Overuse of acetaminophen, underuse of the HPV vaccine, confronting chronic pain…
July 31, 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.
Peggy Orenstein’s opinion piece in Saturday’s New York Times highlights one of many difficult decisions faced by patients with breast cancer: whether to have the non-cancerous breast removed “just to be safe.” The procedure, contralateral prophylactic mastectomy (CPM), has become increasingly performed in recent years. However, research suggests that CPM provides almost no survival benefit. Patients’ perceptions of their actual chances of contracting a second cancer, may be a driver. Successful efforts to curb this trend will require physicians to better understand how the “visceral reaction” of a cancer diagnosis affects treatment choices.
Clinical guidelines recommend first line pain-killers like acetaminophen for low back pain. However, Vox cites that until recently there had been no large scale studies looking at the drug’s effectiveness in treating this problem. A recent Lancet article suggests that acetaminophen is no more effective at treating low back pain than a placebo. This is an important finding because while many people believe acetaminophen to be harmless, there are potential side effects and risks for harm, just as with any other drug. Instead the study recommends that doctors encourage patients to stay active and seek further care if the pain does not improve within two weeks.
Traditional fee-for-service reimbursement has been cited as a major reason for increasing healthcare costs and unnecessary care. An alternative payment system, pay-for-performance, seeks to fix the problem, focusing on quality of services delivered, rather than quantity. Yet as Aaron Carroll notes in The Upshot, results are mixed. Defining “quality” is exceedingly difficult, and studies show that offering extrinsic rewards (like financial incentives) can undermine intrinsic motivations (the desire to help people). Let’s hope that pay-for-performance doesn’t incentivize the very behaviors it was designed to discourage.
In a striking example of medical underuse, the CDC announced this week that less than half of American children receive the human-papilloma virus (HPV) vaccine. As James Hamblin reports in The Atlantic, “If as many people got vaccinated against HPV as do against whooping cough… there would be thousands fewer cases of head, neck, and pelvic cancer in men and women every year.” Unfortunately, however, vaccination rates have only improved marginally over the past few years. Part of the issue may stem from a lack of clinical guidance: the HPV vaccine is often not recommended to the same extent as other vaccines, such as meningitis and Tdap.
In response to Janice Lynch Schuster’s essay “Down The Rabbit Hole: A Chronic Pain Sufferer Navigates The Maze Of Opioid Use,” Keith Wailoo, in Health Affairs, discusses the dichotomous nature of our country’s pain dilemma. “People coping with chronic pain,” Wailoo writes, “confront a double-faced problem: a society simultaneously providing too much relief and too little.” Policy goals have vacillated wildly, from an emphasis on pain management to concerns surrounding regulation. Addressing these issues will be critical in developing a sensible approach to treating pain patients.
The late Arnold Relman’s review of The American Health Care Paradox: Why Spending More Is Getting Us Less (by Elizabeth Bradley and Lauren Taylor), in The New York Review of Books, supports the authors’ basic assertion that “inadequate social services in the U.S. contribute to our poor national health.” However, he is unconvinced that greater emphasis on and expansion of welfare programs is the solution. Rather, “it makes sense to consider how reforming the payment and organization of medical care could reduce the heavy burden of unnecessary waste, fraud, and bureaucratic overhead on our medical care system.”
Susan Hecker’s satirical letter to a patient, posted on KevinMD, is a poignant illustration of the challenges facing today’s physicians. The irony of improved “quality” in an age of 10-minute appointments and endless paperwork is both disheartening and terrifying. As she writes, “… I will likely rush through our time together and gloss over details. I will need to spend my time multitasking with the computer as I can only prove the quality of my care by checking boxes…” While efficiency is a popular buzzword among today’s policy wonks, Hecker’s piece forces us to acknowledge the grim realities of everyday practice that are needed to achieve such “quality care.”
As he continues his medical student internship this summer, Jonah P. Zuflacht recalls, in last week’s blog, how this summer’s experience at the Lown Institute has helped shape the medical culture he wants to join. The key ingredients in the art of healing, he says, remain compassion, understanding, and approachability, rather than treating the patient as “a vessel of disease.”