Routine mammograms and the importance of rating preventive services

This week’s news from the U.S. Preventive Services Task Force (USPSTF) on routine breast cancer screening has caused quite the stir. The USPSTF shared their new ratings of preventive services for breast cancer: Mammograms work really well in women in their 60s, pretty well in women in their 50s and not so well in their 40s. If you want to have mammograms in your 40s prepare for more confusing results including additional imaging to clarify and in some cases, a biopsy to be certain. And their recommendations included a couple of small but important points: breast self exam doesn’t lead to early detection of breast cancer nor do breast exams by doctors (remember we are only talking about women who have NO symptoms). The big news: Doctors and patients in their 40s should talk to each other about what to do rather than just do the same thing all the time out of pure routing. What’s wrong with that?

We seem to have developed the view that more prevention is always better, more testing is better than less, and that more information is always helpful. But this week’s news challenges that notion…and that is what it was meant to do. Making decisions is hard, especially when we have a health problem. But it’s also true when there are health issues we may not have yet. Surprise, life isn’t simple.

The focus in the media has been on the USPSTF recommendations without sufficient attention to some important context issues. These include:

1) Breast cancer (and for that matter almost all cancers) is not one disease. They afflict us in multiple forms each with a different natural history. Some breast cancers are very aggressive and respond slowly if at all to our treatment options. Others are slower growing and very responsive treatment.

2) Mammography is a better test in some people and for some cancers than it is for others, especially when screening at an early stage is what we want from it.

3) The USPSTF focuses on recommendations for primary care doctors for patients with no symptoms getting routine care.

And the politicians on both sides should be ashamed of themselves for treating 16 volunteers from the private sector so shabbily. The USPSTF has been around for 25 years (some silver anniversary). It has always approached ratings of preventive services more rigorously than any public or private body. The task force is focused on recommendations for primary care not for specialists---they assume oncologists would not be seeing many completely healthy women who don’t have cancer. Several of them have spent their careers focused on prevention and have been recognized repeatedly for extraordinary performance. The rest are seasoned clinicians and successful researchers who are at the peak of their careers. The one thing you can be certain of is that each of them could make a lot more money spending their time on some other activity than this one.

So their timing wasn’t great. They meet three times a year and topics to address are planned months if not years in advance. The irony is that if they had paid attention to politics and delayed the mammography decision then we would have to be concerned about a political agenda. They are so independent they don’t think they need a political consultant or pollster --- they make their decisions based on science rather than opinion polls.

So let’s all pause and make sure we really want to vilify 16 scientists from the private sector who just provided prevention ratings for breast cancer preventive services based on the best science available. And the most controversial advice they provided was we should no longer use a cookbook approach to a serious problem but instead talk to our doctors about all the details, the pros and cons.

I think they all deserve one word……thanks.

—John Santa, M.D., M.P.H., director, Consumer Reports Health Ratings Center

FDA announces review of Lasik: Are you a good candidate?

Spurred by complaints of adverse events, the Food and Drug Administration announced yesterday that they would launch a multi-year study to examine the potential impact on quality of life from Lasik laser-vision correction surgery. Lasik surgery permanently reshapes the cornea with a laser but consumers face a lack of reliable data about the frequency of troubling side-effects, such as dry eyes, halos, and blurry vision.

We think that an FDA review is a good thing. Consumer Reports Health's recent Lasik survey found that many patients (53 percent) dealt with distressing side effects—some of them for up to six months after the surgery. And while most people (about 80 percent) were satisfied with the procedure, nearly two-thirds were disappointed to find that they still had to wear glasses or contact lenses at least occasionally.

Lasik surgery and similar operations are elective, not essential, medical procedures, which makes such side effects all the more distressing—and most people have to pay thousands of dollars out-of-pocket for it. The data for long term safety and effectiveness of the procedure is currently unknown, due to insufficient data. And much of what we do know comes from the doctors who make a living providing the surgery. The FDA just admonished 17 such providers for not keeping adequate records on adverse events.

