Friday, April 29, 2011

The Top Ten Prescribed Drugs in the U.S.

 The top 10 prescribed drugs in the U.S. for 2010 in order of prescriptions written are:
  • Hydrocodone (combined with acetaminophen) -- 131.2 million prescriptions
  • Generic Zocor (simvastatin), a cholesterol-lowering statin drug -- 94.1 million prescriptions
  • Lisinopril (brand names include Prinivil and Zestril), a blood pressure drug -- 87.4 million prescriptions
  • Generic Synthroid (levothyroxine sodium), synthetic thyroid hormone -- 70.5 million prescriptions
  • Generic Norvasc (amlodipine besylate), an angina/blood pressure drug -- 57.2 million prescriptions
  • Generic Prilosec (omeprazole), an antacid drug -- 53.4 million prescriptions (does not include over-the-counter sales)
  • Azithromycin (brand names include Z-Pak and Zithromax), an antibiotic -- 52.6 million prescriptions
  • Amoxicillin (various brand names), an antibiotic -- 52.3 million prescriptions
  • Generic Glucophage (metformin), a diabetes drug -- 48.3 million prescriptions
  • Hydrochlorothiazide (various brand names), a water pill used to lower blood pressure -- 47.8 million prescriptions.
Notice that most of these are generic so they aren't the ones that make the most money for Big Pharma.  Those drugs are not offered in generic and they brought in  n $307 billion  in 2010.  What was number one?  Drumroll........

Lipitor, a cholesterol lowering statin.

In case you wondered who is paying for these drugs...Commercial insurance helped pay for 63% of all prescriptions.  Medicare Part D (Federal government) paid for 22% of prescriptions.  The average co-payment for a prescription was $10.73.  The average co-payment for a branded drug was $22.73.

If you are paying for prescriptions, make sure you ask your physician if it is available in generic.  It can save you a lot of $$.

Thursday, April 28, 2011

Physicians Complicit in Gitmo Torture

As more and more facts come out of Guantanamo Bay prison, one of the worst is that physicians caring for the detainees may have been part of torture of the inmates.  Physicians for Human Rights researchers examined medical records, affidavits and third party examinations of nine prisoners who claimed they were tortured at Gitmo.  They found injuries that were highly consistent with torture and abuse in the medical records, yet the physicians failed to document mental and physical conditions that suggested torture.  Instead the doctors talked about regular health issues and never mentioned causes for injuries like bone fractures, contusions, lacerations and nerve damage.

According to the report, the Gitmo physicians turned a blind eye to potential evidence of torture.  One patient experienced nightmares, memory lapses, depression and suicidal thoughts.  A diagnosis of Post-traumatic stress disorder was not made, but instead the physician told him "to relax when guards are being more aggressive," the medical records showed.  In another case, medical personnel allegedly "certified" the detainee's "fitness" to continue being interrogated after several periods of unconsciousness.

After the September 2001 terrorist attacks, the Bush Administration redefined interrogation acts such as sleep deprivation, temperature extremes, forced nudity, prolonged isolation and stress positions as "safe, legal ethical and effective."   Waterboarding became a household word and shocking reports managed to leak out of the prison.

The report states there is "solid, specific evidence of both human rights abuses at Guantanamo Bay and the apparent complicity of medical personnel in the abuse."  The failure of physicians to document the causes of injury or to ask questions constitutes clear ethical breaches by the medical personnel.  The Declaration of Tokyo states, "The physician's fundamental role is to alleviate the distress of his or her fellow human beings, and no motive, whether personal, collective, or political, shall prevail against this higher purpose."

There is no question that physicians are ethically bound to care for patients and actively resist participating in torture or harm of prisoners.  I wrote about this way back in 2007 (check it out) and again in 2008 (check it out)

It is truly sad to be writing about this subject again in 2011.

Iacopino V, et al "Neglect of medical evidence of torture in Guantanamo Bay: a case series" PLoS Med 2011; DOI:10.1371/journal.pmed.1001027.

Wednesday, April 27, 2011

Insurance Hall of Shame Award

I am giving this weeks Shame award to Cigna HealthCare.  They are most deserving for their insurance product that someone actually pays for.  I do not know what the monthly premium is but I would sure love to know.  The physicians bill was $306.00.  Of course the insurance company paid zero.  This is not unusual at all.  First they disallowed some of the bill as "Not Covered/Discount."  The remainder...$220.14 was applied to the patient's deductible for 2011.  So far Cigna has applied $3,584.30 toward the deductible in 2011 for this patient.

Do you think the patient will reach the deductible in 2011?

The annual deductible for this patient is $99,999.00.

