In my previous post- The Problem With Insulin - I mention concerns about a recently published consensus statement from the ADA (essentially the new ADA 2009 guidelines) which no longer recommends the new drugs Avandia and Januvia, suggest that other newer drugs (Actos and Byetta) are less preferred, and essentially leaves the recommended options to treat type 2 diabetes as metformin, sulfonylurea and insulin. I have also previously mentioned that though the older, generic medications do work, most patients will eventually fail the pills. This means that the "new" guidelines essentially recommend using old pills until they fail, and then everyone goes on insulin. The problem is that insulin is not benign, and it may not be the best way to go.
Three studies presented June 2008 the ADA (VADT, ACCORD and ADVANCE which I have blogged about before-here and here) not only failed to show cardiovascular benefit with aggressive diabetes control, but there was substantial hypoglycemia in the intervention arms (which used more insulin) and in ACCORD, the study was stopped early because of increased deaths. Regarding ACCORD, some the experts stated that " it is biologically plausible that severe hypoglycemia could increase the risk of cardiovascular death in participants with high underlying CVD risk.
Two new studies give further evidence to this hypothesis. The first is from the New England Journal of Medicine and has been mentioned in multiple news reports. The NICE-SUGAR trial randomly assigned 6100 medical-surgical ICU patients to intensive control (sugars between 81 to 108 mg/dL) or to conventional control ( sugars 180 mg/dL or less) and achieved these targets with the use of intravenous insulin. Patients who were in the intensive group had about a 14% increase in death. Not surprisingly, severe hypoglycemia (sugars less than 40) occurred in 206 of 3016 patients (6.8%) in the intensive-control group and 15 of 3014 (0.5%) in the conventional-control group (P<0.001).
Another study, not given the same degree of media attention, was also published in today's Archives of Internal Medicine. This study looked at close to 400 outpatient diabetics on insulin, and gave half metformin in addition to insulin (the other half got placebo). Doctors could increase the insulin in both groups and both groups tried to achieve the same targets for sugar control. After 4.3 years' follow-up, there was no difference between groups in the composite outcome of microvascular disease (e.g., progression of retinopathy, nephropathy, or neuropathy) and macrovascular disease (e.g., MI, heart failure, stroke, or diabetic foot). However, macrovascular disease by itself showed a nearly 40% reduction for the patients taking metformin. By treating just 16 patients with metformin on top of insulin, as opposed to insulin alone, you could prevent one heart attack, stroke, etc. Though you can read this study as "metformin is good," I read the study as "insulin may be bad." The patients on metformin, not only achieved better sugar control, but did so using LESS INSULIN, and heart attacks were prevented.
Don't get me wrong. Insulin is a wonder drug, particularly for Type 1 diabetics who would die without it. However, for Type 2 diabetics there are other choices. Besides the fact that insulin seems to be linked with heart attack and deaths, patients can suffer even from mild hypoglycemia, they have to check their sugars much more regularly, and they have to inject themselves, which can't be too much fun.
My concern is that despite having other options, despite the burden on patients, and despite more and more evidence showing that insulin (in type 2 diabetics) can be harmful; the new ADA guidelines continue to promote insulin use even more than a few years ago. Why would they do this? Instead of pushing type 2 diabetics to insulin earlier and earlier, shouldn't we be saving this as a last resort (like surgery or dialysis) once all other options have failed? As I have speculated before, it is the endocrinologists that make the guidelines, and they may have a bias toward keeping patients on injectable agents.
Tuesday, March 24, 2009
Tuesday, March 17, 2009
An aspirin a day does keep the doctor away.
Though not picked up that much by the print media, you have probably seen on the news or the web new recommendations for taking daily aspirin to prevent heart attacks and strokes. You may know about the potential heart benefits from aspirin, since the folks at Bayer continue to remind the public of this. However, the benefits are real, and newer recommendations should help.
The new recommentation from the U.S. Preventive Services Task Force which is published in the Annals of Internal Medicine is that most men between 45 and 79 and most women between 55 and 79 should take an aspirin a day.
For men, aspirin was found to prevent heart attacks, and for women it was found to prevent strokes. The optimal dose of aspirin is not clear, but benefit was seen as low as 75 mg was about as effective as higher doses. Thus, a generic baby aspirin a day is probably the cheapest and most effective dose.
