too quickly with the task of keeping up a blog! So far he's covered vitamins, the perils of Pharma, and mammography.

And more recommendations for less screening...

2009-11-20T06:00:00.002-05:00

This time from the American College of Obstetrics and Gynecology (ACOG), for later and less frequent cervical screening among young women. A number of people interviewed by the NYTimes once again don't seem to acknowledge that there might be harms from screening; in fact, one of the ACOG guideline authors points out quite a few harms, that she claims makes the case for limiting Pap smears more compelling than that for limiting mammography.

cervical cancer
screening
guidelines

New mammography recommendations from USPSTF

2009-11-19T16:26:00.003-05:00

By now you've heard that the US Preventive Services Task Force has updated their recommendations on mammography this week. In fact, the recommendation for women 50-74 is the same as before (B recommendation). The Task Force now recommends against routine screening for women 40-49, and states that the evidence is insufficient either way for women 75 and over.

Gary Schwitzer's Health News Blog analyzes coverage by the three major network news outlets and found that it was light on evidence. And while waiting for a plane, I caught a glimpse of Florida Congresswoman Deborah Wasserman-Schulz commenting on CNN about the guidelines. The congresswoman earlier this year sponsored legislation, known as the EARLY act, to promote intensive screening and breast self exam training for young women. This legislation has been criticized by cancer experts. Wassermann-Schulz apparently doesn't see any possible downside to screening. In addition, in saying that the guidelines are "patronizing" and that women need more information not less, she apparently ignores the Task Force's statement that

The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms.

breast cancer
screening
guidelines

Clear prescription drug labels that present risks and benefits

2009-11-07T14:49:00.003-05:00

Hi folks, me again; no, I'm not dead yet!

Anyway, lest it get lost, this NYT Prescriptions blog describes an effort - now in Congress - to introduce charts (drug fact boxes) to drug labeling that present clinical benefit and side effects, side by side, in the form of understandable absolute risks. Seems so simple, but this information usually gets buried in drug-approval applications and doesn't make it into the labeling at all. And all you hear or read in direct-to=consumer drug advertising is rapid-fire or small-print, nonquantitative laundry lists of symptoms that have reported in drug studies, with no indication of whether such symptoms even differed between test and control groups, and they generally carry a legalistic, "FDA made us say this" tone. Sen. Barbara Mikulski (D-Maryland) drafted the legislation.

prescription drugs
drug labeling
FDA

Improving the End-of-Life Experience

2008-11-23T07:41:00.002-05:00

The "Engage with Grace" project was created by Paul Levy, of the Running a Hospital blog, and Matthew Holt of The Health Care Blog:

We make choices throughout our lives - where we want to live, what types of activities will fill our days, with whom we spend our time. These choices are often a balance between our desires and our means, but at the end of the day, they are decisions made with intent. But when it comes to how we want to be treated at the end our lives, often we don't express our intent or tell our loved ones about it.
This has real consequences. 73% of Americans would prefer to die at home, but up to 50% die in hospital. More than 80% of Californians say their loved ones “know exactly” or have a “good idea” of what their wishes would be if they were in a persistent coma, but only 50% say they've talked to them about their preferences.
But our end of life experiences are about a lot more than statistics. They’re about all of us. So the first thing we need to do is start talking.
Engage With Grace: The One Slide Project was designed with one simple goal: to help get the conversation about end of life experience started. The idea is simple: Create a tool to help get people talking. One Slide, with just five questions on it. Five questions designed to help get us talking with each other, with our loved ones, about our preferences. And we’re asking people to share this One Slide – wherever and whenever they can…at a presentation, at dinner, at their book club. Just One Slide, just five questions.
Lets start a global discussion that, until now, most of us haven’t had.
Here is what we are asking you: Download The One Slide and share it at any opportunity – with colleagues, family, friends. Think of the slide as currency and donate just two minutes whenever you can. Commit to being able to answer these five questions about end of life experience for yourself, and for your loved ones. Then commit to helping others do the same. Get this conversation started.
Let's start a viral movement driven by the change we as individuals can effect...and the incredibly positive impact we could have collectively. Help ensure that all of us - and the people we care for - can end our lives in the same purposeful way we live them.
Just One Slide, just one goal. Think of the enormous difference we can make together.
(To learn more please go to www.engagewithgrace.org. This post was written by Alexandra Drane and the Engage With Grace team)

Op-Ed on Health Care Reform

2008-11-23T07:25:00.002-05:00

Shannon Brownlee, author of Overtreated, and Ezekiel Emanuel, author of Healthcare: Guaranteed, two thoughtful people working toward making our health care "system" more fair, safe, and efficient, have an Op-Ed in favor of health care reform in today's Washington Post. Their goal is to dispel some myths about health care, starting with the canard that the U.S. system is the best in the world. Interestingly, further down, the authors cite survey data showing that 70 percent of Americans feel that the system needs major changes if not a complete overhaul. Still, it helps to repeat outloud and often that our system is not the best - just the most expensive. The comments about the costs of health insurance, and who pays them, are well taken and less obvious.