We’ve also asked patients about the quality of life after the surgery. In addition, we’ve combed the latest studies and surveyed nearly 800 patients who have had the surgery. If you’re considering having LASIK, our Patient Power Toolkit can help you decide if the procedure is right for you.

The toolkit includes:
    * A tool to help you determine whether you're likely to be satisfied based on your expectations compared to the experience of others.
    * Detailed information from consumers who have had the surgery.
    * A safety assessment of laser vision-correction surgery based on the latest evidence.
    * A guide to choosing a surgeon, including key questions to ask and red flags that should prompt you to get a second opinion.
    * What to expect before, during, and after the surgery.
    * The costs of surgery, insurance coverage, and payment options.

—Kevin McCarthy, associate editor

How does physician-assisted suicide affect the family?

The rights and wrongs of physician-assisted suicide have been much debated. Rightly, most of the focus is on the person choosing to die. But what of the families they leave behind? In most circumstances, suicides wreak emotional devastation on families. Guilt, regret, anger, and grief cause much suffering after the suicide of a family member. So, we might expect to find the same emotions triggered by physician-assisted suicide.

However, new research suggests that isn’t necessarily the case. In a study in Portland, Oregon, where physician-assisted suicide has been legal under certain circumstances for 10 years, doctors interviewed family members around a year after a physician-assisted death, by lethal prescription.

They found 11 in 100 had some form of depression, and 2 in 100 still had symptoms of grief. But when researchers interviewed people whose family members had died naturally of terminal illness such as cancer, they found much the same results. The main difference was that people whose family member had opted for physician-assisted death felt more prepared for and accepting of the death.

Is it ADHD, or something else?

An 11-year-old boy I’ll call Joseph was brought to my office by his concerned parents. He was throwing fits every morning because he hated to go to school.

As a psychologist with a part-time practice assessing attention and emotional disorders, my first thought was that Joseph’s refusal to go to school might be related to either separation anxiety or a behavior disorder. But as I questioned the parents, I learned that Joseph didn’t have trouble separating from his parents when it was time for his soccer games or to play with his friends. In general he was a well-behaved, compliant boy who, except for school refusal, showed no signs of defiant behavior.

On further questioning, the father revealed that he himself had some trouble with reading and often lost interest in activities at work. When I asked about Joseph’s reading and attention, his parents said that they knew he was a smart boy, but the teacher had mentioned that he had been missing details and tended to space out during reading assignments.

After a learning evaluation with a clinical neuropsychologist that included getting feedback from the school, Joseph was diagnosed with a minor reading disability and attention deficit disorder. It turned out that he was avoiding school because he was embarrassed about his declining performance and inability to complete reading assignments as quickly as his peers.

Joseph’s parents asked the school to make the recommended accommodations, including sessions with a reading specialist, extended time for reading assignments, and moving his seat to the front of the classroom. This helped improve Joseph’s performance and attitude. He was soon able to go to school without the morning outburst.

While most people think of children with attention deficit hyperactivity disorder (ADHD) as screaming and climbing the walls, a number of children like Joseph suffer primarily from symptoms of inattention, such as missing details, losing things, being forgetful, or avoiding disliked activities. It can be difficult to untangle learning and attention problems from the emotional consequences of experiencing these issues.

Health care reform: Continuing the conversation

Our new survey on the continuing woes of our health care system has drawn considerable comment from people with passionate views both for and against the reform legislation being debated in Congress.

We’re guessing that some of those who have come here are new to Consumer Reports and may not be aware of the work we’ve been doing for years on the U.S. health system, such as the visitor who wrote:

Give us reviews of the insurance companies so that we the consumers can make informed decisions.

As longtime readers know, we’ve been reporting on health insurance for the past several years. Subscribers can access our Ratings of PPOs and Ratings of HMOs, and all visitors can learn how to select good health plans, avoid bad ones, and make the most of the coverage they have.

Several commenters pointed to cancer survival statistics showing that Americans live longer after diagnosis with many cancers than do people living in European countries with universal health care. These statistics are a favorite of health-reform foes, but FactCheck.org, a project of the nonprofit Annenberg Public Policy Center of the University of Pennsylvania, cautions that:

How to catch the flu and how not to—surgical masks may be helpful

Hate it when somebody coughs right into your face and eyes? You're not just germ-phobic, that may be the most likely way to transmit influenza, according to a newly published study.

