One interesting point made in the article is that an awful lot of the gains we have made in life expectancy have come from public health rather than medical advances. The article claims that the increase from the public health revolution in the late 1800s did more to increase life expectancy than antibiotics. Which makes sense, not getting sick is more effective than any treatment once you are sick.
A sibling comment mentions that lobbyists worked to get the 21st Century Cures Act passed, but a potentially bigger issue with the act is that it transfers $3.5 billion of public health spending to medical research.
The kicker is that doctors will often refuse these same treatments when offered, which is not a good reflection on their efficacy (again covered in How Doctors Think). This is not an indictment of modern medicine (which is often very effective on acute care), just a recognition of the limitations.
Exercise helped reduce my depression and anxiety, and I tried to cure it without medication for 2 years. Finally I gave in and went on a low dose of lexapro, in addition to my usual exercise and healthy diet, and I recovered within weeks. Completely changed my life. I know this is just my anecdote, but when natural remedies fail, don't be afraid of medicine.
"the same inferior medical outcomes are attributed to most, if not all forms of back surgery."
I ran, not walked, to this thread without reading the article just to talk about back surgeries.
It is stupefying and outrageous that people allow themselves to get butchered up (yes, butchered up - go read about spinal fusions, etc.) for an outcome that could easily be achieved by merely walking a few miles a few days per week.
This is only a problem in the US (aka "list of countries with private healthcare"). In Canada, we are actively trying to prevent any medical procedure possible because of the huge expense.
I just completed a huge app to educate and prevent diabetic foot amputations. It costs $70,000 to remove a foot and the government is really trying to cut down on these if they are preventable. Patient gets to keep their foot, government doesn't have to spend money - win win!
In the US, a hospital would be stupid to make an app like this. Why would you want less foot amputations? You don't get the $70k from the surgeries and you also don't get to subscribe them to a lifetime of therapy and prosthetics. Chop off more feet, I say!
The article specifically addresses the fact that profit motive alone does not account for the prevalence unnecessary treatment.
Further, only about 20% of US hospitals are private, for-profit endeavors. Over 75% are not-for-profit or government. Of course, they are still affected bybthings like revenue, prestige, "performance" metrics, etc. But Canadian hospitals suffer from those same drivers.
I applaud the work you are doing, but I question your confidence that the US system is the only system with these issues.
if riskFromTreatment <= riskFromNoTreatment:
doTreatment
In most public systems:
if (treatmentCost <= someThresholdPerBenefit) && (riskFromTreatment <= riskFromNoTreatment):
doTreatment
In practice, treatment outcomes are pretty similar, but more treatments are preformed in the USA system. Being a for-profit system is one cause, but so is the litigation culture. Not doing every possible treatment and test can lead to the physician being accused of being negligent.
> In the US, a hospital would be stupid to make an app like this. Why would you want less foot amputations?
My Uncle died a few years ago when a tree fell on him while working in his back yard. While trying to stabilize him, a doctor put in a request to have a surgeon amputate his leg to prevent complications once he was stabilized. My uncle died that day, and a day later a surgeon and anesthesiologist came to amputate his leg. When he wasn't found in his hospital room, they went down to the morgue, amputated his leg there, and billed the insurance company for the procedure... including the cost of anesthetizing the dead man.
Ridiculous stories like this abound in the American system of healthcare.
That simply isn't how it works in the US. There are specific standards of care for diabetes including annual foot exams. Insurance companies, and federal and state governments, require providers to report on those quality measures and penalize them for insufficient compliance.
>This is only a problem in the US (aka "list of countries with private healthcare").
This is complete nonsense and I'd like to see the source of this. Do you really think the state has any incentive to prevent health insurance and treatments from costing a lot? Spoiler alert: It doesn't. The state never has any incentive to save, it grows and grows. The more socialised and rigid your healthcare system, the more bloated it gets, and the more doctor and insurance mafia you get.
The strongest incentive to save is if the customer is free to decide. We see this time and time again. We do not have to force the people to save money, the market forces do a wonderful job all by themselves.
Now, what's got to happen is that patients inform themselves and diversify diagnosis. The crux of the problem is that patients seek advice from the exact same people who can make large financial gains if the patient opts for a certain treatment. Now, this is really just a beginner's mistake in negotiation and not something you can fix at the state level (since if you try to do that, the costs are socialised, but the poor judgement of the patient remains)
What needs to happen is that if doctors say "Don't inform yourself about your condition and don't read on the internet", get up, tell them to fuck off and get informed - like you would about every other service you like to buy. NEVER tolerate being taught ignorance. Nothing good comes out of ignorance, ever.
FWIW, I lived with someone who chopped diabetics' feet off for her living, and she always, always, always did her best to make that option a last resort, "the only alternative is total incapacitation" medical decision.
She would have loved to have an app like this.
So in my anecdotal experience at least, doctors are at least trying to do the right thing.
> In the US, a hospital would be stupid to make an app like this. Why would you want less foot amputations? You don't get the $70k from the surgeries and you also don't get to subscribe them to a lifetime of therapy and prosthetics.
Isn't the prognosis something like 2 years after foot amputation for people with diabetes?
Better early treatment keeps them alive for longer and thus buying all the test strips and injecting pens plus needles plus etc.
