Thursday, July 30, 2009

Medication Pill Splitting Safe? Dangerous? Depends.

FDA press release titled "Tablet Splitting: A Risky Practice" is unfortunately a very misleading title and makes you wonder whether FDA is independent enough from the pharmaceutical industry.

Yes, no doubt people are trying to make their healthcare dollars last and are skipping pills, taking them less often, or even splitting them, but is dividing pills really a risky practice?

The points FDA says splitting isn't safe include:
  • You might get confused about the correct dose.
  • Equal distribution of medicine in split tablets is questionable.
  • Some tablets are hard to split.
  • Not all pills are safe to split.
All true. But buried at the end of the news bulletin FDA notes:
FDA has approved drugs where tablet splitting is part of the manufacturer’s drug application. "If the tablet is approved for splitting, the information will be provided in the drug’s professional prescribing information," says Mansoor Khan, Ph.D., director of the Division of Product Quality Research in FDA's Office of Pharmaceutical Science.

What do you believe? Personally, I would suggest Consumer Reports take on medication splitting. They suggest you don't split these medications:

  • Chemotherapy drugs
  • Anti-seizure medicines
  • Birth control pills
  • Blood thinners (Coumadin, warfarin)
  • Capsules of any kind that contain powders or gels
  • Pills with a hard outside coating
  • Pills designed to release the medication over time in your body
  • Pills that are coated to protect your stomach
  • Pills that provide drug release throughout the day
  • Pills that crumble easily, irritate your mouth, taste bitter, or contain strong dyes that could stain your teeth and your mouth.

Still confused if you can skip, decrease dosage, or split the pills? Do you know what you should really do?

Ask your doctor or pharmacist! Sometimes skipping medication is like not taking it at all or increases your risk of having a much more expensive medical complication occur. For example stopping the blood thinner PLAVIX within a year of having a heart stent could block it causing you to have a heart attack! Taking it every other day may not be safe either or substituting aspirin.

Other options include less pricey, but often equally effective generic medications. But how could you possibly know unless you ask for help?

Who do you call?

Ask your doctor or pharmacist!

If either make you feel embarrassed or small, doubtful given this economy, then find another doctor or pharmacist!

Sunday, July 26, 2009

Real Simple Magazine - Time Saving Healthcare Tips

The August issue of Real Simple has many time saving tips when dealing with healthcare.

Many are from yours truly! It's focuses on preventive health, pharmacy, and the area I'm most often referenced is how to get the most out of a doctor's visit!

Enjoy and stay healthy!

Thursday, July 23, 2009

Getting Good Value in Health Care - Dr. Pauline Chen

Dr. Pauline Chen, columnist for the NY Times, penned a great article titled "Getting Good Value in Health Care". It's a great piece because it is so politically incorrect. As a primary care doctor I know the value of prevention. In the healthcare reform debate, people are touting "savings" in prevention when as Dr. Chen points out accurately that this is NOT the case.

There is no savings with preventive care. Healthier people live longer and consequently have opportunities later to develop other illnesses which increase costs.

The real point is that preventive interventions can improve quality of life and prevent premature death. Wouldn't we all want to do the right things to be around with family and friends to our fullest potential? Doing the right things won't save money, probably cost neutral, but the value, being around people we love is priceless.

Where I work, the simple preventive checklist Dr. Chen discusses is easy as each patient upon registration gets a list of age appropriate interventions - mammogram, vaccinations, cholesterol, colon cancer screening, and whether they are up-to-date so both patient and doctor know if more needs to be done.

The sad part is that I know that is the exception to the rule in this country. As a result too many Americans (80,000 annually) die prematurely because they don't get the right preventive care or treatment that we know works.

That is the real tragedy because not all patients have access to this important information, doctors are often too busy and overwhelmed, and communities and third party systems don't have the capabilities to support reminders and interventions.

This disparity is what compelled me to write my book because in the end knowing these simple rules should NOT be a mystery to anyone.

Monday, July 20, 2009

Just Say NO to a Public Healthcare Plan

First let me be entirely clear. I agree that healthcare should be available to all and affordable. I agree that the current healthcare system is fragmented, not patient or doctor friendly, and is out of control (that is why I wrote my book to help every individual navigate our current nightmare we call the US healthcare system).

The problem is that fixing the healthcare system isn't simple and certainly shouldn't be done by the government. Plenty of myths exist including the following.

