This review has caused an uproar in the Hep C community, inciting a debate between Cochrane researchers and Hep C researchers and advocates. Cochrane researchers claim there is no evidence that DAAs improve mortality or that they cause fewer adverse events compared to a placebo. The researchers also found a high risk of bias in all of the included trials due to industry funding.

Many doctors have spoken up against the Cochrane review, saying the clinical trials included in the review were not designed to measure mortality or other long-term effects. They also note that the introduction of DAAs in the UK has already led to a drop in Hep-C related mortality. However, some of the doctors who criticized the Cochrane review are themselves being paid thousands of dollars by Hep-C medication manufacturers.

One thing is clear, some non-industry funded research would help the debate.

The post Conflicts of interest complicate Hep C research debate appeared first on Lown Institute.

Social spending and health

Cooper maps health outcomes and poverty rates by neighborhood, finding a strong link between poverty and illness. He estimates that health care spending would fall by 30% if all Americans were as healthy as wealthy Americans.

While Cooper is right that poverty and other socioeconomic factors are powerful determinants of health outcomes, there is less evidence for his claim that a healthier country would necessarily lead to lower health care spending.

There’s a growing body of evidence that social spending is related to health outcomes. Countries that spend more on social services (such as pensions, job training, and food assistance) relative to health care spending have higher life expectancy and lower infant mortality rates. This effect holds when looking at long-term health outcomes, comparing the US to other high-income democratic countries, and even comparing states within the US.

Health spending and waste

But the converse is not necessarily true: that higher social spending will automatically lead to lower health care spending. This relationship is especially tenuous in the US health care system, where much of the care that is delivered is unnecessary and driven more by the supply of resources (such as hospital beds and physicians) and less by the needs of patients. Harmful and unnecessary care is rampant, and perhaps surprisingly, it afflicts low-income as well as high-income patients.

To reduce spending we need to take a multi-pronged approach, working to reduce overuse in health care while fighting for more investments in social services. We spend at least $200 billion each year on unnecessary and harmful care. Imagine if we could extract that waste out of the health care system and spend the money on public goods that can help all Americans have an opportunity to live a healthier life.

The post Poverty or health care waste – which do we tackle first? appeared first on Lown Institute.

In the doctor’s office, I am typically situated between my mother and the physician, translating her conditions to the doctor and relaying the doctor’s instructions back to my mother. As I sit in between what is clearly an awkward dynamic for us all, I am faced with the question of, “Why?”

Why does a child from the age of nine have to take on such responsibilities for her family to be healthy? Why does the sibling of an individual with developmental disabilities carry on so much weight in preparing for their future? Why is it that frustration seems to be the predominant emotion I feel when thinking about my health?

These questions drive me as a person and a student to better understand the complexities behind the health care system. Through academia, I found a framework and language to guide my understanding, studying areas of public health such as health literacy, disability access, and economic empowerment of underserved communities. In my experience interning at the Sibley Innovation Hub, I learned how innovation and design can be transformative in the health care system.

Too often, the answer to “Why” is often that someone in power said, “Because.” This is why I found that understanding the system was not enough; I hoped and wanted to challenge the system entirely.

I look forward to pushing back against our unequal, inefficient health care system at the Lown Institute this summer.

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However, perhaps there’s a bit more blame to go around. Patients were infected when they received steroid injections for back pain, a procedure the The New York Times news item about Cadden’s sentencing described as “routine.” Treating back pain is difficult, because there is a plethora of treatment options and no universally effective treatment. But the evidence to support steroid injections for back pain just isn’t there.

This conclusion isn’t new. A Cochrane meta-analysis published almost ten years ago found “no strong evidence for or against any type of injection therapy” for low-back pain. Since the Cochrane review was published, several randomized trials have found no long-term benefits of steroid injections compared to placebos. Given the financial cost and risk of side effects, most experts recommend these injections only as a last resort.

