Archive for September, 2013

Affordable Care Act — the right to health care

boxersPresident Obama vs. Republican Congress.  Another grudge match, the sweaty pugilists in the corners, puffs of smoke from the cigars in the front row, the referee  holding the mike, saying  it’s the 8th round, the clang of the bell, the jabs, the left hook, bam – a hard right to the teeth, finally the round ends with a flurry of punches under the belt.  We now interrupt the show for an important announcement.

HEALTH CARE IS NOT A CONTEST.  We are not in a reality show, this is real life.   The consequences are life and death.  Why is there an argument or a fight?

The sky-box view.  Look down at the basic arguments of the two sides:

  • Obama — health care is a right
  • Republican congress — health care is not a right
  • Both agree — health care costs too much

The punches and counter punches.

Punch:  The southern US has poor health care
Counter:  Not our problem, don’t fix it with our money

Punch:  Insurance companies are unethical
Counter:  They are just businesses trying to make a profit

Punch:  Primary care is better and more efficient
Counter:  The market determines what is better or more efficient

Punch:  Everybody should have access to health care
Counter:  Only those who have money should have access

Punch:  If everybody has insurance the system would be more fair
Counter:  Don’t tell me to buy insurance, I will do what I want.

Punch:  Raise taxes to pay for the uninsured
Counter:  We can’t afford higher taxes

Punch:  We already pay enough to provide good health care for everybody
Counter:  We don’t want regulations.  Some of us get great health care already

Punch:  U.S. health care only ranks 30th in the world
Counter:  Poverty and old age are the fault of individuals, don’t count them

Punch:  We need government oversight of health care quality
Counter:  That’s what lawyers are for

Punch: Women need care for female health problems
Counter:  What is good enough for men is good enough for women

Punch:  The constitution gives the right to life, liberty and the pursuit of happiness.  You can’t have any of those things  without being healthy.
Counter:  The Constitution says nothing about a right to health care.

Punch:  All this fighting makes me forget about poor health care quality and high cost
Counter:  Me too.

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Accountable Prescribing — end does not justify means

gun1

Nancy Morden MD MPH with others from the Dartmouth Institute for Health Policy and Clinical Practice published a nice “Perspective” in NEJM 3694;4:299-302.    The essence of the article is the observation that published goals of treatment which don’t specify how to reach the goal lead to prescribers” jumping the gun” with strong expensive medications rather than a prudent step by step approach.

A good example from the article is controlling blood pressure.  Guidelines state the desired blood pressure goal is less than 140/90.  Prescribers tend to skip dietary management, skip lowering the salt intake, skip reducing alcohol consumption and jump right to strong blood pressure medications (with the attendant drug allergies, risks and costs).

Another criticism is stopping a medication too soon.  The example is beta-blocker medication after a heart attack.  It is not enough just to start the medication.  The medication must be continued indefinitely.  Too often the medication is stopped because the reason for starting it is forgotten.

Here are the areas the authors found problematic:

  • Blood pressure control
  • Cholesterol management
  • Diabetes control
  • Clot prevention for occlusive vascular disease
  • Lipid control for coronary artery disease
  • Long term beta-blocker after heart attack
  • Avoidance of antibiotics for acute bronchitis
  • Drug use generally in the elderly

From the patient standpoint:  if a health care provider says you have some condition or diagnosis make sure to ask for a step-wise approach to treatment.  In other words, ask for simple or less expensive things to be tried first.  Then insist on follow-up to see if the first steps work.  If the simple things work, you win.  Make sure to research the diagnosis on the internet to exhaust the simple and low cost alternatives.  Later, if the simple things are not enough move on to the next step.

There are obviously situations where a slow cautious approach is not correct.  If you are having a heart attack or a stroke or a blood clot it’s too late to do simple things.

Make sure to understand how long a medication might be needed — if it is “until something better is found” then stick to it and make sure the providers give a good reason for stopping (particularly if you change providers).