The reason why everyone should not take this is that even aspirin has some side effects, mainly gastrointestinal bleeding. GI bleeds can be serious, require hospitalizations, surgery and can even cause death. The older you are the higher your risk for heart attack and stroke, but the higher you risk is for GI bleeds. For example, if you took 1000 65 year old women, each with about a 7% risk of having a stroke, your would probably prevent 12 of them from having a stroke, but cause and equal number of GI bleeds. Thus, even if you fall within the age range, if your risk of heart attack and stroke is low, aspirin may not be for you. Patients older than 79 were not routinely recommended for this because of the higher risks of GI bleeds, even though some patients older than 79 may be good candidates. Similarly, people younger than 45 were not recommended because there was not clear enough evidence of benefit.
If you are not taking an aspirin a day, and think you might benefit, please discuss this with your doctor.
The new recommentation from the U.S. Preventive Services Task Force which is published in the Annals of Internal Medicine is that most men between 45 and 79 and most women between 55 and 79 should take an aspirin a day.
For men, aspirin was found to prevent heart attacks, and for women it was found to prevent strokes. The optimal dose of aspirin is not clear, but benefit was seen as low as 75 mg was about as effective as higher doses. Thus, a generic baby aspirin a day is probably the cheapest and most effective dose.
The reason why everyone should not take this is that even aspirin has some side effects, mainly gastrointestinal bleeding. GI bleeds can be serious, require hospitalizations, surgery and can even cause death. The older you are the higher your risk for heart attack and stroke, but the higher you risk is for GI bleeds. For example, if you took 1000 65 year old women, each with about a 7% risk of having a stroke, your would probably prevent 12 of them from having a stroke, but cause and equal number of GI bleeds. Thus, even if you fall within the age range, if your risk of heart attack and stroke is low, aspirin may not be for you. Patients older than 79 were not routinely recommended for this because of the higher risks of GI bleeds, even though some patients older than 79 may be good candidates. Similarly, people younger than 45 were not recommended because there was not clear enough evidence of benefit.
If you are not taking an aspirin a day, and think you might benefit, please discuss this with your doctor.
Tuesday, March 10, 2009
Electronic Cigarettes
I appeared on the local news regarding electronic cigarettes. This is a follow up to a piece on the CBS morning show (see video below). The more closely I investigated this issue, the more I became concerned.
Electronic cigarettes are nicotine delivery systems that look like actual cigarettes. When the user inhales, the nicotine in cartridges within the elecrtonic cigarettes vaporizes the nicotine and it is inhaled. In addition, part of the process leads to the appearance of "smoke," though this is not really smoke, it is essentially water vapor. Though the lack of actual tobacco in these products is theoretically better than cigarettes in some way, mainly decreasing the carcinogenic effect and eliminated harms from second hand smoke, the electronic cigarette is dangerously being promoted as safer alternatives to cigarettes that contain tobacco as well as possible aids to smoking cessation. Make no mistake: these products are not safe, in some ways could be riskier than cigarettes, will not be effective smoking cessation aids, and are scarily unregulated by the FDA and far too available in the US.
Manufacturers and sellers will claim that there is research to support that they are safe, but these are mouse and not human studies, and they are done not by goverment agencies like the FDA, but by the products manufacturers. Thus, there is not good evidence that these products are safe. Though tobacco cigarettes are known to be dangerous, these should not be considered a safe alternative.
Unlike other nicotine products sold in the US like the patch, gum, and lozenge which has gone through intestive testing, the e-cigarette has not. More importantly, the purpose of these approved products is that they slowly release nicotine to help people quit tobacco, and they have studies that prove they work. By vaporizing nicotine, and inhaling it, this will lead to very rapid absorption, and high levels of addiction; possibly even higher than real cigarettes themselves.
Currenlty, most e-cigarettes are made in China and bought on the internet, where it is very difficult for federal agencies to regulate. However, unlike tobacco, which does not (yet) come under FDA jurisdiction, these products are clearly drugs. Though the FDA may have limited ability to stop what is being sold on the Internet from other countries, they must do a better job in regulating what is sold here. These products are being sold in shopping malls in the US, and this must be put to a stop. The World Health Organization has called for the manufacturers of these products to stop making and promoting them.
