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Ask Stanford Med, Cardiovascular Medicine, Health Policy, In the News, Technology

Stanford expert weighs in on new guidelines for statin use

statinsAs you may have read, the American Heart Association and the American College of Cardiology recently released a new set of guidelines for lowering cholesterol, along with an online risk-assessment calculator. But two independent reviewers found that the calculator’s design was flawed, overestimating many people’s risk for heart problems and potentially driving an over-prescription of statin drugs. (Their comments were posted today on The Lancet.) Controversy about the guidelines and online tool raised questions at the recent annual meeting of the American Heart Association and prompted a press briefing yesterday in which the two issuing organizations stood in support of the risk calculator.

Earlier this year, Mark Hlatky, MD, professor of health research policy and of cardiovascular medicine at Stanford, released a different sort of heart-related calculator, comparing five-year outcomes for two heart-disease interventions. I posed some questions to Hlatky about the the new online tool and guidelines; his answers appear below.

What are your thoughts on the design of the online risk calculator released with the new guidelines?

I’ve tested the spreadsheet in the guideline and agree that the risk estimates appear to be high. There are several possible reasons for this, but a key change is that the current version is to predict the risk of heart attack AND stroke, not just heart attack. So by design all the numbers are higher than prior calculators.

The other issue is that they have used different data than the prior “Framingham risk calculator” to produce these numbers, so there may be additional differences in the estimates from the ones everyone has been using.

New York Times piece includes comments from Johns Hopkins’ Michael Blaha, MD, who notes that the data sets used, from the 1990s, were too old to be accurate in determining how risk factors such as cholesterol level and blood pressure could lead to heart attacks and strokes in today’s population. Do you agree?

The overall risk of coronary disease in the population has been decreasing over time, so using older data to predict current risk might over-estimate the risk.  This is only a problem if the lower risk is due to factors OTHER than improvements in the traditional cardiac risk factors. For example, rates of smoking have gone down, so overall population risk is going down too. But that’s not necessarily a problem for the risk calculator because smoking is included in the calculator. But if all smokers have been smoking less, the risk attached to being a smoker today might be lower than the risk of being a smoker years ago.

What do you think are the implications of this controversy – for doctors, patients, and the medical research review process?

The controversy might confuse the public, so it’s a shame it couldn’t have been avoided. The review process appears to have been flawed, since this criticism was leveled earlier in the development of the guideline.

On a more substantive level, the risk level is now set so low (7.5 percent over 10 years) that many people in the population who have “optimal risk factor levels” (systolic blood pressure 110 or below, total cholesterol 170 or below, HDL cholesterol of 50 or above, no diabetes and non-smoker) would targeted for statin treatment simply on the basis of their age.  The calculator puts men age 63 and older with “optimal risk factor levels” at elevated risk, and all women age 71 and above with “optimal risk factor levels” at elevated risk. It’s a little hard for many to accept that everyone above a certain age should be on a statin, and there’s no direct evidence to back up this pretty sweeping recommendation.

Previously: Heart bypass or angioplasty? There’s an app for that, Exploring the cost-effectiveness of statin use among kidney patientsWider statin use may be cost-effective way to prevent heart attack, strokeNew test for heart disease associated with higher rates of procedures, increased spending and Stanford researcher cautions against widespread use of statins
Photo by AJC1

Health Costs, Health Policy, In the News

Is “Big Med” the future of health care?

The current special issue of the Journal of the American Medical Association takes the history and vitals of the U.S. health-care system’s finances. And, as NPR’s Shots blog reports, experts conclude that the cost of “drugs, hospital stays, doctors and bureaucracy” – rather than the number of diagnostic tests ordered or the size of the aging Baby Boomer population – accounts for over 90 percent of spending increases on health care since 2000.

What’s the prognosis? Maybe the large and concentrated market power of “Big Med,” says the Shots piece, borrowing the term from a JAMA analysis. But, like big airlines, the consolidation of services into fewer large bodies could produce better efficiency and safety while leading to a loss of quality in the consumer experience.

Previously: Making health care better and more affordableThe history of U.S. health care in about 1,000 words, An expert’s historical view of health care costs, Stanford expert urges physicians to take the high road in slowing health care spending and Does the Affordable Care Act address our health-cost problem?