It is difficult to make rational decisions when there is a political advantage to be had by misrepresenting the facts. Every system, whether private or socialized, medical or otherwise, has to decide to how allocate limited resources. When party leaders, along with popular media, can successfully label this "death panels," I don't see hope for a rational solution.
Insurance companies have the incentive, not hospitals themselves. There are plenty of US insurance companies that would pay for the app if it meant they could avoid paying $70K for a foot amputation.
Sadly, the problem is not just excessive treatment, but also lack of them, for the exact same reason: medics seemly hate science.
Example: Thyroid disease diagnostic and treatment problems are so common, that there are organizations made solely to support thyroid patients, including having lawyers specialized in suing doctors to force them to start treatment...
The reason for that, is that although there is plenty of research showing that the 80s blood tests are too conservative (they only show positive to people that are usually too damaged beyond any repair), many doctors insist in using solely those tests, and ignore symptoms and newer blood tests.
This does have to do with pharmaceutic industry though, some of the organizations pushing for the 80s tests are all supported by pharma companies, and the same companies also have lobbists that try to get in the way of allowing research of treatments that would skip such companies, for example many patients only improve when using "alternative" but centuries old methods that were known to work for centuries, yet lobbists and pharma companies try to convince doctors and politicians that these ancient methods are "wrong because they are old", and don't allow even research to proceed properly, the leading manufacturer of thyroid medicine that works is in Thailand, because in most other countries their business is considered shady or sketchy.
Same thing happen in psychiatry, problems that are popular in the public mind are overdiagnosed, specially when they have expensive medication, yet when the problems aren't popular, psychiatrists refuse to treat sufferers. I found a strange case with ADHD: kids are being pumped full of meds due to the fact that they keep disrupting classrooms and ADHD is a "popular" disease with kids, but all adults I know that are actual sufferers from ADHD to the point of disrupting their adult lives, struggle to find treatment, with the usual excuse from doctors being that the meds are "too dangerous" (then why give it to the kids by the boatload?) or that people in their 20s seeking meds must be some kind of junkie looking to boost academic performance, nevermind if non-academic symptoms are there too.
>The 21st Century Cures Act—a rare bipartisan bill, pushed by more than 1,400 lobbyists and signed into law in December—lowers evidentiary standards for new uses of drugs and for marketing and approval of some medical devices.
It shows again that we will not have sane healthcare system when there are thousands of lobbyist working to keep it insane.
Here's a semi-random blog post with a handful of examples[1]. Generally speaking European countries are much quicker to approve most drugs and tend to have better health outcomes on average even though you can point to individual disasters like Thalidomide. But on the other hand beta blockers were available in Europe about a decade before they were in the US and would have saved about 10,000 lives a year during that time.
What the article is talking about and what that bill seems to address are two separate issues. Whether you have high or low evidentiary standards for a new treatment is, under our current system and almost any system I've ever seen proposed, independent from whether doctors will end up completely correctly using those new systems. Doctors already have that responsibility and are already failing in that responsibility for a variety of complicated reasons, apparently, but it's easy to construct "solutions" that make it even worse. How do you out-expert the very people you've trained to be experts in the first place? That may not be unsolvable but it surely isn't a trivial problem to be fixed with some regulation here and some pamphlets there.
We've frequently discussed on HN the idea that sky-high evidentiary standards for new treatments may have passed the point where they are doing more harm than good. While I'm sure there are disagreeable details in the new bill, the broad strokes of the bill are things that the HN gestalt has at least been talking about for a while. It's not like it's a sudden out-of-the-blue idea that nobody's ever heard of before.
On the other hand, you had situations where people were smuggling drugs into the country for HIV treatment. Or you have drugs that we know are safe, and initial research shows a lot of promise, but are unavailable.
A patient with a serious condition should not be denied a possible treatment, as long as it's proven that it won't hurt him.
Surprised every time I'm in the US and see commercials for drugs and procedures that are administered by doctors being directed towards patients with the ending "ask your doctor about xyz".
I'm fairly sure this kind of thing ends up with patients asking/pressuring doctors for treatments they don't need.
Unsurprisingly, the FDA thought of this. They have concluded so far that drug ads are a net benefit for consumers.
> Other highlights of the surveys include:
> Most physicians agreed that because their patient saw a DTC ad, he or she asked thoughtful questions during the visit. About the same percentage of physicians thought the ad made their patients more aware of possible treatments.
> Many physicians thought that DTC ads made their patients more involved in their health care.
> Physicians thought the ads did not convey information about risks and benefits equally well. Seventy-eight percent of physicians believe their patients understand the possible benefits of the drug very well or somewhat, compared to 40 percent who believe their patients understand the possible risks, and 65 percent believe DTC ads confuse patients about the relative risks and benefits of prescription drugs. In addition, about 75 percent of physicians surveyed believed that DTC ads cause patients to think that the drug works better than it does, and many physicians felt some pressure to prescribe something when patients mentioned DTC ads.
> Eight percent of physicians said they felt very pressured to prescribe the specific brand-name drug when asked.
> DTC ads help patients have better discussions with their physicians and provide greater awareness of treatments. The study demonstrated that when a patient asked about a specific drug, 88 percent of the time they had the condition that the drug treated. And 80 percent of physicians believed their patients understood what condition the advertised drug treats.