No that is not a typo.  Enough said?

(Thanks to my colleague JS for sending me the provider explanation of medical benefits report)

Monday, April 25, 2011

Good News for Coffee Drinkers

According to research published in the American Journal of Clinical Nutrition, habitual drinking of 3 cups/day or more of coffee is not associated with an increased risk for hypertension compared with less than 1 cup/day.  The study did a meta-analysis of six different trials that looked at a total of 172,567 participants.  They did find, however, a slight increase in hypertension in people who drank 1-3 cups compared to those who drank 0 or 1 cup/day.  There seemed to be no sex difference and there was no difference between smokers and non-smokers.

A couple of points should be noted.  They were unable to distinguish the effects of caffeinated and decaffeinated coffee, differences in serving size and brew strength.  We know that a cup of Sanka might be different than an espresso.  Also, all of the studies were performed in white populations.

While it is not the definitive answer, it does help  (white) coffee drinkers that drink over three cups a day know that it doesn't increase blood pressure.

(yummy cappuccino from The Steps of Rome, North Beach, San Francisco)

Saturday, April 23, 2011

How Drug Marketing Influences Use

There is do doubt that the way pharmaceutical companies market drugs to both doctors and consumers sways prescribing and drives up health costs.  Prescription drug costs have outpaced other health care spending and are predicted to exceed the growth rates for hospital care and physician services going forward from 2010-2019.

Two researchers (Howard Brody, MD, PHD, University of Texas Medical Galveston and Donald Wright, PhD,  University of Medicine and Dentistry of New Jersey) have outlined 6 things that have a large effect on physicians and lead us into prescribing drugs that may not be needed.   It's not just the pharmaceutical marketing that has led us to this is also how journals publish literature that physicians rely on for changing medical practice.  Here are the 6 strategies that influence us:
  •  Reducing thresholds for diagnosing disease.  For example, a diabetes diagnosis used to be fasting blood sugar above 130.  Now it is glucose above 100.  There is no evidence that tight control leads to improved outcomes in preventing stroke, total mortality, blindness or renal failure.  Early detection  is a good thing if it helps with diet and exercise but recent data shows that the intensive therapy (HbA 1c-<6%) group did worse.
  • Relying on surrogate endpoints rather than outcomes as goals.  We know that Statins lower cholesterol.  From 1994-2006 the use of Statin drugs by adults 45 and older increased 10 fold.  In a meta-analysis of 11 clinical trials involving 65,229 participants of high-risk patients without prior cardiovascular disease, the Statin use did not lower all- cause mortality.  Surrogate endpoints make it easier for marketers to make claims that the drug will benefit the patient.
  • Exaggerating safety claims.  When drugs are initially tested, the test population is usually homogeneous and small.  As a larger number of patients take the drugs, the potential for adverse effects increases.  We need to always be aware of this.
  • Exaggerating efficacy claims.  Marketers often emphasis that a new drug is better than an established (lower cost) drug when actually the drug performs no better than the old one.  New drugs might have an advantage for a smaller subset of patients but marketers emphasize the benefit for everyone.
  • Creating "new"  diseases.  Social anxiety disorder (aka: shyness),  Erectile Dysfunction (aka: aging men), Pre-diabetes etc. creates millions of new customers who might benefit, but will also be exposed to high cost and potential side effects.
  • Encouraging unapproved uses.  It is illegal for a pharmaceutical company to market a drug for a non-indicated condition, but that doesn't stop physicians who are on the honorarium payroll from shilling for dollars.  This has been a common practice that has just lately had a light shown on it.
I am not bashing big Pharma here.  They have a product to sell and patients and physicians are the customer.  It is up to physicians to understand the subtle marketing manipulation and published research.  We need to remember that epidemiological data linking a risk factor to a bad outcome does not prove that changing the risk factor by taking a drug will reduce the risk for an individual  patient.

Modern pharmaceuticals are lifesavers and have increased longevity and good health for millions.  But we should always stop and think before we start a patient on a "lifetime" drug if they have no complaints and make sure we are really preventing an outcome, not just a lab test.

(Jama, Vol 305, No.11)

Wednesday, April 20, 2011

Limiting IVF Embryo Transfers

Everyone knows about "Octomom" and her octuplets born after in-vitro fertilization (IVF).  That was an extreme case, but multiple births resulting from unregulated artificial reproductive technologies have skyrocketed over the last decade.  The increased rate of twins, triplets and even higher multiples are due to in-vitro treatments and those women and infants are at much higher risk of pregnancy complications, premature birth and long term health problems.