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Lung Cancer Screening — wheel of fortune

lung nodule

You smoked 2 packs a day for 20 years.  Your doctor orders  the low-dose CT screening (above).  Your doctor says you have a lung nodule, now what?  That’s a lot to think about but before anxiety builds too much you need to know that of all the people with a nodule on their first scan 19 times out of 20 it is NOT lung cancer.

By asking some questions it is possible to work through the complicated logic of what to do next.

What if I am that unfortunate 1 out of 20?

If you know for sure the nodule is cancer you would get that nodule removed.  Sure it’s a big surgery, hurts for weeks (sometimes longer), in the hospital for several days, and tons of risks the surgeon will recite.  No walk in the park but the odds of a cure are better at an early stage.  Lung cancer is a killer so it is easy to conclude:  get rid of that nodule

What if that nodule is a bad type called “small cell” cancer? 

Most specialists agree that chemotherapy is the treatment of choice.   Surgery for small-cell cancer is not helpful and may actually shorten your life.  A biopsy before surgery may help to avoid surgery for this type of cancer.

What if I am one of the lucky 19?

If all 19 get surgery there would be a lot of discomfort only to be told after surgery the nodule was just a scar or a harmless irritation.  Biopsy or follow-up x-rays are sometimes helpful to avoid surgery.

What if I get a needle biopsy of the nodule?

A shot of numbing medicine, a long needle between the ribs,  a tiny bit of tissue removed, and finally the pathologist sends a report.  Such biopsies are 95% accurate.  The wheel of fortune lands in one of 5 major categories:

  • No cancer found
  • Small-cell lung cancer
  • Non-small-cell lung cancers
    • Adenocarcinoma
    • Squamous cell carcinoma
    • Large cell carcinoma
  • Other cancers (much less common)
    • Mesothelioma
    • Sarcoma
    • etc.
  • Something which is not cancer

A needle biopsy answers critical questions.  If it shows non-small-cell lung cancer surgery is the next step.  If it is small-cell cancer the next step is chemotherapy.  If it is something else, like tuberculosis, then entirely different treatment is needed. If it is “no cancer found” then you are back to square one — meaning a nodule is present and the cause is unknown (possibly a cancer that was missed by the needle).

I am willing to take some risk to avoid procedures.

We started this discussion with a 1 out of 20 chance of cancer.  Is there some way to improve on the accuracy of that prediction?  1 out of 20 does not sound so good.  But, if the odds of cancer in your situation are 1 out of 100 that would be more favorable.

Improved risk assessment

Canadian Annette M. Williams, MB and others reported in the New England Journal of Medicine in September 2013  an improved mathematical prediction method.  Most pulmonary doctors and radiologists can readily provide the statistic.  Basically, if the calculated risk score is below 5% then the chance of cancer is about 1 out of 100 .

If the risk is low  you might just choose to get a CT scan every few months.  If the size of the nodule does not change for 2 years then it is harmless.  One sure thing, cancers grow.  No growth means no cancer.  But, if the nodule does grow you could change the plan and get the biopsy or surgery — there is a risk to letting a cancer grow for a few months (it could spread) but there are risks to biopsies and surgery as well.

If the cancer risk is high you might want to go ahead with a biopsy.

nodule shape

The above are the outlines of nodules 1) round  2) lobulated  3) irregular and 4) spiculated.  Cancerous nodules can take any shape but tend toward the spiculated (spiny) form.

The improved statistical method is based on a few details about the nodule.  Sex (women are more likely to have malignant nodules), size (the larger the nodule the more likely it is malignant),  location (upper lobe nodules are more likely malignant) and spiculation (see diagrams).

If you want to calculate the risk statistic yourself, have a calculator and know the details listed above then click this: Calculate Risk.  But, be warned, this calculation only applies to people who have a risk for cancer to begin with, not the incidental nodule found in a lifetime non-smoker or someone who only smoked a few years.

The forgoing material is intended as education, not a substitute for the evaluation and advice of your health care provider.  If it seems helpful print it and take it to your provider for discussion.  Medical care changes with time so always get up to date information.

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