January 29th, 2008 by Dr. Val Jones in Health Policy
1 Comment »
I attended an excellent brown bag lunch with Dr. Greg Downing today. He’s the program director for the U.S. Department of Health and Human Services’ (HHS) Personalized Health Care Initiative. He spoke about some of the challenges associated with incorporating genetic test results into a personalized health record, and how consumer demand is fueling biotech companies to offer tests long before their clinical significance has been determined.
Here are some interesting statistics that Dr. Downing mentioned:
Only 15% of Americans have their medical records in an electronic format that they can access
About 30% of clinical decisions are based upon evidence from quality research
At least 70% of genetic tests are requested by patients, rather than clinicians
At the same time, HSS Secretary Mike Leavitt has issued this vision statement about personalized health care:
“Personalized health care is providing the right treatment, for the right patient, for the first time, every time.”
So what we have here is an incredible gap between our aspirations and reality. While we want to leverage genetic information for disease prevention purposes, subjecting the entire population to a “needle in a haystack” search for disease predictors is extremely expensive. In addition, genes rarely provide black and white answers regarding disease risk. Sure there’s the Huntington’s Disease gene (which really does have a nearly 100% correlation with the development of the disease), but the vast majority of genes have much more gray significance, with shades of predisposition and uncertainty.
Biotech companies sense America’s eagerness to peer into its health future, and are actively engaged in direct to consumer advertising. With tests ranging in price from $300-$3000 dollars, and wealthier clients willing to pay for the tests, they stand to make a good profit without clear improvements in health outcomes, or patients even knowing how to interpret their results.
Connecticut Attorney General Richard Blumenthal (D) recently said his office is investigating the accuracy of claims Myriad makes about the test in the ads, including issuing a subpoena for information about the ads. Blumenthal said his office has received complaints from professional caregivers, clinicians and scientists who believe the test has a “very high potential for misinterpretation and overreaction.”
In a rather extreme case of putting the cart before the horse, a potential susceptibility to suicidality (while on particular anti-depressants) was linked to a certain gene sequence. The day after the publication of this preliminary research one company was offering the genetic test directly to patients for $500/test.
So ultimately I agree with Dr. Downing’s cautionary message: let evidence based medicine be the foundation upon which personalized medicine is built. Mad dashes for genetic enlightenment don’t mean much if we don’t know how to interpret the test results. And let’s not forget the role of environmental factors in our health. You may have longevity genes, but if you’re engaged in risky behaviors, what good are they?
I do believe that the study of genetics is critical to our understanding of health and disease, but we need to do the research to learn how to leverage what we learn. Research is costly and slow, but the rewards are worth the investment. If you are going to undergo genetic testing online, make sure that you do so with a reputable company like DNA Direct that offers evidence-based tests with genetic counseling as part of the package, so that you will know what your test(s) mean. Of course, the best plan is to discuss genetic testing with your doctor.
And as for Secretary Leavitt, I applaud his vision and look forward to the day when we’ll all have access to our health information online, and we’ll receive the right treatments at the right time, every time… Let’s just say we’re not there yet.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
January 5th, 2008 by Dr. Val Jones in Uncategorized
No Comments »
Welcome to 2008’s first edition of Revolution Rounds, my biweekly round up of the best Revolution Health expert blog posts. Not surprisingly, there’s a decidedly New Year’s theme in this collection of posts. If you’re looking to stick to a New Year’s resolution, be sure to check out the Revolution Health groups section of the site. Whether you’d like to lose weight, quit smoking, or improve your relationships – there’s a group of like minded souls out there resolving to do the same!
Health tips
Dr.
Stacy has 20 New Year’s resolutions for kids. She has even organized them
by age group for you.
New
Year’s resolutions are more likely to succeed if you follow this advice. Mira Kirshenbaum has some great tips for adults.
Would
you like to lose weight effortlessly? Sandra
Foschi suggests that good sleep habits can contribute to
weight loss.
Reading
the right blog could save your life. Dr. HJ Lenz describes how one woman
learned about certain treatment options from his colorectal cancer blog, and it
changed her life.
Would
you like to stop snoring? Dr. Steve Poceta
has some excellent tips.
The best treatment for autism may not be a drug, but human caring.
Robin Morris discusses the findings of some recent research.
Do
you struggle with jet lag? Dr. Vivian Dickerson has some suggestions for
reducing your symptoms.
Pedometers
can encourage increased exercise. Dr. Jim Herndon suggests that a pedometer
might be an excellent addition to your weight loss resolution!
In
case you need another good reason to quit smoking: Dr. Mark Perloe reminds
us that smoking a pack a day can increase the risk of erectile dysfunction by
40%.
Think
you know how to insert eye drops? Think again. Dr. Jackie Griffiths has
some special advice for those of you who need eye drops regularly.
Did you know?