The good news, is that the rate of smoking in the US has decreased. More importantly, there are very effective ways of quitting. If you are a smoker and interested in quitting, the best thing to do is to speak with your doctor, who can help you work on changing habits and behaviors. There is now very good evidence and current guidelines recommend that EVERY smoker interested in quitting be offered medication. This can be in the form of nicotine replacement such as the patch or gum. Pills have be shown to be even more effective and both bupropion and Chantix are available by prescription. Finally, call 1-800- QUITNOW, a free 24/7 counselling service.
video
Watch CBS Videos Online
Electronic cigarettes are nicotine delivery systems that look like actual cigarettes. When the user inhales, the nicotine in cartridges within the elecrtonic cigarettes vaporizes the nicotine and it is inhaled. In addition, part of the process leads to the appearance of "smoke," though this is not really smoke, it is essentially water vapor. Though the lack of actual tobacco in these products is theoretically better than cigarettes in some way, mainly decreasing the carcinogenic effect and eliminated harms from second hand smoke, the electronic cigarette is dangerously being promoted as safer alternatives to cigarettes that contain tobacco as well as possible aids to smoking cessation. Make no mistake: these products are not safe, in some ways could be riskier than cigarettes, will not be effective smoking cessation aids, and are scarily unregulated by the FDA and far too available in the US.
Manufacturers and sellers will claim that there is research to support that they are safe, but these are mouse and not human studies, and they are done not by goverment agencies like the FDA, but by the products manufacturers. Thus, there is not good evidence that these products are safe. Though tobacco cigarettes are known to be dangerous, these should not be considered a safe alternative.
Unlike other nicotine products sold in the US like the patch, gum, and lozenge which has gone through intestive testing, the e-cigarette has not. More importantly, the purpose of these approved products is that they slowly release nicotine to help people quit tobacco, and they have studies that prove they work. By vaporizing nicotine, and inhaling it, this will lead to very rapid absorption, and high levels of addiction; possibly even higher than real cigarettes themselves.
Currenlty, most e-cigarettes are made in China and bought on the internet, where it is very difficult for federal agencies to regulate. However, unlike tobacco, which does not (yet) come under FDA jurisdiction, these products are clearly drugs. Though the FDA may have limited ability to stop what is being sold on the Internet from other countries, they must do a better job in regulating what is sold here. These products are being sold in shopping malls in the US, and this must be put to a stop. The World Health Organization has called for the manufacturers of these products to stop making and promoting them.
The good news, is that the rate of smoking in the US has decreased. More importantly, there are very effective ways of quitting. If you are a smoker and interested in quitting, the best thing to do is to speak with your doctor, who can help you work on changing habits and behaviors. There is now very good evidence and current guidelines recommend that EVERY smoker interested in quitting be offered medication. This can be in the form of nicotine replacement such as the patch or gum. Pills have be shown to be even more effective and both bupropion and Chantix are available by prescription. Finally, call 1-800- QUITNOW, a free 24/7 counselling service.
video
Watch CBS Videos Online
Monday, March 2, 2009
Blogger Tara Parker-Pope in today's NY Times' Well section entitled A Hurdle for Health Reform: Patients and Their Doctors, discusses that in order to cut health care costs, doctors and patients are going to have realize that the newest treatments and medications don't always equate to the best care.
Though I disagree somewhat with her focus on prescription drugs ( her example that "most hypertension patients still use costlier drugs marketed by pharmaceutical companies" is not entirely accurate since most hypertension drugs are now generic, and insurers have made it much more difficult lately to get the newer, more expensive drugs); however, her sentiment is right on target. If we want to lower health care costs, then everyone can't get everything. In certain cases, some degree of rationing is going to have to occur. However, in many cases just using good scientific evidence will do the trick. Here are just a few things that patients can do to reduce health care costs now:
1. Don't demand antibiotics. As I have written before, colds are caused by viruses which do not respond to antibiotics. Most viruses take a week or so to resolve. Just because you still feel bad after a few days does not mean you need an antibiotic. A common thing I hear from patients is "when I get this sick, the only thing that makes me better is an antibiotic." Remember that colds resolve on their own, so if you start the antibiotic on day #7, was it the antibiotic working or the cold resolving on its own? Also, the placebo effect is about 30%. Doctors realize that the reason patient come in when they are sick is that they have tried the usual remedies and want to feel better. However, in most cases, rest, fluids and over the counter medications, as well as time, is what works best when you are sick.