1. Medicare works. Why not expand Medicare for all?
One of the biggest myths is that Medicare is a success.


Medicare will become insolvent if nothing is done over the next 10 years. Patients who are on traditional governmental Medicare and not some complementary version of it via an insurance company (supplemental plan or Medicare HMO aka Medicare Advantage) are finding fewer and fewer doctors willing to take straight Medicare. Why? It doesn't reimburse enough to pay the bills. The program Medicaid, which serves the poor, is even worse. If patients do find a doctor who is taking straight Medicare or Medicaid there is often an intolerably long wait to be seen.

2. Government can squeeze costs out of the healthcare system by offering competition.

Sure, by playing hardball and setting prices which may be artificially low. The Obama administration should be commended for tackling the difficult problem of providing universal coverage (not to be confused with nationalization of healthcare) as well as making it affordable. President Obama can get there by setting reimbursement rates to fit his agenda. Whether the rates reflect reality is another question. This is why insurance companies are so concerned about a public plan.

Also, realize this. If there was an insurance company that was able to offer great coverage at a lower price, then why wouldn't it do so already? Typically low cost goods and services which are comparable to more expensive options do well in the marketplace. Why not with health insurance? Simple. Because there is no individual mandate, that is everyone needs to buy health insurance, health insurance is pricey as the young and healthy don't subsidize those who truly need it. As a result, the only purchasers are those who will use it causing costs to skyrocket.

If the government is so good at squeezing costs out, then why don't we have the government produce cheaper cars and set up an airline?

If the government wishes to expand healthcare, it must do the following at a minimum.

  • Require everyone to purchase health insurance. With everyone participating, the costs of those who truly need it is spread across those who are healthy. Without an individual mandate, health care will be too expensive.
  • Change the reimbursement structure on how doctors are paid. Massachusetts learned with their universal coverage that having insurance doesn't mean access and certainly doesn't mean better costs because doctors are paid to do more. A state panel recommended that doctors get paid a salary.
  • Think seriously about capping damages for medical complications, malpractice, and misdiagnoses. Patients and families who are harmed should be adequately compensated, but not outrageous fees collected by lawyers, rather via an arbitration system. Too often, extraordinary damages may make the individual and family feel better, but often drive doctors out of the state. Many states have critical shortages of specialists for these reasons.
  • Standardize benefits packages across the states. A health insurance plan for a healthy individual shouldn't vary significantly from San Francisco to New York any more than a car purchased on the different coasts are similar, but not identical. The large difference in health insurance costs for the same coverage is due to varying state requirements and simply adds more administrative costs and hassles with little benefit.
If the federal government wishes to get into healthcare, then it must do so by setting up a delivery system like the VA, which has consistently outperformed doctors and hospitals in the community.

Simply offering a public insurance plan is not the answer and will drive insurance companies out of business.

When the government needed to step up and help citizens of Hurricane Katrina, it failed miserably and although it could be argued it was due to incompetence of certain individuals, the reality is that FEMA doesn't know how to move goods and people quickly and efficiently.

Who succeed to do their jobs exceedingly well and become the unlikely heroes? The private sector - specifically Fedex and Wal-mart, two organizations whose livelihood depend on getting things moved quickly and reliably.

President Obama should be commended. His goal should focus on changing the parameters which the healthcare system operates. It should not however have a new public plan as that would be a disaster.

As a side note, the Republicans are in complete disarray arguing that the healthcare system doesn't need fixing. It is broken. Simply saying no, doesn't help anyone deal with a crisis that left unchecked will bankrupt our country.

Tuesday, July 14, 2009

Coronary Calcium Scans Can Raise Cancer Risks

Interesting articles from the Annals of Internal Medicine and reported in HealthDay courtesy of Yahoo.

In summary, there is risk of radiation with using CT scan to determine if there are blockages in the coronary arteries. Note that from the article, "having such a screening test every five years would cause 42 additional cases of cancer among 100,000 men and 62 additional cases among 100,000 women."

Yet as one of the doctor notes it isn't proven that this screening test saves lives or is better at predicting who is at risk for heart disease than the usual measures of cholesterol, blood pressure, smoking status, age, and gender. (You can calculate your risk of having a heart attack or dying of a heart attack using the calculator provided by the National Cholesterol Education Program).

Interestingly, when hormone replacement therapy (HRT) for women in menopause was found to increase risk of cancer by 8 in 10,000 or 80 in 100,000, which is a little more than the increased cancer risk by this CT scanning, doctors and women essentially stopped using HRT. It was probably easier to do because there were alternatives to HRT.

