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Transcript of Medical Myths Busters
8/7/2019 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.