2. MRI doesn't necessarily mean best test. Some patients have a notion that a CT scan is better than an X-ray and an MRI is best. MRI is certainly one of the most expensive tests, but not necessarily the best. One of the best imaging studies to look at bones are plain old X-rays. Imaging is based more on what you are looking for, not which is the best test. One of the biggest drivers of health care costs is diagnostic imaging. Many studies are simply not needed. In addition, especially in the case of CT scans, exposure to radiation is not necessarily without potential harm.
3. Patients have to accept watchful waiting. There are certainly true emergencies where hours or even minutes are critical and some study or procedure must be done right away. However, these situations are rare. Demanding that studies be done ASAP adds to costs because often symptoms resolve on their own. Though reassurance and peace of mind may be worth something, in many instances this is breaking the health care bank.
4. Spend out of pocket money on things that work. There's no question that health care is just too expensive for the average American, and asking the general population to help foot the bill seems ridiculous. However, while patients are paying a lot in premiums and co-pays, they are also spending billions of dollars on thing that have not been proven to work, and in some cases may be harmful. I have blogged before about vitamins and natural cold remedies that likely do nothing to improve health. If we took all the money that patients spent on vitamins, supplements, diet pills, pills that enlarge your penis, etc. (excluding things known to be useful like Calcium and Vitamin D), this would add up to billions of dollars that could be used for things proven to save lives like mammograms, colonoscopies, and smoking cessation treatments. I believe if we regulated all health products like medications and devices, this would decrease costs in the long run. Given that the manufactures of these products gave $3 million in campaign contributions in 2008, I doubt that this is going to happen any time soon.
5. We need malpractice reform. It is hard to measure the number of unnecessary tests doctors order because they fear getting sued. Part of this has to do with the fact that, in general, the public feels that every test ought to be ordered even when there is only the smallest possibility of a potential disease. More importantly, bad things do happen, even when the correct decision is made, and we currently have no system set up to compensate patients when bad things do happen, other than to sue their doctor. This is not something that patients can do per se, but they can support a system that replaces our current one.
Though I disagree somewhat with her focus on prescription drugs ( her example that "most hypertension patients still use costlier drugs marketed by pharmaceutical companies" is not entirely accurate since most hypertension drugs are now generic, and insurers have made it much more difficult lately to get the newer, more expensive drugs); however, her sentiment is right on target. If we want to lower health care costs, then everyone can't get everything. In certain cases, some degree of rationing is going to have to occur. However, in many cases just using good scientific evidence will do the trick. Here are just a few things that patients can do to reduce health care costs now:
1. Don't demand antibiotics. As I have written before, colds are caused by viruses which do not respond to antibiotics. Most viruses take a week or so to resolve. Just because you still feel bad after a few days does not mean you need an antibiotic. A common thing I hear from patients is "when I get this sick, the only thing that makes me better is an antibiotic." Remember that colds resolve on their own, so if you start the antibiotic on day #7, was it the antibiotic working or the cold resolving on its own? Also, the placebo effect is about 30%. Doctors realize that the reason patient come in when they are sick is that they have tried the usual remedies and want to feel better. However, in most cases, rest, fluids and over the counter medications, as well as time, is what works best when you are sick.
2. MRI doesn't necessarily mean best test. Some patients have a notion that a CT scan is better than an X-ray and an MRI is best. MRI is certainly one of the most expensive tests, but not necessarily the best. One of the best imaging studies to look at bones are plain old X-rays. Imaging is based more on what you are looking for, not which is the best test. One of the biggest drivers of health care costs is diagnostic imaging. Many studies are simply not needed. In addition, especially in the case of CT scans, exposure to radiation is not necessarily without potential harm.
3. Patients have to accept watchful waiting. There are certainly true emergencies where hours or even minutes are critical and some study or procedure must be done right away. However, these situations are rare. Demanding that studies be done ASAP adds to costs because often symptoms resolve on their own. Though reassurance and peace of mind may be worth something, in many instances this is breaking the health care bank.
