Medical Myths Busters

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Medical Myths Busters How to Save Billions of Dollars Annually in Health Care Costs

Transcript of Medical Myths Busters

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Medical Myths Busters

How to Save Billions of Dollars

Annually in Health Care Costs

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³As a rule, we disbelieve all the

facts and theories for which wehave no use.´William James

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The Big Picture

� In 2006, for the first time in our history, we

spent over $2 trillion dollars on health care.

� At over $7000 per person, that almost twice

the amount Canada spends on health care.

� Canada out performs the U.S. on all major 

health indices (except rates of ETOHabuse).

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Medical Myth Busters� Much of what we do in medicine is based

on either incomplete science or, often times,

no scientific evidence at all.� Estimates suggest that only 20% of medical

decisions rely on evidence based medicine.

� Recent revelations bring into question thedata provided by pharmaceutical companiesin drug outcome studies.

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The CPE

Who Really Benefits from this Time

Honored Tradition?

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The Annual Physical

� In 1947 the AMA recommended ³an annualphysical examination for all persons over age 35.´

� In the era before evidence based medicine, therewas little to suggest these exams loweredmorbidity or mortality.

� However, they became an integral part of most

primary care practices (and still are to this day).� Most insurance companies pay for this annual

exam (some even pay for ³executive physicals´costing as much as $7000). The only notable

exception is the nation¶s largest insurer.

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The Annual Physical

� Complete blood counts, urine analysis, metabolic

panels, TSH measurements, ECGs, and chest x-

rays are often ordered as screening tests withoutany documented benefit. (CBC $143 million

annually; UA $47 million)

� Even the time honored practice of auscultating the

heart and lungs provide no benefit to healthyindividuals.

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The Annual Physical

� Annual physicals are the most commonreason for visiting a doctor according to the

CDC.� In 2000, they accounted for 64 million

office visits, out of 824 million visits over all.

� The cost for these exams were in excess of $7 billion.

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The CPE

� In 1981, the American College of Physiciansrecommended that individualized selective

longitudinal health maintenance should replace theannual physical exam. The AMA made a similar recommendation in 1983.

� Despite these long-standing recommendations,

may physicians still view them as necessary. For example, in a large randomly selected survey onNew England physicians, 90.6% stated thatperiodic exams should include a CPE.

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Why Still DoT

hem?

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Antibiotics and Sinusitis� This is the season of the URI. Patients will

seek out your treatment for these

uncomfortable symptoms.  You will

diagnose some with bacterial sinusitis and

treat them with antibiotics.

� Are you really doing them any good?

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Antibiotics and Sinusitis� A double-blind , randomized, placebo controlled

study looked at the effects of antibiotics and nasal

steroids on acute sinusitis.� Two or greater diagnostic criteria were needed:

purulent rhinorrhea with unilateral predominance,

local pain with unilateral predominance, purulent

rhinorrhea bilaterally, presence of pus in the nasalcavity.

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Antibiotics and Sinusitis� This trial used amoxicillin 500mg TID for 7 days

and/or budesonide 200uq qd for 10 days vs.

placebo.� Outcome measures were proportion clinically

cured at day 10 using patient symptom diaries and

the duration and severity of symptoms.

� The authors show that neither antibiotics nor nasal

steroids had any effect in reducing symptoms over 

placebo.

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How many patients with sinusitis

do you treat with antibiotics?

Would a simple saline flush relieve

symptoms and help reduce thegrowing rates of antibiotic resistance?

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Sleep and the Elderly

³Oh doctor, I sleep terribly.  I haven¶t

had a good night sleep in years´Agnes, ag e 83

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Sleep and the Elderly� We commonly believe that the quality of 

sleep deteriorates with age.  In fact, it seems

so obvious, few have questioned thiswisdom.

� According to sleep researcher and

psychiatrist Dr. Michael Vitiello, ³Older people complain more about their sleep;

they just do.´

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Sleep and the Elderly� Current research now appears to question

this established belief.

� According to recent studies, sleep does not

change much from age 60 on.

� Poor sleep appears to be more related to

illness or the medications to treat them.

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Sleep and the Elderly� Nearly one-half of all people over 65 do not

have chronic sleep problems.

� Healthy older people are asleep 85% of the

night (compared to 20 year olds who sleep

95% of the night without awakening).

� Their sleep is disrupted by brief wakefulmoments typically lasting 3 to 10 seconds.

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Sleep and the Elderly� The real problem is the number of ailments

that can effect the elderly; chronic pain,

restless leg syndrome, urinary problems.