Many patients imagine that unnecessary or useless treatments can’t hurt, but the risk of harm is always present, whether or not a treatment is effective or needed.

The post Both negligence and overuse to blame in deadly meningitis outbreak appeared first on Lown Institute.

The event began with a few words from a panel of clinicians and patients before opening up the conversation to the audience. The panelists included Dr. Galina Tan, a resident at Cambridge Health Alliance, Dr. Vikas Saini, president of the Lown Institute, patient Herb Solloway, and Dr. John Levinson, a cardiologist at Mass General Hospital.

Here are our key takeaways from the event:

• EMRs affect numerous areas of clinical practice, including doctor-patient communication, clinician well-being, patient safety, and overuse
• EMRs are a result of a system that’s highly dysfunctional
• People in all areas of health care want to work together to turn EMRs from a hindrance to a benefit.

To learn more about the event, read the full write-up on the Right Care Alliance blog!

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Advancing meaningful measures

Frustration with inappropriate quality measures drove Dr. Ronald Adler, Associate Professor of Family Medicine at UMass Medical School, to create Care That Matters, a primary care physician advocacy group dedicated to promoting more meaningful quality measures – and eliminating inappropriate measures. “Most of the measures we were getting graded on didn’t correlate with outcomes that matter: better health for our patients or lower costs for our patients or the system as a whole,” says Adler. He hated spending time on unhelpful measures when he could be interacting with patients in more meaningful ways. Adler and his colleagues wanted to draw attention to the lack of evidence behind these measures.

So Adler partnered with Dr. Alan Drabkin, Section Editor for Family Medicine at DynaMedPlus and Assistant Professor at Harvard Medical School, and Dr. Courtney Scanlon and Dr. Brian Randall from Tufts University School of Medicine, to conduct an evidence-based critical appraisal analysis for quality performance measures. They presented this research at the 2017 Lown Conference and received an Audience Choice Award.

Checking the check boxes

In their abstract, “Checking the Check Boxes: An Evidence-based Review of Quality Performance Measures,” Drabkin, Adler, and colleagues evaluated a subsection of the MIPS quality performance measurements. Among the 65 MIPS quality measures for Primary Care, only 20 met their criteria for an appropriate measure. Twenty-one were not supported by evidence that the measure is appropriate and that the benefits of performing the action outweighed the costs or other harms. Another 24 had evidence of effectiveness and benefit, but weren’t specified adequately enough to allow for reliable implementation.

Adler and Drabkin point out that requiring completion of inappropriate measures not only wastes time for physicians, it can also cause real harm to patients. For example, if a doctor has an elderly patient whose blood pressure is slightly above the performance target, she could benefit from giving the patient a medication to reduce blood pressure, even though that would increase the patient’s risk of falls. “It’s very problematic when a quality measure pits the interest of the physician against the interests of the patient,” says Adler.

The measurement snowball effect

Why do we have so many guidelines that are harmful or ineffective? Adler and Drabkin say it’s an issue of putting the cart before the horse. Everyone is on board with measuring quality, so they propose more and more measures, with no one stopping to evaluate them. “There’s a compelling case to measure, so we have grasped on anything we can measure,” says Drabkin, “Things often get implemented before they’re properly vetted.”

The research in this abstract is just the start of a larger project – applying this analysis to all 271 MIPS measures across 28 specialties before making this information public. The team intends to create a searchable tool that physicians can use to make informed decisions about which quality measures are most appropriate to choose for their own practices.

The post When quality performance measures don’t pass the test appeared first on Lown Institute.

Unfair markups in the ED

Researchers from Johns Hopkins analyzed the effect of this billing software on ED prices by looking at billing records in emergency rooms across the country. They found that patients were being charged 3.4 times higher on average beyond what Medicare would pay for ED services. However, these markups varied wildly, with some hospitals not marking up ED bills at all, and others charging almost 12 times what Medicare pays. With that amount of variation, it’s no wonder most ED clinicians have trouble estimating the cost of care for common treatments.

