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The New Health Dialogue

A Blog from New America's Health Policy Program

Disease Creep: How we're fooled into using more medicine than we need.

December 22, 2011
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This is a guest post from independent medical investigative journalist Jeanne Lenzer. She is a former Knight Science Journalism Fellow and a frequent contributor to BMJ, and has published works in  The Atlantic, The New York Times Magazine, Discover, The New Republic, and other outlets.

When doctors recommend tests, drugs or surgeries to prevent bad outcomes (think cholesterol-lowering agents to prevent strokes or cardiac stents to prevent heart attacks) they tap into our deepest sense of what constitutes commonsense: An ounce of prevention. Catch it early. A stitch in time.

It can’t be a bad thing to catch problems early, can it?

Unfortunately, one of the toughest things to explain is why detecting some illnesses at their earliest stages can cause more harm than good. Take this example: Since elevated cholesterol is associated with a higher risk of cardiovascular disease, doctors often prescribe drugs known as statins to people with elevated cholesterol levels in the hopes of reducing their risk of a heart attack or stroke.

Here comes the part that’s tough to explain – because it is so counterintuitive: Statins only help individuals who already have had a heart attack or stroke (with a few exceptions, and more on that later).

Of course, this makes no sense to most people. Isn’t the whole point of taking cholesterol-lowering agents to prevent a heart attack? Why should anyone wait until after a heart attack or stroke to begin taking a drug designed to prevent a heart attack or stroke?

The answer rests with disease creep and the simple statistical quirks that come with it. In the past, doctors treated diseases that caused symptoms. But now we have tests and imaging machines that can detect risk factors and illnesses in their earliest stages. Like cholesterol. Elevated cholesterol is not a disease. It doesn’t cause symptoms. It is a risk factor. People with high cholesterol levels are somewhat more likely to develop a heart attack or stroke, but they are at far less risk than individuals who already have cardiovascular disease. This is the definition of disease creep: when pre-conditions or risk factors are treated as if they are the same as the actual disease state.

Here’s a thought experiment (with purposefully exaggerated numbers) to help understand this puzzle: Imagine a group of people who have the rare but awful Disease A, which is so terrible that all of its victims will die. Now imagine the discovery of Wonder Drug X, which cures half of the patients with Disease A. Unfortunately, Wonder Drug X does have a pretty bad side effect profile – it’s a very powerful drug, after all – and 10 percent of people who take it will die from liver failure. Despite this worrisome side effect, Wonder Drug X is truly an advance for patients with Disease A: For every 200 patients with the disease who are treated, 100 will now survive and only 10 of the 100 survivors will die of the drug’s side effects. That means 90 more people out of 200 will survive thanks to Wonder Drug X.

But now imagine a different group of 200 people, who don’t actually have disease A, but instead have a genetic marker which “is associated with” Disease A. In this scenario only 1 in a million people in the general population will get disease A. If you have the genetic marker, the risk is much higher, such that 2 of these 200 people will develop the disease at some time in the future. The genetic test gets highly promoted – “find out your risk early, because we now have a treatment that works, and the sooner you’re treated, the better!” There is a tiny grain of truth to this – of the 2 people identified by the genetic test, 1 (50%) will now be saved by Wonder Drug A.   This might sound just as good as before; here’s a group of people with 10,000 times (!) the risk of the general population to develop a uniformly fatal disease. Surely it’s worth taking a drug that can cure that disease in half the cases, isn’t it?

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But it really isn’t the same. Because saving that one life isn’t remotely worth the harm caused by Wonder Drug X in these 200 people. For while each individual is at a 10,000 fold risk of the disease, only 2 are destined to die from it. On the other hand, if they take Wonder Drug X, roughly 20 (10 percent of the 199 survivors) will die unnecessarily of liver failure.

Unwrapping Early Presents: It's a new Health Wonk Review!

December 22, 2011
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It's that time again, folks! The Health News Watchdog hosts this week, at Gary Schweitzer's Health News Review. We've got a great collection of posts on everything from bundled payments and playtime with robot surgery to prostate cancer and informed consent.

Check it out!

Before you cut me, cut the legalese!

December 15, 2011
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Ever read a credit card agreement?

Yeah, I haven’t either.

We all know it’s important to understand the terms and conditions attached to these all-important pieces of our financial lives, but credit card agreements are long, boring and full of unintelligible boilerplate legal language. Even if we did read them, whether we'd learn anything is far from certain.

That’s why the Consumer Financial Protection Bureau (the new financial regulator born of the Dodd-Frank Act) has created a new, simplified version of a credit card agreement that is designed to provide consumers with something they can actually read before signing up for the card. The hope is that the documents will become useful tools for comparing different card offers, rather than being the thing you dig through to find out what went wrong when your rate suddenly goes up.

The Creative Commons project has used a similar system very effectively for dealing with its copyright licenses. Each CC license (there are several, allowing different levels and types of usage) is a complete contract, full of legalese and probably incomprehensible to most people. In addition, though, the contracts have “human-readable” summaries that lay out the important differences between licenses, and clearly state what people may and may not do with copyrighted material. The summary states that it isn’t the full license—it’s not a legal document -- and it doesn't lay out all the specific details that might be relevant in some cases, but for most people it's good enough.

Anyone who's ever had surgery, or even a colonoscopy, knows that the legal paperwork in medicine is just as dense as it is in banking--and the stakes are much higher. Given that, it seems like there should be a huge movement in the medical community toward creating human-readable paperwork for patients. The current system is clearly failing: people sign the documents, but the ideal of informed consent is being left behind. In too many cases, patients give consent--but they aren't informed. 

