Latest Blog Posts & Articles


Doctors Can’t Be Trusted to Tell Patients Whether They Should Receive Robotic Surgery

Patients often rely on physicians for information about their treatment alternatives. Unfortunately, that information is not always objective.

Consider a man with early stage prostate cancer interested in surgical removal of his tumor, but uncertain whether it is better for the surgery to be performed with the help of robotic technology. He asks his surgeon for advice, and the surgeon explains that, while robotic surgeries have some advantages (smaller incisions, less blood loss), the advantages are “tiny and unimportant.” And besides: “You do have some smaller incisions with the robotic, but if you added up all the incisions from all the ports and from the incision to remove the prostate itself, it ends up equaling about the same incision length.”

Can that physician’s description of robotic technology be trusted?

My friend and colleague Angie Fagerlin led a study of prostate cancer decision-making that took place across four Veterans Affairs medical centers. As part of that study, she audio-recorded clinical interactions between patients and their surgeons. In some of these interactions, patients asked about the pros and cons of robotic surgery.

As it turns out, some urologists worked at VAs that had access to robotic equipment and others did not. In an analysis lead by Karen Scherr (an MD/PhD student at Duke), our research team discovered that surgeons who had access to the robot were more generous in describing its advantages over standard “open” surgery. When no robot was available, physicians downplayed its advantages. This is illustrated in the following figure, showing the percent of statements physicians made indicating that robotic surgery was inferior, equivalent or superior to traditional surgical approaches:

Doctors Can't Be Trusted Robotic Surgery

Importantly, I do not think physicians are willfully misleading patients about the pros and cons of robotic surgery. Instead, I think most physicians believe the robot is better (in the right hands) but when it is unavailable, doctors try to reassure patients that they will still receive state-of-the-art care. For example, one patient expressed anger that the robot was not available at his VA Hospital: “you see, that’s what’s so stupid about the VA!” The physician tried to assuage his concerns: “If you look at long-term outcomes related to cancer and cancer recurrence,” the surgeon said, “there has really been no difference. That’s why the VA system has not really invested in the robot.”

To read the rest of this article, please visit Forbes.

Posted in Uncategorized | Tagged , , ,

Competition at Work!

Recently, pharmaceutical companies have been pricing many of their products at astounding values. A couple years ago, in fact, an amazing new hepatitis C drug came to market priced at about $90,000 per patient. But since that time, several other companies have come to market with competing products. That has brought the overall price of these drugs down, and we are finally seeing a decline in how much money we are spending treating hepatitis C. Here is a picture of that decline, which he came across thanks to @Altarum_CSHS:

Competition at Work

Posted in Uncategorized

Obamacare Reduced Racial Disparities in Healthcare Insurance

Research led by Stacey McMorrow (a former student of mine) shows that Obamacare was especially helpful in enabling black and Hispanic people obtain healthcare insurance:

Photo Credit: Health Affairs

Photo Credit: Health Affairs

Disparities in insurance rates among either groups are declining:

Photo Credit: Health Affairs

Photo Credit: Health Affairs

 

 

 

Posted in Uncategorized | Tagged

Need More Evidence the U.S. Healthcare Market Is Screwed Up?

In a healthy consumer market, people compare the price and quality of goods inside whether it’s worth paying extra money to get the best possible products. In healthcare, it’s often almost impossible to figure out what things cost. And when you figured it out, the price variation often makes no sense at all – having no relationship to the quality of the good in question.

Consider this picture, which we came across thanks to @zackcooperYale. It shows almost a 6-fold variation in the cost of MRI tests in Miami, Florida:

Need More Evidence the US Healthcare Market Is Screwed UpThis is not what a healthily functioning market looks like!

Posted in Health & Well-being | Tagged ,

Historic Drop in U.S. Uninsured Rate

Yet another picture of the steep drop in the percent of Americans without healthcare insurance, post Obamacare. Thanks for sharing this, Dina Pomeranz (@DinaPomeranz).

Historic Drop in US Uninsured Rate

Posted in Uncategorized

Bias in Scientific Citation

Here is a figure reproduced in Fortune, showing that when researchers publish articles raising questions about the harms of salt, they cite other researchers who raised similar questions. By contrast, when they definitively argue in favor of the harms, they cite other definitive colleagues.

Photo Credit: Fortune Magazine

Photo Credit: Fortune Magazine

Some of this makes scientific sense. If you show a particular phenomenon exists in the real world, you want to show other people who have found similar phenomena. If your evidence supports a specific theory for why the phenomenon exists, you’ll cite other people who’ve laid out those kinds of theories. But there is potentially a nefarious side to this, too. You might only cite like-minded scientists to make your argument look stronger than it is. Or you might cite those scientists because you hope they will become reviewers of your paper, since journal editors might look at your references to decide who to send the article to.

Science is a process. Often a very messy one. And the messiest part is often our own underlying biases. Best to be aware of those biases and try to fight them. That will speed along the process.

 

 

Posted in Uncategorized

Would Prince Be Alive Today If He’d Had a Different Doctor?