4. Spend out of pocket money on things that work. There's no question that health care is just too expensive for the average American, and asking the general population to help foot the bill seems ridiculous. However, while patients are paying a lot in premiums and co-pays, they are also spending billions of dollars on thing that have not been proven to work, and in some cases may be harmful. I have blogged before about vitamins and natural cold remedies that likely do nothing to improve health. If we took all the money that patients spent on vitamins, supplements, diet pills, pills that enlarge your penis, etc. (excluding things known to be useful like Calcium and Vitamin D), this would add up to billions of dollars that could be used for things proven to save lives like mammograms, colonoscopies, and smoking cessation treatments. I believe if we regulated all health products like medications and devices, this would decrease costs in the long run. Given that the manufactures of these products gave $3 million in campaign contributions in 2008, I doubt that this is going to happen any time soon.
5. We need malpractice reform. It is hard to measure the number of unnecessary tests doctors order because they fear getting sued. Part of this has to do with the fact that, in general, the public feels that every test ought to be ordered even when there is only the smallest possibility of a potential disease. More importantly, bad things do happen, even when the correct decision is made, and we currently have no system set up to compensate patients when bad things do happen, other than to sue their doctor. This is not something that patients can do per se, but they can support a system that replaces our current one.
Wednesday, February 25, 2009
Obama on Health Care
For starters, let me say I am a huge fan of our new President. I voted for him, donated to his campaign, and am a proud member of Doctors for Obama
I listened closely to his speech last night looking for signs of what is to come next in health care reform. Though his speech was historic, to my surprise it left me somewhat disappointed on the matter of health care. Below is what the President said:
Our recovery plan will invest in electronic health records and new technology
that will reduce errors, bring down costs, ensure privacy, and save lives. It
will launch a new effort to conquer a disease that has touched the life of
nearly every American by seeking a cure for cancer in our time. And it makes the
largest investment ever in preventive care, because that is one of the best ways
to keep our people healthy and our costs under control. This budget builds on
these reforms. It includes an historic commitment to comprehensive health care
reform - a down-payment on the principle that we must have quality, affordable
health care for every American. It's a commitment that's paid for in part by
efficiencies in our system that are long overdue. And it's a step we must take
if we hope to bring down our deficit in the years to come.
In summary: Electronic Medical Records, the cure for cancer, preventative care, and universal coverage. Though all of these things are important, I am not sure this is the right focus.
I am in favor of Electronic Medical Records, but we have to be careful how we invest in this. I have already commented that the almost $20 Billion dollars from the stimulus package may not be well spent. It goes primarily to hospitals, which probably already have their own systems. The key is interoperability, and I don't know if there are any provisions for this in the bill. Also, the VA system has an amazing electronic medical record. Why not adopt this system and use the money to give every health care provider (hospital, office, clinic) the ability to access this one shared system rather than just padding hospital's bottom lines?
I would love to see the cure for cancer, and we have made great strides. I support more research in this area. However, cancer is not one disease but many complex diseases. Though cancer research is certainly a worthwhile cause, money spent on it today and in the near future will do nothing to improve the health care crisis we face today. I am for spending money on cancer research, but if funds are limited, we need to first spend money on fixing the current system now.
As a primary care physician, prevention is what I do every day. Prevention is key and critical. One of the reasons we spend so much on health care is because as a nation we are not well. Prevention is a broad term, and it is not clear from the President's speech what his focus is on. However, part of prevention (and an important part in my biased opinion) is strong relationships with, quality care by and reasonable access to primary care physicians. I am extremely disappointed that there was no mention of improving our primary care infrastructure. I wish he would have said something like "we will invest in primary care, because this is key to comprehensive health care reform"
Similarly, universal coverage is great, but somewhat has to be there to see all these patients with health insurance. This is the lesson we can learn from the Massachusetts plan. No policy maker or pundit, including our President, should mention universal coverage without mentioning improving access to primary care providers. Fewer students are going into primary care, more and more primary docs have stopped accepting insurance or have gone concierge.
I continue to support our President, and believe he will lead us down the right path. He has a cadre of experts in health care policy that are phenomenal. In addition, his speech essentially mandated that health care reform will not wait, which I am thankful for. Perhaps I am reading too much into a political speech. However, the center of any health care reform must address improvement in primary care.
Tuesday, February 17, 2009
Common Things
Regular Check Ups for Men
Health News journalist Gary Schwitzer beat me to the punch in his critique about the Washington Post's article on health care screening for men in his post Disease-mongering by the Washington Post: here we go again.
Mr. Schwitzer correctly points out that many of these recommendations are not uniformly agreed upon or evidenced based, and yet they are treated "as if they were handed to Moses on stone tablets ."