� These medical issues cause fragmentation

of sleep and lead to many adverse

consequences.

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Sleep and the Elderly� Research shows that the effect of 

sleeplessness on chronic pain can be

enormous.

� Fragmented sleep can alter pain pathways

resulting in more sensitivity to pain, less

ability to inhibit pain pathways,development of more spontaneous pain like

headaches and backaches.

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Treat the Medical Problem and

Sleep Will Improve

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OCPs and Abx

What would you tell your patient?

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Antibiotics and Oral

Contraceptives� Since the early 1970s, doctors cautioned

women taking birth control pills to use

another form of contraception if prescribedantibiotics.

� Anecdotal evidence seemed to support the

belief that antibiotics interfered with theeffectiveness of OCPs.

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Antibiotics andO

CPs� With one exception (rifampin)

³pharmacokinetic studies of other 

antibiotics have not shown any systematicinteraction between antibiotics and OC

steroids.´ Obstetrics and Gynecolog y

2001;98:853-860.

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Antibiotics andO

CPs� A meta-analysis looked at 167 article published

between 1966-1999.

� ³In pooled results obtained from relatively smallpopulations, oral antibiotics«have not

significantly affected the pharmacokentitcs of 

ethinyl estrdiol, levonorgestrel, and

norethindorone of reduced the serumconcentrations of gonadtrophins.´

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Winter¶s Chill and Asthma

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Asthma and Cold Weather � The common belief is that exercising in

cold weather will exacerbate asthma.

� According to exercise physiologist Kenneth

Rundell of Marywood University in

Scranton, PA, ³no matter how cold the air 

is, by the time it reaches your lungs, it isbody temperature.´

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Asthma and Cold Weather � The problem is not the cold, but the dryness

of the air.  Asthma is also exacerbated by

activity in hot, dry air.

� As simple study of volunteers with

exercise-induced asthma showed that their 

airways constricted in response to dryness,not changes in temperature.

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T

ake Home Message:

Asthmatics jogging in Arizona will

have just as frequent exacerbationsand those running in Alaska

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Cranberry Juice and UT

I� Common belief is that cranberry juice will

treat an active urinary tract infection.

� However, cranberry juice does not inhibit

bacterial growth, nor does it sterilize the

urinary tract.

� Therefore, cranberry juice has no effect onacute urinary tract infections.

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Cranberries and UT

Is� Studies have shown that daily ingestion of 

cranberry juice or tablets will decrease the

incidence of recurrent UTIs.� The mechanism of action appears to be attributed

to  proanthocyanidins which may inhibit e. coli

adhesion to uroepithelial cells.

� Unfortunately, the cost of cranberry juice or 

tablets ranges between $600 and $1400 annually.

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T

ake Home Message:

Forget the cranberry juice cocktail

and take the Bactrim.

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Diets and Bones

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Calcium and Fractures� Common belief is that calcium supplementation

alone will prevent osteoporotic fractures.

� Many women take calcium supplementation after menopause.

� The daily recommended dose of calcium in

postmenopausal women is 1200 mg²the amount

in two glasses of skim milk and two yogurts.

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Calcium and Fractures� There have been multiple studies measuring the

role of calcium supplementation and bone density.

� Most conclude the 1200 mg of calcium willincrease bone density to a small degree²2%.

� However, no studies have shown that calciumsupplementation actually reduces osteoporotic

fractures.� One study seemed to suggest that low impact

exercise was far more efficacious for promotingbone density than calcium supplementation.

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What do you tell your patients?

Women taking calcium

supplementation had a 47% higher 

risk of cardiovascular events than

women taking placebo.

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Why Pfizer Loves Us

(Us = Doctors)

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Lipitor and Life� Statins are among the most widely

prescribed drugs in the world.

� They work very well; they lower cholesterol

and decrease the risk for heart attack.

� Do they however, prolong life?

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Lipitor and Life� YES--In middle-aged men with documented

cardiovascular disease, statin users are less likelyto die than those on placebo.

� However, for healthy men and women with highcholesterol, and for people over 70, stain use hasno impact on longevity.

� According to Dr. Mark Ebell, deputy editor of American Family Physician, ³«patients with lowrisk benefit very little, if at all.  We end up over treating a lot of patients.´

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Lipitor and Life� A 2006  meta-analysis published inThe Archives

of Internal Medicine looked at seven trialincorporating 42,000 patients.  Most were middleaged men without documented heart disease.Statins did not reduce mortality.