Photo Credit: Billboard

Photo Credit: Billboard

Prince died of an opioid overdose. A tragic and avoidable fate but, even more tragically, one that is becoming increasingly common in the United States. Some people who overdose live on the edge of society – homeless and with no access to good medical care. Prince, by contrast, had several mansions and a number of physicians actively involved in his care, physicians aware of his problem with opiates. In fact, just days before he died, Prince’s airplane had to emergently land because he experienced symptoms of opioid overdose.

With so many physicians at his disposal and so much evidence his opioid use was spiraling out of control, did Prince die because his physicians were particularly bad at handling his needs?

Sadly, the answer is probably no. Although I have no inside knowledge of Prince’s care, from what I can tell, his physicians are not very different from the ones caring for many people with opioid addiction. Many, if not most, physicians are simply not prepared to offer proper help to patients struggling to control their use of prescription narcotics.

The best evidence I have to back up this claim comes from a study published January in the Annals of Internal Medicine. The research team was led by Marc Larochelle from Boston Medical Center. Larochelle looked at what happened to patients after they experienced a nonfatal opioid overdose like Prince did in the airplane ride a few days before his death. Specifically, he assessed whether their doctors reduced the dose of their opioid medications. He found that doctors did not reduce people’s narcotic doses very much.

(To read the rest of this post, please visit Forbes.)

Posted in Uncategorized

An Easy (But Politically Complicated) Way To Save Billions Of Dollars On Medical Care

Photo credit: KAREN BLEIER/AFP/Getty Images

Photo credit: KAREN BLEIER/AFP/Getty Images

I sometimes worry that my wife Paula won’t be able to see me grow old. Not that I expect to outlive her. She is four years my junior and has the blood pressure of a 17-year-old track star. It’s her eyesight I’m worried about, because she is at risk for a form of blindness called macular degeneration. Paula is the youngest in a long line of redheads, several of whom have been diagnosed with this illness. Her fair-haired grandmother developed macular degeneration and was eventually unable to see her bridge hand and had to give up her golf game, just when she was threatening to score below her age. Fortunately, Paula should be able to avoid her grandmother’s fate, because we now have outstanding treatments for this disease.

Too bad these treatments are costing us billions more than they should. The price of some macular degeneration treatments is staggeringly high, and both doctors and the pharmaceutical company making the treatments are motivated to keep it that way. If we as a country want to forestall blindness in people like my wife, without going bankrupt in the process, we need to pressure our government to do some hardball negotiating.

By way of background, my grandmother-in-law suffered from what ophthalmologists call “wet” macular degeneration. Frail little blood vessels began proliferating in the back of her retina. It’s not unusual to have lots of blood vessels back in the retina. It’s that red blood, after all, that causes so many of us to look possessed in family photos, with red eyes staring demonically into the lens. But in wet macular degeneration, there’s even more blood vessels than normal in the back of the eye, and they are more inclined to leak than typical blood vessels. This leaking fluid damages the nerve cells we depend upon to see light and darkness. For years, there was little doctors could do to slow these leaks.

Then along came Avastin.

Some of you may recognize Avastin as being a cancer drug. That’s true. Avastin works by disrupting a chemical our body makes to promote blood vessel growth. Tumors that depend on new blood vessels to grow are thereby thwarted by the drug. So, too, is macular degeneration. No new frail blood vessels means no blood vessel leakage!

Many ophthalmologists treat wet macular degeneration by injecting Avastin directly into the back of patient’s eyeballs. (Under local anesthesia, of course!) And the drug isn’t even terribly expensive. By one estimate, Medicare pays about $50 a pop for monthly Avastin injections. There is a problem with this effective and affordable treatment, however. Avastin has never been approved by the FDA to treat macular degeneration. Physicians are allowed to use it as an off-label treatment, but because it is off label, it needs to be reformulated by pharmacies into an injectable form, and before standards for such reformulation were bolstered, some patients experienced eye infections from contaminated vials.

Fortunately, there is a second drug to treat macular degeneration, one very similar in its chemical composition, another blood vessel-blocking drug called Lucentis. Unlike Avastin, Lucentis is FDA-approved to treat the disease. That means it is made by the manufacturer in a ready-to-inject formulation, and there is no need for pharmacies to do any additional prepping. Lucentis is just as good as slowing the progression of macular degeneration as Avastin. There’s just one little problem with Lucentis, however. Instead of costing Medicare $50 per pop, it costs up to $2,000.

To read the rest of this article, please visit Forbes.

 

Posted in Uncategorized | Tagged , , ,

Specialty Drugs at Especially High Prices

There have been many wonderful new medications in the past decade or so, drugs that finally bring hope for many people with serious illnesses like rheumatoid arthritis, multiple sclerosis and even some advanced cancers. But these drugs often come at a high price. Here is a snapshot of drug spending in 2014, courtesy of the Kaiser Family Foundation:

Kaiser Family Foundation

Kaiser Family Foundation

 

Posted in Uncategorized | Tagged ,

Peer Comparison Can Reduce Antibiotic Prescribing

Very interesting article in the Lancet recently, from the nudge unit in the United Kingdom. They give physicians feedback on how much they prescribed antibiotics compared to their peers, and found that such feedback reduced antibiotic prescriptions.

Peer Comparison Can Reduce Antibiotic Prescribing

I hope to see more of this work!

 

 

Posted in Uncategorized | Tagged , ,