Addiction, Health Policy, Public Health

Breaking Good: How to wipe out meth labs

Breaking Good: How to wipe out meth labs

methlabEarlier today I testified about methamphetamine laboratories to West Virginia Governor Earl Ray Tomblin’s Advisory Council on Substance Abuse. Like more than a dozen other states in the “meth belt,” my home state is suffering from a wave of explosions, fires, burns, poisonings and environmental destruction stemming from laboratories operated by small-time “meth cooks.”  Fortunately, as I told the Advisory Council, this is a problem that we already know how to solve.

Meth cooks make their drug using pseudoephedrine (PSE), which they extract from certain cold medicines such as Sudafed. The precise proportion of these cold medicines that are purchased to produce methamphetamine is not known, but it is clearly very large. A recent study published in JAMA found that per-capita consumption of PSE-containing medicines in counties with meth labs exceeds that of counties without labs by as much as 565-to-1.

In light of this connection, the states of Oregon and Mississippi returned PSE-containing products to prescription-only status, which was how they were regulated until 1976. Meth labs have virtually disappeared in both states.

Most state legislatures in the meth belt have introduced legislation to copy Oregon and Mississippi’s approach, but these bills have all failed. Part of the reason is intense lobbying by the companies that produce PSE-containing products, but another part is that some voters and legislators believe that cold and allergy sufferers will have a hard time getting relief if a prescription for PSE-containing medications is required.

This worry is not usually well-founded, as there are more than 100 over-the-counter cold medications available which provide relief to almost all people with stuffy noses, fevers and the like. However, in the rare case of an individual who truly needs a PSE-containing medication, innovative biochemistry has come to the rescue with the development of medications that contain PSE that is harder for meth cooks to extract.

These companies created cold medications (e.g., Zephrex-D) which use polymers or lipids to bond with PSE in a fashion that reduces the possibilities for conversions to meth. Even if the possibilities for PSE extraction are reduced by only two-thirds by these new medications, meth cooks would effectively be put out of business because their required materials would exceed the value of the drug they make. Meanwhile, consumers with chronic allergies do not suffer reduced access to PSE-containing products.

The public policy option available to meth belt states is thus something that should satisfy all parties. PSE-containing cold medications would be returned to prescription-status, with an exemption for such medications that independent laboratories prove yield only a de minimus amount of PSE for meth preparation.

It’s a rare opportunity for a clear win-win in public policy. That’s why I strongly encouraged Governor Tomblin’s advisors to pursue it with courage and enthusiasm.

Addiction expert Keith Humphreys, PhD, is a professor of psychiatry and behavioral sciences at Stanford and a career research scientist at the Palo Alto VA. He recently completed a one-year stint as a senior advisor in the Office of National Drug Control Policy in Washington. Dr. Humphreys has no financial or personal connections to any company that produces cold medications (extraction resistant or not).

Previously: Examining how addiction in the U.S. has changed over the last decade, Can an antidepressant help meth addicts stop using?, The Florida Governor’s questionable actions on drugs and Stanford Health Policy Forum focuses on America’s methamphetamine epidemic
Photo by 16 Miles of String

Emergency Medicine, Health Policy, Imaging, Pregnancy, Research, Stanford News

Studying the best approach to diagnosing appendicitis in pregnant women

Studying the best approach to diagnosing appendicitis in pregnant women

OLYMPUS DIGITAL CAMERAWhen it comes to pregnant women, managing abdominal pain and diagnosing appendicitis can be a tricky proposition for doctors. Current practice includes an ultrasound followed by further imaging if the diagnosis remains unclear, but some providers and patients are hesitant to use one common imaging tool – a CT scan. That’s because of its use of radiation, and its possible risk to the fetus.

Zachary Kastenberg, MD, is a general surgery resident at Stanford and reports that he and his colleagues encounter this issue relatively frequently in the emergency department. “We often find ourselves guiding expecting mothers and fathers through difficult, anxiety-provoking decisions with minimal evidence to support differing practitioner perspectives,” he recently told me, noting that acute appendicitis is the most common cause of non-obstetric surgery in pregnant women.

