Doctors without Science

Seth Roberts at his best:

Extremely Disappointing Facts About Doctors

The gist of Unaccountable: What Hospitals Won’t Tell You … by Mart Makary, a med school professor at Johns Hopkins, is that doctors have failed to regulate themselves. Nobody else regulates them, so they are unaccountable. In many ways, Makary shows, bad behavior (e.g., unnecessary treatment, understating the risks of treatment) is common. Hospitals hide how bad things are. Makary mostly discusses surgeons — he’s a surgeon — but gives plenty of reasons to think other specialties are no better.

The book is one horror story after another. At one point, Makary quit medical school. He was disgusted and appalled by seeing doctors — his teachers — push an old woman to consent to an operation she didn’t want and didn’t need. She refused, again and again, but the doctors kept pushing. Makary objected. He was ignored. Finally she agreed. The operation killed her.

I know Peter Attia as a co-founder, with Gary Taubes, of the recently formed Nutritional Science Initiative. Makary met him when Attia did a surgery residency at John Hopkins Hospital. Attia had seen a doctor about back pain and had been told he needed surgery. They operated on the wrong side, causing damage that prevents Attia, an excellent athlete, from playing most sports. Eventually Attia left medicine. He felt “modern medicine was too frequently dishonest with patients, at times understating risks and overtreating patients as a matter of reflex” — “as a matter of reflex” meaning “as a matter of course”, i.e., usually. And Johns Hopkins Hospital is one of the better hospitals in America. “Almost everyone I talk to has a story about a friend or a family member who was hurt, disfigured, or killed by a medical mistake,” writes Makary. He has six such stories, including his grandfather and his brother. His grandfather died from unnecessary surgery.

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A sane healthcare system?

The specifics of this outbreak, published, oddly, in the American Journal of Psychiatry are the same as every other outbreak: A patient, in this case a homeless African-American man, has a cough. His cough is mostly ignored because people cough all the time and the clinicians are focused on his schizophrenia. Eventually, someone gets an X-ray (In Jacksonville it was eight months into the illness), TB is diagnosed and then public health workers scramble to locate the hundreds of people he might have exposed. In an adequately funded and sane healthcare system, information from previous visits, including old chest X-rays, might have been available; so too any relevant information about his TB status; perhaps an X-ray would have been easier to obtain (outpatient mental health facilities don’t often have the equipment) – all aspects of the “medical home” at the center of the ACA. Which is why it’s so distressing to see governors like Scott turn away additional Medicaid funding in order to make a political stance against President Obama.

Not taking care of the ill is stupid

A few days ago, while awaiting the Supreme Court ruling on the Obama health-care law, I called a few doctor friends around the country. I asked them if they could tell me about current patients whose health had been affected by a lack of insurance.

“This falls under the ‘too numerous to count’ section,” a New Jersey internist said. A vascular surgeon in Indianapolis told me about a man in his fifties who’d had a large abdominal aortic aneurysm. Doctors knew for months that it was in danger of rupturing, but, since he wasn’t insured, his local private hospital wouldn’t fix it. Finally, it indeed began to rupture. Rupture is an often fatal development, but the man—in pain, with the blood flow to his legs gone— made it to an emergency room. Then the hospital put him in an ambulance to Indiana University, arguing the patient’s condition was “too complex.” My friend got him through, but he’s very lucky to be alive.

Another friend, an oncologist in Marietta, Ohio, told me about three women in their forties and fifties he was treating for advanced cervical cancer. A pap smear would have caught their cancers far sooner. But since they didn’t have insurance, their cancers were only recognized when they caused profuse bleeding. Now they required radiation and chemotherapy if they were to have a chance of surviving.

Even inexperienced physicians like me, still in my residency, have these kinds of stories to tell. They’re tragic. But worse, they’re just so stupid. Notice how, in each instance, the problem still ends up being taken care of, only now it’s emergent, farther along, more risky, and of course, more expensive to treat. This is part of the ludicrous nature of the opposition to health care reform. There is no way to get out of paying for these things. All we do by denying people coverage for necessary medical treatment is guarantee that in a few days, months, or years, they’ll be in the emergency room, only now it will cost ten times as much to fix, at greater risk to the patient. This is also backed up by the international experience of health care. Every other industrialized country has universal coverage, many have far superior care, not to mention superior service (France anyone?) to the United States. Yet every one of the countries pays far less per capita (most less than half) than we do on health care. Data from studies within our own country show it’s cheaper for the state to cover the uninsured than to let them stay uninsured. Because of EMTALA, passed by that notorious socialist Ronald Reagan, everybody gets emergency care whether they are insured or not, and fully 50% of emergency care is uncompensated, costs which get transferred to the insured and the tax payers.

Is health-care a medical or a social problem?

The savage cuts to Greece's health service budget have led to a sharp rise in HIV/Aids and malaria in the beleaguered nation, said a leading aid organisation on Thursday.