� A 2002 study entitled ³Prosper´ published inLancet show no decrease in mortality among statinusers over age 70.

� A 2004 meta-analysis published in JAMA look at13 studies incorporating 20,000 women, bothhealthy and heart disease, showed no decreased

mortality.

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Lipitor and Life� Statins may not improve overall mortality,

but what about improving quality of life by

preventing MI?

� There are no studies that show statin users

have better quality of life that non-statin

users.

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Take Home Message:

Your 45 year old healthy male patient

with an LDL of 180 will not benefit

from Lipitor.  Unless he owns stock 

in Pfizer.

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The Big Money

Broken hearts, broken knees and

nuking breast cancer 

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Broken Hearts� Over two million patients annually undergo

cardiac catheterization in the US.

� About 800,000 of these patients are in the

midst of an acute MI.

� The majority of these procedures are

elective, for chest pain, shortness of breath.

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Broken Hearts� Over one million stenting procedures are

now done annually, double the number only

5 years ago.

� However, approximately 80% of all

myocardial infarctions occur when plaque

ruptures from arteries that were notsignificantly occluded.

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Broken Hearts

� The found that 31% of PTCA procedures

were performed for appropriate indications.

� 54% of PTCA was done for uncertain

indication, and 14% for inappropriate

indication.

� The odds of receiving inappropriate PTCAvaried with geography.

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Broken Hearts

� For CABG, 75% of the procedures were

deemed appropriate, 15% uncertain, and

10% inappropriate.

� Again, there was regional variation with

respect to who was likely to undergo

inappropriate CABG.

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Broken Hearts

� A 1995 study found a very strong correlation

between the availability of catheterization labs and

the numbers of PTCA and CABGs performed.� Dr. Eric Topol, a cardiologist from Scripts Clinic

in La Jolla, CA found that patients in the south

central region (TX, AL, MS) underwent far more

procedures than anywhere else in the US. Thenumber of cath labs per capita is the highest in the

south.

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Broken Hearts

� The US has more cath labs per capita than

any other developed country and people in

the US undergo invasive procedures far for often.

� However, our mortality rates for heart

disease are no lower (and much higher compared to several countries).

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Why Do Patients Undergo So

Many Catheterizations in the US?

Could there be an economic

incentive?

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The Scope and Sore Knees

� Arthroscopic surgery is done routinely to relieve

the pain of osteoarthritis in arthritic knees.

� This surgery is performed on over 225,000Americans annually.

� Efficacy was established based on specialist

consensus.Orthopedists generally agreed that the

surgery was beneficial to the patient.

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Arthroscopic Surgery

� Annual total cost of this procedure is over $1

billion.

� Dr. Nelda Wray, Chief of Medicine, Houston VAMedical Center designed a study to look at the

efficacy of this procedure.

� 180 patients were with similar degrees of knee

arthritis were randomly assigned to three groups.

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Arthroscopic Surgery

� The first group was treated with lavage of 

the joint; the second lavage and

debridement; the third underwent a shamoperation.

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Arthroscopic Surgery

� Results:  Equal numbers of patients in all three

groups stated they felt better after the surgery, but

none improved on objective tests of knee function.

� After completion of the study, the US Veterans

Affairs Department issued a statement putting a

hold on surgeries stating the surgeries are ³notindicated´ solely for the relief of pain.

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Has There Been a Change in

Practice?

How many arthroscopies are still

performed on arthritic knees?

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Breast Cancer and High Dose

Chemotherapy

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Breast Cancer 

� The total cost of this treatment began at$150,000 and could rise to $500,000 if 

complications arose.� Insurance companies balked at payment

until lawsuits forced them into paying.

� Hundreds of hospitals began chemotherapyand transplantation services because of large reimbursements for this treatment.

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Breast Cancer 

� The problem, however, was that this

treatment was never proven to be more

effective in clinical trials than standardchemotherapy regimes.

� In 1991, a randomized clinical trial was

begun to test the validity of the treatment.Instead of completing the study in the

planned 5 years, it took almost 10.

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Breast Cancer 

� Four out of five trials showed no advantage

of HDC over conventional treatment. The

fifth, a study from South Africa whichshowed positive benefit, was found to be

blatantly fraudulent.

� In the end, 42,000 women underwent HDCwith transplant at a total cost of $3.4 billion.

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At least 9,000 of these women

died, not from their cancer, but

from the treatment.

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Take Home Message

Never stop questioning; It may save a

few hundred dollars of unnecessary

testing, or it may save a life.