Be skeptical of medical herds’ stampede

Dear Reader,

Americans love to be individuals. We hate waiting in line and chafe at being part of a crowd, especially when it comes to our health care.

But just as we stand on the brink of a promising era of personalized and precision medicine — when doctors and hospitals will base treatments on our highly personalized genetic and molecular make-up — we’re also getting corralled too often into medical herds. Pre-diseases, they’re called.

The only thing we share in these sizable crowds is that we bear signs suggesting we may, eventually, develop a serious medical condition.

Skeptical experts warn that over-diagnosis of what some dub pre-diseases will result in over-treatment that will cost the country billions of dollars in unneeded care. They also will cause major anxiety and even harm for many, some of whom will be subjected to cascade of follow-on, costly, invasive, and even risky procedures and therapies, including expensive and potentially harmful prescription drugs.

Be skeptical and don’t let yourself, loved ones, or friends be buffaloed into more care than we really need.

The controversy over new blood pressure guidelines

You’re sitting in your doctor’s exam room, knowing that you’ve packed on a few more pounds than you should. You’re gulping a lot of sugary beverages, you’re drinking more alcohol than you ought, and work and family life have stressed you so much you barely exercise.

A knock on the door, and in breezes the doctor, scrolling through your medical record on her laptop. If your practitioner is like so many, she will spend less than 16 minutes seeing you. During that time, she not only may need to type a ton of information about you into your electronic health record, she also may be required to spend critical time determining if you are depressed, abusing substances, or eating poorly.

And, bam, suddenly you find yourself in a dizzying discussion because your doctor decides you’re pre-diabetic. Or maybe you’ve now got hypertension (high blood pressure). Maybe she orders more tests because she’s concerned about screens that gives hints of cancer or heart disease.

It’s scary stuff. It can cost you, dearly.

Let’s presume the best intentions in your doctor’s diagnoses — that they’re medically sound and absent profit motives. Don’t ignore or dismiss your doctor’s medical advice. But don’t be shy, if and when your caregivers shove you into one of these big herds of pre-disease. Just because you tested with high levels of blood sugar, are you really pre-diabetic? If your blood pressure happened to be elevated today, do you really have hypertension? If you’re sometimes gimpy, are you suddenly arthritic?

Knowing how millions of patients get rounded up in some major medical herds can be illuminating and helpful to you, so let’s start with an example:

HYPERTENSION

The warning: The American Heart Association, the American College of Cardiology, and nine other expert groups recently redefined high blood pressure as a reading of 130 over 80 or higher. The old standard was 140/ 90. The change, the first in 14 years, means that 46 percent of American adults, many younger than 45, now are considered hypertensive. That compares with 32 percent of them previously. The advocates said they considered new information that shows how damaging high blood pressure can be and how it contributes to heart disease and stroke. They said they did not wish to see more Americans take drugs to improve their blood pressure readings. Instead, they said they hope that by putting out more rigorous standards doctors can persuade more patients to lose weight, improve their diet, get more exercise, take in less alcohol and sodium, and lower their stress.

What the skeptics say: The new guidelines are fear-mongering and are based on a rigorous study with complex and controversial results, says Aaron E. Carroll, a pediatrician, medical researcher, member of the Indiana University School of Medicine faculty, and a contributor to the evidence-based “Upshot” column in the New York Times. He said the guideline change by itself riled him sufficiently that his own blood pressure likely rose for a bit. He and others say that scaring patients by telling them they have hypertension won’t help them “eat right, exercise, drink responsibly, and not smoke.” Richard Hoffman, a doctor and director of the Division of General Internal Medicine for the University of Iowa Carver College of Medicine, also criticized the blood pressure guidelines, describing them with the useful, succinct Number Needed to Treat, an invaluable metric to help patients better understand the value of various therapies. “As we keep lowering the threshold for diagnosing high blood pressure, the number needed to treat has increased from around 1 to about 100 – meaning you’d need to treat about 100 mildly hypertensive people with blood pressure-lowering drugs to prevent one cardiovascular event over 5 years,” he told HealthNewsReview.org.

