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Newsflash! Advertisers Lie! Jim McVeagh Feb 28

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Yes, I know it is almost impossible to fathom such depravity, but some pharmaceutical advertisers make unsubstantiated claims in medical journals! (/SARCASM OFF) Such is the conclusion of Ben Goldacre of the Guardian, writing on the Bad Science Blog. Goldacre is writing about a recent research article in the Netherlands Journal of Medicine “Are claims of advertisements in medical journals supported by RCTs?“. The article comes to the conclusion that only 40% of the adverts quoted a high-quality RCT (Randomised Control Trial) that actually supported the claims made in the advert (some trials were high quality but did not support the claims). Scarily, only 17% of the claims were supported by a relevant, good quality RCT that was not sponsored by the pharmaceutical company.

The study had 250 medical students go through 158 RCTs from 94 advertisements using a modified version of the Chalmers’ score. Why medical students? Goldacre suggests amusingly that they are cheap! But the real reason is that the students had just completed the section of their study that deals with appraising evidence-based medicine. They were therefore about as able to judge the trials as an average GP, perhaps more so. They were given an objective scoring system to follow and they had no previous exposure to prescribing the drugs being advertised. This would have given an accurate, unbiased assessment of the worth of these trials without resorting to the use of statisticians or academics. This gives a good “real world” picture of the value of these trials, should a GP or hospital doctor have asked for them.

It comes as no real surprise that so few of the advertisements had decent clinical data to back them up. This has been a common finding in many studies including this large swiss study of 2068 adverts. Goldacre cites this excellent meta-analysis of 24 studies on this subject from the open access journal Plos One. Even as far back as 1992, the highly regarded Annals of Internal Medicine published this study whose conclusions included:

In 44% of cases, reviewers felt that the advertisement would lead to improper prescribing if a physician had no other information about the drug other than that contained in the advertisement.

The moral of the story being that when the drug rep or an advert makes a claim, always insist on reading the cited study. I have done this from the time of my graduation, nearly thirty years ago, and my impression is much the same as these studies. About half of the claims made by reps are verifiable. To be fair on the drug reps, most of them do not know how to judge a study and are just going by what they have been told. And they are almost always perfectly willing to find you a copy of the paper.

From an ethical point of view, I cannot see how any doctor could change his prescribing habits without at least assessing the claims made by pharmaceutical companies, formally. I know many of my colleagues take the recommendations of the specialists they use, relying on their judgement as to the worth of the product. I think this is not an unreasonable thing to do, as most specialists are more able to assess these claims than the average GP. However, I still make it a policy to assess papers myself, as even my specialist colleagues may not be immune to the lure of the shiny new pill on the market.

So what makes a paper a bad one? Essentially, bias in selection, lack of controls and low numbers. The first two are quite easy to spot once you know a little about the subject, the last is the commonest reason for considering a trial dubious. I can’t tell you how many times I have seen adverts claiming a great “P” value of 0.001 (That’s Probability, not Methamphetamine, BTW – anything less than 0.05 suggests that this is not a random chance). When you ask how many were in the study, you keep getting answers like 30 or 50. This means that it is dangerously likely that the result may simply be a type 1 error (the small sample has accidentally been taken from an abnormal part of the population – giving a spuriously significant result). This is a particular problem in medical trials. This is not to say that small trials are not worth doing, but that the result should always be treated with caution. Multiple small trials with the same result are much more reassuring, as is a large trial with a similar result.

Clearly adverts effect the way doctors prescribe drugs, otherwise drug companies would not run them. This is worrying considering that half of the claims made are either unverified or blatantly false. Prescribing medicine should be done on a purely evidence-driven basis. Prescriptions based on what pharmaceutical companies want you to believe, leave doctors open to charges that there is no more scientific basis to conventional medicine than to something like homeopathy. Worse, it could seriously disservice a patient, all in the name of the pharmaceutical company making another buck.

Doctors owe it to their patients to check out pharmaceutical company claims in full. It is stupid to accept the word of a person who has a vested financial interest in his product and it is nonsense to get our medical knowledge from the glossy brochures of drug reps.