Currently the US Preventive Services Task Force doesn't recommend it. The American Heart Association only suggests it for certain cases. Yet, unfortunately the state of Texas requires that the procedure be covered for all despite no evidence it works. Perhaps that is why a city in Texas was singled out as spending the most for medical care in a recent piece by physician author Atul Gawande in the New Yorker.

There are alternatives to using a CT scan to check the arteries to determine risk factor for heart disease. Until proven, it is best to stay away. Also, more importantly, quit smoking, stay active, maintain a healthy weight, control your blood pressure (ideally less than 120/80, but see your doctor if greater than 140/90), and control your cholesterol.

The entire article is here.

Coronary Calcium Scans Can Raise Cancer Risks
HealthDay Reporter by Ed Edelson

Mon Jul 13, 11:48 pm ETMONDAY, July 13 (HealthDay News) -- When weighing whether a coronary calcium scan is worth the risk, a new study suggests that arriving at an answer won't be clear-cut or easy.

A team of researchers from the U.S. National Cancer Institute and Columbia University found that the average range of radiation exposure from having such a screening test every five years would cause 42 additional cases of cancer among 100,000 men and 62 additional cases among 100,000 women. However, given the wide range of radiation doses seen in the study, the increase could be as low as 14 cases and as high as 200 cases among 100,000 men, and as low as 21 cases or as high as 300 cases among 100,000 women.

This is an issue of growing importance on the American medical scene, said Dr. Andrew J. Einstein, director of cardiac computed tomography research at Columbia University, and a member of a team that reports its findings in the July 13 issue of the Archives of Internal Medicine.

"There has been great interest recently in computed tomography, owing to the fact that the number of CAT scans has grown tremendously in the United States," Einstein said. "The National Council on Radiation Protection & Measurement estimates that 70 million are done per year."

The study in which Epstein took part looked at a form of computed tomography that scans for calcium deposits in heart arteries. CAC scanning, as it is called, is one of the lesser-done forms of computed tomography, but a private organization, Screening for Heart Attack, Prevention and Education, has proposed that it be done annually on 50 million Americans, and a new Texas law mandates health insurance coverage of the procedure.

The new study looked at what a dose of radiation in a single CAC scan would be, and found an enormous variation. There is no single protocol -- set of rules -- for such a scan, which can be done on a variety of equipment, Einstein said. "This was first proposed in 1990, and CT scanner technology has changed, so it is not clear what the protocol might be," he noted.
The study found roughly a 14-fold difference in radiation dosage among the various CAC scan protocols. Eliminate two or three "outlying" readings, and the difference is still threefold, Einstein said.

But those estimates are suspect, said Dr. Thomas G. Gerber, an associate professor of medicine and radiology at the Mayo Clinic, and co-author of an accompanying editorial, because it is based on extrapolation of the damage done to people exposed to high doses of atomic bomb radiation at Hiroshima and Nagasaki.

"At the very low doses used in medical imaging, there is a huge controversy about whether there is an increased risk of anything," Gerber said. "Estimates of increased risk are based on a linear no-threshold hypothesis. There is even a theory that chronic exposure to low doses of radiation might be beneficial."

There is equal cloudiness on the benefit side of the equation, said Gerber. "I am not a strong proponent of screening," he added.

"The risk of cardiac events increases if calcium is present in the arteries," Gerber said. "But you can't pick up blockages before they are 70 percent or more. There is some debate about whether the risk predicted by coronary calcium screening is incremental [adds to] the risk predicted by conventional risk factors. It stands to reason that it might be, but that is not proven."
The U.S. Preventive Services Task Force recommends against using CT scans in screening programs, and the American Heart Association says they should be used for "selected individuals" at intermediate risk.

So what do physicians do about CAC scanning in the real world?

"I like using it for patients at intermediate risk of coronary disease, when I do not know how aggressive therapy should be," Einstein said. "For such patients, it is a fantastic test."

"In my practice I use it for patients with no symptoms but an unfavorable risk factor profile," Gerber said. "If there are risk factors but they are adamant about not changing their lifestyle or taking coronary medication, I think it sometimes helps patients realize their coronary atherosclerosis [hardening of the arteries] has begun."

A definitive study of the risk-benefit ratio of CAC scanning is unlikely, Einstein said. The people in question are not at high risk of heart disease, and "the rarer an event is, the larger the sample size that is needed," he said. "A randomized controlled trial would require hundreds of thousands or millions of patients, with adequate follow-up."