The incidence of HIV/Aids among intravenous drug users in central Athens soared by 1,250% in the first 10 months of 2011 compared with the same period the previous year, according to the head of Médecins sans Frontières Greece, while malaria is becoming endemic in the south for the first time since the rule of the colonels, which ended in the 1970s.

Reveka Papadopoulos said that following health service cuts, including heavy job losses and a 40% reduction in funding for hospitals, Greek social services were "under very severe strain, if not in a state of breakdown. What we are seeing are very clear indicators of a system that cannot cope". The heavy, horizontal and "blind" budget cuts coincided last year with a 24% increase in demand for hospital services, she said, "largely because people could simply no longer afford private healthcare. The entire system is deteriorating".

It seems to me that access to health-care is the primary determinant for the quality of health-care – the biggest improvement for a health-care system is making sure all people have access.

A psychiatrist that is a pharma shill?

Just one link, there is more where this came from…

A prominent Emory University psychiatrist failed to tell the school about $500,000 he received from drug maker GlaxoSmithKline PLC while heading a government-funded research project studying Glaxo drugs, Sen. Charles Grassley alleged.

The payments to Charles Nemeroff, chairman of the Atlanta university's psychiatry department, compensated him for making presentations to doctors about Glaxo drugs, including its big-selling antidepressant Paxil, according to records Sen. Grassley obtained from Emory and Glaxo. The senator made the allegations in a letter to Emory President James W. Wagner dated Thursday.

In correspondence with Emory officials who police conflict-of-interest issues, Dr. Nemeroff repeatedly denied having a significant financial relationship with Glaxo, according to the records cited by Sen. Grassley, an Iowa Republican who has been investigating ties between academic researchers and the medical industry.

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Statins: "Funding from the test drug company was associated with results (OR=20) and conclusions (OR=35) that favor the test drug."

In this 20 minutes lecture by Beatrice Golomb, she mentions (among others) a interesting study:


So funding from the industry can skew research results? Who would have though that!?

Study weaknesses included:

• Inadequate blinding
• Lack of concealment of allocation
• Poor follow-up
• Lack of intention-to-treat analyses

It is always the same: Blinding, blinding, blinding and proper controls – at least they got the last one right. A study that was not properly blinded may be helpful to explore association ("Could it be?") or safety at a phase I stage, but to draw definite conclusions one needs properly blinded and controlled studies.

Here's the abstract:

Factors Associated with Findings of Published Trials of Drug–Drug Comparisons: Why Some Statins Appear More Efficacious than Others
Lisa Bero, Fieke Oostvogel, Peter Bacchetti, and Kirby Lee

Abstract


Background
Published pharmaceutical industry–sponsored trials are more likely than non-industry-sponsored trials to report results and conclusions that favor drug over placebo. Little is known about potential biases in drug–drug comparisons. This study examined associations between research funding source, study design characteristics aimed at reducing bias, and other factors that potentially influence results and conclusions in randomized controlled trials (RCTs) of statin–drug comparisons.

Methods and Findings
This is a cross-sectional study of 192 published RCTs comparing a statin drug to another statin drug or non-statin drug.

Data on concealment of allocation, selection bias, blinding, sample size, disclosed funding source, financial ties of authors, results for primary outcomes, and author conclusions were extracted by two coders (weighted kappa 0.80 to 0.97). Univariate and multivariate logistic regression identified associations between independent variables and favorable results and conclusions. Of the RCTs, 50% (95/192) were funded by industry, and 37% (70/192) did not disclose any funding source.

Looking at the totality of available evidence, we found that almost all studies (98%, 189/192) used only surrogate outcome measures. Moreover, study design weaknesses common to published statin–drug comparisons included inadequate blinding, lack of concealment of allocation, poor follow-up, and lack of intention-to-treat analyses.

In multivariate analysis of the full sample, trials with adequate blinding were less likely to report results favoring the test drug, and sample size was associated with favorable conclusions when controlling for other factors.

In multivariate analysis of industry-funded RCTs, funding from the test drug company was associated with results (odds ratio = 20.16 [95% confidence interval 4.37–92.98], p < 0.001) and conclusions (odds ratio = 34.55 [95% confidence interval 7.09–168.4], p < 0.001) that favor the test drug when controlling for other factors. Studies with adequate blinding were less likely to report statistically significant results favoring the test drug.


Conclusions
RCTs of head-to-head comparisons of statins with other drugs are more likely to report results and conclusions favoring the sponsor's product compared to the comparator drug. This bias in drug–drug comparison trials should be considered when making decisions regarding drug choice.

"More Evidence that Universal Health Care Would be Less Expensive"

We've written quite a bit about single payer health care systems as well as other models that are a mixture of public and private spending.

We've also analyzed some of the sources of excess cost of US healthcare to other countries. What is uniformly true about universal health care systems is that they all spend less on medical care per capita than the US. …

More Evidence that Universal Health Care Would be Less Expensive – denialism blog