> Doctors believe that patients understand that they need to consult a health care professional about appropriate treatment. Eighty-two percent responded either "very well" or "somewhat" when asked whether they believe that their patients understand that only a doctor can decide whether a drug is right for them.
Folks can argue that the FDA is biased in favor of drug companies at the expense of consumers, but then this would be a huge problem with the central mission of the FDA. It's not clear why we would trust it for approving drugs/treatment, but not trust it for considering the affects of adverisements.
I find these utterly idiotic: you are telling patients about side effects of some drug with pretty pictures and a pleasant voice but only a doctor can prescribe them and you would assume understand the side effects and contraindications. What is the point? Other than obviously make drug companies more money.
Yes, there's a range of products available now to many health systems that help with this exact problem. The category is called Clinical Decision Support. A CDS program may see a prescription or lab test deemed unnecessary by medical guidelines/evidence and warn the physician.
However, there's still a long ways to go in terms of UX, interoperability, adoption, etc.
The ProPublica version of the article has a chart at the end showing an evaluation of the benefit vs risk of a treatment (search "A Different Way to Think About Medicine"):
So one way to avoid unnecessary treatments is to seek out doctors who are willing to discuss treatments in similar terms. They may lack the information to build such a precise estimate, but they should still be willing to talk in a clear way about the risks and benefits of a given treatment.
Sometimes medicine helps patients, sometimes the medical-industrial complex makes work for itself. I took a lot of medicaid patients to & from doctor appointments where nothing much was accomplished.
> In 2012, Brown had coauthored a paper that examined every randomized clinical trial that compared stent implantation with more conservative forms of treatment, and he found that stents for stable patients prevent zero heart attacks and extend the lives of patients a grand total of not at all. In general, Brown says, “nobody that’s not having a heart attack needs a stent.” [...] Nonetheless, hundreds of thousands of stable patients receive stents annually, and one in 50 will suffer a serious complication or die as a result of the implantation procedure. [emphasis added]
This is a very important issue. Doctors are over prescribing and jumping to unneeded surgeries. The question is, are they doing it out of fear of a malpractice lawsuit for denying a patient what they need or is it from kickbacks, incentives and the knowledge that the persons insurance will pay them?
Just because something works doesn't mean it's not a broken system.
Suprised that no one else has commented on this article.
Three months later, his cholesterol had improved markedly, he had lost 15 pounds, and the chest pain never returned.
And it just goes to show you, that Dr. Brown might have saved the executive a stent procedure, but they are still promulgating the myth that cholesterol causes CHD. It's a side effect not the cause. There are plenty of people that have high cholesterol and don't have blocked arteries.
If it were, treatment with anti-cholesterol drugs such as statins (the most used) or even a new class of drugs called PCSK9 inhibitors wouldn't have such a clear cause-and-effect on reducing cardiovascular events and mortality.
Since removing cholesterol from circulation reduces cardiovascular disease, you can view it as a cause and not as a mere marker of disease.
I have, according to my MRI, severe cervical stenosis. I also have carpal tunnel, which was diagnosed first. Based on my symptoms and the awful looking MRI, 4 highly regarded spine surgeons recommended a 2 level fusion right away. The 5th doctor, instead recommended carpal tunnel and ulnar nerve releases. My symptoms abated by 80+% and is something I can live with comfortably.
None of the 4 other doctors even considered dealing with my carpal tunnel first, which, combined with stenosis causes what's called a 'double crush' scenario. Only one surgeon recommended the least invasive and risky procedure for me! Even though a fusion in the future is likely, for now the risk - reward for such a procedure does not warrant immediate action.
I also think it's worth noting that that 5th doctor is the only female of the group. She was the only one that didn't seem gung-ho about the fusion. I'm not saying gender plays a role but...
>Public health researchers at Harvard found that elderly patients were less likely to die or be readmitted to the hospital within 30 days if treated by female doctors rather than male. The study doesn’t explain why this happens, but prior studies have found that female doctors tend to spend more time with patients, communicate better, and follow clinical guidelines more often than their male colleagues.
The article gives an introductory example of a patient that was referred to two different cardiologists, both of whom wanted to do an angiogram. The article doesn't mention of course that the cardiologists get paid per angiogram performed. The remuneration per unit time for seeing the patient in clinic and carefully discussing the options and evidence is drastically less than just doing the angiogram. Some cardiologists will also have a target number of angiograms they need to perform every year specified by arrangements with the angiogram facility.
So although it is widely known that doing angiograms and inserting stens in patients with stable coronary artery disease is a waste of time, perverse incentives in a fee for service model result in these outcomes. As such it isn't a good example of evidence-free medicine. In Australian public hospitals, the cardiologists are paid the same salary regardless of whether they do zero or 1000 angiograms a year. They are very happy not to do unnecessary angiograms in line with the current evidence. If anything, this introductory example shows that a health system needs to be set up to facilitate and encourage evidence-based practice.
Otherwise this article rehashes many points about clinical trials and interpreting medical evidence, without a really coherent theme, except maybe to (yet again) criticise doctors.