Risks and harms: Critics note that it can be tough to get accurate blood-pressure readings, even in doctor’s offices with nurses or MDs administering the test. They may need to be taken three or more times to ensure faulty readings don’t occur because of patients’ discomfort and nerves, or even if they may have dashed up the stairs because they were late for an appointment. Meantime, bad readings and the new guidelines may lead more doctors to put more patients, including their older ones, on drugs that can have risky side effects. They can, for example, make some older patients dizzy or woozy, leading to dangerous falls. Aggressive advertising that promotes the new guidelines has added to opponents’ concerns, increasing their worry about over-treatment of hypertension. Alan Cassels, a drug policy researcher affiliated with the University of Victoria in Canada, reported in Healthnewsreview.org that excessive treatment for high blood pressure can be especially perilous for older patients, including drugs leading to kidney failure. In an exchange on the site, Cassels received this analysis of aggressive hypertension treatment, as recommended under the new guidelines: For each 1,000 patients treated. Helped: 8 heart failures prevented, 6 deaths by cardiovascular causes prevented. Harmed: 18 acute kidney injuries or renal failures caused, 10 hypotensions (abnormally low blood pressure) caused, 6 syncopes (loss of consciousness due to low pressure) caused, 8 electrolyte abnormalities caused. Overall, 12 deaths by any cause were prevented for every 24 serious adverse events caused. It can get a bit thick. But readers may wish to know more, too, about the Systolic Blood Intervention Trial, aka SPRINT. It has been influential not only in shifting  blood-pressure guidelines but others also are interpreting and extending its data in disputed and hyped fashion to topics like hypertension control and dementia.

“Pre-diabetes:” A useful label, or not?

Another medical herd that might have a corral near you is called pre-diabetes.

The warning: The respected Centers for Disease Control and Prevention deems pre-diabetes to be a “serious health condition where blood sugar levels are higher than normal, but not high enough yet to be diagnosed as type 2 diabetes.” The agency estimates that 84 million or so American adults—more than 1 out of 3—have reached this state, with 90 percent of them unaware of it. “Pre-diabetes,” the agency warns, “puts you at increased risk of developing type 2 diabetesheart disease, and stroke.” CDC experts have defended this characterization as a key way to raise consciousness to get patients to avert the increasing and real harms of actual diabetes, a disease diagnosed in 30 million Americans (9.4 percent of the population).

What the skeptics say: How useful or meaningful is a condition if so many Americans share it? And how apt is it to call Americans pre-diabetic based on blood sugar readings? As Dr. Victor Montori, an endocrinologist and diabetes specialist at the Mayo Clinic, explains, in older people, these numbers normally rise as the pancreas produces less insulin and the body becomes more insulin resistant. An editorial in the respected medical journal JAMA Internal Medicine pointed out that before 2000, almost no one had even heard of “pre-diabetes,” a diagnosis that skeptics have denounced as so sweeping as to be an unhelpful “medicalization.” Critics say doctors shouldn’t scare patients with a disease. Physicians, instead, need to take the time to counsel and care for them so they lose weight, exercise, and eat better. These are consensus steps that could keep Americans, young and old, in better shape, including by reducing their risk of advancing to type 2 diabetes and heart illness.

Risks and harms: As Ann Van den Bruel, a physician, researcher, and University of Oxford faculty member, has noted, studies have shown that 65 percent of younger patients diagnosed as pre-diabetic but left untreated do not advance to diabetes within a decade. Further, she has written, “Treating people with pre-diabetes delays the development of diabetes by 2 years but provides no long-term benefits and has two important side effects: It increases the number of patients on diabetes drugs (many of whom would never develop diabetes), and it prolongs the duration of treatment in those who do develop diabetes since treatment for pre-diabetes and diabetes are the same.” Meantime, insulin, a drug critical in the treatment of diabetes, has skyrocketed in price, and US officials have failed to figure a way to get back in control the price of the life-changing and life-saving medication. And medical groups recently have disagreed among themselves on what ought to be an optimal blood sugar level for diabetics.