Being from Minnesota, I am guessing Gary reads the online version, and would probably be even more miffed to know that the print version (which I get being in DC) has pictures of celebrities for the various age ranges (Justin Timberlake for 20's, Will Smith for 40's, Harrison Ford for 60's) as if these celebrities get these studies done or endorse the information.
My favorite piece of misinformation is the testicular exam which the Post claims is recommended for men 20-35, including regular self-testicular exams. Except the U.S. Preventive Services Task Force (USPSTF) actually recommends against this, giving it a Grade D recommendation. This means not that it is controversial or their is evidence lacking like prostate cancer screening, but that there is actually evidence that it may even be harmful. Testicular cancer is one of the most curable cancers we have. Lance Armstrong had metastasis to the brain, and look how well he did. Guys who are checking their testicles regularly are likely to find something that is not harmful/normal and will only cause them needless worry, and in some cases, a few unnecessary tests.
I highly recommend the USPSTF's pocket guide to screening. Though there are some things that are controversial that they don't recommend that I will often do (like prostate cancer screening), this is a very good starting point for what men and women should be doing.
Common Colds
My university's newspaper interviewed me for an article about myths regarding the common cold. The questions the young reporter asked were quite good and common questions asked by patients. Here's the link to the full article, a quick summary:
Health News journalist Gary Schwitzer beat me to the punch in his critique about the Washington Post's article on health care screening for men in his post Disease-mongering by the Washington Post: here we go again.
Mr. Schwitzer correctly points out that many of these recommendations are not uniformly agreed upon or evidenced based, and yet they are treated "as if they were handed to Moses on stone tablets ."
Being from Minnesota, I am guessing Gary reads the online version, and would probably be even more miffed to know that the print version (which I get being in DC) has pictures of celebrities for the various age ranges (Justin Timberlake for 20's, Will Smith for 40's, Harrison Ford for 60's) as if these celebrities get these studies done or endorse the information.
My favorite piece of misinformation is the testicular exam which the Post claims is recommended for men 20-35, including regular self-testicular exams. Except the U.S. Preventive Services Task Force (USPSTF) actually recommends against this, giving it a Grade D recommendation. This means not that it is controversial or their is evidence lacking like prostate cancer screening, but that there is actually evidence that it may even be harmful. Testicular cancer is one of the most curable cancers we have. Lance Armstrong had metastasis to the brain, and look how well he did. Guys who are checking their testicles regularly are likely to find something that is not harmful/normal and will only cause them needless worry, and in some cases, a few unnecessary tests.
I highly recommend the USPSTF's pocket guide to screening. Though there are some things that are controversial that they don't recommend that I will often do (like prostate cancer screening), this is a very good starting point for what men and women should be doing.
Common Colds
My university's newspaper interviewed me for an article about myths regarding the common cold. The questions the young reporter asked were quite good and common questions asked by patients. Here's the link to the full article, a quick summary:
- The flu shot does not give you the flu, but can cause mild symptoms
- Vitamin C does not help prevent or treat the common cold
- A wet head in cold weather will not cause a cold, but can increase your susceptibility to catching a virus that will cause a cold
- Chicken soup actually works (with evidence to prove it)
- Colds are caused by viruses. Please don't ask your doctor for antibiotics just because you feel "really sick." They will not help, and an only increase strains of resistant bacteria.
- The flu shot is only protective of influenza which is one of many, many bugs that can make you sick. Just because you got the flu shot and then caught a cold does not mean it didn't work.
- All pill forms of decongestants are now over the counter. This is part due to money issues and part due to FDA regulatory changes. The bottom line is that for a cold, there is little I can offer you in the way of a prescription that you can't get over the counter.
- Fever is not necessarily bad. It is the body's natural response to fighting a cold. You are literally burning up the virus. Don't treat a number. If your temperature is 101, but you're not miserable, not taking a Tylenol might be a good idea. However, if you simply feel rotten, taking this will probably not hurt and can certainly make you feel better.