Things have improved in the last 10 - 15 years. Clinical trials come under more scrutiny, trial pre-registration has become more common (although not strictly enforced), health systems gather more and more data about patient outcomes outside of clinical trials and manipulative marketing practices by pharmaceutical companies have been curtailed drastically.
In my opinion, the challenges for evidenced based medicine in the next decade are:
1. Getting some decent data about nutrition. There are really remarkably few useful things we can say about how nutrition relates to health.
2. Reducing unnecessary interventions towards the end of life in an ageing population. Healthcare and healthcare research is not well suited to de-escalating care.
3. Transitioning from a one-size-fits-all approach doing clinical trials in 1000s of undifferentiated patients, to collecting 1000s of data points about each individual patient (blood and metabolic variables, genome sequencing, immune profiling, microbiome etc) and using that data to get them healthy and keep them that way. Needless to say, the difficulties in doing this will make doing a randomised controlled trial look like a walk in the park.
4. Fighting pseudo-scientific diagnostic tests and treatments. Examples of this are everywhere - Theranos, gene therapy clinics in undisclosed locations in South America, quantified self services that have no proven health benefits, virtually every supplement ever sold, multivitamins...
5. Fighting the politicisation of health care. This is a very worrying trend that can easily render all our scientific efforts irrelevant - eg anti-vaxxers, far-right intolerance of harm minimisation measures like abortion and decriminalising drug use.
6. Studies on how to most effectively treat people with non-invasive treatments. "Take this pill once a day" has a far higher compliance rate than "exercise more."
I am thinking of the example mentioned in "The Power of Habit" where one group of knee surgery patients was given a brochure about post-surgery treatment, like PT, exercise, etc. The other was give the same brochure with blank pages to write out a specific plan for following the recommendations. Of course, the second group fared much better.
The system is also rigged against cost-savings from small providers.
My wife is an ophthalmologist in private practice. Recently, we were looking at the economics of buying a laser to do a common treatment for patients with glaucoma, called a Selective Laser Trabeculoplasty (SLT).
Even with a decent understanding of medical reimbursement models in the United States, I was still kind of shocked by what I found.
The laser to perform the procedure costs about $30,000 to purchase.
The Medicare allowable for a physician performing the procedure in a standalone surgery center is about $315. There's really no reason that the procedure needs to be performed in a surgery center, and Medicare does let the physician bill about $30 more if they bought a laser for their office, and performed the procedure there. But, at an increase of $30/procedure, you'd have to be doing a ton of SLTs to make buying your own laser financially attractive vs. just using the local surgery center's.
Where things get crazy, is in terms of facility fees.
If a physician performs an SLT procedure at an ambulatory surgery center, the physician's medicare allowable is about $315, and the surgery center can bill a separate facility fee of about $290, making the total procedure cost medicare just over $600.
If my wife's practice were bought by a hospital tomorrow, and they brought an SLT into her office, every time she performed an SLT in the exact same office that was now hospital owned, they'd be able to bill the $315 physician fee, plus a "hospital outpatient department" (HOPD) facility fee of $443, bringing the total cost of the procedure to over $750.
So, to recap the total costs to medicare:
Physician does the procedure in their privately owned medical practice: $345
Physician does the procedure in a surgery center: $600
Physician does the procedure in a hospital-owned medical practice: $750
You want to know why independent medical providers are getting bought up by hospitals and large health systems at an alarming rate? That's why. Because for doing the exact same thing, they get paid by medicare and private insurance companies (whose rates are largely based off of medicare reimbursement rates) 2x what a provider can on their own.
You hear a lot in the healthcare market about the efficiencies of scale, and how large integrated healthcare organizations are doing amazing things. You don't hear a lot about the potential for independent practitioners to reduce costs, but it's absolutely there, and largely ignored.
That said, medicare is (or at least was under the ACA) moving toward a "pay for performance" model, where instead of getting paid more for doing more angiograms, cardiologists will get paid more for keeping their patients from needing angiograms in the first place. There are still plenty of issues, but I think broadly that's the right direction for healthcare reimbursement to be going.
Does anyone know what the problem is that the 21st Century Cures Act is solving? The claim was made that treatments are being withheld pending FDA approval. Is it illegal to use FDA-unapproved drugs, or is it that insurance is not covering unproven treatments?
A big part of the 21st Century Cures Act is to incentivize new antibiotics. Right now the FDA requires the same standards for antibiotics as for other drugs.
That can be a problem if you are trying to test a new antibiotic for a very rare drug resistant strain. You need 100 patients in your trial to hit statistical significance, but only 50 cases happen in the US each year.
So you run a smaller trial, get the best data you can and the FDA gives you conditional approval. You agree to a patient registry to collect post approval data where in time you get full FDA approval.
It's not illegal to take them, but yes I doubt insurance will cover unapproved treatments. Also, while it's not directly illegal for a doctor to prescribe an unapproved drug, I think it would open them up to malpractice lawsuits, and it just seems like a bad idea in general. Here's a doctor's blog post about this issue: http://thehealthcareblog.com/blog/2013/08/26/should-a-doctor...
Check the story of AIDS treatment in 1980s - there were drugs available on other markets that essentially brought patients to life, but they had to be literally smuggled into US.
> Steven Galson [...] has called the strengthened approval process created in 1962 the FDA’s “biggest contribution to health.” Before that, he said, “many marketed drugs were ineffective for their labeled uses.”
