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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 22 of 22. This is the beginning of the thread.
Posted by Phillipa on October 22, 2012, at 21:40:05
Here we go the withdrawal of medical care. Phillipa
Medscape Medical NewsGeneral Health Checks Unlikely to Benefit Patients
Elizabeth DeVita-Raeburn
Oct 22, 2012
Authors & Disclosures
Editors' Recommendations
Graying America Gets Wired to Cut Healthcare Costs
Agendas of "Asymptomatic" Patients Who Request Check-Ups
Medical Practice Management News & Perspectives
Performing general health checks and screening asymptomatic adults for diseases or their risk factors did not reduce either overall morbidity or mortality, according to a review published online October 17 in the Cochrane Database of Systematic Reviews.
The large number of participants and deaths in the studies, the long follow-up, and the absence of a reduction in cardiovascular and cancer mortality suggest that general health checks are unlikely to be beneficial, conclude Lasse T. Krogsbøll and colleagues, all from the Nordic Cochrane Centre in Denmark.
The review included data from 16 randomized studies from primary care or community settings comparing health checks or no health checks in adults "unselected" for disease or risk factors.
Fourteen studies (182,880 participants) had outcome data available for analysis. Nine trials provided data on total mortality (155,899 participants, 11,940 deaths). In those trials, the median follow-up time was 9 years, the authors note, which yielded a risk ratio of 0.99 (95% confidence interval [CI], 0.95 - 1.03) for the health check group compared with the nonhealth check group.
Eight trials provided data on cardiovascular mortality (152,435 participants, 4567 deaths; risk ratio, 1.03; 95% CI, 0.91 - 1.17), and 8 trials on cancer mortality (139,290 participants, 3663 deaths; risk ratio, 1.01; 95% CI, 0.92 - 1.12).
One trial revealed an increase in the diagnosis of hypertension and hypercholesterolemia with health checks. Another found an increase in self-reported chronic disease. Two of 4 trials found more people taking antihypertensive medication with health checks, and another found a 20% increase in the total number of new diagnoses per participant over the course of 6 years compared with the nonhealth check group.
Benefits Smaller, Harms Greater
In addition to the lack of clear benefit, general health checks potentially cause harm, the authors write. "[E]xperience from screening programmes for individual diseases have shown that the benefits may be smaller than expected and the harms greater," they note.
Among the harms they cite are the diagnosis of conditions that were never destined to cause symptoms or death and the risk for unnecessary treatment. "While we cannot be certain that screening leads to benefit, all medical interventions can lead to harm," the authors note. The study, however, did not document harm.
The researchers "make an excellent point that a well person can go in for a general check-up and have screening done that can lead to a cascade of events that can lead to more harm than good," Glen Stream, MD, MBI, chair of the board of directors at the American Academy of Family Physicians, said.
However, "some of the methodology in the studies they reviewed were not all that strong," Dr. Stream told Medscape Medical News. He also noted, among other issues, the lack of specific data on harm caused by general health checks. "It makes you wonder if there's [just not] good information out there," he said.
The authors defined general health checks as screens of the general population for more than one disease or risk factor in more than one organ system. Screening methods varied considerably from study to study, including questionnaires, physical exams, blood assays, imaging, stool testing, and the assessment of cardiovascular risk factors.
Studies that enrolled people older than 65 years were excluded. Subgroup and sensitivity analyses did not change the findings, the authors said. The results, they add, are consistent with earlier reviews.
Health Checks a Recent Phenomenon
Health checks of healthy people are a recent phenomenon, the authors noted. The evolution of medicine and new diagnostic methods in the latter half of the twentieth century, they write, has "increased expectations that many diseases can be prevented or discovered before there is irreversible damage." However, studies such as this one suggest that these expectations may not be met, they add.
The authors of the study acknowledged other problems in most of the trials, citing lack of blinding and missing outcome data as the 2 most common issues. "[D]etection bias, biased reporting of subjective outcomes, and biased drop-out were major concerns in many of the trials," they add.
Despite this, the authors of the study were emphatic about the overall significance of their findings. "Public healthcare initiatives to systematically offer general health checks should be resisted, and private suppliers of the intervention do so without the support from the best available evidence," they conclude.
Dr. Stream does not agree. "They made a stronger conclusion than the evidence the presented in their discussion section would support, because they didn't demonstrate harm," he said.
From his point of view, he said, the study raises as many questions as answers. Are doctors merely measuring the wrong things? Is there a hidden benefit in establishing a doctor-patient rapport that benefits care when problems do arise? "It's a call-out to the research community," he said.
Part of the salary for Krogsbøll was supplied by Trygfonden. The other authors and commentator have disclosed no relevant financial relationships.
