Where's the beef? Show me the money! Where's the evidence?

An excellent series by the NY Times, which is increasingly asking the right and hard questions about healthcare and its costs is in the column, the Evidence Gap. The most recent piece discusses the reimbursement by Medicare for prostate cancer using radiation treatment known as a CyberKnife. Although there is no evidence that is it any better than current therapies, whether you as a patient have the CyberKnife treatment covered is mainly based on where you live. Medicare doesn't reimburse for the procedure in California or Texas, even though it is a national plan.

Shocking? Hardly. These are the kinds of disparities that arise in our healthcare system everyday. Often the treatments aren't driven by science but by reimbursement.

When you get any treatment, ask your doctor, where's the proof that the treatment you offer is better than others? As the article implies, you may get a newer procedure not because it is necessarily better than others, but because someone, like Medicare will pay for it.

We're 42nd! We're 42nd! We're 42nd!

An analysis by a team from Harvard Public Health found that life expectancy not only may have hit a peak, but for many Americans has fallen.

Counties in the South found that more deaths were due to risk factors like smoking, obesity, and high blood pressure which caused more cancers, emphysema, and diabetes. Obviously the causes could be multifactorial. Certainly the counties with worsening life expectancy were poorer. Do those individuals have adequate health insurance or ability to get preventive healthcare? Do they have access to healthy food choices like fruits and vegetables? Can they afford them? Is there access to parks and other forms of recreation that allow physical activity or are the areas devoid of them and instead require people to drive more?

As the nation with the most financial and intellectual resources, we should do better than a life expectancy of 42 in the world. Increasingly, our country is becoming into two Americas, those that reach their full potential and those that are left behind. We need a serious system overhaul.

From the article:

• Last September, the U.S. Centers for Disease Control and Prevention reported that U.S. life expectancy had risen to almost 78 years in 2005 -- up from 75.8 years in 1995 and 69.6 years in 1955. The United States ranks around 42nd in the world in life expectancy.
  
• "The majority of these counties were in the Deep South, along the Mississippi River, and in Appalachia, extending into the southern portion of the Midwest and into Texas," Ezzati's team wrote.
• "One of the questions we are asking is whether our ranking in the world is getting increasingly worse because we are not doing a good job of taking care of the worst-off," Ezzati said.
• "Life expectancy decline is something that has traditionally been considered a sign that the health and social systems have failed, as has been the case in parts of Africa and Eastern Europe," said Christopher Murray of the University of Washington, who worked on the study.
• "The fact that is happening to a large number of Americans should be a sign that the U.S. health system needs serious rethinking."
• The study is available at http://medicine.plosjournals.org/perlserv/?request=get-document& doi=10.1371/journal.pmed.0050066.

Dutch Study Suggests that Obese Patients Cheaper to Treat

A Dutch research study found that perhaps over the long-term smokers or obese patients are less expensive to treat than thin and healthy individuals. Although many have assumed that addressing obesity and smoking would save money, this study suggests otherwise. Researchers believe that obese patients, who had more cases of diabetes, and smokers and diabetics, who had more cases of heart disease, died sooner. Those that were healthy lived longer but suffered from debilitating illnesses like Alzheimer's or strokes which in the long run ended costing more. Findings were as follows:

• healthy people lived 84 years, cost from age 20 on about $417,000
• smokers lived about 77 years, cost about $326,000
• obese people lived about 80 years, cost was $371,000

What does this mean? A couple of caveats. First, the research was done on Dutch data, both on how common various diseases were as well as the cost of illness. These values don't necessarily mean the same result would occur in the United States. Since the Netherlands ranks better than the United States in keeping people healthy, it is likely that even the healthy group doesn't live as long as we would expect. The second caveat is perhaps an intervention needs to be made for those that are thin and healthy to prevent them from having strokes and Alzheimers.

Why Don't Adults Get Vaccinated?

It's kind of depressing to keep reading about how our healthcare system fails to do the basic preventive tests and interventions that doctors and researchers know that can keep us healthy and lead productive lives. Here's another example in Time magazine's article Why Don't Adults Get Vaccinated?

A survey of 7000 adults found that most could only name the flu vaccine and that the hepatitis A, B, the shingles vaccine, the pneumococcal vaccine, the diphtheria, tetanus, and pertussis vaccine, weren't mentioned as easily.

Excerpts from the article:

• Just 2% of adults have had the new combo shot for tetanus, diphtheria and pertussis (better known as whooping cough), even though pertussis rates in adolescents and adults have soared in the last 20 years. The disease, a major child killer before the childhood vaccine was introduced, can cause coughing so forceful it breaks a patient's ribs or leaves him vomiting.
• Despite clamorous public debate and high-profile media coverage about the first cancer vaccine, which protects against the human papilloma virus, only about 10% of young women reported receiving at least one dose of the three-dose vaccine.
• Vaccines should be a cornerstone of preventive medicine. "They can prevent serious illness and death. They can save money and help keep us healthy, and at work and able to take care of our families, says Schuchat, who is also director for the CDC's National Center for Immunization and Respiratory Diseases. "We obviously have a lot of work to do and it involves literally rolling up our sleeves."