Sam Peltzman in "Regulation of Pharmaceutical Innovation" provides statistical evidence that the "safe and effective" 1962 Amendments reduced the development of new effective treatments as well as new ineffective ones, for a net decrease in positive results.
This is an excellent and disturbing article. However, something very important was missed.
Let me start by saying that I think that whenever we have a problem in this country, one of the things we should do is look at how other countries handle it to see if there is anything useful we could learn.
That being the case, we need to know how other countries handle the over-treatment problem. Are there studies on this? Perhaps the authors could write a follow-up article.
My way of life dictates adequate exercise, healthy diet and normal sleep patterns.
I come from a family of strict vegans. No, I’m not here to promote either veganism or non-veganism. I’m in my early 40’s and have been exercising since I was a teenager. My routine includes running, cycling, strengthening exercises, lifting light weights, and I do one or two of these a couple times a week. IMO, any and all physical activity is a form of exercise. Usually, my day starts in the early hours. And, as I’m getting older, my endurance levels have been getting significantly better now than during my schooldays, 20’s, or 30’s and with regard to my work I’m getting more productive, too.
I also think that those who are not predisposed to any genetic conditions are in a league of their own. Even those who inherit a predisposition can benefit from delayed onset of a condition by practicing a healthy lifestyle. I’m not a medical professional, so my assumptions may or may not carry any weight.
All I’m trying to do is keep such treatments as are being discussed here at bay and I will keep at it as long as I possibly can :)
Is this a correlating effect with the fact that a large number of published scientific results are botched? If researchers are not allowed to do good science they are no more progressive than the augur reading from the entrails of a fish.
[+] [-] maxerickson|9 years ago|reply
A sibling comment mentions that lobbyists worked to get the 21st Century Cures Act passed, but a potentially bigger issue with the act is that it transfers $3.5 billion of public health spending to medical research.
[+] [-] arafa|9 years ago|reply
The kicker is that doctors will often refuse these same treatments when offered, which is not a good reflection on their efficacy (again covered in How Doctors Think). This is not an indictment of modern medicine (which is often very effective on acute care), just a recognition of the limitations.
[+] [-] seibelj|9 years ago|reply
[+] [-] rsync|9 years ago|reply
I ran, not walked, to this thread without reading the article just to talk about back surgeries.
It is stupefying and outrageous that people allow themselves to get butchered up (yes, butchered up - go read about spinal fusions, etc.) for an outcome that could easily be achieved by merely walking a few miles a few days per week.
[+] [-] jbob2000|9 years ago|reply
I just completed a huge app to educate and prevent diabetic foot amputations. It costs $70,000 to remove a foot and the government is really trying to cut down on these if they are preventable. Patient gets to keep their foot, government doesn't have to spend money - win win!
In the US, a hospital would be stupid to make an app like this. Why would you want less foot amputations? You don't get the $70k from the surgeries and you also don't get to subscribe them to a lifetime of therapy and prosthetics. Chop off more feet, I say!
[+] [-] Hnrobert42|9 years ago|reply
I applaud the work you are doing, but I question your confidence that the US system is the only system with these issues.
[+] [-] graeham|9 years ago|reply
In the USA:
if riskFromTreatment <= riskFromNoTreatment: doTreatment
In most public systems:
if (treatmentCost <= someThresholdPerBenefit) && (riskFromTreatment <= riskFromNoTreatment): doTreatment
In practice, treatment outcomes are pretty similar, but more treatments are preformed in the USA system. Being a for-profit system is one cause, but so is the litigation culture. Not doing every possible treatment and test can lead to the physician being accused of being negligent.
[+] [-] ideonexus|9 years ago|reply
My Uncle died a few years ago when a tree fell on him while working in his back yard. While trying to stabilize him, a doctor put in a request to have a surgeon amputate his leg to prevent complications once he was stabilized. My uncle died that day, and a day later a surgeon and anesthesiologist came to amputate his leg. When he wasn't found in his hospital room, they went down to the morgue, amputated his leg there, and billed the insurance company for the procedure... including the cost of anesthetizing the dead man.
Ridiculous stories like this abound in the American system of healthcare.
[+] [-] nradov|9 years ago|reply
https://www.qualitymeasures.ahrq.gov/summaries/summary/48831...
[+] [-] Kenji|9 years ago|reply
This is complete nonsense and I'd like to see the source of this. Do you really think the state has any incentive to prevent health insurance and treatments from costing a lot? Spoiler alert: It doesn't. The state never has any incentive to save, it grows and grows. The more socialised and rigid your healthcare system, the more bloated it gets, and the more doctor and insurance mafia you get.
The strongest incentive to save is if the customer is free to decide. We see this time and time again. We do not have to force the people to save money, the market forces do a wonderful job all by themselves.
Now, what's got to happen is that patients inform themselves and diversify diagnosis. The crux of the problem is that patients seek advice from the exact same people who can make large financial gains if the patient opts for a certain treatment. Now, this is really just a beginner's mistake in negotiation and not something you can fix at the state level (since if you try to do that, the costs are socialised, but the poor judgement of the patient remains)
What needs to happen is that if doctors say "Don't inform yourself about your condition and don't read on the internet", get up, tell them to fuck off and get informed - like you would about every other service you like to buy. NEVER tolerate being taught ignorance. Nothing good comes out of ignorance, ever.