- Most cold medicines come in combination. It is often disorienting to try to figure out what the active ingredients are in each variety of Robitussin. Most colds cause congestion, so you want something with a decongestant in it. In general, antihistamines just make you sleepy and can thicken secretions, thus making congestion worse. Antihistamins should be mainly reserved for allergies. Guaifenesin, the active ingredient in plain Robitussin, may or may not help, but probably doesn't hurt. Dextromethorphan (the DM part of Robitussin DM) does reduce a cough. Thus for a simple cold, I would take a plan decongestant +/- Guaifenesin, and add DM if a cough is present. I would avoid combinations that contain antihistamines. I would also take my pain medicines/anti-pyretics like acetaminophen and ibuprofen separately and not in combination.
Wednesday, February 11, 2009
$19 Billion For Health IT-Money Well Spent?
Medpage today reported that in yesterday's Senate approval of the stimulus package, that $19 Billion dollars would be allocated to health IT. According to the MedPage report, "The Senate bill allocated about $19 billion to upgrade hospitals' electronic records systems and limited how much an individual hospital could receive to $1.5 million."
Granted, this is only about 2% of the entire stimulus bill, but $19 billion is a lot of money. I am all for improving health IT, but is this where we want to spend the money? I am just a doctor, not a politician, political pundit or economist; so maybe I don't understand the stimulus plan. I thought that the point of the stimulus plan was to create jobs and help people. Since there are several proprietary products on the market, it is unlikely that spending on health IT will create a lot of extra jobs, but rather sell a lot of softwared and some hardware. More importantly, who is the health IT spending helping?
There are 7,569 hospitals in the US. That comes to roughly $250,000 per hospital, though not every hospital gets the same amount (and there is a limit of $1.5 million for an individual hospital). That's a lot of money. Do we really want to give a quarter of a million dollars to each hospital to improve their health IT? Many hospitals already have their own electronic medical records? Do they really even need this? What about the 20% of the hospitals that are for profit, are they getting some of this money?
There is no question that Health IT will substantially improve the quality of care delivery in this country, and in the long term is a worthwhile investment. The real question is how and where should we invest? I would argue that the hospitals are not the best place to go. Fortunately, most Americans with health problems are not in the hospital. Certainly hospitalized patients comsume more health care dollars, but there is no good evidence that health IT actually saves money. Would it not be better to invest in Health IT that actually keeps patients out of the hospital? In addition, as mentioned, many hospitals already have an electronic medical record/electronic ordering, whereas most practicing physicians (especially primary care) do not have an EMR. Would it not be better to give $85,000 to each primary care physician to set up his or her own EMR? Better yet, use the money to come up with a system that actually works, is easy to use and distribute, improves quality of care for all and decreases costs?
Health IT is important, and should be an important part of health care reform. However, giving $19 Billion directly to hospitals to beef up systems that many already have is not money well spent.
Granted, this is only about 2% of the entire stimulus bill, but $19 billion is a lot of money. I am all for improving health IT, but is this where we want to spend the money? I am just a doctor, not a politician, political pundit or economist; so maybe I don't understand the stimulus plan. I thought that the point of the stimulus plan was to create jobs and help people. Since there are several proprietary products on the market, it is unlikely that spending on health IT will create a lot of extra jobs, but rather sell a lot of softwared and some hardware. More importantly, who is the health IT spending helping?
There are 7,569 hospitals in the US. That comes to roughly $250,000 per hospital, though not every hospital gets the same amount (and there is a limit of $1.5 million for an individual hospital). That's a lot of money. Do we really want to give a quarter of a million dollars to each hospital to improve their health IT? Many hospitals already have their own electronic medical records? Do they really even need this? What about the 20% of the hospitals that are for profit, are they getting some of this money?
There is no question that Health IT will substantially improve the quality of care delivery in this country, and in the long term is a worthwhile investment. The real question is how and where should we invest? I would argue that the hospitals are not the best place to go. Fortunately, most Americans with health problems are not in the hospital. Certainly hospitalized patients comsume more health care dollars, but there is no good evidence that health IT actually saves money. Would it not be better to invest in Health IT that actually keeps patients out of the hospital? In addition, as mentioned, many hospitals already have an electronic medical record/electronic ordering, whereas most practicing physicians (especially primary care) do not have an EMR. Would it not be better to give $85,000 to each primary care physician to set up his or her own EMR? Better yet, use the money to come up with a system that actually works, is easy to use and distribute, improves quality of care for all and decreases costs?
Health IT is important, and should be an important part of health care reform. However, giving $19 Billion directly to hospitals to beef up systems that many already have is not money well spent.
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