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Globalization Poses Health Risks

The global economy is a mixed blessing – while we may
benefit from access to less expensive goods and services, by using them we rely
on the quality standards of their country of origin.  In an alarming expose, the New York Times
reveals how far behind China
is in the application of quality and safety standards to their food and
pharmaceutical products.

I have voiced concerns in this blog before about the
melamine/pet food scandal and the implications it may have for humans, as well
as the fact that many Chinese citizens trust western medicine over their own
traditional practices for matters of serious illness.  But this latest Times article has further
described the risk that counterfeit Chinese products can pose to the global community:

Toxic syrup has
figured in at least eight mass poisonings around the world in the past two
decades. Researchers estimate that thousands have died. In many cases, the
precise origin of the poison has never been determined. But records and
interviews show that in three of the last four cases it was made in China, a major
source of counterfeit drugs.

“Everybody wants to
invest in the pharmaceutical industry and it is growing, but the regulators
can’t keep up,” Mr. Zhou said. “We need a system to assure our safety.”

… Families [in Panama] have
reported 365 deaths from the poison, 100 of which have been confirmed so far.

When it comes to your health and the safety of the medicines
you use, you’re only as safe as the weakest link in the manufacturing or regulatory
process.  Prescription medications are
carefully regulated in the US,
but there is no such oversight in the herb and supplements market.  So buyer beware…  Check out places like consumerlab.com to get
some objective information about safety before you pop those “health pills.”

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Good news for celiac disease sufferers – biopsies may not be necessary for diagnosis

In a recent study published in the British Medical Journal, researchers found that blood tests and a history of patient symptoms might be all that’s needed to diagnose the majority of individuals with celiac disease. Until now, a diagnosis required a biopsy of the intestinal wall.

It is estimated that celiac disease (caused by an autoimmune reaction to wheat gluten) remains undiagnosed in a whopping 85% of cases. This may be due to the fact that symptoms are often non-specific (diarrhea and constipation, fatigue, anemia, tooth enamel defects, weight loss, and dry skin are some of the symptoms).

The researchers report:

We devised and evaluated a clinical decision tool that used a combination of pre-endoscopy serological testing (for tissue transglutaminase antibodies) and assessment of symptoms to identify patients with coeliac disease. This decision tool might help increase the detection of coeliac disease in patients attending for gastroscopy without the need to perform routine duodenal biopsy.

As efforts are underway to increase awareness in the primary care community about the disease, it is good to know that diagnosis may no longer require an invasive test!

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Herbal Remedy May Reduce Urinary Tract Infections?

The number one Google news item today is a report of a mouse study (published in Nature Medicine, but apparently still embargoed to the public as it is not listed on their website) that suggested that an herbal supplement could (in combination with antibiotics) “eradicate” urinary tract infections.

In usual fashion, the buzz preceded the science, and now we have thousands of people on the lookout for forskolin (a root extract of coleus) tablets from the local health food store. Do these have any possible merit?

A recent review of the literature about this herb was conducted by the good docs at Harvard, and turned up “no conclusive evidence for its [forskolin’s] use for any health condition.”

My friend Dr. Charles also read the reports of this “miraculous” new cure – which posits that recurrent urinary tract infections are caused by pockets of bacteria that hide inside bladder walls. Dr. Charles rightly points out that there are many different points of entry for bacteria, and that an herb which (and we don’t know that it even does this) relaxes bladder walls would surely not affect the alternate routes of entry, hence it cannot be curative in all cases.

So my friends, I’m sorry to say that there is little justification for enthusiasm yet. But we will follow the research with interest, in case human subjects do indeed show benefit in the future.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Made in America: The Institute of Medicine

I had dinner with a small group of people recently – and Harvey Fineberg, President of the Institute of Medicine, was our dinner speaker. A few things struck me as he reviewed the history of this 37 year old institution.

First of all, The British Medical Journal published a thought-provoking article about the top 5 things that Britain and the US could learn from one another’s healthcare systems. Of all the possible things that they could highlight about US Healthcare, the Institute of Medicine was listed in the #1 slot.

Well, my goodness – is that the very best of what US medicine has to offer? The IOM?

Maybe so. Here’s the Reader’s Digest version (forgive me Dr. Fineberg) of the history and purpose of the IOM.

President Lincoln founded the National Academy of Sciences back in 1863 for the purpose of advising the public in an objective manner on matters of science.  The NAS has expanded to include 3 newer organizations: the National Research Council (1916), the National Academy of Engineering (1964), and  the Institute of Medicine (1970).

The IOM consists of members elected by peers in recognition of distinguished achievement in their respective fields. It has about 1,200 members. But here’s why this organization is so unique: all of the members VOLUNTEER their time! Can you imagine another organization that could get 1,200 doctors to work for free? Yes, they volunteer – and they do so gladly because it is an honor to be part of the task force to advise the public in an objective manner on matters of medicine. The IOM gets no money from the government, it survives on donations and volunteerism.

The IOM is uniquely positioned to formulate unbiased assessments of important medical questions. It is medicine in its purest form – the facts and the data are the only foundation of their analyses. No government funding, no pharmaceutical intervention, no personal agendas. Just the pursuit of truth.

Apparently the IOM produces 1 report per week! The most famous of which may be their “To Err Is Human” (2000) report which uncovered the shocking frequency of medical errors, and included recommendations for new patient safety initiatives.

A lesser known report actually debunked lie detector tests…

And so, as I considered Dr. Fineberg’s description of the IOM I began to realize why other industrialized nations are jealous of our institute. I am so glad that President Lincoln had the foresight to create an objective, “collective wisdom” vehicle for advising the nation. The question now becomes: does the nation hear what they’re saying?