New research,  published in the Journal of Pediatrics, looked at admissions at just one hospital in Montreal, Quebec and found multiple embryo transfers was responsible for a significant proportion of admissions to the neonatal intensive care unit (NICU).  These infants were born severely preterm.  Six babies died and 5 developed severe intraventricular hemorrhage or bronchopulmonary dysplasia.  The researchers extrapolated their data to the entire country of Canada and said that a universal single-embryo transfer policy would have prevented 840 NICU admissions, 40 deaths and 42,488 days in the NICU.  The cost was $40 million annually.

There are currently no regulations in the United States that limit a fertility clinic from implanting numerous embryos into a woman's womb.  The United Kingdom, France, Australia and Germany have legislation with limits to the maximum number of embryos to be transferred.  In the USA we believe the decision about how many embryos to implant should be left to the clinical judgment of doctors.  Because of the expense and emotions involved with infertility treatment, couples want to maximize their chances of getting a viable pregnancy...even if it means they will have twins or triplets.

For some patients, the chances are slim that they will get pregnant, despite the best technology.  There is a wide range between women and age is not the only factor.  One 40 year old is not the same as another 40 year old and the embryo quality can vary widely.  Now that technology allows doctors to grow the embryo in the lab for 5 days,  instead of the usual three days, higher quality embryos can be selected. 

It is hard to believe that 100 years ago most doctors didn't even really understand "woman's issues".  Most women had no knowledge of their bodies and birth was a random event...difficult to prevent and difficult to influence.  The changes have been rapid and amazing and we are learning how to be successful without causing harm from our technology.

(Dr. Michael Kamrava, Octomom's doctor, implanted 12 embryos!)

Aqueduck for Kids

The management (that would be me) at EverythingHealth gets lots of solicitations for product review and placement.  I decline most of them,  but I did say yes to a nifty little device for kids called Aqueduck.  I figured I had a build in tester in my little grand-daughter.   We all know that hand-washing is the best way to prevent colds, flu and other infections.  Anything we can do to make it easy for little ones to scrub their hands has got to be a good thing.

My test case of one adorable 2 year old returns with a big thumbs up  for Aqueduck.  It may not be a scientific study, but the reviews were positive.  Mom says the Aqueduck extender was easy to install on the faucet and it is fun to use with water gently guided where it should be; over the hands.

At an affordable price of $12.99, Aqueduck delivers on making hand-washing fun and accessible for toddlers.

Tuesday, April 19, 2011

Elbow Bursitis


My lovely 87 year old patient took a tumble and sustained some bruises a few weeks ago.  Fortunately she had no broken bones but she did land on her right elbow.  The elbow swelled up and was tender and warm to the touch.  The fluid was drained and it was bloody.  In her case the fluid reaccumulated.  Now several weeks later this is what it looks like.  It is cool to the touch and not tender.   It feels like a ripe avocado or heirloom tomato...filled with fluid.  She is able to flex and extend her arm with no problem.

She has olecranon (elbow) bursitis.  In this case it is from trauma and bleeding under the surface of the skin. It has persisted because I caught her leaning on a walker with her forearms and pressing on this area. 

Olecranon bursitis is common and usually it will resolve.  It is important to watch for infection, increased pain and warmth.

Thanks to FP for allowing her elbow to be the teaching case of the day.

Medical Grand Rounds

Check it out.  Grand rounds is up at Bedside Manner.  Go here to read the best of this weeks blogosphere on patient centered health.  Of course EverythingHealth is selected also!

Monday, April 18, 2011

Prominent Surgeon Resigns Over Semen Reference

Dr. Lazar Greenfield, the inventor of the Greenfield filter, has now resigned as President of the American College of Surgeons for a big oops.  Dr. Greenfield wrote an editorial for Surgery News, a publication for Surgeons from the American College of Surgeons.  In the now famous Valentine's Day issue he said semen was a "mood enhancer" for women and would be a better gift than chocolate.   He was responding to an article that cited the research of evolutionary psychologists who wrote that women who did not use condoms and had sex with men may be less depressed.  (The publishing of bad science was also a oops for the College).  Go here to read Dr. Greenfield's musings on unprotected sex being a treatment for depression and the benefits of semen on the "vascularized vagina". 

I'm sure he is now wondering himself, "What the heck was I doing writing that"?  It wasn't an off-hand remark.  It was a professional op-ed for heavens sake!  Needless to say there was a backlash from women surgeons that ended up being his undoing.

Comments and concerns about his statement were varied and even women had different views. 
Dr. Colleen Brophy, Professor of Vascular Surgery at Vanderbilt said, "I was aghast.  I've gone back and reviewed the science and it is erroneous.  But I'm resigning from the college not so much because of the editorial but because of the leadership's response to it."  The American College of Surgeons has more than 75,000 members.  About 10% are women.  The five women on the 22-member governing board issued a letter requesting that Dr. Greenfield step down.