More information
For more on coronary calcium scans, go to the U.S. National Heart, Lung, and Blood Institute.

Friday, July 10, 2009

1 Out of 3 Breast Cancers Overtreated or Screening Finds 2 Out of 3 Deadly Breast Cancers?

Associated Press discussed a recent article in the BMJ which found that 1 out of 3 breast cancers were overtreated based on review of breast cancer screening programs in Britian, Canada, Austrailia, Norway, and Sweden. Specifically that screening tests are unable to tell which breast cancers are potentially more deadly and which ones are less so.

The study's results are troubling not because of the screening tests inability to differentiate between aggressive cancers compared to more slow growing. The problem with this report is what the public hears and does.

Specifically, women might not get screened.

Note that the countries listed all have better healthcare outcomes than the United States. There levels of screening are far better than in the United States. We already are the worst among industrialized countries on doing basic things like vaccinations, cholesterol, blood pressure control, and screening tests like mammograms, colon tests, and prostate exams. As a country, there is probably a lot more we must do before we have the issue of "overtreatment".

If both men and women hear that screening causes cancers to be overtreated that they won't get screened. There will be too many preventable deaths and major costs to families which are bankrupting.

What the report could have said was screening in fact detects potentially fatal cancers 2 out of 3 times.

From the article -

Study: 1 in 3 breast cancer patients overtreated
By MARIA CHENG – 21 hours ago
LONDON (AP) — One in three breast cancer patients identified in public screening programs may be treated unnecessarily, a new study says. Karsten Jorgensen and Peter Gotzsche of the Nordic Cochrane Centre in Copenhagen analyzed breast cancer trends at least seven years before and after government-run screening programs for breast cancer started in parts of Australia, Britain, Canada, Norway and Sweden.
The research was published Friday in the BMJ, formerly known as the British Medical Journal. Jorgensen and Gotzsche did not cite any funding for their study.
Once screening programs began, more cases of breast cancer were inevitably picked up, the study showed. If a screening program is working, there should also be a drop in the number of advanced cancer cases detected in older women, since their cancers should theoretically have been caught earlier when they were screened.
However, Jorgensen and Gotzsche found the national breast cancer screening systems, which usually test women aged between 50 and 69, simply reported thousands more cases than previously identified.
Overall, Jorgensen and Gotzsche found that one third of the women identified as having breast cancer didn't actually need to be treated.
Some cancers never cause symptoms or death, and can grow too slowly to ever affect patients. As it is impossible to distinguish between those and deadly cancers, any identified cancer is treated. But the treatments can have harmful side-effects and be psychologically scarring.
"This information needs to get to women so they can make an informed choice," Jorgensen said. "There is a significant harm in making women cancer patients without good reason."
Jorgensen said that for years, women were urged to undergo breast cancer screening without them being informed of the risks involved, such as having to endure unnecessary treatment if a cancer was identified, even if it might never threaten their health.
Doctors and patients have long debated the merits of prostate cancer screening out of similar concerns that it overdiagnoses patients. A study in the Netherlands found that as many as two out of every five men whose prostate cancer was caught through a screening test had tumors too slow-growing to ever be a threat.
"Mammography is one of medicine's 'close calls,' ... where different people in the same situation might reasonably make different choices," wrote H. Gilbert Welch of VA Outcomes Group and the Dartmouth Institute for Health Policy and Research, in an accompanying editorial in the BMJ. "Mammography undoubtedly helps some women but hurts others."
Experts said overtreatment occurs wherever there is widespread cancer screening, including the U.S.
Britain's national health system recently ditched its pamphlet inviting women to get screened for breast cancer, after critics complained it did not explain the overtreatment problem.
Laura Bell of Cancer Research UK said Britain's breast cancer screening program was partly responsible for the country's reduced breast cancer cases.
"We still urge women to go for screening when invited," she said, though she acknowledged it was crucial for women to be informed of the potential benefits and harms of screening.

On the Net:
Copyright © 2009 The Associated Press. All rights reserved.

Wednesday, July 8, 2009

Healthcare Reform Does NOT Require Rationing

The Washington Post printed a piece titled, "In Retooled Health-Care System, Who Will Say No?". Obviously a very tricky question to answer. The healthcare system without significant changes will generate costs out of control.