Researchers from UC-Berkley’s School of Public Health and the University of Illinois at Chicago’s School of Public Health concluded that close contact spraying of respiratory droplets with the influenza virus carried the greatest risk of infection, followed by hand contact with contaminated surfaces, and inhaling particles carrying the virus. The study was published in Risk Analysis: An International Journal published by the nonprofit Society for Risk Analysis, and used mathematical modeling to examine the theoretical risk of catching an influenza A virus—a type of influenza virus that includes the new H1N1 and several seasonal strains—through various types of exposures when a healthy person is caring for someone bed-ridden with the flu.

While these findings are theoretical, meaning they aren’t based on observations of actual people who caught the flu, they do give an idea of the best ways to prevent the flu. That starts with the flu vaccines, which should prevent your body from actually becoming infected. But evidence shows that influenza vaccines aren’t 100 percent effective, so good hand hygiene, covering coughs and sneezes, and avoiding close contact with sick people are crucial—even if you’ve been vaccinated.

Underinsured, the sequel

Health care reform isn’t just about covering the uninsured. It’s also about making sure that those who do have insurance can rely on it to pay the bills if they get sick, without leaving them with unmanageable debt. Sadly, that’s often not the case today, as Kaiser Health News documents in a series of reports done in partnership with National Public Radio.

The struggles of Jim and Martha Martin and their teenage daughters Sara and Rebekah, profiled in one of the articles, show how inadequate insurance can be. The parents, who live in Maine, hold down five part-time jobs between them yet have only limited coverage, mainly Martha’s plan (which only covers her) from her part-time supermarket deli job, and Sara’s through a student policy offered by her college. It’s nowhere near enough.

More medical bills are coming. Martha needs to have a hysterectomy next month, and she says her insurance will pay only $1,000 of the hospital bill.

For the Martins, 2009 is starting to look a lot like 2008. Last year they paid $6,210 in health insurance premiums for themselves and daughter Sara, plus another $13,955 in uncovered hospital bills after Rebekah's surgery.

It added up to almost 45 percent of their total income of $44,815.

We’ve explored the dilemma of the underinsured repeatedly in the past several years (see our health insurance reports from 2007 and 2009). Right now we’re in the process of analyzing the reform bills under consideration in Congress to see if they will give real relief to hardworking, struggling families like the Martins.

—Nancy Metcalf, Senior Program Editor

 

Get vaccinated, Doc!

One statistic jumped out at me as I was gathering material for our coverage of the swine (H1N1) and seasonal flu vaccines:  Less than half of health-care professionals get the flu shot each year.  Such a low vaccination rate has led to flu outbreaks in hospitals and nursing homes, research suggests. Plus, sick doctors and nurses can’t—or at least shouldn’t—go to work, and their absence could be especially critical this coming "two-flu" season. Indeed, the CDC puts health-care professionals at the top of the flu vaccine list in part because they are so vital. But the surveys suggest that this message isn’t getting through.

We know that breaking the chain of infection—preventing transmission of the flu from caregivers and household members to people at high risk of complications—will reduce illness, hospitalization, and mortality.  The same holds true for health-care professionals.  Yet surveys conducted during the last few annual flu outbreaks show that most of them don’t get vaccinated. This year, at least one state health department is mandating that all health care workers be vaccinated for influenza including hospital and physician staff, nursing home caregivers and staff, and home caregivers.

This coming flu season public-health officials will no doubt urge us, the public, to get our flu shots early and do every thing we can to stop the spread of the flu.  We should make the same request of our health care professionals, and especially those who care for pregnant women and immunocompromised patients.

This year, as I get my flu shot at the end of September or early October, I intend to ask the person giving me the shot if they've had theirs as well. I urge you to do the same.
 

--Christopher Hendel, Associate Director, Health

Don't get the flu shot? Find out if your excuses are myth or reality. Then keep up to date with our H1N1 (swine) flu coverage and recommendations.