Kastenberg said he wanted to help “influence the management and diagnosis of abdominal pain in pregnant women and to inform practitioners regarding the relative risks of abdominal imaging and fetal radiation during pregnancy.” And so he and colleagues performed a comprehensive cost-effectiveness analysis of the diagnostic strategies for appendicitis during pregnancy. Using a computer-based model, the researchers examined the costs and short- and long-term risks of the interventions, and various quality-of-life measures across the lifetime of a cohort of 25-year-old mothers-to-be and their fetuses.

What the researchers found was that in the vast majority of cases, preoperative imaging is the most prudent choice for managing pregnant women with suspected appendicitis. They also determined that magnetic resonance imaging (MRI) – which doesn’t involve radiation – is the most cost-effective diagnostic strategy, and that CT – even when taking into consideration the potential risks of radiation-associated childhood cancer – is a cost-effective option when MRI isn’t available. The latter finding is particularly important for those hospitals (usually smaller or rural ones) that don’t have an MRI machine or access to skilled MRI interpretation at night or on weekends.

Kastenberg acknowledged that patients may still experience anxiety associated with radiation exposure. But he says he hopes the analysis “will give physicians the confidence to guide patients through an educated discussion of the risks and benefits of preoperative imaging, including CT, when confronted with this difficult clinical situation.”

Kastenberg is a post-doctoral fellow in Stanford’s Center for Health Policy and the Center for Primary Care and Outcomes Research. The research appears in the October issue of the Journal of Obstetrics and Gynecology.

Photo by Daquella Manera

Health Policy, Medicine and Literature, Patient Care, Stanford News

Abraham Verghese on health-law battle: “We’ve worried so much about the process, not the patient”

Abraham Verghese on health-law battle: "We’ve worried so much about the process, not the patient”

In the ongoing political struggle over the implementation of the Affordable Care Act, a key component - the patient - remains under-discussed, argues Abraham Verghese, MD, a professor of medicine at Stanford. Verghese recently gave a talk at the University of Denver, and his thoughts on the new law, and his call for judicious use of medical tests and procedures, and attention to bedside manner, were among the topics of discussion. Barbara Ellis of the Denver Post reported in a blog piece earlier this week:

“We’ve worried so much about the process, not the patient,” Verghese said. “If the purpose of Obamacare is to help people get health insurance; if its purpose is to not punish people with pre-existing conditions; if its purpose is to promote quality health care … then what’s so bad about it?”

“Whatever Obamacare does, it will put a premium on not ordering medical tests willy-nilly,” he said. “It will force physicians to come up with a rational idea of what to do next.”

Verghese also talked about technology and how it can improve the quality of care, so long as physicians address the patient first. “A physical exam is a ritual. Someone is telling me their intimate details, allowing themselves to be touched,” he said, according to the Post. “That’s a ritual that’s important to patient care.”

Previously: Abraham Verghese’s Cutting for Stone: Two years as a New York Times best sellerA call for extended bedside-manner training and Can the use of devices among physicians lead to “distracted doctoring?”

Events, Health Policy, Mental Health, Patient Care, Stanford News

Upcoming Stanford Health Policy Forum to focus on mental illness

Upcoming Stanford Health Policy Forum to focus on mental illness

The horrifying mass murders at the Washington Navy Yard and Sandy Hook Elementary School were both committed by individuals with long-standing mental-health problems. The events galvanized a national discussion about how to improve the accessibility and quality of our mental-health system.

At the same time, these tragedies can paint in the mind of the public a false image of the mentally ill as universally violent and dangerous rather than human beings in need of assistance and compassionate care. That may account for why a shamefully large number of mentally ill people are behind bars. L.A. County Sheriff Lee Baca has found himself heading what he calls “the nation’s largest mental hospital:” The L.A. County Jail.

While protecting public safety is a critical concern, it’s important to maintain perspective when analyzing the role of mental illness in violent crime. Harold Pollack, PhD, of the University of Chicago puts it this way:

Millions of Americans suffer from some form of severe mental illness, or SMI. It’s important to remember that the vast majority of these men and women have never committed a violent crime and never will commit one. Indeed, the mentally ill are often victims of violent crime, a social problem that has not received sufficient attention.