Are those aches of age, or are twice as many Americans really arthritic?

If doctors haven’t herded you into other pre-disease groups, and you’re of a certain age, you might be pushed into the sore bunch with suspected arthritis.

The warning: It’s more than morning aches and pains, beyond knee or elbow stiffness or the ache from overexertion. The federal Centers for Disease Control and Prevention estimates that 54 million Americans, more than 1 in 4 of the population, suffers from arthritis. But rheumatologists now argue that, especially among those between the ages of 45 and 64, the disease is underestimated. They say more research is warranted because, based on their analysis of national health surveys, as many as 91 million American adults may be afflicted with painful joint destruction from arthritis in its two major forms: osteo (attributable largely to wear and tear) and rheumatoid or RA (in which the immune system erroneously attacks joints). As the Wall Street Journal reported, there are more than 100 types of arthritis, and these can be diagnosed correctly with “a combination of a physical exam, history-taking, X-rays, and lab tests.” Specialists argue that early diagnosis can be beneficial, not only in helping to alleviate patients’ pain and discomfort but also in preventing irreversible deterioration in arthritics’ conditions — arthritis is a leading cause of US work disability and is one of the most common chronic conditions in the country.

What the skeptics say: With a rapidly graying population, which also includes significant numbers of obese individuals, there’s little disagreement that arthritis’ burdens will only increase for the United States. But even rheumatologists, experts in the disease, express concern about saying so many Americans are arthritic. This could result in over-diagnosis and over-treatment, notably with new and expensive drugs, as well as with common painkillers that carry their own side effects and risks. Experts also are watching with growing concern the rise of knee and hip replacements, particularly among older Americans whose procedures are covered by Medicare. As Robert Landewé, MD, PhD, and professor of rheumatology from Amsterdam Rheumatology and Clinical Immunology Center, the Netherlands, wrote to colleagues recently in a specialist medical journal: “After a long history of therapeutic nihilism and acquiescence, the focus in rheumatology has shifted from caring for the disabled to actively finding the unrecognized, from a wait-and-see policy to early intervention, and from careful step-up treatment with poorly effective but toxic drugs to immediate intervention with powerful new drug combinations,” he said. “To date, no one seems to bother about over-diagnosis and over-treatment, since for the first time in history we have an opulence of effective drugs and more are coming.”

Risks and harms: As with other conditions, does telling patients they have a known disease like arthritis better or worsen their motivation to deal with it themselves — notably by losing weight and exercising, regimens that research has shown to be highly effective but difficult to carry out and sustain? Meantime, doctors and patients may attack arthritis symptoms with medications, including steroids and nonsteroidal anti-inflammatory drugs (NSAIDs), that carry with them increasing potential for harms. RA can signal the presence of powerful inflammations within the body, a reason why experts warn that this form of the disease often is accompanied by serious risks of heart disease. But arthritis medications can increase arthritics’ heart disease risks. Aggressive RA treatment may lead some patients to be prescribed new types of drugs: biologics. As the Arthritis Foundation describes them: “Genetically engineered proteins originating from human genes, biologic drugs target specific parts of the immune system that fuel inflammation.” These medications may increase patients’ infection risk, and they can be pricey, costing as much as $5,000 or $6,000 a month. Although Americans’ forebearers lived shorter lives and many engaged in long, back-breaking labor, they didn’t show signs of suffering from arthritis. But now the disease, combined with demonstrated, debilitating, and painful degeneration, is leading hundreds of thousands of baby boomers to undergo knee and hip replacement operations each year. These procedures aren’t cheap nor pleasant nor guaranteed for patients’ lifetimes. They carry risks that shouldn’t be underestimated.

Maybe you don’t belong in this roundup?

Why do doctors stampede patients into medical herds, and what can be done about this?