The federal government is loathe to do what England has done by indicating what is and isn't covered.

Patients certainly don't know what tests, imaging studies, or medications are needed to stay healthy or get better. Often they are fooled by slick advertising as well as the false belief that more is better (perpetuated by medical dramas like ER and House).

Insurance companies have tried, but given their past track record it is doubtful they can lead the change.

So who will say no? It's the doctors. Frankly it isn't as much as saying no as it is about refocusing what patients really want. What they really want is just the tests, imaging studies, and medications that they need to get better and well. They really don't want everything under the sun.

Research shows that we do too many tests, procedures, and interventions and the outcomes are actually worse! There is plenty of opportunity to still deliver high quality care without falling into the trap, which we are all victim to that newer is better. Don't buy this lie!

The problem is that the reimbursement system rewards doctors to do more. Until that changes, nothing will change. If reimbursement does change, then will doctors have the ability to counsel their patients on what the right care is when in the past, it was wrongly believed that more is better?

Monday, July 6, 2009

Misleading Advice - Sacramento Magzine article - 8 Medical Tests that MIGHT Save Your Life

Forbes ran a similar article about 8 medical tests that could save your life earlier this year. It was accurate, thoughtful, and correctly identified the "test madness" that is pervasive in our country. In a completely different perspective, Sacramento magazine had an article in the July issue titled as 8 medical tests that can save your life.

Unfortunately, that isn't true. The article perpetuates the lie that more testing is better.

The article would have been better titled as tests that MIGHT save your life.

The heart scan, vascular screenings, even the annual skin cancer check, not one has been proven to save lives. Theoretically they seem to make sense, but there is no evidence.

And that's the problem.

Our healthcare system spends a lot on high-tech gee-whiz imaging studies and the public is infatuated with these tests with television shows, like House, which highlight their use. Yet a recent article in the New Yorker by physician writer Atul Gawande, found while we in the United States order more tests we aren't healthier for it.

The problem with increasing technology and actually worse health outcomes has been illustrated in Shannon Brownlee's book Overtreated. Doctors assumed that metastatic breast cancer patients would need bone marrow transplants to save their lives, because of the phenomenal success of curing blood cancers like leukemias and lymphomas with the same treatment.

Insurance companies refused because there was NO proof to that theory, even though it sounded nice. Ultimately, insurance companies buckled due to public pressure and outcry when breast cancer patients felt that it was denial of medical care. Was it a win for patient advocacy?

Here's the sad irony. Despite many desperate women undergoing brutal chemotherapy for bone marrow transplant, the research results finally showed that standard chemotherapy was better. Bone marrow transplant killed women, who falsely believed that it was superior. They died unnecessarily and needlessly because there was no proof.

Conclusion? This Sacramento magazine article should have been titled as 8 Medical Tests that "MIGHT" Save Your Life rather than "CAN". Save your money on these questionable exams. There is a reason why insurance companies won't pay for them. They aren't proven to save lives.
In the end, that is what really matters.

Infant's Tylenol and Children's Tylenol Not the Same

My appearance at the local ABC affiliate in Sacramento today. Sharon Ito summarized the variety of topics beautifully.

I will be at the Sacramento - Arden-Dimick library on Monday July 20th from 630 pm to discuss how to talk to your doctor. It has been a topic well received when I have spoken at various places including Intel, Sun City Lincoln, and Borders.

SACRAMENTO, CA - On Monday's Live_Online, Kaiser family physician Davis Liu, talked about the proper use of medication and answered your medical questions.
In the wake of the FDA's recommendation about lowering the over-the-counter dosage of Tylenol, Liu said parents should know that infant and children Tylenol products contain different dosages.

Liu said the infant formula is more concentrated than the children's variety, so parents should stick with the age and dosage requirements for each Tylenol product.

Liu also said if patients have had a prior drug or alcohol addiction, they need to tell their doctor before they receive any new medications, so their sober status isn't put in jeopardy.

Liu also said patients need to tell their doctors if a medication or a medical test is too costly. Doctors might be able to substitute a cheaper drug or postpone a test, without putting the patient's health at risk.

Liu will be presenting a workshop on How to Talk to Your Doctor on Monday, July 20, at 6:30 p.m. at the Arden-Dimick Library in Sacramento.

You can see the entire interview with News10's Sharon Ito in the Live Online Archive.
You can always send an e-mail to:

News10/KXTV Copyright 2009 / All Rights Reserved

Here's the entire interview.


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