[+] [-] compiler-guy|9 years ago|reply
She would have loved to have an app like this.
So in my anecdotal experience at least, doctors are at least trying to do the right thing.
[+] [-] maxerickson|9 years ago|reply
[+] [-] mhb|9 years ago|reply
Perhaps, but in this example, shouldn't you be considering the insurance company as the entity with the motive to prevent expensive treatments?
[+] [-] DanBC|9 years ago|reply
Isn't the prognosis something like 2 years after foot amputation for people with diabetes?
Better early treatment keeps them alive for longer and thus buying all the test strips and injecting pens plus needles plus etc.
[+] [-] tasty_freeze|9 years ago|reply
[+] [-] refurb|9 years ago|reply
[+] [-] lend000|9 years ago|reply
[+] [-] speeder|9 years ago|reply
Example: Thyroid disease diagnostic and treatment problems are so common, that there are organizations made solely to support thyroid patients, including having lawyers specialized in suing doctors to force them to start treatment...
The reason for that, is that although there is plenty of research showing that the 80s blood tests are too conservative (they only show positive to people that are usually too damaged beyond any repair), many doctors insist in using solely those tests, and ignore symptoms and newer blood tests.
This does have to do with pharmaceutic industry though, some of the organizations pushing for the 80s tests are all supported by pharma companies, and the same companies also have lobbists that try to get in the way of allowing research of treatments that would skip such companies, for example many patients only improve when using "alternative" but centuries old methods that were known to work for centuries, yet lobbists and pharma companies try to convince doctors and politicians that these ancient methods are "wrong because they are old", and don't allow even research to proceed properly, the leading manufacturer of thyroid medicine that works is in Thailand, because in most other countries their business is considered shady or sketchy.
Same thing happen in psychiatry, problems that are popular in the public mind are overdiagnosed, specially when they have expensive medication, yet when the problems aren't popular, psychiatrists refuse to treat sufferers. I found a strange case with ADHD: kids are being pumped full of meds due to the fact that they keep disrupting classrooms and ADHD is a "popular" disease with kids, but all adults I know that are actual sufferers from ADHD to the point of disrupting their adult lives, struggle to find treatment, with the usual excuse from doctors being that the meds are "too dangerous" (then why give it to the kids by the boatload?) or that people in their 20s seeking meds must be some kind of junkie looking to boost academic performance, nevermind if non-academic symptoms are there too.
[+] [-] skolos|9 years ago|reply
It shows again that we will not have sane healthcare system when there are thousands of lobbyist working to keep it insane.
[+] [-] Symmetry|9 years ago|reply
[1]http://www.advicegoddess.com/archives/2017/01/11/the_fda_pro...
[+] [-] jerf|9 years ago|reply
We've frequently discussed on HN the idea that sky-high evidentiary standards for new treatments may have passed the point where they are doing more harm than good. While I'm sure there are disagreeable details in the new bill, the broad strokes of the bill are things that the HN gestalt has at least been talking about for a while. It's not like it's a sudden out-of-the-blue idea that nobody's ever heard of before.
[+] [-] makomk|9 years ago|reply
[+] [-] kolinko|9 years ago|reply
A patient with a serious condition should not be denied a possible treatment, as long as it's proven that it won't hurt him.
[+] [-] hinkley|9 years ago|reply
"No thanks, grandma. We don't want none of your 21st Century cures here."
[+] [-] alkonaut|9 years ago|reply
I'm fairly sure this kind of thing ends up with patients asking/pressuring doctors for treatments they don't need.
[+] [-] jessriedel|9 years ago|reply
> Other highlights of the surveys include:
> Most physicians agreed that because their patient saw a DTC ad, he or she asked thoughtful questions during the visit. About the same percentage of physicians thought the ad made their patients more aware of possible treatments.
> Many physicians thought that DTC ads made their patients more involved in their health care.
> Physicians thought the ads did not convey information about risks and benefits equally well. Seventy-eight percent of physicians believe their patients understand the possible benefits of the drug very well or somewhat, compared to 40 percent who believe their patients understand the possible risks, and 65 percent believe DTC ads confuse patients about the relative risks and benefits of prescription drugs. In addition, about 75 percent of physicians surveyed believed that DTC ads cause patients to think that the drug works better than it does, and many physicians felt some pressure to prescribe something when patients mentioned DTC ads.
> Eight percent of physicians said they felt very pressured to prescribe the specific brand-name drug when asked.
> DTC ads help patients have better discussions with their physicians and provide greater awareness of treatments. The study demonstrated that when a patient asked about a specific drug, 88 percent of the time they had the condition that the drug treated. And 80 percent of physicians believed their patients understood what condition the advertised drug treats.
> Doctors believe that patients understand that they need to consult a health care professional about appropriate treatment. Eighty-two percent responded either "very well" or "somewhat" when asked whether they believe that their patients understand that only a doctor can decide whether a drug is right for them.
https://www.fda.gov/Drugs/ResourcesForYou/Consumers/ucm14356...