Cochrane Database Syst Rev. Published online October 17, 2012
Posted by Dinah on October 22, 2012, at 22:53:03
In reply to General healthchecks unlikely To Benefit Patients, posted by Phillipa on October 22, 2012, at 21:40:05
Here we go...
Giant coincidence isn't it? That these studies coincide with healthcare austerity?
Posted by jono_in_adelaide on October 22, 2012, at 23:21:52
In reply to Re: General healthchecks unlikely To Benefit Patients » Phillipa, posted by Dinah on October 22, 2012, at 22:53:03
This is nothing new - it has been generaly held outside of the US and Canada that annual physicals for young healthy people are at best a waste of time.
Posted by SLS on October 23, 2012, at 0:00:16
In reply to Re: General healthchecks unlikely To Benefit Patients, posted by jono_in_adelaide on October 22, 2012, at 23:21:52
> This is nothing new - it has been generaly held outside of the US and Canada that annual physicals for young healthy people are at best a waste of time.
The conclusions of this article seem counterintuitive to me.
Breast cancer and cardiac irregularities are often asymptomatic. The life of a close friend of mine was saved by a regular routine of annual mammograms. Another was saved by a routine colonoscopy. Perhaps the quality of the examinations should be questioned, and not the quantity.
I am sure that the numbers selected from the database are accurate. However, the selection protocol might bias the statistics and their interpretation.
I don't know.
- Scott
Posted by Dinah on October 23, 2012, at 1:18:24
In reply to Re: General healthchecks unlikely To Benefit Patients, posted by SLS on October 23, 2012, at 0:00:16
Routine screenings for diabetes is also a life saver.
Posted by Phillipa on October 23, 2012, at 12:18:42
In reply to Re: General healthchecks unlikely To Benefit Patients, posted by SLS on October 23, 2012, at 0:00:16
Welcome to our new healthcare. I remember an old not literally babbler who lived in a foreign country & several other countries where mammograms are only done every five years three if had breast cancer and first one a year after the cancer is negative. I think one country is England. Correct me if wrong. Phillipa
Posted by jono_in_adelaide on October 23, 2012, at 17:44:51
In reply to Re: General healthchecks unlikely To Benefit Patients, posted by SLS on October 23, 2012, at 0:00:16
"Breast cancer and cardiac irregularities are often asymptomatic. The life of a close friend of mine was saved by a regular routine of annual mammograms. Another was saved by a routine colonoscopy. Perhaps the quality of the examinations should be questioned, and not the quantity."
Yes - certain tests are of proven value (mamograms for women over 40, cholesterol for everyone over 40, checks for colon cancer in people over XXXXX, what hasnt been proven usefull is a general annual physical in a physicians office for everyone
Posted by Hugh on October 23, 2012, at 18:32:12
In reply to Re: General healthchecks unlikely To Benefit Patients, posted by jono_in_adelaide on October 23, 2012, at 17:44:51
My dad's annual PSA test, at the age of 77, led to a diagnosis of prostate cancer. Even though the cancer hadn't spread, and was very unlikely to kill him, his doctors treated it aggressively, with hormonal therapy and a course of what was supposed to be 42 radiation treatments. After 17 treatments, a stress test led to an immediate aortic valve replacement and double bypass. Two weeks after heart surgery, my dad resumed his radiation treatments. After an additional 17 treatments, he died of a cardiac arrest. He had been greatly weakened by his aggressive cancer treatment. His heart surgery weakened him further had caused him to development atrial fibrillation, a condition he'd never had before. I and the rest of my family believe that my dad's doctors treated him to death. If it hadn't been for routine screenings, there's a good chance he'd still be alive.
Posted by SLS on October 23, 2012, at 19:14:36
In reply to Re: General healthchecks unlikely To Benefit Patients, posted by jono_in_adelaide on October 23, 2012, at 17:44:51
> "Breast cancer and cardiac irregularities are often asymptomatic. The life of a close friend of mine was saved by a regular routine of annual mammograms. Another was saved by a routine colonoscopy. Perhaps the quality of the examinations should be questioned, and not the quantity."
>
> Yes - certain tests are of proven value (mamograms for women over 40, cholesterol for everyone over 40, checks for colon cancer in people over XXXXX, what hasnt been proven usefull is a general annual physical in a physicians office for everyoneI understand what is being said. I hope this report serves to motivate others to take a closer look at this issue.
- Scott
Posted by SLS on October 23, 2012, at 19:30:13
In reply to Re: General healthchecks unlikely To Benefit Patients, posted by Hugh on October 23, 2012, at 18:32:12
Hi Hugh.
