February 22, 2013 | 3:33 pm

Healthcare That You Should Avoid, part 2

Posted by Albert Fuchs, M.D.

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A chest X ray. One of many
tests you shouldn't have
routinely. Credit: Aidan
Jones/Wikimedia commons

16% of all spending in the US is on healthcare. About half of that is spent by federal, state, and local governments, and the other half is spent by the private sector. In 1970 about 7% of all spending was for healthcare. Total annual spending on healthcare per person has increased from less than $1,000 in 1970 to about $8,000 now.

Defenders of our current healthcare spending are quick to point out that while we’re spending much more, we’re getting much better healthcare. New technological developments are constantly bringing better treatments to patients, and patients are living longer. The increased expense, they would argue, is worth it. But we shouldn't believe them. In all other sectors (housing, transportation, food, …) quality improves while prices drop. We spend a smaller fraction of our money on transportation than we did a generation ago despite the fact that cars are safer and more fuel efficient and that commercial airline travel is inexpensive enough to be enjoyed by the middle class. We are right to expect medical care to become both better and cheaper over time.

Why hasn't it? I believe our current insurance payment system rewards overutilization and drives prices up. (I wrote a series of posts analyzing the issue in 2009.) Because the vast majority of healthcare dollars are not paid by the patients receiving the care, there is little disincentive to provide care that has little or no benefit. In fact there is a great incentive to the doctor to provide as much such care as possible.

Besides high prices, this has resulted in a healthcare culture in which doctors offer and patients have come to expect tests and treatments which have been proven to be entirely without benefit. Last April in an attempt to educate both doctors and patients about interventions that are valueless, the American Board of Internal Medicine Foundation partnered with a number of physician specialty societies and formed an initiative called Choosing Wisely. I wrote about it at the time. The program listed 45 different tests and treatments in nine different specialties that doctors shouldn't offer and that patients should question.

This week, Choosing Wisely has expanded this list. Many new physician specialty societies have come on board and the list of valueless tests and treatments has grown to 90. Among the new recommendations are:

• Don’t perform EEGs for headaches. The American Academy of Neurology finds that EEGs don't help in diagnosing the cause and do not improve outcomes.
• Don’t recommend feeding tubes in patients with advanced dementia; instead offer oral assisted feeding. The American Geriatrics Society reviewed the evidence that careful hand-feeding is as safe in patients with severe dementia and that tube feeding leads more frequently to agitation and worsening skin sores.
• Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium. The American Geriatrics society reminds us of the risks of motor vehicle accidents, falls and hip fractures can more than double in older adults taking sleep medicines.
• Cough and cold medicines should not be prescribed or recommended for respiratory illnesses in children under four years of age. The American Academy of Pediatrics reminds us that these medicines have little benefit in young children and have potentially serious side effects.

Feel free to browse the list yourself. It is a fascinating gallery of bad medicine. I must confess that I’m guilty of some of the misdeeds myself. I have a handful of older patients who take Ambien (zolpidem). How delighted will they be when I refuse their pharmacy’s request for the next refill and tell them that there are safer alternatives?

Choosing Wisely is a worthwhile effort. It may prevent patient harm and improve care. But I suspect it will not make a dent in costs. As long as doctors have a financial incentive to provide inappropriate care, some of them will. As long as patients have little financial incentive to assure that their care is appropriate, many of them will not.

Learn more:

Medical Waste: 90 More Don'ts For Your Doctor (Shots, NPR’s health blog)
Group Urges Health-Test Curbs (Wall Street Journal)
Doctors list overused medical treatments (Los Angeles Times)
Choosing Wisely

My last post about Choosing Wisely: Healthcare That You Should Avoid

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

February 15, 2013 | 2:41 pm

The Pathogens on Cupid’s Arrow

Posted by Albert Fuchs, M.D.

“Love is a burning thing
And it makes a fiery ring”
-- Johny Cash

On Valentine’s Day some think of chocolate, or wine, or flowers. Physicians think of sexually transmitted infections (STIs). This week with perfect timing, the Centers for Disease Control and Prevention (CDC) released two studies quantifying the burden of STIs in the U.S. The studies estimated the nationwide burden of eight STIs – chlamydia, gonorrhea, syphilis, genital herpes, human papillomavirus (HPV), hepatitis B, HIV, and trichomoniasis. The results showed that there are about 20 million new cases of these STIs annually, and that the prevalence of STIs, that is the number of new and existing infections at a given time, is 110 million. Over half of the STIs, both in terms of new infections and prevalent infections, are due to HPV, the virus that can cause genital warts and cervical cancer. And most of the infections are in young people between the ages of 15 and 25. How romantic!

As if that wasn’t enough to throw a wet blanket on the national mood, this week’s Morbidity and Mortality Weekly Report followed up on a story I first wrote about a year ago – the emerging threat of multi-drug resistant gonorrhea. Gonorrhea remains a serious public health threat in the U.S. with over 300,000 new cases reported in 2011. Peruse my post from a year ago for the detailed history of the gonorrhea bacterium repeatedly overcoming whichever antibiotic we use against it. Since the 1940s gonorrhea has developed resistance to sulfanilamide, penicillins, tetracyclines, and most recently fluoroquinolones. That leaves cephalosporins as the last family of antibiotics uniformly effective against gonorrhea.

This week’s report warns that strains of gonorrhea resistant to cephalosporins have been isolated in Japan, France, and Spain in the last few years. Strains in the U.S. remain sensitive to cephalosporins, but laboratory measures of cephalosporin sensitivity in isolated strains are slowly decreasing. No other effective antibiotic alternative is on the horizon, so the appearance of cephalosporin-resistant gonorrhea may essentially mean the appearance of untreatable gonorrhea. How romantic!

So as we approach the end of the antibiotic century, perhaps we should all try to rediscover the virtues of monogamy. That may sound quaintly retrogressive, but no more so than the notion of having no treatments for common infections.

“You must remember this
A kiss is still a kiss
A sigh is just a sigh
The fundamental things apply
As time goes by”
-- Herman Hupfeld

Learn more:

'Ongoing, severe epidemic' of STDs in US, report finds (Vitals, NBC News)
CDC Warns of Super-Gonorrhea (ABC News)
'Severe epidemic' of sexually-transmitted diseases is sweeping the nation, warns CDC on Valentine's Day (Daily Mail)
CDC Grand Rounds: The Growing Threat of Multidrug-Resistant Gonorrhea (Morbidity and Mortality Weekly Report)
Incidence, Prevalence, and Cost of Sexually Transmitted Infectious in the United States (CDC Fact Sheet)

My last post about multi-drug resistant gonorrhea: Untreatable Gonorrhea – The Next Infectious Threat

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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