Folks can argue that the FDA is biased in favor of drug companies at the expense of consumers, but then this would be a huge problem with the central mission of the FDA. It's not clear why we would trust it for approving drugs/treatment, but not trust it for considering the affects of adverisements.
[+] [-] coldcode|9 years ago|reply
[+] [-] greendesk|9 years ago|reply
The article mentions how one patient googled his condition and sought a second opinion. I imagine that this direction is common among patients.
I am afraid that once I get old I will also be pushed to have unnecessary treatments.
[+] [-] ch4s3|9 years ago|reply
However, there's still a long ways to go in terms of UX, interoperability, adoption, etc.
[+] [-] maxerickson|9 years ago|reply
https://www.propublica.org/article/when-evidence-says-no-but...
So one way to avoid unnecessary treatments is to seek out doctors who are willing to discuss treatments in similar terms. They may lack the information to build such a precise estimate, but they should still be willing to talk in a clear way about the risks and benefits of a given treatment.
[+] [-] rsync|9 years ago|reply
Yes - exercise and a simple diet.
Michael Pollan speaks of it in the 21st century and the greek philosophers spoke of it in the negative-fourth century.
And every thoughtful person in-between.
Go look - every philosopher you've ever heard of has taken some amount of time to pontificate about health and diet and has concluded the same thing.
[+] [-] taxicabjesus|9 years ago|reply
> In 2012, Brown had coauthored a paper that examined every randomized clinical trial that compared stent implantation with more conservative forms of treatment, and he found that stents for stable patients prevent zero heart attacks and extend the lives of patients a grand total of not at all. In general, Brown says, “nobody that’s not having a heart attack needs a stent.” [...] Nonetheless, hundreds of thousands of stable patients receive stents annually, and one in 50 will suffer a serious complication or die as a result of the implantation procedure. [emphasis added]
(This comment recycled from the earlier submission of the propublica version this story: https://news.ycombinator.com/item?id=13705761 )
[+] [-] AnsemWise|9 years ago|reply
Just because something works doesn't mean it's not a broken system.
Suprised that no one else has commented on this article.
[+] [-] AnsemWise|9 years ago|reply
Didn't refresh
[+] [-] e40|9 years ago|reply
And it just goes to show you, that Dr. Brown might have saved the executive a stent procedure, but they are still promulgating the myth that cholesterol causes CHD. It's a side effect not the cause. There are plenty of people that have high cholesterol and don't have blocked arteries.
<sigh>
[+] [-] regardmore|9 years ago|reply
If it were, treatment with anti-cholesterol drugs such as statins (the most used) or even a new class of drugs called PCSK9 inhibitors wouldn't have such a clear cause-and-effect on reducing cardiovascular events and mortality.
Since removing cholesterol from circulation reduces cardiovascular disease, you can view it as a cause and not as a mere marker of disease.
[+] [-] un-devmox|9 years ago|reply
None of the 4 other doctors even considered dealing with my carpal tunnel first, which, combined with stenosis causes what's called a 'double crush' scenario. Only one surgeon recommended the least invasive and risky procedure for me! Even though a fusion in the future is likely, for now the risk - reward for such a procedure does not warrant immediate action.
I also think it's worth noting that that 5th doctor is the only female of the group. She was the only one that didn't seem gung-ho about the fusion. I'm not saying gender plays a role but...
[+] [-] nommm-nommm|9 years ago|reply
>Public health researchers at Harvard found that elderly patients were less likely to die or be readmitted to the hospital within 30 days if treated by female doctors rather than male. The study doesn’t explain why this happens, but prior studies have found that female doctors tend to spend more time with patients, communicate better, and follow clinical guidelines more often than their male colleagues.
[+] [-] Gatsky|9 years ago|reply
So although it is widely known that doing angiograms and inserting stens in patients with stable coronary artery disease is a waste of time, perverse incentives in a fee for service model result in these outcomes. As such it isn't a good example of evidence-free medicine. In Australian public hospitals, the cardiologists are paid the same salary regardless of whether they do zero or 1000 angiograms a year. They are very happy not to do unnecessary angiograms in line with the current evidence. If anything, this introductory example shows that a health system needs to be set up to facilitate and encourage evidence-based practice.
Otherwise this article rehashes many points about clinical trials and interpreting medical evidence, without a really coherent theme, except maybe to (yet again) criticise doctors.
Things have improved in the last 10 - 15 years. Clinical trials come under more scrutiny, trial pre-registration has become more common (although not strictly enforced), health systems gather more and more data about patient outcomes outside of clinical trials and manipulative marketing practices by pharmaceutical companies have been curtailed drastically.
In my opinion, the challenges for evidenced based medicine in the next decade are:
1. Getting some decent data about nutrition. There are really remarkably few useful things we can say about how nutrition relates to health.
2. Reducing unnecessary interventions towards the end of life in an ageing population. Healthcare and healthcare research is not well suited to de-escalating care.
3. Transitioning from a one-size-fits-all approach doing clinical trials in 1000s of undifferentiated patients, to collecting 1000s of data points about each individual patient (blood and metabolic variables, genome sequencing, immune profiling, microbiome etc) and using that data to get them healthy and keep them that way. Needless to say, the difficulties in doing this will make doing a randomised controlled trial look like a walk in the park.