Read my interview with Shannon Brownlee here.

Straight shooting on evidence from the NYTimes

2008-07-28T22:55:00.002-04:00

Just noticed a new series exposing health care interventions that don't work, in the NYtimes... not in the health section, but in the business section. The first article is on an apparently dangerous prosthetic hip socket, and highlights the US' failure to implement device registries that could allow the identification of faulty implants of various kinds.

Here's the blurb:

The Evidence Gap: An Imperfect Picture

Articles in this series will explore medical treatments used despite scant proof they work and will consider steps toward medicine based on evidence.

I don't know how many of these are planned, but I imagine they could fill a couple years' worth of weekly columns.

Regarding this article, I'd quibble with the idea that registry data are evidence, per se; the problem with interpreting the data is that there are no controls. One application for registry data stems from the fact that pre-market randomized trial data that provide actual evidence for devices (and drugs for that matter) are inadequate. In this case, the faulty devices in question were found to be contaminated with oil, more of a manufacturing quality-control issue than a general validity issue. The former point still holds, but registries can still provide a useful function in pointing to problems.

Best study name ever

2008-05-02T10:29:00.003-04:00

Thanks to my friend Pam Marcus for passing this along. I thought it was an appropriate way for me to celebrate my reentry into blogging.

Lacasse A, Rey E, Ferreira E, Morin C, Bérard A: Validity of a modified Pregnancy-Unique Quantification of Emesis and Nausea (PUQE) scoring index to assess severity of nausea and vomiting of pregnancy. Am J Obstet Gynecol. 2008 Jan;198(1):71.e1-7.

Thank you, CBO

2007-11-14T13:59:00.000-05:00

California HealthLine today reports on a new Congressional Budget Office Report that finds that inefficient delivery of health care, and delivery of interventions of dubious value, will swamp the effect of the aging of the population in increasing health care costs over the foreseeable future.

"The nature of the long-term fiscal problem has been misdiagnosed," Orszag said, adding that the aging population "is not by any means the main factor" behind the projected rise in cost growth. He noted that many new medical treatments and tests are "of dubious value." He said that in their efforts to stem the growth of health care costs, Congress and federal policymakers need to promote cost effectiveness and "evidence-based" medicine (Reuters, 11/13).

Obviously Congress needs to take the lead in addressing this struggle. Senate Finance Committee chair Max Baucus pledged to address the problem aggressively; I hope he does, and I hope Budget Chief Orszag doesn't lose his job saying what needed to be said.

NY Times skewers "natural" claims of beauty products

2007-11-01T08:30:00.000-04:00

Natural does not equal healthier, nor does it even equal, well, natural. An article in today's Times skewers the marketing ploys of a variety of beauty products available at stores like Whole Foods, and reiterates that there's no evidence that individual ingredients benefit health or beauty, or that claims of their natural or organic provenance are even necessarily true. Manufacturers profit handsomely on consumers' emotional beliefs that natural is somehow better.

"We’re seeing an increased consciousness that what you put on your body is as important as what goes in your body,” said Jeremiah McElwee, the senior coordinator in charge of personal care at Whole Foods, which is the company’s fastest-growing department. “The biggest impetus for buying natural or organic body care is the perceived health benefit.”

Emphasis on "perceived."

New website on reporting guidelines

2007-10-25T23:23:00.000-04:00

The Equator website serves as a resource for consistent, accurate reporting in the literature of new research in a variety of health disciplines (e.g., systematic reviews, clinical trials, observational studies). Several of these disciplines have their own guidelines (e.g., the CONSORT guidelines for clinical trials), which are enforced by some of the leading journals. The site provides resources for authors, editors, and guideline developers.

reporting guidelines

Another online evidence-based medicine course

2007-10-23T19:32:00.000-04:00

This one is from the University of North Carolina Health Sciences Library (my favorite library in the whole world, as it happens...) and the Duke University Medical Center Library.

(The photo is of UNC's Old Well, which is more photogenic than the library...)

New quality/safety blog

2007-10-23T11:00:00.000-04:00

Robert Wachter, professor at UC San Francisco, author of Internal Bleeding, and patient-safety leader and innovator, has a new blog. This post nicely illustrates the health care quality learning curve as experienced by interns.