Even hospitals in poor and underserved neighborhoods overcharge. According to the Johns Hopkins study, markups were especially high at for-profit hospitals with higher populations of uninsured, Hispanic, and African American patients.

A harmful new reimbursement policy

But even for insured patients, the ER may be about to get more expensive. Blue Cross Blue Shield of Georgia announced recently that they will no longer reimburse patients for ED visits that turn out not to be emergencies. As doctors and policy experts have pointed out, there is no way for doctors or patients to know whether a certain symptom is truly an emergency or not until an examination is performed. If people are worried about paying for a “false alarm” ED visit, they might forgo life-saving care.

Essentially, insurers are demonstrating “profits first, people last behavior,” said Rebecca Parker, MD, FACEP, president of the American College of Emergency Physicians. Then again, so are hospitals. The ED needs to continue to be an inclusive place for all kinds of care, even care that could be found in more appropriate settings like primary care practices — if only we had a robust primary care system. Until then, watch out for unfair and non-transparent prices.

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So when Donald Trump told Lown over dinner that he would end the Cold War with “one hour of discussion” with Soviet leader Mikhail Gorbachev, Lown was skeptical.

As Lown told CNN, he met with Trump hoping to discuss funding for research. Instead, Trump wanted to talk about his plan to negotiate a nuclear arms deal with the Soviet Union face to face with Gorbachev. “He didn’t understand the complexity of the issues,” said Lown.

History seems to be repeating itself: Turns out health care reform is more complicated too.

The post Trump’s views on Cold War too simplistic, Dr. Lown says appeared first on Lown Institute.

Does this special treatment make the rich any healthier? Maybe not.

Tiger Woods

Tiger Woods is one of hundreds of thousands of patients who received spinal fusion surgery in the last year (his fourth back surgery since 2014). Spinal fusion has been criticized for being no more effective than non-surgical options for many people and for contributing to long-term opioid dependence. Woods was recently found sleeping in his car by the side of the road, due to post-surgery medication.

Unnecessary services

The Baltimore Sun reported last year on how medical centers competing for wealthy patients are offering more services, many of which are unnecessary. For example, hospital websites advertising “executive health programs” included screenings for many tests that aren’t proven to save lives, according to the US Preventive Services Task Force. This increased “observational intensity” for high-income patients turn up incidental findings, causing unnecessary treatment and patient anxiety, researchers note in NEJM.

Steve Kerr

Another high-profile sports figure, NBA coach Steve Kerr also received back surgery to repair a ruptured disk in 2015, and is still dealing with pain from leaking spinal fluid as a complication of the surgery. Kerr is outspoken about regretting the initial surgery, telling the Washington Post, “If you’re listening out there, stay away from back surgery…Rehab, rehab, rehab. Don’t let anyone get in there.”

Getting enough time with your doctor without feeling rushed and being able to schedule same-day appointments is one benefit of concierge medicine. But when it comes to harmful overtreatment, even the wealthy are not immune.

The post Even the rich don’t always get right care appeared first on Lown Institute.

Apparently not, according to a study that found no measurable difference in muscle fatigue or pace for the runners who wore compression gear versus runners who didn’t. Here’s the surprising part: The study was sponsored by Nike, a company that manufactures the tights.

Most industry-sponsored studies produce positive results, and the fact that Nike made them public is all the more unusual. Research on the effectiveness of drugs and devices that are funded by industry are more likely to have positive results and conclusions. As Megan Thielking notes in STAT, the tendency for studies to accentuate the positive is especially prevalent in exercise and nutrition research.

Nike could have filed away the study and never published the results, as is the case for many clinical trials funded by industry. Instead they presented the results at the American College of Sports Medicine’s annual meeting. Maybe Nike is sending a message to other manufacturers: When it comes to being transparent and publishing the bad along with the good, companies should just do it.

The post Nike bucks the trend, publishing negative study results about its own product appeared first on Lown Institute.