What perhaps is more disturbing is that many adults aren't vaccinating their children.

These reports only illustrate the increasing importance that you must take charge of your health and ask and even demand preventive tests and interventions you need to stay healthy and live longer as it is clear that our healthcare system won't do it for you.

Alzheimer's Disease - Searching for Preventive Treatments

The New York Times article Finding Alzheimer's Disease Before a Mind Fails illustrates the challenges facing doctors, researchers, patients, and families on finding preventive treatments, which do not currently exist, as well as challenges to help those afflicted with the illness. This is the last article in a six piece series which identified the six killers in America, heart disease, cancer, stroke, chronic obstructive pulmonary disease (emphysema), diabetes, and Alzheimer's.

The series was an excellent review of the challenges facing us and many of the shortcomings of our healthcare system in providing the right preventive care consistently and routinely to keep us healthy and living longer. It seems like we all take it for granted that our healthcare system is the worst among industrialized countries in keeping us healthy.

Personally, I see these problems as unacceptable and this shocking disparity gives me the motivation to educate everyone on what they must do to stay healthy and live longer.

Shocking, But Not Surprising - US Healthcare System Ranks Last

In a Health Affairs article which looked at how well 19 industrialized countries kept their citizens healthy, the United States ranked last. Which countries ranked best (in order of best to worst performance)?

• France, Japan, Australia, Austria, Canada, Denmark, Finland, Germany, Greece, Ireland, Italy, Netherlands, New Zealand, Norway, Portugal, Spain, Sweden, the United Kingdom and the United States.

The authors looked at how these countries did on decreasing the death rate among those under age 75 between 1997 to 1998 and 2002 to 2003. Specifically, were countries better than others decreasing the death rate by improving the healthcare system by timely effective delivery of care?

• In 1997–98, the U.S. ranked 15th out of the 19 countries on this measure—ahead of only Finland, Portugal, the United Kingdom, and Ireland—with a rate of 114.7 deaths per 100,000 people. By 2002–03, the U.S. fell to last place, with 109.7 per 100,000. In the leading countries, mortality rates per 100,000 people were 64.8 in France, 71.2 in Japan, and 71.3 in Australia.

Had the performance improved to the levels by the top three countries, 75,000 to 101,000 Americans would still be alive today.

Sadly, our country's poor performance is not a surprise. In our country, the healthcare system as a whole provides the known preventive tests and interventions proven to save lives only 55 percent of the time. Slightly better than a coin flip. As Americans pay more per capita for healthcare than any other country in the world, our system isn't the best at keeping us healthy. Unless you take the initiative and ask for tests and interventions that will keep you healthy for a long time, you might get the right care half the time. Are you willing to risk it?

Free Drug Samples Don't Help Those in Need

An article in the upcoming issue of the American Journal of Public Health found that free drug samples distributed by drug reps are not being given to those in need, but rather to patients who have health insurance. Findings from the report include:

• about 12 percent of all Americans have received at least one free sample
• 13 percent of those with insurance were given a sample, while about 10 percent of those uninsured for all or part of the year got one, a statistically significant finding
• 72 percent had income above 200 percent of the federal poverty line, while 28 percent had incomes below that level

The study also found that the recalled pain reliever, Vioxx, was in 2002, the most frequently distributed medication even though the medical indications for its use should have been limited to those at high risk for stomach ulcers and bleeds. It was learned shortly afterwards that Vioxx increased the risk of heart attacks.

Why is this important to you? The author of the study initially thought that it was possible that the free medication samples had a good benefit which was to help provide a safety net to those with inadequate or no health insurance. However, this article only reinforces the perception that drug companies are out to market their medications, which isn't always in your best interest.

What You Must Do to Stay Healthy

The American healthcare system only consistently delivers the right preventive care 55 percent of the time. As a result, tens of thousands of Americans die prematurely from avoidable deaths because simple interventions weren't done. Doctors are increasingly busy and may not have enough time to tell you all you need to know to stay well. One study showed that a doctor working full time would need an extra day to counsel patients on what steps they should do to keep healthy. As a result preventive screening tests for cancers like breast cancer, prostate cancer, and colon cancer, which are leading causes of death, aren't performed routinely and regularly for those who need it. With more patients paying higher deductibles and co-pays, you must know what you should ask for and then get it done.

For breast cancer screening, this means women at average risk should have a mammogram at age 40. Men at average risk should begin screening for prostate cancer at age 50. Both genders should have colon cancer screening, either a sigmoidoscopy with annual stool testing or a colonoscopy starting at age 50. You may need to check with your doctor if you are at higher risk as you may need to be screened earlier or more frequently. A major misconception is that only individuals with a family history are at risk for cancer. While they are at higher risk, the vast majority of new cancer cases occur in individuals without a family history.

The same preventive screening tests and interventions also apply to other problems like high blood pressure, high cholesterol, and diabetes. Do you know what the ideal blood pressure is? How often should you have it checked? When should you be screened for diabetes? Are you at risk?

