Medical education grants, the number needed to harm, and remembering Jessie Gruman
July 17, 2014
The RightCare Weekly is a newsletter that helps you stay on top of important news in the ongoing quest to move the U.S. health care system toward delivering the right care to all patients. We’ll bring you the most important stories, news articles, and opinion pieces of the week, along with our interpretation of why they’re important for patients, doctors, and communities.
We’re pleased to announce the launch of our first round of Young Innovator Grants, which will offer students, residents, and junior faculty members funding to develop programs that train clinicians to avoid overuse and develop stronger relationships with patients. Check out the program’s website, read the Call for Proposals, and apply today!
As promised, today we bring you the Healthcare Triage video on the Number Needed to Harm (NNH), the companion to last week’s video on the Number Needed to Treat (NNT).
Considered together, the NNT and the NNH give a complete picture of what you can expect from a treatment, either as a patient or as a clinician. Bearing in mind the different outcomes that they sometimes measure,* comparing the NNT to the NNH can give you a clearer idea of whether you’re more likely to benefit from a treatment or be harmed by it. Read more about NNTs for some common tests and treatments at theNNT.com.
Niacin (also called vitamin B3) has been used for decades to raise levels of HDL cholesterol (good cholesterol) in people with heart disease, to reduce their risk of dying from a heart attack or stroke. This week, a large randomized trial found that niacin, in fact, offered no benefits. It doesn’t reduce heart attacks, strokes, or deaths, and actually increases rates of diabetes and other serious complications. Dr. Harlan Krumholz wrote about the study for the New York Times‘s Well blog, noting that:
“If you are taking niacin, talk with your doctor about whether you should continue. Many patients will probably choose to bypass a medication without clear benefit and with documented harms. For those who decide to continue taking the medication, the hope would be for an experience different from those of the tens of thousands of participants in the recent trials. If you are not taking niacin, then realize that there is little reason to start.”
A new study published by the Journal of the National Cancer Institute on mammography in older women shows an increase in spending on mammography – but no improvements in the detection of breast cancer. As the Incidental Economist notes, not only was there an increase in the number of mammograms performed between 2001 and 2009, there was an increase in the use of digital mammography, as opposed to less expensive film mammography. Those changes led to a 47% increase in spending on screening per Medicare beneficiary – but made no difference in terms of increasing detection or detecting cancers earlier. This increased spending is just another detriment from universal breast cancer screening campaigns, especially since screening doesn’t reduce mortality.
Anahad O’Connor of the New York Times reports on androgen-deprivation therapy, which has long been believed to shrink prostate cancers by suppressing hormones like testosterone. A recent JAMA study suggests that increased use of the treatment does not actually improve survival rates. Around a quarter of patients over 75 get the treatment, and although it has not been shown to extend their lives, it does substantially increase the risk for fractures, diabetes and heart disease. This is especially true for older patients with slow-growing cancers, many of whom are unlikely to experience any symptoms from their cancer.
Zack Berger, an internist at Johns Hopkins School of Medicine, has authored a new pledge for patient-centered care. The pledge is an effort to get away from “feel-good boilerplate” and make specific commitments about how he plans to interact with his patients:
“I will always: Ask the patient what she wants, hopes, fears, believes to be true about her health. Ask the patient what she prefers. Tell the patient what options are available.”
Sadly, Jessie Gruman, PhD, a prominent patient advocate and founder of the Center for Advancing Health, died this week. She was a powerful voice for what patients want and need. She spoke at our 2012 and 2013 conferences, and served on our clinical advisory council. She will be profoundly missed. Remembrances have been posted by Vikas Saini, Dave deBronkart, and many others.
* An NNT or NNH always measures some specific benefit or harm. Benefits might include avoiding hospitalization, relief of pain, or even preventing death. Harms might be minor, such as headache or diarrhea, or serious, such as developing diabetes or dying from a heart attack. Sometimes the outcomes being measured are very different, and it might be worth experiencing minor harm to potentially get a very important benefit. For example, if a treatment has an NNT of 200 to prevent death, and an NNH of 10 for headache, you might decide the treatment is worth it.