 

Hand washing: Public humiliation works

As flu season approaches, everyone is talking about hand washing, especially health-care professionals. But will more talking mean more doing? A couple of public humiliations helped make me become a better hand washer.

The first occurred when, as a relatively new certified nurse midwife, I was training to assist on cesarean sections. I scrubbed in with the doctor, chatting as we completed the ritualized five minutes of hand washing. We were off to a good start—or so I thought. But when we were gloved and gowned and ready to go the doctor said, "So, who trained you to scrub anyway? Start over, and this time keep your hands up, so the dirty water doesn’t run back over them." As the assembled operating room team watched and waited, I shamefacedly washed my hands again. Suffice it to say my presurgical hand washing became scrupulous that day.

The second occurred in my office at the hands of a well-informed patient. I had just finished what I considered to be an exceptional prenatal visit and was saying as much to the office staff when they informed me that the patient had refused to see me again. The offense? I hadn’t washed my hands before her physical exam.

You never know what’s coming for ya

I finally saw the movie The Curious Case of Benjamin Button this weekend and woke to a bright morning thinking the movie’s refrain “You never know what’s coming for ya.” So I was primed for the unexpected as I read the troubling content on Dead By Mistake, a site that features the results of a Hearst investigative report on medical errors. The site’s most compelling feature is the set of 30 profiles and heart wrenching photos of lives lost unexpectedly under circumstances that certainly seemed preventable.

This new content echoes the report we released in May as part of our Safe Patient Project.  Our report, To Err is Human—To Delay is Deadly, looks at specific infection-preventing practices state by state and the status of legislation to make hospital infection rates available to consumers.  Ten years ago the Institute of Medicine declared that as many as 98,000 people die each year needlessly because of preventable medical harm, including health care-acquired infections. Ten years later, we don’t know if we’ve made any real progress, and efforts to reduce the harm caused by our medical care system are few and fragmented. In fact, we gave the country a failing grade on progress on select recommendations we believe necessary to create a health-care system free of preventable medical harm.

Do not-for-profit nursing homes provide better care?

The decision to move my grandmother to a nursing home was very difficult for my parents. After all, when my grandmother was a girl in "the old country" (her native Germany), families would care for their elders in their home. And my parents did in fact do this for several years. But eventually my grandmother's worsening dementia and health meant that she required more care than my parents could safely provide, and they decided a nursing home was the best option. But then they were faced with another difficult decision: Which nursing home would provide the best-quality care, and how might they determine this?

These are common questions, and not just among concerned family members. Researchers and policy makers are also keen to learn which nursing homes provide the best care—and why. One factor thought to influence care quality is what's called "profit status": whether a facility is a for-profit business or a not-for-profit venture. One school of thought holds that not-for-profit homes deliver better care because this is more central to their mission, and they do not need to divert financial resources to shareholders and taxes. But another view suggests that for-profit nursing homes actually provide superior and more efficient care because they feel added pressure to compete on price and quality.

Many studies have put these opposing theories to the test, and researchers have recently published a review that summarizes their results. Overall, they found that not-for-profit nursing homes deliver higher-quality care than for-profit facilities. (This echoes our own findings from an analysis in 2006.) In the new review, the researchers looked at 82 studies done from 1965 to 2003. Forty found better care at not-for-profit homes, while three studies gave the nod to for-profit facilities. The remaining 39 studies had mixed results.

Shattering the myths about health reform

In a USA Today editorial today, Steven Findlay, senior health policy analyst at Consumers Union, sheds some light on the myths about health-care reform, many of which have frightened Americans. In it he debunks the notion that our system is headed toward socialized, government-run medicine with a side of rationed care:

"Cookbook and rationed care? This fear stems from concerns that the government aims to dictate what doctors do and cut costs by limiting access to care. These notions are wrong. Rather, what [President] Obama and both Democratic and Republican leaders want to do is aggressively measure the quality of care that doctors and hospitals deliver and change the way those providers get paid so quality of care—rather than quantity—is rewarded. That's hardly a socialistic notion."