4. Fighting pseudo-scientific diagnostic tests and treatments. Examples of this are everywhere - Theranos, gene therapy clinics in undisclosed locations in South America, quantified self services that have no proven health benefits, virtually every supplement ever sold, multivitamins...
5. Fighting the politicisation of health care. This is a very worrying trend that can easily render all our scientific efforts irrelevant - eg anti-vaxxers, far-right intolerance of harm minimisation measures like abortion and decriminalising drug use.
[+] [-] Hnrobert42|9 years ago|reply
I am thinking of the example mentioned in "The Power of Habit" where one group of knee surgery patients was given a brochure about post-surgery treatment, like PT, exercise, etc. The other was give the same brochure with blank pages to write out a specific plan for following the recommendations. Of course, the second group fared much better.
[+] [-] atourgates|9 years ago|reply
My wife is an ophthalmologist in private practice. Recently, we were looking at the economics of buying a laser to do a common treatment for patients with glaucoma, called a Selective Laser Trabeculoplasty (SLT).
Even with a decent understanding of medical reimbursement models in the United States, I was still kind of shocked by what I found.
The laser to perform the procedure costs about $30,000 to purchase.
The Medicare allowable for a physician performing the procedure in a standalone surgery center is about $315. There's really no reason that the procedure needs to be performed in a surgery center, and Medicare does let the physician bill about $30 more if they bought a laser for their office, and performed the procedure there. But, at an increase of $30/procedure, you'd have to be doing a ton of SLTs to make buying your own laser financially attractive vs. just using the local surgery center's.
Where things get crazy, is in terms of facility fees.
If a physician performs an SLT procedure at an ambulatory surgery center, the physician's medicare allowable is about $315, and the surgery center can bill a separate facility fee of about $290, making the total procedure cost medicare just over $600.
If my wife's practice were bought by a hospital tomorrow, and they brought an SLT into her office, every time she performed an SLT in the exact same office that was now hospital owned, they'd be able to bill the $315 physician fee, plus a "hospital outpatient department" (HOPD) facility fee of $443, bringing the total cost of the procedure to over $750.
So, to recap the total costs to medicare:
Physician does the procedure in their privately owned medical practice: $345
Physician does the procedure in a surgery center: $600
Physician does the procedure in a hospital-owned medical practice: $750
You want to know why independent medical providers are getting bought up by hospitals and large health systems at an alarming rate? That's why. Because for doing the exact same thing, they get paid by medicare and private insurance companies (whose rates are largely based off of medicare reimbursement rates) 2x what a provider can on their own.
You hear a lot in the healthcare market about the efficiencies of scale, and how large integrated healthcare organizations are doing amazing things. You don't hear a lot about the potential for independent practitioners to reduce costs, but it's absolutely there, and largely ignored.
That said, medicare is (or at least was under the ACA) moving toward a "pay for performance" model, where instead of getting paid more for doing more angiograms, cardiologists will get paid more for keeping their patients from needing angiograms in the first place. There are still plenty of issues, but I think broadly that's the right direction for healthcare reimbursement to be going.
[+] [-] darkerside|9 years ago|reply
[+] [-] refurb|9 years ago|reply
That can be a problem if you are trying to test a new antibiotic for a very rare drug resistant strain. You need 100 patients in your trial to hit statistical significance, but only 50 cases happen in the US each year.
So you run a smaller trial, get the best data you can and the FDA gives you conditional approval. You agree to a patient registry to collect post approval data where in time you get full FDA approval.
[+] [-] burkaman|9 years ago|reply
[+] [-] kolinko|9 years ago|reply
[+] [-] unknown|9 years ago|reply
[deleted]
[+] [-] WalterBright|9 years ago|reply
Sam Peltzman in "Regulation of Pharmaceutical Innovation" provides statistical evidence that the "safe and effective" 1962 Amendments reduced the development of new effective treatments as well as new ineffective ones, for a net decrease in positive results.
[+] [-] woodandsteel|9 years ago|reply
Let me start by saying that I think that whenever we have a problem in this country, one of the things we should do is look at how other countries handle it to see if there is anything useful we could learn.
That being the case, we need to know how other countries handle the over-treatment problem. Are there studies on this? Perhaps the authors could write a follow-up article.
[+] [-] happy-go-lucky|9 years ago|reply
My way of life dictates adequate exercise, healthy diet and normal sleep patterns.
I come from a family of strict vegans. No, I’m not here to promote either veganism or non-veganism. I’m in my early 40’s and have been exercising since I was a teenager. My routine includes running, cycling, strengthening exercises, lifting light weights, and I do one or two of these a couple times a week. IMO, any and all physical activity is a form of exercise. Usually, my day starts in the early hours. And, as I’m getting older, my endurance levels have been getting significantly better now than during my schooldays, 20’s, or 30’s and with regard to my work I’m getting more productive, too.
I also think that those who are not predisposed to any genetic conditions are in a league of their own. Even those who inherit a predisposition can benefit from delayed onset of a condition by practicing a healthy lifestyle. I’m not a medical professional, so my assumptions may or may not carry any weight.
All I’m trying to do is keep such treatments as are being discussed here at bay and I will keep at it as long as I possibly can :)
[+] [-] fsloth|9 years ago|reply