Let’s give most practitioners the benefit of the doubt: Misdiagnosis is a significant problem in medicine, with research showing as many as 15 percent of medical diagnoses are wrong. But doctors, when they see familiar markers and patterns in patient data, also may be making bona fide calls, based on current, albeit often conflicting, standards in the field. They may think they’re doing well by their patients to describe them as being in pre-disease or early-condition phases. They also may be eager to group like patients together to see common problem patterns in hopes of developing treatment improvements. That is the ambition, for example, in a big proposal to get 1 million Americans to share deeply personal genetic and other health data as part of a national precision medicine initiative. (That initiative has drawn its own fire). But really?

If you look at the three herds just discussed, you may recognize some common therapies that may be harder for doctors to recommend and to help patients with. These are non-medical interventions like better controls of diet, exercise, and alcohol consumption, not to mention stopping smoking. Experience shows it’s tough for all of us to lose weight once we gain it, and it gets tougher when the needed losses get big. Doctors may think they have little sway over social determinants of health — everything from the safety of neighborhoods  for walking to healthful options at groceries and restaurants and even rodent-free apartment buildings. So, instead of tackling hard health issues like obesity head on, American doctors, as they too often do, tut-tut a little with their patients but then whip out their pads and write drug prescriptions.

Under pressure from patients and purportedly fearing malpractice lawsuits — an unfounded and counter-factual worry — doctors also may practice “defensive medicine,” ordering lots of unnecessary tests and screenings, defending their use “in an abundance of caution.”

This also has led to other types of medical herds, including individuals diagnosed with “early” cancers and “potential” heart conditions. These are detected with ever more sensitive medical tests or powerful diagnostic devices that find aberrant cells (sometimes termed pre-cancerous) or structures (aneurysms in aortas) that maybe, might, potentially could become problematic for patients. Some clinicians have dubbed these incidentalomas. But as Americans have experienced with mammograms and PSA tests, many screenings find unusual cells or formations that are benign or so slow-growing that patients and doctors should just wait and watch to see if they develop.

Still, your care and medical records may now show you as a cancer, arthritis, or heart disease patient. That alone can affect your health insurance coverage and cost — an issue your doctor needs to consider and discuss fully with you.

Your caregivers — including your doctor, hospitals, and medical labs — must share your medical record with you, and you should check it regularly to ensure it is accurate and up to date.

Your doctor also should be clear with you about all the treatment options, besides medication, to reduce your blood pressure, avoid type 2 diabetes, or address worsening joint pains.

Your doctor also needs to be clear with you about whether her proposed course of action is for the short or long term: When you’re diagnosed as pre-diabetic, hypertensive, or on the brink of arthritis, if you take recommended steps, will she revisit your condition and stop your prescribed drugs? It may be a great idea for you to keep eating, drinking, and exercising sensibly and in moderation. But will you be taking medications for a lifetime? If you’ve become a patient with a chronic condition, you, of course, become a boon to Big Pharma,which sees you now as a source of bread-and-butter revenue. Drug makers also are big donors to patient advocacy groups — organizations that tens of millions of sick Americans rely on for credible health information, including sometimes assisting in setting standards to determine who has a disease and who’s on its brink.

It also needs to be said that your doctor must ensure you know about not just the benefits but also the risks and potential harms of any course of treatment or prescription drug. You have the critical, fundamental right to informed consent. This means that those who wear white coats and hold fancy medical credentials must give you important facts so you can make intelligent decisions about what treatments to have and where to get them. By the way, don’t let your doctor ignore or dismiss your complaints about side-effects of drugs routinely recommended, say, to control blood sugar or blood pressure. Your quality of life can be reduced significantly if you walk around all the time with a headache, need to go to the bathroom frequently, or, as sometimes occurs with blood-pressure medications, you can’t control a persistent dry, hacking cough.

But here’s hoping you don’t get buffaloed into becoming part of a medical herd and, instead, you have terrific access to safe, affordable, efficient, and excellent medical care — which treats you well and focuses on you as an individual, so you stay healthy and well!

Photo credit: bison, Creative Commons,  Lori Iverson / USFWS; info graphics, federal Centers for Disease Control and Prevention

IN THIS ISSUE


The controversy over new  blood pressure guidelines

“Pre-diabetes” A useful label or not?

Are those aches of age, or are twice as many Americans really arthritic?