Other comments on the  blogs were varied.  One woman said she wasn't offended at all. "Americans take the topic of sex way to seriously...lighten up".  Another professional women said "Obviously you really don't understand the horrible symbolism represented..."  And finally, "...It's just a good-natured suggestion to make love: not appropriate, perhaps for the editorial pages of a medical journal, but innocent enough." (that comment from a male)

This article and Dr. Greenfield's editorial bring up issues that are deeper than political correctness.  Despite the dramatic increase of women into general surgery and surgical sub-specialties, there remains a huge under-representation of women in the leadership positions.  Women surgeons receive lower salaries and are more vulnerable to discrimination, both obvious and covert.  Many women surgeons are not given the most involved surgery cases...they are relegated to breast surgery or office procedures.  There is no doubt the glass ceiling persists in academic surgery.

As a woman who has lived and thrived professionally in a man's world, I have learned to roll with the sexist comments and attitudes.  I don't take myself or others too seriously and I see sexist men as dinosaurs that are on their way out.   But as we struggle with covert discrimination against women and lesbians, it is important to speak out loudly when the profession steps out of it did here.

Dr. Greenfield's statement does not take away his many contributions to surgery.  I know other (men) who have worked with him and they think highly of him.  Let the American College of Surgeons use this incident to shine a light on their affairs and make needed strides toward equality and respect.

Saturday, April 16, 2011

Walking Challenge

The New York Times had an article recently about what is the single best exercise.  Lots of experts weighed in about what for is best to build endurance and strength.  There are advocates for old fashioned calisthenics, biking and resistance training but many times people don't sustain these types of activities as they get older.  The demands of jobs, adult life, parenthood and just plain aging leads to more sedentary lifestyles for most people.  The best exercise is done throughout life and many believe consistent,  brisk walking is the activity that is sustainable long term.

Walking helps with weight control, mental memory, reduction in diabetes and cardiovascular disease.  And it doesn't require any equipment or extra money.  Add hilly inclines and bursts of brisk power walking and you have an almost perfect aerobic activity.

The best exercise is the one you will do regularly.  Dancing counts as does biking, gym workouts, nordic skiing, spinning, swimming and any number of sports.  But many of these require equipment or going someplace or having partners.  Walking can be done by just walking out the door.

If you have an activity that you do regularly at least 4 times a week, great.  But be honest.  Do you really really do it?   If  you are one of the millions of adults who find you are doing less and less (and possibly getting fatter and fatter) each year, I would like to challenge you to start walking.   Brisk walking is considered a 15 minute mile.  Go ahead and challenge yourself and see if you can keep up that pace.  If you can't, no worries, start where you are and stick with it.

The challenge is on for you couch potatoes.  Go here to print a monthly calendar that you can use to schedule your work out and stick with it.  It is a great way to explore your neighborhood, be out in nature and develop an activity that you can do throughout your life.

Wednesday, April 13, 2011

EverythingHealth on a Break

EverythingHealth is still on a break while we deal with repairs from a sprinkler line break.  Please click on the links on the right and you will find the best of health blogs.  Check back daily and we'll be back soon.  All is well.

Friday, April 8, 2011

Answer to the Medical Challenge

The answer is varicella (chickenpox) in a teenager who had not been vaccinated.

Your diagnostic acumen was right on and I initially thought it might be dermatitis herpetiformis too, but Chickenpox it is.  For more info on Varicella, check out my old post.

I am sorry for the delay with the answer.  This disaster zone is what has been keeping me busy at EverythingHealth.

P.S. that is not me in the hazmat suitI am behind the camera.

Wednesday, April 6, 2011

Diagnostic challenge

What is the diagnosis:
1.  Dermatitis herpetiformis
2.  Impetigo
3.  Measles
4.  Secondary syphilis
5.  Varicella  (Chickenpox)

Make your best diagnosis and commit in a comment.  The answer will be posted tomorrow!!!

(Image from NEJM)

Tuesday, April 5, 2011

GOP Health Plan

I am all for any proposal that will improve heath care in America.  Improvement means controlling costs, covering all Americans so no one has to worry about going bankrupt to pay for health care.  Improvement means access to quality care without having to worry about losing your job, which means losing your coverage.  Improvement means a system where all incentives are aligned to prevent disease, rather than using expensive technologies and hospitals to treat disease after the fact.  Any proposal that gets us there has my vote.

