KOLAHUN

Avandia lives...maybe

The FDA apparently thinks that physicians should continue to prescribe Avandia.  Which in a regulatory sense may make a difference, but practically will any clinician still prescribe Avandia? 

Key sentence from the article:  "Avandia global sales last year were $3.4 billion, but they have plunged since May."

Look, Avandia may or may not significantly increase heart attacks or deaths from cardiovascular deaths.  The main Nissen and Wolski article shows increased odds risks for both:

In the rosiglitazone group, as compared with the control group, the odds ratio for myocardial infarction was 1.43 (95% confidence interval [CI], 1.03 to 1.98; P=0.03), and the odds ratio for death from cardiovascular causes was 1.64 (95% CI, 0.98 to 2.74; P=0.06).

But as we've already seen, odds ratios less than 3 may not be so clinically relevant and the second confidence interval crosses 1, rendering it statistically insignificant. 

Nonetheless, what can be shown from the study is that while Avandia may only possibly increase harm, Avandia for sure does not decrease myocardial infarcts or deaths.  From an outcome standpoint, then, it may not benefit diabetics.  Meaning, even if the blood sugars of diabetics are better controlled by Avandia, that may not decrease a patient's chance of a cardiovascular death while using the drug. 

Couple that with clinicians' fear that they might eventually get sued for prescribing Avandia, and it now becomes radioactive. 

(Though I do predict that we'll see a hell of a lot more Avandia pens, paper-pads, mouse-pads, and other goodies as the GlaxoSmithKline drug reps ramp up the "Avandia is still a good drug" bit.)

6:20AM

A couple of half-written posts wait in the queue...but a short story of the early riser first.

Carrie needed a ride to the train station (on her way to Atlanta, Chatanooga and London) so she picked me up at 6:10AM!  As we passed the clinic en route, there sat a man, camped out with his bag of pork rinds, waiting for the clinic to open. 

It was 6:20AM. 

The clinic opens at 8AM...

Anyway, when asked what he needed, the man replied he had Lupus and needed a referral for dermatology and medicines so his skin doesn't break into a rash in the sun, a common problem with Lupus called photosensitivity. 

This same process happens all over the city, where patients allocate whole days in the hopes of seeing a clinician.  Meanwhile, the clinics keep on chugging each day, trying to care for as many patients as possible, trying to maintain sanity in the meanwhile. 

...at least we got sweet music to drown our troubles this week...Satcho Fest.

The cost of asthma

Over the past two decades, the treatment of asthma passed into an entirely new paradigm, reflecting a revolutionary new understanding of its pathophysiology.  For those who haven't experienced or seen an asthma attack, it can be appropriately described as 'the feeling of drowning.' 

We used to think that the fundamental pathophysiology involved 'broncho-spasm' - i.e. squeezing down of the airways, asphyxiating the patient.  The resulting treatment would be to use medicines that dilated the bronchioles during an acute attack.  These broncho-dilaters invariably involved albuterol, or other medicines in its class.

However, we now know that the pathophysiology of asthma involves 'inflammation,' which then causes the the bronchospasm.  So while broncho-dilaters like albuterol still play a part in the acute treatment, anti-inflammatory medicines can actually improve both the acute flare-up and reduce future attacks.  The most common anti-inflammatory medicines are steroids, either taken orally or inhaled through special devices called MDIs (meter dose inhalers).

However, the advance in the treatment paradigm has left two problems. 

1. Many clinicians and patients haven't yet begun using steroids, leaving many patients woefully unprepared to prevent an attack...
2. Inhaled steroids, the medicine which will help prevent an attack, costs markedly more than the medicine used in the acute phase, leaving patients woefully unprepared to prevent an attack:

• Albuterol MDI - $20 per inhaler
• Flovent MDI (a steroid inhaler - usual dose) - $220 per inhaler
• Advair Discus (a steroid inhaler + albuterol equivalent - usual dose) - $199

The magic of New Orleans - part 1

Now that I moved to the Treme from Uptown, I run into many more 'second-lines'.  And with each one, I relish in the fact that I live in such a wonderful, unique and historic city. 