Be skeptical; be very skeptical

2007-10-22T12:17:00.000-04:00

The Kaiser Daily Health Policy Report has a piece today about an effort to survey Wellpoint's many (35 million) about their physicians in order to provide consumer-based rankings, also to include comments. All together now: "The plural of anecdote is not data." Indeed, as one consumer group interviewed by Kaiser said, these rankings are likely to be skewed to the negative by patients who have had bad experiences. There are better ways to collect consumer-centered data - for example, AHRQ's CAHPS measures - than mass rants of the type Wellpoint proposes.

I don't have much use for Zagat's restaurant reviews, either, for the same reason.

Gross, but thought-provoking

2007-10-10T19:40:00.002-04:00

Kent Sepkowitz, writing for Slate, asks whether we might not be better off in terms of immunity by living under less sterile conditions. His recommendation to scientists: figure out if there's a level of excrement we can eat that would boost our immune systems without killing us. I imagine susceptibility varies by age, and I do know that we live longer as a population than we used to before sanitation. Other than that, I'm not a microbiologist, and I can't decide whether this idea is completely wacky or not.

Any discussion?

Good news on hospital death rates

2007-10-10T17:15:00.001-04:00

The Agency for Healthcare Research and Quality has released new data showing that mortality rates for six conditions and six procedures have declined steeply over a 10-year period from 1994 to 2004. In brief,

AHRQ compared the death rates for 1994 and 2004 for patients who were hospitalized for heart attack, congestive heart failure, stroke, pneumonia, gastrointestinal hemorrhage, or hip fracture.

For every 1,000 patients admitted for their condition:

o Heart attack deaths fell by 43; deaths from congestive heart failure, pneumonia, and stroke each dropped roughly 30; deaths from gastrointestinal hemorrhage declined by 21; and 16 fewer died from hip fracture.

For every 1,000 patients who underwent six surgical procedures examined:

o Abdominal aortic aneurysm repair deaths plunged from 103 to 74;
o Deaths from craniotomy – an operation for brain lesions and other conditions – declined from 83 to 68;
o Deaths from heart bypass surgery fell from 48 to 28, angioplasty deaths diminished from 16 to 12, those from carotid endarterectomy – an operation to avert stroke – fell from 12 to 7, and
o Deaths from hip replacement surgery declined by half – from 4 to 2 per every 1,000 operations.

The death rates for the six conditions and six surgical procedures are risk-adjusted, meaning that AHRQ’s researchers took into account differences in how ill patients were over time when calculating the results.

Isn't getting old hard enough as it is?

2007-10-09T08:00:00.000-04:00

The New York Times today reports on various forms of mistreatment and bias against elderly gay people, especially in assisted-living and long-term care facilities. There are not a lot of data here, just a few anecdotes and examples of efforts to address the problem, but that's ok - the fact that it ever occurs is unacceptable. And you can sort of see what's going on - elderly people slowly lose their ability to control the environment they live in, and the world at large is still quite homophobic. So if you've grown up in the closet and eventually gotten past all the barriers to coming out, you now find yourself in a position of going back in, or struggling mightily to surround yourself with people who will accept you.

The problem simply had never occurred to me, and I have few words to express how sad it makes me.

Why universal coverage is not socialized medicine

2007-10-08T08:34:00.000-04:00

Ezekiel J. Emanuel, bioethicist at the National Institutes of Health, lays it out in this Washington Post op-ed piece.

The Antidote in translation

2007-10-07T08:57:00.001-04:00

Scanning links to this blog in Technorati, I found that one of my recent posts (mostly consisting of data from AHRQ) has been fully translated into German! Thanks to Healthy Index for taking the time to include the content. Based on my very limited German, it does appear that this was done by a human, not by a machine like Babelfish, which is helpful in a pinch but not particularly reliable, and sometimes downright hilarious, at least for language geeks like me.

Edit: thanks to my friend Z, with whom I probably should have checked before posting, for pointing out that it is an automatic translation after all. (Just goes to show how nonexistent my German really is these days...) So my new German readership are probably scratching their heads a bit.

One of my readers pointed out the following amusing choice of a bullet, however:

O arme Amerikaner really just means "Poor Americans," (meaning Americans without resources) not "Oh, you poor Americans." At least I think it does... Europeans don't feel that sorry for us, do they?

AHRQ e-updates available

2007-10-03T17:02:00.000-04:00

The Agency for Healthcare Research and Quality has a new email notification service, where users can sign up for new Agency information (research, guidelines, etc.) in categories of their choosing. Sign up here.

health care quality