The real goal of the new credit card agreement is not only to disclose the terms of use, but to help customers make active choices among their credit options. Patient decision aids (which we've written about before) are a crucial tool for doing that in a medical setting. There's a huge opportunity to make patients much better off by giving them information that they can use to make decisions. Here's hoping  health care agencies will follow the CFPB's lead, and push hard for patients to have understandable and comparable information about their treatment (and non-treatment) options.

The End of Blockbuster Drugs?

December 13, 2011
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The expiration of Pfizer's patent on atorvastatin--the chemical behind the blockbuster cholesterol-lowering pill Lipitor--marks a potentially transformative moment for the drug industry. Currently the best-selling drug in the world, Lipitor (and soon several of its fellows) will have to compete with cheaper generics for market share, putting pressure on drug companies to come up with the next round of blockbusters.

We hope that doesn't happen--and in her column over at TIME Ideas, Shannon Brownlee has some comments on why. Basically, the structure of the pharmaceutical industry pushes doctors toward prescribing and patients toward taking lots of pills that we don't really need. That's driving Here's her commentary on what might change to mitigate that pattern in the future:

"...even while Pfizer is now attempting to hold on to its market share by cutting deals with pharmacy benefits managers and directly targeting patients, there are several possible solutions to the blockbuster problem, some of which will happen all on their own. Genomics research will clarify who can really benefit from which drugs and who won’t be helped at all and will make it harder and harder to sell a pill to everyone. Through efforts like the National Physicians Alliance’s Top 5 project, doctors will become even more aware of marketing tactics and will be motivated to stop doing things that don’t benefit patients.Some experts have suggested changing patent law to give drug companies a set amount, say 15 years, of market exclusivity starting from the time they bring the drug to market. (Under current patent law, the clock starts ticking when the patent on the molecule is filed but development might take longer.) This might discourage the legal maneuvering they now engage in (tinkering slightly with the formula, etc.) to delay the moment when generics come in. I think it would be more effective to outlaw, or at least curtail, direct-to-consumer drug advertising, which has contributed mightily to the industry’s success in selling sometimes inappropriate drugs to patients."

You can read the full column here. We'll continue to cover any interesting developments in the blockbuster drug saga--to stay on top of all our posts, don't forget to follow us on Twitter!

Health Wonk Review: Holiday Shopping Guide Edition!

December 8, 2011
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This week's Health Wonk Review is so good, I'm not going to even try to summarize it. Ladies and gents, I give you the Holiday Shopping Guide!

Thanks to Brad Wright for hosting, and check back with us in two weeks when Gery Schweitzer hosts at Health News Review!

Ken Murray on "How Doctors Die"

December 2, 2011
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USC med school professor Ken Murray has an article over at Zocalo Public Square outlining the difference between how most people die and how doctors die. As he says, "It's not like the rest of us, but it should be."

Doctors are deeply familiar with how people usually die, and the incredible suffering that the medical system sometimes imposes on them. Because they've seen a lot more medically-induced suffering, and are more familiar with the limits of medicine in extending life, doctors are much more likely to die at home, with little medical intervention. That's a much better match with most people's stated preferences--many more Americans say they'd like to die at home (as opposed to in a hospital) than actually do.

Murray's closing point contradicts Dylan Thomas's famous admonition, but it gets at the core insight of his years in medicine. Maybe we can all learn from it:

"If there is a state of the art of end-of-life care, it is this: death with dignity. As for me, my physician has my choices. They were easy to make, as they are for most physicians. There will be no heroics, and I will go gentle into that good night. Like my mentor Charlie. Like my cousin Torch. Like my fellow doctors."

Escape Fire at Sundance

December 2, 2011
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Congratulations are in order for the cast and crew of Escape Fire: The Fight To Rescue American Healthcare.  The documentary was just picked up to premiere at the Sundance Film Festival in January 2012!

The film "examines the powerful forces trying to maintain the status quo, a medical industry designed for quick fixes rather than prevention, for profit-driven care rather than patient-driven care," and presents the vision of those medical professionals and other advocates working tirelessly for a more effective, health-centered system. You can see the trailer and more information here.

Once again, congratulations to the creators, Matthew Heineman and Susan Froemke, and to the rest of the cast and crew. We're looking forward to seeing the final product!

What do you get if you put two economists in a room?

December 1, 2011
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Three opinions. Right?

Well, apparently not--at least not on some issues. The University of Chicago's Institute on Global Markets has pulled together a panel of respected academic economists, and is asking them to agree or disagree with a series of policy-related statements. Watching the consensus (or lack thereof) is interesting on a variety of topics, but we found last week's statement particularly notable:

There are no consequential distortions created by the tax preference that favors obtaining health insurance through employers.

Obviously, we care because it's health-related, but the level of consensus is interesting as well. Contrary to the common perception of economists as constantly disagreeing with each other, 95% of economists surveyed either disagreed or strongly disagreed with the proposition. Taking their confidence in their answers into account, 97% disagreed (63% strongly).

The poll doesn't ask whether the employer-sponsored system, or even the tax preference, is a good thing--it only asks if it creates distortions. On that, the near-unanimity sends a strong messge: both labor markets and health care markets are affected by the subsidy. It keeps people pinned to jobs that they'd prefer to leave, and induces over-insurance and over-consumption of health care. Addressing that overconsumption--and the incentives that create it--is critical to bringing down our long-term health costs.

Thanks to Jodi Beggs of Economists Do It With Models for the tip on the IGM Forum.

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