I bought this second-line music CD for my sister and I keep meaning to steal it back for a few listens.  But nothing matches actually joining in any random second-line...or, if one gets a chance, catching all the Mardi Gras Indians and the spectacular second-lines on Super Sunday

SPOILER! SPOILER! SPOILER!

Harry gets his throat slit by Hermoine, who happens to be an al-Qaeda terrorist!

(...joke stolen from Carrie)

Have a good weekend...be back with postings on Sunday evening...

Weekend reading recommendations

• Killing Mr. Lebanon - if Iraqi and Afghani politics are anywhere as complicated, we're screwed trying to intervene in either country
• The Great Influenza - the origins of the American medical system, the ties between war and plague, and the forgotten disease
• King Leopold's Ghost - greed, deception, colonialization, the conquest of land and the seeds of a historic mess in central africa
• The Curious Incident of the Dog in the Night-Time - the first paragraph made me laugh, the rest felt appropriately somber

What level nominal charge?

A lady just came into our clinic at 4:30 on Friday evening with her male partner and wanted us to perform a pregnancy test.  Told that we had just closed for the weekend and that she can go to any pharmacy and buy a similar test, she replied that she "has NO money."  Of course, when asked, she admitted to smoking intermittently, perhaps a pack a day.

Here are her potential costs:

1. one pregnancy test = $7.99
2. three packs of cigarettes = 8.39

(per Dr. AN, a frequent cigarette purchaser, cheap cigarettes cost $2.79 per pack, though here it's a bit more...)

Of courses, all services and tests in our clinic are free, which means we end up getting abused by a few patients (very few in reality).  We've all thought of implementing a nominal charge per visit/test/etc - we just don't know what level to put it at and how to administer it.  Any thoughts?

(As for the patient, unless she's having actual symptoms of abdominal pain or vaginal bleeding, there's no emergency to knowing she's pregnant.  She should just start taking some pre-natal vitamins and iron pills and hold off on the alcohol/tobacco/drugs until she's sure.  There's no harm in undertaking any of these measures, while there may be world of benefit for the potential fetus.) 

No more diet coke!!!

Googling around for 'health care blog', the Health Care Blog comes up early in the search. 

Overall, the site seems informative on health issues.  However, on reading this recent post about the dangers of diet soda consumption, it strikes me that perhaps the blogger didn't really read the article referred to. 

The article in question, by Vasan et. al, regarding the risk of soda consumption on progression to metabolic syndrome, emanates from another subset analysis of the famed Framingham study.  And upon reading the lay media's conclusion that Vasan's articles shows that drinking diet sodas doesn't decrease the risk of metabolic syndrome (relative to regular sodas), the blogger comments:

"No difference in my on-rushing likelihood of heart disease--according to the latest iteration of the Framingham study—the long running study of 9,000 patients in Massachusetts.

Might as well go back to the chocolate malts…."

Um...no...neither the original Vasan et al. article in Circulation nor the Yahoo story says any such thing.  Let's get to the easy part first, the Yahoo story.  Three paragraphs into the story, we find this:

"The study's senior author, Dr. Vasan Ramachandran, emphasized the findings don't show diet sodas are a cause of increased heart disease risks. But he said they show a surprising link that must be studied."

Ok, now let's get to the actual article by Vasan et al.  They describes a cohort study where a group of people who drank <1 soda per day were compared over time with another group of people who drank >1 soda per day.  After about 4 years, the group which comprised soda drinkers, had increased odds of acquiring metabolic syndrome (Odds ratio: 1.44, 95% confidence interval 1.20-1.77).   

So does this mean that one's odds of ending up with metabolic syndrome increase with soda consumption?  Or that decreasing soda consumption will invariably decrease metabolic syndrome?  NOT AT ALL.  All it means is that soda drinkers have an association with metabolic syndrome, not that soda drinking causes metabolic syndrome. 

(It would be akin to arguing that since no two countries who have a McDonald's have attacked each other, if we build a McDonald's in every country, we'd end up with world peace! - oh wait, Thomas Friedman already made a similar esteemable point.)