I think it would be wonderful for the IOM to allow Revolution Health to be an outlet for disseminating their information to the public. After all, our mission is to empower consumers with the most credible health information available… and my friends, after hearing Dr. Fineberg’s speech, I don’t think it gets any better than the IOM.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Pay for performance – more red tape without improved quality of care

We all agree that improving healthcare quality is a critical goal, but there is no real consensus on how to achieve that goal. In recent years, a “Pay for Performance” or P4P strategy has been put forth by the US government’s Center for Medicare and Medicaid Services (CMS). The gist of the strategy is to pay physicians more or less based on certain disease outcome measures of the patients they treat. So if a physician treats a large group of patients with diabetes, that physician would be paid more/office visits if, on average, those patients demonstrated lower blood sugar levels, lower cholesterol levels, and less evidence of end-organ damage on various tests.

P4P assumes that a patient’s chronic disease outcomes are completely dependent upon the physician. To me, this underlying assumption (that the patient is not involved in his/her own health) is offensive. It is offensive because it assumes that patients are not in control of their lifestyle choices, that their circumstances can be summed up by lab tests, and that their doctor takes all the credit for their hard work to control their disease. It also assumes that patients and families need not be partners in the quest for optimum health – no, that is solely the responsibility of the physician. Ultimately, P4P is disrespectful to patients – it takes them out of the health equation, it presumes that they’re passive participants, and it depersonalizes medicine.

And it gets worse. If physicians are paid more for patients who do well, they will be tempted to “cherry pick” the most motivated and privileged patients. How does this help the patients who need the most help? It will further earmark them for lower quality care.

One of my favorite bloggers, Dr. Richard Reece, echoes my sentiments, further explaining how ludicrous it is to assume that doctors are in full control of patient health outcomes:

People spend 99.9 percent of their time outside of doctors’ offices and hospitals. This time gap is particularly important in patients with chronic disease. Your outcomes depend on how and where you live and work…

Many patients don’t follow doctors’ orders. Many never fill prescriptions, fail to get refills and avoid exercise.

Half-way technologies–stents, coronary bypasses, joint replacements, statins, etc.–don’t eliminate underlying diseases or change their basic pathophysiology. The problem here, of course, is many patients have overblown expectations at what these technologies will accomplish and often return to the behavior that led to the problem in the first place.

Even CMS recognizes the limitations of P4P:

Pay-for-performance is in its early stages of development and a great deal of work still must be done to determine the best method of approaching a comprehensive program.

But that doesn’t stop them from promoting the program to states that are in desperate need of federal funds:

CMS will provide technical assistance to those states that voluntarily elect to implement pay-for-performance programs. We also plan to work with states to encourage that evolving pay-for-performance programs include an evaluation component to provide evidence of the effectiveness of this methodology.

For some further examples of how P4P doesn’t work, check out the following blogs: 1) disaster in the nursing home setting and 2) a summary of recent research studies on the ineffectiveness of P4P by Dr. Poses (via KevinMD).

Then what is the real issue that we’re trying to get at?

Quality care is dependent upon the regular application of evidence-based medicine (EBM) to clinical situations. What is EBM? Every medical decision that physicians make should have a good reason behind it – and that reason, whenever possible, should be based upon scientific evidence that the decision has worked in the past. What I mean is that we spend billions of dollars on medical research to learn the difference between truth and error, and doctors should do their level best to apply the research findings to the care decisions they make each day. Now, keep in mind that there are about 6000 research articles published each day in the medical journals world-wide… so it may come as no surprise that (as Dr. Reece explains):

It’s well-documented doctors only follow preventive and treatment guidelines 50 percent to 55 percent of the time. Moreover, doctors could do a much better job communicating with and educating patients, deploying the Internet (for example) to reach patients when they are outside of the immediate care setting.

So what we really need to do, is support physician education efforts to incorporate the very best research findings into their clinical practice of medicine. How can a physician keep up with all the latest research? I maintain that the government’s efforts would be better spent on hiring physician task forces (to summarize the very latest evidence for the treatment of every disease and condition – and then supply simplified guidelines to docs across the country) than on scheming up ways to penalize physicians for treating patients who are sicker and less willing or able to take control of their health. It would be great if physicians were incentivized to use the latest clinical guidelines in their care of patients – but basing the incentives on outcomes (rather than on applying the guidelines) cuts out the patient’s responsibility as a partner in the treatment. As Dr. Feld rightly points out, quality care based on EBM could be vastly improved through a central EMR.

And what can patients do?

In this new era of consumer directed healthcare, patients need to understand that they really are co-partners with their doctors. A doctor can give you all the best possible advice, but if you don’t take the advice, then that doctor’s work on your behalf may be in vain. I believe that patients should be aware of the care guidelines that doctors use to treat them – and have access to a simple check list to track their own progress. I am personally helping to translate clinical guidelines into consumer-friendly lists for patients so that they can actively participate in, and follow along with, their care plan (so stay tuned for that). Revolution Health is committed to empowering consumers – and helping them to be a full partner on the road to wellness. In fact, we are developing a full suite of su
pportive services (including health coaches, chronic disease management programs, insurance advocates, nurse call lines, physicians available via email, and more) that will make it much easier for them to stay on track. In addition, we are enabling physicians to customize educational information for their patients, and participate (via IT) in a broader relationship with them.

There are many exciting improvements in healthcare currently under development. The Internet will play a central role in connecting patients and physicians to the scientific information that will help them get the best care no matter where they are or which doctor they see. I don’t believe that P4P is anything more than another misguided attempt to “improve healthcare quality” by creating more of the red tape that keeps doctors and patients from meaningful personal interactions.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

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