San
Francisco’s mayor has proposed a soda tax. Dr. Jim Hill explains that this
money is unlikely to put a dent in the obesity epidemic.
In
some cultures childhood epilepsy is treated by burning the feet with hot coals.
Dr. Jide Williams describes this horrific practice in rural Africa.
Snowblower
injuries are still quite common even though manufacturers have been working for
over 30 years to make the machines safer. Dr. Jim Herndon explains.
It
is possible to create embryos for the purpose of treating certain diseases, not
strictly for procreation. Dr. Mark Perloe discusses some of the ethical
dilemmas associated with stem cells.
Fitness
is more important than fatness. Dr. Vivian Dickerson explains.
Excess
weight in childhood is linked to adult heart disease. Dr. Jim Hill suggests
that fitness and weight control should begin early to promote good health in
adulthood.
Many
physicians need to work on their empathy. Dr. Mike Rabow explains that
younger physicians may be more empathic than older ones.
Your
emotional state can dramatically affect your physical health. Dr. Joe Scherger discusses this mind-body connection.
Demanding
parents may cause their childrens’ teachers to burn out. Dr. Stacy Stryer
describes this unfortunate phenomenon.
Skim
milk consumption may be linked to prostate cancer. Dr. Julie Silver raises
the question of whether or not skim and low fat milk are over-rated in their
health benefits.
You
don’t need both eyes to have good depth perception. Dr. Jackie Griffiths,
Revolution Health’s ophthalmologist, explains.
Newer
isn’t automatically better. Dr. Mike Glode bemoans the fact that we have
the tendency to rush after the latest medical technology without stopping to
analyze the cost benefit ratio.
Personal Stories
One
woman had an unpleasant surprise on her 40th birthday: a massive
stroke with left hemi-neglect! Dr. Olajide Williams describes the event
with poetic language.
Laughter
is the best medicine. Dr. Stacy Stryer describes how she puts this axiom
into practice in her family.
Dr.
Julie Silver was prompted by her daughter to become one of Charlie’s angels.
You’ll have to read the post to get the reference.
Vitamin
hawkers exaggerate their product’s benefits without recourse. Dr. Mike
Glode describes one interesting example of this phenomenon.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
December 17th, 2007 by Dr. Val Jones in Uncategorized
No Comments »
It’s time for the 4th annual Medical Blogger awards… nominate your favorites at MedGadget:
This competition
is designed to recognize the very best from the medical blogosphere,
and to highlight the diversity and excitement of the world of medical
blogs.
The categories for this year’s awards will be:
— Best Medical Weblog
— Best New Medical Weblog (established in 2007)
— Best Literary Medical Weblog
— Best Clinical Sciences Weblog
— Best Health Policies/Ethics Weblog
— Best Medical Technologies/Informatics Weblog
— Best Patient’s Blog
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
December 15th, 2007 by Dr. Val Jones in Health Policy, Opinion
5 Comments »
More healthcare dollars are spent on end-of-life measures than perhaps any other single expense. About 25% of Medicare’s 2.8 trillion dollar budget is spent on care for people in the final year of life. That works out to be about $2500/person/year that we spend on government funded end-of-life care. Medicare spending overall is closer to $10k/person/year in this country… and given that the average household pays $6K in taxes/year… you can see that we’re in a real pickle when it comes to healthcare spending (and that’s just for Medicare).
In a recent blog post, PandaBearMD suggests that it’s time to “put granny down.” This gallows humor speaks to what the medical community has been been discussing in more academic terms. Here are some interesting sound bites (click on links for full references):
Terminally ill patients should be treated outside of acute care facilities. …Acute care hospitals are, by definition, set up for handling acute conditions – trauma, childbirth, orthopedics, heart attacks, etc. Terminal illnesses are not acute conditions, and therefore should be treated in a facility or setting that is chronic-care oriented.
The technological advances that medicine has witnessed in the last few decades are no more apparent than in the ICU. Yet when used inappropriately, this technology may not save lives nor improve the quality of a life, but rather transform death into a prolonged, miserable, and undignified process.
Hospice care can reduce the cost of end-of-life care by 30% or more (though this is debated).
“We don’t operate in a closed health care system, where there is a fixed number of dollars for health care, and thus the need to choose how to allocate those dollars,” said Dr. Weissman. “Our health care system is open-ended, which is why the cost of health care goes up every year. So we’re not making a tradeoff of spending more on the elderly and thus not using those resources on children’s care.
While it is fairly obvious that we deliver a lot of unnecessary, costly, and heroic medical care at the end of life, determining how to ration this care is fraught with moral and ethical dilemmas.
What sort of population-based rules should we institute to govern access to acute care services at the highest level? Would limiting care to people based on age or comorbidities sit well with Americans? Imagine that you’re 65 – just entering retirement and expecting to enjoy another 20 years of life – and you’re disqualified from top tier medical treatments because of your age. Who has the right to judge your worthiness of top medical technology?