Moreover, in cohort studies like this one, odds ratios of <3 mean very little.  So the whole point of the paper, that soda consumption may increase the odds of a person having metabolic syndrome, doesn't even meet the threshold of clinical significance.  In the end, given that we can't find a causation for any type of soda, surely we can't make any conclusions about a particular subset of sodas!

(Public disclaimer - I live on at least 6 Diet Cokes a day, so if you're going to bring some pansy epidemiological reason I should stop, at least bring your "A" game...)

If it aint working...

The Commonwealth Fund reported their State Health Rankings in June, 2007.  To view your individual state's performance, go here. 

They study re-iterates two well known principles:

1. Higher quality does not mean higher costs.
2. Better access is associated with better quality across states; insurance matters.

My current home state of Louisiana owns the following dubious ranks:

• Overall : 46
• Access: 33
• Quality: 41
• Avoidable Hospital Use & Costs: 51
• Equity^*: 28
• Healthy Lives: 50

What particularly bothers me about working here in an outpatient free clinic in New Orleans is the abject failure of the local public hospital - Charity Hospital/University Hospital (MCLNO) -  to provide any meaningful outpatient access to patients.  The hospital maintains so few outpatient clinics and allows such inflexible access that patients end up going to the ER for even the simplest medical task: medication refills, lab checks, etc. 

Patients, in turn, having no access to primary care, reflexively treat the ER as their medical home.  The ER staff at MCLNO, while excellent in emergency care (by definition!), don't provide optimal routine and preventive health care.  Since by law they can't 'dump' patients, they tend to minimally treat the patients who show up at the door.  The patients now 1) satisfied by this minimal care and 2) realizing they can't get into the outpatient clinic, simply wait until the next time they need medications, feel chest pain, have an asthma attack, etc, and the vicious downward spiral continues.

How to improve this system?  I don't know, yet.  I'm currently grappling with

• the desire for a re-vamped, simple city/state/national health care system akin the the VA healthcare (single-payer, single-provider) versus
• the lack of political viability of such a system and moving on to an already forming ad hoc free/low-cost clinic system. 

Not the WWE...no steroids for you

I read this supposed definitive study in this week's NEJM, which concludes:

"In infants with acute moderate-to-severe bronchiolitis who were treated in the emergency department, a single dose of 1 mg of oral dexamethasone per kilogram did not significantly alter the rate of hospital admission, the respiratory status after 4 hours of observation, or later outcomes."

The US federal government funded this study and found that, well...medicines don't help.  So to make my larger point that NIH/federally funded studies are far more believable than industry studies, I searched the NIH library (pubmed.com) to find industry underwritten studies that show benefits of using medicines for bronchiolitis. I could then prove the bias of big PHARMA!

The most recent relevant study I found on this matter showed that:

"a single injection of dexamethasone yielded a significant clinical benefit for the treatment of previously healthy, young children hospitalized with acute bronchiolitis.".

Aha!  I thought.  Unfortunatley for me, the Thai government funded this other study.  And since I don't know much about the Thai medical system and have no overreaching point about the difference in qualities between US and Thai research, I'm left stymied. 

Damn. 

What's the motivation?

The NEJM just published this novel study on Wednesday, and already the NYTimes and the Washington Post have reported and analyzed it. 

Wow.

I'm impressed by the power the NEJM editors have - enough to sway the nation's two most prominent newspapers to give frontpage coverage and hold internet chats on a topic of their choosing.  However, briefly reading the article, I'm more impressed by it's scientific importance than it's policy implications.  The authors used novel techniques of social mapping I haven't really seen in the medical literature, which will potentially spawn a whole new area of research. But the 'uniqueness' of the article implicitly argues against using it as a basis of social reform, given that, well, it hasn't been replicated. 

So I'm unclear what benefit a national discussion on this topic will yield.  Are there really that many people who are interested in 'social mapping,' or are these national publications going to be giving credence to an unreplicated 'theory'?  And what role do the NEJM editors have in prematurely promoting an immature idea?