To dig into these important issues in a productive way, the medical school’s next Health Policy Forum will be devoted to the topic “Serious Mental Illness: How can we balance public health and public safety?” Harold Pollack and Lee Baca will come to Stanford for the forum and will be joined by our own Laura Roberts, MD, chairman of the Department of Psychiatry and Behavioral Sciences. The policy forum is open to the public and will be held this Thursday from 11:30 A.M. to 1:00 P.M, at the Li Ka Shing Center. If you’re a local reader, we hope you can attend and join in the conversation.

Addiction expert Keith Humphreys, PhD, is a professor of psychiatry and behavioral sciences at Stanford and a career research scientist at the Palo Alto VA. He recently completed a one-year stint as a senior advisor in the Office of National Drug Control Policy in Washington.

Previously: Examining mental health policies in the wake of school shooting tragedy, Probing the underlying physiological causes of mental illness

Health Policy, Public Health, Stanford News

One in four California children live in poverty – and other bleak statistics from new Stanford index

One in four California children live in poverty - and other bleak statistics from new Stanford index

Stanford just released its new poverty index for California, and the statistics are grim. Among the eye-popping numbers: 25 percent of all children here live in poverty, as well as 30 percent of the state’s immigrant population. Expensive housing, especially in urban areas, and a weak job market are among the contributor factors.

A Stanford News story today discusses more of the findings and their significance:

Under the new measure, 22 percent of Californians live in poverty, and that figure would be even higher if not for the state and federal safety nets, including CalFresh, the state’s food stamp program; CalWORKs, the state’s cash assistance program; and the federal Earned Income Tax Credit.

If these programs were not in place, the child poverty rate would increase by another 12 percentage points, raising it from nearly 25 percent to nearly 37 percent of all children.

The research helps to establish that California, often thought of as the land of plenty, is “in fact the land of poverty,” [David Grusky, PhD, a sociology professor who serves as the director of Stanford's Center on Poverty and Inequality] said.  It also shows, he said, that those who “want to cut back the food stamp program have to own up to the poverty-increasing effects of that change.”

“We developed the California Poverty Measure because we can’t have a meaningful policy debate in this state without knowing how proposed changes in policy will affect the lives of real Californians,” he said.

Previously: Doctors tackling child hunger during the summer, U.S. Census Bureau releases new data on income, poverty, and health insurance coverage and Food stamp use shows scope of child poverty

Health Policy, Mental Health, Patient Care, Stanford News

Addressing psychiatric “bus therapy” and its underlying problems

Addressing psychiatric "bus therapy" and its underlying problems

4756317503_2afb86be75In the current issue of JAMA Psychiatry, Stanford’s Smita Das, MD, PhD, MPH, a researcher in psychiatry and behavioral sciences, and Judith Prochaska, PhD, MPH, an associate professor of medicine with the Stanford Prevention Research Center, have an editorial (subscription required) on the resurgence of “bus therapy” – the practice of under-resourced state psychiatric hospitals handing patients a one-way ticket out of town to become another state’s responsibility.

Das and Prochaska write that the problem of patient dumping isn’t new; rather, it gained attention during the 1970s after mental health disorders were deinstitutionalized but measures weren’t established to meet the needs of displaced people seeking care.

The piece notes that the problem has been exacerbated by cuts to non-Medicaid state mental health spending in 29 states and Washington, D.C. during 2009-2012, and that one particularly struggling state – Nevada – has bused more than 1,500 patients in the last five years to California, most of them to San Francisco or Los Angeles. (The New York Times also recently reported on this issue.)

The authors set the scene with a typical case of a psychiatric patient relegated to bus therapy and sent to San Francisco:

He is brought to the county psychiatric emergency service, which, hectic and often over capacity, treats nearly 6000 patients annually (of which 39% are not San Francisco residents). The patient needs housing, a psychiatrist, case manager, primary care provider, and transfer of Medicaid or general assistance—a package known colloquially as the San Francisco Special. Placements are challenging—the county hospital reduced its acute in-patient psychiatry capacity 50% in the last 5 years owing to budget shortfalls—yet out-of-state visitors are not turned away.

In the editorial, Das and Prochaska argue that current reshaping of health care spending and guidelines makes for an ideal time to address patient dumping and find solutions to the practice’s underlying causes, and she suggests increasing mental health budgets, transitional interventions, and proven methods of health-care delivery such as telemedicine and group therapy to serve patients and reduce provider burnout.