I'm sorry that you lost your father.
> My dad's annual PSA test, at the age of 77, led to a diagnosis of prostate cancer. Even though the cancer hadn't spread, and was very unlikely to kill him, his doctors treated it aggressively, with hormonal therapy and a course of what was supposed to be 42 radiation treatments. After 17 treatments, a stress test led to an immediate aortic valve replacement and double bypass. Two weeks after heart surgery, my dad resumed his radiation treatments. After an additional 17 treatments, he died of a cardiac arrest. He had been greatly weakened by his aggressive cancer treatment. His heart surgery weakened him further had caused him to development atrial fibrillation, a condition he'd never had before. I and the rest of my family believe that my dad's doctors treated him to death. If it hadn't been for routine screenings, there's a good chance he'd still be alive.
One might conclude that it wasn't the diagnostics that proved lethal, but rather, the treatment decisions that were made subsequently.
- Scott
Posted by Hugh on October 23, 2012, at 20:59:45
In reply to Re: General healthchecks unlikely To Benefit Patients » Hugh, posted by SLS on October 23, 2012, at 19:30:13
> Hi Hugh.
>
> I'm sorry that you lost your father.Thanks.
> One might conclude that it wasn't the diagnostics that proved lethal, but rather, the treatment decisions that were made subsequently.
I think it was a combination, but more of the latter than the former. If my dad had gone to the Mayo Clinic, as we urged him to do, it's likely that his prostate cancer wouldn't have been treated so aggressively, and it's possible that they wouldn't have been so eager to operate on his heart. My uncle had a similar heart operation done at the Mayo Clinic, and they monitored his clogged arteries for years before they operated. At the Mayo Clinic, the doctors work on salary, so they make the same amount no matter the number of surgeries or radiation treatments they do. This was not the case with my dad's surgeon or with his oncologist. There's a chance that monetary gain played a large role in their decisions to treat my dad as they did.
Posted by Phillipa on October 23, 2012, at 21:40:00
In reply to Re: General healthchecks unlikely To Benefit Patients » SLS, posted by Hugh on October 23, 2012, at 20:59:45
Personally I see the endo, see dermatologist,see pdoc,have had US of ovaries at my request 5 years ago, get mammograms, Have had MRI's of back, brain, pituitary, since I hardly eat. Doesn't matter what cholestol is as not giving up the lindtt truffles. And that's the only source of fat I eat. So since the internist refers for everything. I've pooped out on doctors. Each time I've gone something else is found. Enough is enough for me. Phillipa
Posted by Phillipa on October 23, 2012, at 21:41:36
In reply to Re: General healthchecks unlikely To Benefit Patients » Hugh, posted by Phillipa on October 23, 2012, at 21:40:00
But I disagree with this as many probably me also need annual wellness care. If this is an indication of what's to come. We are in heaps of trouble. Phillipa
Posted by jono_in_adelaide on October 23, 2012, at 22:25:25
In reply to Re: General healthchecks unlikely To Benefit Patients, posted by Phillipa on October 23, 2012, at 21:41:36
Phillipa, Australia has been using cost effectiveness tests and evidence based medicine for the past 25 years, and it hasnt resulted in anything bad, indeed, we have a higher life expectency than the US, while spending about 1/3 less on healthcare.
Posted by Dinah on October 24, 2012, at 4:00:30
In reply to Re: General healthchecks unlikely To Benefit Patients, posted by jono_in_adelaide on October 23, 2012, at 22:25:25
"Evidence based medicine."
Shudder. I can certainly see what that means in psychiatry. CBT for everyone, whether or not it works for an individual. It *should* work for you, and if it doesn't, tough cookies. What do you mean you aren't feeling chipper after that course of Prozac?
"Cost effectiveness tests" doesn't inspire me with confidence either. It doesn't benefit the tribe to give these tests, even if it saves the lives of individual members of the tribe.
I can't decide if I'm glad I'm old because at least I don't have to see by the numbers, bottom line medicine being forced down the throat of former individuals. Or somewhat depressed that I'm entering the period of life when, evolutionarily speaking, my benefit to the tribe lessens, while my cost to the tribe increases at a time of bottom line health care.
Posted by jono_in_adelaide on October 24, 2012, at 18:24:47
In reply to Re: General healthchecks unlikely To Benefit Patients, posted by Dinah on October 24, 2012, at 4:00:30
Cost effectiveness means you use the cheap first line drugs forst (for example, sertaline which costs $4 per month) and reserve the ones costing $400 per month for resistant cases.
It means insurance doesnt accept paying $400 per month for the latest drug when it hasnt been shown to be any more effective than the old cheap ones.