So what must be done to fix the system? Findlay urges creative thinking and proposes that the medical industry be challenged to cut costs and change its "General Motors gas-guzzler mindset" by reducing waste and inventing more efficient systems.

Rating the House health reform proposal

In testimony before the House Education and Labor Committee yesterday, Consumers Union’s senior policy analyst, Bill Vaughan rated the House Tri-Committee Draft Proposal for Health Care Reform on how well it met our criteria for meaningful reform for consumers. As explained in a seven-page editorial in the August Consumer Reports, we’re looking for health reform that:

• covers everyone,
• makes insurance simple,
• provides information on quality of care,
• helps employers to offer protection for workers,
• rewards good care—not just more procedures,
• frees doctors to practice medicine,
• and gives you the freedom to choose your plan.

So how does the house proposal rate? Here’s some of what Vaughn told the house committee, including suggestions for what can be improved.

The Tri-Committee proposal will bring us to the goal of affordable, quality dependable health care for all. But we also know that even more savings are possible and can be directed toward spurring breakthrough research if we all work together.

Covers everyone: The House proposal would create a national health insurance exchange that consumers can use to find guaranteed health insurance, regardless of pre-existing conditions. Private plans would compete with the option of a public plan to keep insurance affordable. Subsidies for those making less that 400 percent of the poverty level would expand access to health care to millions of Americans who can’t afford it today.

No news is not always good news

One thing I really like about my doctor is I don’t have to chase her to get the results of my tests. Each time, she calls me herself to let me know that my mammograms, lipid profile, and, once, a gall bladder scan, were no cause for concern. Her prompt calls help assure me that I’ll be informed in the future, and alerted to take needed action, in the event that a test result turns out abnormal.

Not all doctors are so reliable all of the time, according to a study out today in the June 22 Archives of Internal Medicine. Researchers reviewed the records of 5,434 randomly selected patients aged 50 to 69 from 23 primary care practices in various cities. Among the over 1,800 abnormal results recorded, researcher found apparent failures to inform patients (or to note that they had been informed) in over 7 percent (or, 1 in every 14) of cases. The authors comment that: "Failures to inform patients of abnormal test results or to document that they have been informed can harm patients and expose physicians to indefensible malpractice liability."

Previous studies have also shown that some tests are "orphaned" without either the physician or patient ever being aware of the results. So whether or not your doctor has a good track record of keeping you informed, it makes sense for consumers to do their part to make sure nothing slips through the cracks. We all need to take charge of our own medical information. These steps will help:

Runaway health costs: What consumers are up against

Here’s a powerful, patient’s-eye view of our healthcare system from the husband of a colleague at Consumers Union. His experience illuminates the painful consequences of a system that tolerates and even rewards piecemeal, uncoordinated, and often unnecessary treatment. See here, here, and here for examples. (I’ve changed the name of his relative out of consideration for surviving family members):

My cousin and I were responsible for managing the affairs of our uncle and aunt because they didn’t have children of their own. I live closer, so a lot of the day-to-day decision-making fell to me. Andrew was about 80 when the couple moved to an assisted living facility nearby. My aunt’s health and memory weren’t what they used to be and she couldn’t keep house any more. After Andrew got there, his condition declined pretty quickly; we were kind of startled. His energy seemed to drop and he needed a walker to get around.

Around Christmas of 2007 he tripped and fell and was taken to a nearby hospital, where he was seen by I don’t know how many doctors. I didn’t even meet most of them. I know he saw them from the bills I got. So many groups and individual doctors seemed to have a little piece of him. I was paying $20 here, $150 there, whatever Medicare didn’t pay. The hospital bill alone was seven pages long.

But I did meet the cardiologist who assured me, almost guaranteed me, that if my uncle got a pacemaker there would be a dramatic change in his mobility and energy. I believe he was the one who put in the pacemaker. My uncle was in the hospital for a couple of weeks, and then at a rehab facility, but afterwards there was literally no change. He could walk just inches at a time with the walker, needed assistance to get in and out of bed, to get to meals.