“This is a relevant and timely issue as the country is experiencing healthcare changes and feeling the impact of low resources in mental health,” Das said in an e-mail. “We hope more providers, administrators and policy makers take note of ‘bus therapy’ as an example of one of the many signs that we need to pay more attention to mental health.”

Photo by Vincent Desjardins

Health Policy, In the News, Nutrition

A discussion of the confusion surrounding “natural” foods

A discussion of the confusion surrounding "natural" foods

Natural foodIf you’ve ever wondered how an organic food item differs from a natural food item, you’ve got good company. This weekend in the San Francisco Chronicle, nutrition and public policy expert Marion Nestle, PhD, MPH, of New York University, addressed a reader’s question related to food labels and how they could be changed to make them easier to understand.

Nestle discusses the the complexity and controversy that surround food labels on her blog, Food Politics, and offers some ideas on how they could be changed for the better in her Chronicle column, Food Matters (subscription required).

From her blog post:

While “natural” does not necessarily mean “healthy” or even “healthier,” it works splendidly as a marketing term and explains why many junk-food manufacturers are switching from expensive organic ingredients to those they can market as “natural.”

The FDA isn’t fixing this situation because, according to a statement in response to a petition by Center for Science in the Public Interest, it’s “not an enforcement priority.”

Manufacturers of highly processed foods could not be happier with this nondecision.

In her blog, Nestle noted that people often use “organic” and “natural” interchangeably. She wrote, “if the public really can’t tell the difference between “natural” and “organic,” the closer the definition of “natural” is to that of “organic,” the less confused they will be.”

Holly MacCormick is a writing intern in the medical school’s Office of Communication & Public Affairs. She is a graduate student in ecology and evolutionary biology at University of California-Santa Cruz.

Previously: Want kids to eat their veggies? Researchers suggest labeling foods with snazzy namesWill redesigning food labels help consumers revamp their eating habits? Organic vs. natural: Tips for parents who want to go green“Natural” or not, chicken nuggets are high in fat, sodium and Study finds fast-food menu calorie counts confusing for consumers
Photo by qmnonic

Addiction, Health Policy, Public Health, Public Safety

How police officers are tackling drug overdose

police car

Drug overdose is now the most common cause of accidental death in the United States, primarily because of the vastly increased availability of pharmaceutical-grade opioids (e.g., Oxycodone, Vicodin). The size and impact of the epidemic can be lessened by a range of public policies, including one that the White House has been touting: Equipping first responders with naloxone hydrochloride.

In opioid overdose, breathing slows to a very low level or even stops completely, which deprives the brain of oxygen. Death or permanent organ damage can be the horrifying result. Enter naloxone, an old, off-patent (and hence inexpensive) medication with a powerful ability to force opioids out of brain receptors. Overdose is thus rapidly reversed.

Naloxone does not cure addiction. Nor does its effect last more than 30-90 minutes. However, that window of time can be used to get the overdosed person to a hospital and subsequently it is hoped into addiction treatment.

Police officers and fire fighters are often the people who discover people who have overdosed. They typically call for medical backup in such cases, but even if the EMTs take only 15 minutes to arrive, that can be too late. Training in how to recognize overdose and to then administer naloxone allows those first responders to save lives that would otherwise be lost.

Police in Quincy, Massachusetts began carrying naloxone in their cruisers in October of 2010, and have been reversing about one overdose every ten days since. Police and firefighters in other parts of the country are now copying Quincy’s successful approach.

The Obama Administration’s embrace of improving naloxone’s availability is one of many signs of how quickly U.S. drug policy has moved in a public health direction. Only a few years ago, drug policy officials in the G.W. Bush Administration condemned the use of naloxone. Today, Obama drug policy officials give out awards to successful naloxone access expansion programs. The result will be fewer overdose and more chances for people with addictions to receive the help they need to become healthy and productive.

Addiction expert Keith Humphreys, PhD, is a professor of psychiatry and behavioral sciences at Stanford and a career research scientist at the Palo Alto VA. He recently completed a one-year stint as a senior advisor in the Office of National Drug Control Policy in Washington.

Previously: Do opium and opioids increase mortality risk?
Photo by Scott Davidson

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