Maybe you don’t belong in this roundup?

U.S. health care: more bucks, less bang


BY THE NUMBERS


84 million

Number of Americans estimated by CDC to have ‘pre-diabetes.’ That compares with 30 million patients MD-diagnosed with actual diabetes.


31 million

Growth in number of Americans who will be diagnosed as suffering from high blood pressure under new expert guidelines.


91 million

Number of Americans who would be deemed arthritic, based on rheumatology research. That compares with CDC estimate of 54 million Americans with arthritis.


$750 billion

Institute of Medicine estimate of annual cost to US health care of over-diagnosis, over-treatment, fraud, and other wasteful spending.

One herd that’s good: Herd immunity

U.S. health care: more bucks, less bang

If it’s a given that so many of us are diabetic or headed that way, that loads of us have serious concerns with our blood pressure, and bunches of us have arthritis — not to mention pre-cancers or early heart disease — are Americans really a sick, sick lot?

Comparatives can be a tricky business.

But year after year, in comparison with other wealthy  developed nations, the United States “continues to lag behind, with higher rates of overall mortality, deaths amenable to health care, and potential years of life lost.”

At the same time, Americans are global pace-setters in the trillions of dollars they expend on health care, “spending more per capita … than any other developed nation.”

The exact reasons for this disparity perplex many experts and generate endless amounts of research, including, as the New York Times described it, an intriguing global comparative study that busted many myths. Researchers led by Anish Jha, a physician and director of the Harvard Global Health Institute, found that rather than being an international outlier, America’s more middling these days as the world catches up with many of the benefits and problems in our health care system. Americans still diverge in distinct and troublesome fashion, researchers reported:

“We pay substantially higher prices for medical services, including hospitalization, doctors’ visits and prescription drugs. And our complex payment system causes us to spend far more on administrative costs. The United States also has a higher rate of poverty and more obesity than any of the other countries, possible contributors to lower life expectancy that may not be explained by differences in health care delivery systems.”

Over-diagnosis and over-treatment, as well as other inefficient and wasteful spending, adds an estimated $750 billion to the $3-plus trillion annual US expenditure on health care, other researchers have found. But Americans don’t necessarily use more health care than others do globally.

As Dr. Jha described it: “It’s not that we’re buying more pizzas, we’re just paying more for each pie. But that doesn’t mean that you can’t still buy fewer pizzas.”

This kind of herd is a good thing: Herd immunity

Being part of a medical herd can be a good thing — if it helps to confer increased immunity through widespread vaccination against an array of communicable diseases.

It’s worth repeating and repeating and repeating: Immunizations carry small health risks, but these are far outweighed by their benefits in protecting us, our spouses, friends, co-workers, and loved ones — especially our children — from illnesses that once inflicted terrible tolls.

But this safeguard reaches its maximum potential if and only if we make a collective commitment to it, defying counter-factual and even hysterical arguments, so we keep to the highest levels of immunization in our communities, creating what experts call collective or herd immunity.

As a federal Health and Human Services agency web site describes this invaluable shield:

“Germs can travel quickly through a community and make a lot of people sick. If enough people get sick, it can lead to an outbreak. But when enough people are vaccinated against a certain disease, the germs can’t travel as easily from person to person — and the entire community is less likely to get the disease. That means even people who can’t get vaccinated will have some protection from getting sick. And if a person does get sick, there’s less chance of an outbreak because it’s harder for the disease to spread. Eventually, the disease becomes rare — and sometimes, it’s wiped out altogether.”

Although extremist movements are racing to propagate illogical and even risky “anti-vax” views and policies, California, for example, has cracked down on exemptions and forced more  youngsters to get vaccinated for their own health and societal protection.

With tens of millions of young people heading off to schools, including colleges and universities, parents should act now to ensure their kids not only meet appropriate laws but also get the maximum health benefits of shots, especially the recommended immunizations, by close, timely consultation with their doctors, especially their pediatricians.

HERE’S TO A HEALTHY REST OF 2018!

Sincerely,

Patrick Malone
Patrick Malone & Associates