Even if you exercise regularly, are at a healthy weight, don't smoke or drink, it doesn't mean you can or should skip these important preventive steps. Identifying and addressing problems early increases your chance of living longer and staying well.

The healthcare system doesn't reliably remind you when you should get these tests done. Your doctor may not have enough time to remind you what to do. Increasingly you are paying more for healthcare. Find out what you need to do to stay well. It's your money. It's your life.

Go to www.davisliumd.com to get the preventive guidelines for adults under the free download section.

Diabetes - What You Need to Do to Stay Well

This past year the New York Times printed a series about the six killers in America which included cancer, diabetes, heart disease, emphysema, stroke, and Alzheimer's. The article on diabetes shows how much more our healthcare system needs to improve to basics and fundamentals of preventive care to keep people healthy and productive. Highlights from the article include:

• Most [diabetic] patients are not doing even close to what they should to protect themselves. In fact, according to the federal Centers for Disease Control and Prevention, just 7 percent are getting all the treatments they need.
• The fault for the missed opportunities to prevent complications and deaths lies with the medical system.
• A recent survey by the American Diabetes Association conducted by RoperASW found that only 18 percent of people with diabetes believed that they were at increased risk for cardiovascular disease.
• Yet, said Dr. David Nathan, director of the Diabetes Center at Massachusetts General Hospital, “when you think about it, it’s not the diabetes that kills you, it’s the diabetes causing cardiovascular disease that kills you.”"
• “Right now, without waiting for lots of exciting things that are almost in the pipeline or in the pipeline, starting tomorrow, if everyone did these things — taking a statin, taking a blood pressure medication, and maybe taking an aspirin — you would reduce the heart attack rate by half.”
• “We already have the miracle pills” — statins and blood pressure medications, he said. And they are available for pennies a day, as generics.
• “We need patient education and physician training that this stuff is out there and this is what we should be focusing on to make a difference in lives.”

Without a doubt, the United States does deliver the most sophisticated and technologically advanced medical care in the world. This is why patients come here to get care that they can't get anywhere else.

That doesn't mean that we do a great job with simple things like vaccination rates, cancer screening, and control of high blood pressure, cholesterol, and diabetes, to levels recommended by expert committees. Although the level of care has improved over the past decade as evidenced by reports from the National Committee for Quality Assurance, there is more we need to do.

Vaccine against "infant killer"

Doctors in Macau, which is near Hong Kong, want the government to pay for the pneumococcal vaccine to protect against Streptococcus pneumoniae. The bacterium dubbed "infant killer" claims nearly 50 children per hour in Asia. The bacterium is already resistant to many antibiotics. Unfortunately the cost of the vaccine is out of reach for many in Asia.

Lui Kin Man, president of the Macau Paediatric Society, said childhood vaccination against the bacteria was important in southern China because treatment was especially difficult.

"In our region, like Hong Kong, Macau and Taiwan, bacterial drug resistance is very high, and pneumococcal (bacteria) is resistant to drugs like penicillin and erythromycin," Lui said in a telephone interview.

"Mortalities (caused by the pneumococcal bacteria) are higher in developing countries and mostly from pneumonia. Of all pneumonia deaths, 40 percent of them are caused by this bacteria," Lui said.

In the United States, prior to the development of a vaccine that protected against Streptococcus pneumoniae, the bacteria annually caused over 700 cases of meningitis, 13,000 cases of blood infections, over 5,000,000 ear infections, and 200 deaths in children under five from invasive disease.

In America, children are routinely offered this vaccine. Recommendations by the Centers for Disease Control suggest that for children, the vaccine is a series of shots given between the age of two to twenty-three months and is known as the pneumococcal conjugate vaccine (PCV). Other children may also get this vaccine at a later age if they have certain medical conditions. The pneumococcal polysaccharide vaccine (PPV) is recommended for adults sixty-five and older or who have other medical conditions. PPV is also given to children over the age of two with chronic illnesses.

With immunization, parents don't need to worry that there children will contract the illness or a bacterium that is resistant to many antibiotics. Yet, in this country many parents question the importance of vaccinations as doctors and parents a world away wish they had the opportunity to immunize.

America's Lagging Health Care System

An editorial from the New York Times reiterates what has been known for quite sometime which is that the American health care system trails that of other industrialized countries. More individuals are becoming dissatisfied with a system that does not support quality, leaves too many without insurance, and continues to increase costs.

The editorial correctly points out that for the system to improve it will require that patients have easy access to primary care doctors. It is the robust primary care doctor network that other countries have that help improve the health of their citizens while keeping costs manageable.

Insurance Type and Appendicitis

An interesting article in the New York Times titled "Likelihood of Burst Appendix Tied to Insurance".

From the report, "But the kind of insurance — or lack of it — had a significant effect. Compared with patients who had private insurance coverage, those on Medicare were 14 percent more likely to have a burst appendix, people on Medicaid were 22 percent more likely, and those with no insurance at all were 18 percent more likely to have a rupture. The differences persisted even after controlling for age, sex, socioeconomic status, type of hospital and other factors."

The authors admit that this is a retrospective study and it is unclear the reasons why the difference was seen.