In the GOP "Path to Prosperity" budget for 2012, they propose a few things that are good and a few big things that are bad...really really bad.  First the good.  Capping the medical malpractice lawsuits for "pain and suffering" would be a huge step forward.  Patients should be compensated for medical errors but the "hit the lottery" windfalls for pain and suffering are costly drivers that make no sense.  There is no place in the world, besides the USA,  that has such onerous medical malpractice lawsuits.  And they drive up cost for everyone.

The plan gives no real details, but it does mention fixing the 29.5% cut in physician reimbursement from Medicare slated for next year.  If that cut goes into effect, there will be few doctors left to treat Medicare patients.  It needs a permanent fix.

Now for the horrific part of their proposal.  They want to turn Medicare into a subsidy program by giving seniors (and the disabled) vouchers that they can use to buy insurance on the open private market.  The system would save money because premium subsidies would tend to grow more slowly than projected health costs per enrollee. However, premiums charged by private insurers for current levels of Medicare benefits are likely to exceed subsidy amounts, forcing beneficiaries to either pay more out of pocket to buy equivalent coverage or settle for less.  Yes, we can certainly save the government money if we just do away with the responsibility for providing health care.  Give seniors a voucher and let them fend for themselves with Blue Cross, United Healthcare and Blue Shield.  We have all seen how well that system works for us!

Under the restructured Medicare program, anyone who turns age 65 beginning in 2022 would choose a private health plan paid for with an adjustable subsidy from the government. The subsidy would be lower for wealthier Americans and higher for sick beneficiaries whose conditions worsen. Low-income beneficiaries would receive extra assistance to cover out-of-pocket expenses. Beneficiaries enrolled in the traditional Medicare program before 2022 can stay there. (So quit your bitching, AARP)

Another aspect of the "Path to Prosperity" is the proposal that the federal government fund its share of state Medicaid programs with block grants, with states continuing to fund their share. The block grant approach would cap the federal contribution to state Medicaid programs and give states more flexibility in operating them. However, it also shifts more of the fiscal responsibility to states,  just when we have record unemployment and rising demand for services.

We all know how solvent most States are right now!!  This shifts the responsibility to states to increase taxes or  reduce benefits for Medicaid.  Can we get any meaner as a nation?

All early analysis of the GOP "Path to Prosperity" shows it will save money.  There is nothing that shows it will hold down health costs.  That doesn't surprise me.  If the government limits it's involvement and coverage of Americans,of course it will save money.   It puts the money into the hands of private insurers and we get to pay more out of our pocket.

I am all for balancing the budget and bringing spending under control.  It is great when our elected officials try to accomplish this.  May I suggest as a beginning that we trim down the 700 military bases that we have in 130 countries in the world.  Our military expenditure accounts for almost 1/2 of the entire World military.(46.5%) followed by China at 6.6%.  Maybe that is how we could achieve a "Path to Prosperity" and still provide health care to our population.

Saturday, April 2, 2011

Breast Cancer Complexity in Personalized Medicine

Scientists at Washington University School of Medicine in St. Louis have conducted the single largest cancer genomics investigation to date by sequencing the entire genomes of tumor from 50 breast cancer patients.  They compared the cancer DNA to healthy cells in the same patient and found mutations that only occurred in the cancer cells.  They uncovered incredible complexity in the cancer genomes of these tumors that had more than 1,700 mutations, most of which were unique to the individual.

To undertake this study, the Oncologists and Pathologists worked with the University's Genome Institute to sequence more than 10 trillion chemical bases of DNA - repeating the sequencing of each patient's tumor and healthy DNA about 30 times to ensure accurate data.  Huge computing facilities were required to analyze this amount of data.  All patients in the trial had estrogen receptor positive breast cancer.

The researchers found that two mutations were relatively common in many of the patient's cancers. Once is present in about 40% of estrogen positive breast cancer and the other present in about 20%.  They found a third mutation that controls programmed cell death and is disabled in about 10% of estrogen-receptor-positive cancers.  This mutated gene allows cells that should die to continue living.  Only two other genes had mutations that recurred at the 10% level.

They found 21 genes that also significantly mutated, but at much lower rates.  Even though these mutations were relatively rare, they still involve thousands of women and are very important to understand.

These highly detailed genome maps are an important first step to designing therapy that is personalized to the patient.  We do not know why treatment works for some women and not others.  It may also help us understand aggressive types of breast cancer that are difficult to treat and occur in young women and African-American women.

Individual and personalized medicine is only possible when the cancer's genetics are known in advance.  We are getting closer each day.

When to Use Urgent Care

We all know that Emergency Departments are over-crowded with long waits and exorbitant fees.  Free standing Urgent Care is a great solu...