It means prescribing a good quality generic for $10 rather than a brand name for $100
I dont see anything wrong with any of these
Posted by Dinah on October 24, 2012, at 21:20:26
In reply to Re: General healthchecks unlikely To Benefit Patients, posted by jono_in_adelaide on October 24, 2012, at 18:24:47
You mean substituting $10 adderall for the very expensive Provigil? I tend towards mild hypomania with certain medications. Provigil *just* keeps me awake without causing unnecessary agitation.
But try convincing an insurance company of that once austerity medicine becomes the theme of the day.
Posted by SLS on October 25, 2012, at 6:48:44
In reply to Re: General healthchecks unlikely To Benefit Patients » jono_in_adelaide, posted by Dinah on October 24, 2012, at 21:20:26
> But try convincing an insurance company of that once austerity medicine becomes the theme of the day.
We are already there in the US. Insurance companies have become the presumptious prescibers of medicines.
It is faulty logic to believe that one chemical entity is equivalent to another, despite their being placed in the same class of medication by the minds of humans. Prozac is not a substitute for Lexapro any more than penicillin is a substitute for Levaquin. If such things were true, we would have only one beta blocker, one calcium channel blocker, one proton pump inhibitor, one NSAID, one antibiotic, etc. The reality seems to be that there is great variability in the physiology of humans and pathogens such that two people will respond differently to, or have different adverse side effects from, the same drug.
- Scott
Posted by herpills on October 25, 2012, at 8:25:23
In reply to Re: General healthchecks unlikely To Benefit Patients, posted by jono_in_adelaide on October 24, 2012, at 18:24:47
> Cost effectiveness means you use the cheap first line drugs forst (for example, sertaline which costs $4 per month) and reserve the ones costing $400 per month for resistant cases.
>
> It means insurance doesnt accept paying $400 per month for the latest drug when it hasnt been shown to be any more effective than the old cheap ones.
>
> It means prescribing a good quality generic for $10 rather than a brand name for $100
>
> I dont see anything wrong with any of theseNothing wrong with this approach, but the problem is how do we determine when the $4 generic is ditched for something that will be more effective? How long does a patient have to suffer on an ineffective treatment until they are given the green light to try the next, more expensive agent? herpills
Posted by Phillipa on October 25, 2012, at 19:00:20
In reply to Re: General healthchecks unlikely To Benefit Patients » jono_in_adelaide, posted by herpills on October 25, 2012, at 8:25:23
Will there be one to tier up to or will many meds be eliminated? Phillipa
Posted by jono_in_adelaide on October 25, 2012, at 21:02:28
In reply to Re: General healthchecks unlikely To Benefit Patients » jono_in_adelaide, posted by herpills on October 25, 2012, at 8:25:23
> > Cost effectiveness means you use the cheap first line drugs forst (for example, sertaline which costs $4 per month) and reserve the ones costing $400 per month for resistant cases.
> >
> > It means insurance doesnt accept paying $400 per month for the latest drug when it hasnt been shown to be any more effective than the old cheap ones.
> >
> > It means prescribing a good quality generic for $10 rather than a brand name for $100
> >
> > I dont see anything wrong with any of these
>
> Nothing wrong with this approach, but the problem is how do we determine when the $4 generic is ditched for something that will be more effective? How long does a patient have to suffer on an ineffective treatment until they are given the green light to try the next, more expensive agent? herpills
>
>
>
>
>
>Well, it works in Australia, and the drug companies play ball - if they can prove that (say) Lexapro is better than generic sertaline, they will be reinbursed a higher price, if they can only show that its equal to it (which is all that they have been able to show) then they recieve the same price for it - and they agree to sell under these terms
Under the national insurance sheme the only drug that is in the restricted catagory is nardil (which costs $200 per month) - the restriction is "depression where phenelzine is the only appropriate drug" - and i guess its upto the doctor to interperate that.
The Australian system lists all the usual antidepressants, about 10 NSAID's, 5 or 6 beta Blockers and god knows how many antibiotics - there is just a structure in place to determine pricing beyond the companys just charging what they want.
The restrictions arnt arduous, and they tend to result in more rational use of drugs (for example quinolone antibiotics are rarely used outside of hospitals in this country, and so resistance to them is rare, compare to the US where levaquin is given out for sinusitis and bronchitis, and resistance to these valuable drugs is common
Posted by Phillipa on October 25, 2012, at 21:42:17
In reply to Re: General healthchecks unlikely To Benefit Patients, posted by jono_in_adelaide on October 25, 2012, at 21:02:28
Levoquin is a horrible med. It messed me up bad psychologically. So now say allergic to it. Phillipa
This is the end of the thread.
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