I know of an elderly woman who accidentally took too many diuretics over the period of two weeks. She became delirious and was admitted to a hospital where the doctors assumed she had end stage Alzheimer’s disease and sent her home with hospice care. Another doctor later discovered the error, rehydrated her and she returned to her usual state of health. It was a close call for that “granny.”
My parents are in their late 70’s and in excellent health, enjoying book writing and traveling. I asked them to read PandaBear’s analysis of end-of-life care in the United States – and how billions of dollars are spent on heroic measures for the frail elderly.
My mother said tersely, “I hope I die in Europe.”
My father replied, “Whether you’re old or young, it’s nice to be alive.”
But I can’t help but think of that patient who was sent home with hospice care for delirium caused by severe dehydration. Will we turn our backs on the elderly and not carefully consider their differential diagnoses simply because of their age? As long time tax payers, are they not the most deserving of access to top technologies if so desired?
This is one tough dilemma – and the best I can advise is that we each create living wills, and save our own money for that rainy day when we need critical care, but are ineligible based on some future population-based rule to save money on futile care. In that case, the wealthy would always maintain access to the best care available.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
November 25th, 2007 by Dr. Val Jones in Expert Interviews
No Comments »
My former mentor, Dr. Richard Robb, is Director of the Biomedical Imaging Resource Center at the Mayo Clinic, Rochester, Minnesota. I first met Dr. Robb as a Summer Undergraduate Research Fellow (SURF) in the Department of Biophysics at Mayo in 1994. Behind his reserved exterior is a man who is bursting with enthusiasm about the amazing technological advances that are making it possible for us to see cells, tissues, and organs in ways barely conceived of several decades ago. Dr. Robb admits that his passion for improving the quality of anatomical visualization is a response to a challenge once given him by a neurosurgeon colleague: “If I can see it, I can fix it.” Dr. Robb’s life’s work is to enable physicians and surgeons to be more effective healers through direct visualization of anatomy and physiology.
I caught up with Dr. Robb (at the Society for Women’s Health Research briefing on imaging and women’s health) and asked him a few questions about the future of medical imaging. Here are some excerpts from our interview:
Dr. Val: What is micro CT and what information does it give doctors?
Dr. Robb: Micro CT is a specialized kind of scanner that works on the same principles as regular CT scanners but it can capture images at much higher resolution. Structures as small as 5-10 microns in size can be seen. Although this is an emerging technology used primarily for research purposes, it has tremendous potential and implications for the future. With such resolution, we’ll be able to do “virtual biopsies” of suspicious tissue that we find with a regular CT and then zoom in with the Micro CT to get a close look at microscopic detail without having to do a biopsy to study them.
Dr. Val: What is SISCOM and who benefits from it?
Dr. Robb: SISCOM is an acronym for “Subtraction Interictal Spect COregistered to Mri.” It is used to pinpoint small parts of the brain that cause epileptic seizures, so that surgeons can effectively remove the diseased tissue. SISCOM uses radioactive tags that are absorbed by the parts of the brain that are over-active during a seizure, and they glow like a lightbulb on SPECT brain scans that are subtracted and registered onto MRI scans. The radiologist can pinpoint the exact focus of the abnormal epileptic discharges and then show the surgeons exactly where they need to resect the tissue. This technique allows surgeons to cure many patients who suffer from seizures that don’t respond to medications.
Dr. Val: What is the most exciting new imaging technology under development and how will it impact health?
Dr. Robb: The most exciting future technologies will allow us to visualize tissue functions at a chemical level. In the next 10 years we’ll see major advancements in image resolution and micro imaging techniques, and eventually we’ll be able to see individual molecules. This technology could actually eliminate the need for surgical biopsies, replacing them with “virtual or digital biopsies”, including close up images of cells and chemical reactions, such as diffusion, all in the context of surrounding macro-sized structures. The effect of the chemical actions and reactions will be expressed visually at the organ function level.
Also, in the next 10-20 years the development and clinical use of “nanobots”, or tiny robotic elements, that can be ingested or injected into the body will become manifest. These may be used with special biomarkers – substances that preferentially label tissue types and pathology within the body. These traveling nanobots can, for example, either go to the biomarkers or expore intelligently certain anatomic domains, taking pictures inside GI tracts, pulmonary airways, or even blood vessels. They will then analyze these images for detection and characterization of abnormalities (like a polyp) followed by administering treatment to the abnormality (e.g., remove it by ablation or radiation or chemicals). The nanobot will remain in the body until it has removed or repaired the targeted pathology or trauma, then it will exit through natural means or “self-destruct” in a safe way. Nanobots could reduce the need for more invasive surgeries, and dramatically improve clinical outcomes with very low risk and morbidity.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