Hat Tip:  David Whyte

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Show Me the Technology Jim McVeagh Feb 06

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The Dominion Post writes yesterday about the looming shortage of oncologists. Four cancer doctors have resigned in a very short space of time. The article explores all the usual reasons why doctors leave, particularly the worrying ones of overwork,  which can only be fixed by employing more hard-to-get doctors. What struck me, though, was the last line – well second-to-last. The last line was Tony Ryall’s spokesman passing the buck to the DHBs – not a good look. Anyway, that second-to-last line was:

He was leaving the public system because he could provide a higher standard of care through a private clinic. “We have the opportunity of getting state-of-the-art machines without having to wait 10 years.” (emphasis mine)

While it is true that non-specialists tend to leave the public health system due solely to money issues, this is not true of specialists. Sure, they do earn a lot more in private practice and their hours are often better, but a very strong motivation is the provision of far better facilities. This would be particularly important for people such as oncologists whose results are often very dependent on the quality of equipment and drugs they have access to. However, I have heard the same comment from many specialists of my acquaintance who have moved from public to private practice. It is no accident that laparoscopic surgery was performed in private practice long before it came into public hospitals, despite its overwhelming superiority to standard surgical procedure in terms of recovery, cosmetic result and, at the end of the day, cost to the patient (or the taxpayer) due to lower length of stays.

Even specialists with private practices working in public facilities often comment that what they do in state health is necessarily inferior to what they can achieve in private.

This is a problem in capital expenditure. Tony Ryall has already indicated that the government can only afford about a third of the capital requests before it. Therefore this problem will simply get worse. The only two solutions are:

  • increase capital expenditure ( not viable in the current economic environment)
  • use the equipment available in private practice

It seems clear to me that there are some areas that will eventually be mostly managed in private practice with the state system providing basic support and, of course, funding. Oncology seems the most likely candidate for this migration with radiation treatment almost certainly moving out of the state system as it becomes next to impossible to justify the high capital costs of parallel state/private systems. This is also directly pertinent to the debate on private practice using state facilities.

New Zealand is a small country. We simply cannot afford to run two expensive medical systems side by side. At some point we are going to have to move away from the ideological block we have against private medicine and allow a mingling between the two systems and a sharing of expensive resources. This is an inevitability unless we wish to see our health statistics slide inexorably down the WHO league tables.

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Two Tiers Jim McVeagh Jan 28

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Dr Tim Parke, the clinical director of the adult emergency department at Auckland City Hospital, puts his concerns into an article in the Herald today. He writes that, in his opinion, the proposed use of public facilities for extra private procedures will produce a two tier system where, eventually, richer patients will have better medical outcomes than poorer ones. He says:

Over time, the difference in survival would add up and eventually, more wealthy patients would survive heart attacks than less well off patients. The cumulative effect of a range of survival differentials in many diseases and injuries would eventually exaggerate the already marked differences in mortality rates between races and social classes.

Unfortunately for Tim’s argument it falls down at one very important point. The two-tier system, he is worried will develop, is already here and has been for many years. Insured and wealthy patients can already access a much greater choice of health care than uninsured ones. To use Tim’s example:

The scenario is thereby foreseeable where two young patients arrive in the emergency department with heart attacks in side-by-side cubicles. One gets the “budget” clot buster treatment option which is probably okay, but the guy next to him opens his wallet and gets the “elite” option of emergency angioplasty with direct opening of the blocked coronaries. Both of these treatments have been shown to work, but angioplasty is slightly better and is very much more expensive.

Currently most hospitals have limited budgets for angioplasties. In the above case the uninsured patient will have to meet a number of criteria (rather like the “points” you have to make for your specialist outpatient appointment). The insured patient can simply get his GP to call an interventional cardiologist in private practice and get his angioplasty – even if he doesn’t meet the “criteria”. As Tim points out, angioplasty does have slightly better results. The only reason that we don’t do it on everyone is because we can’t afford to.

The only difference in the proposal to allow private procedures to be done in public facilities is convenience. The insured person will still get his angioplasty, but he might have to travel a few hours to get it. This may reduce the outcome of his angioplasty – so the only result of disallowing the use of public facilities is to reduce the wealthier person’s chances of a good outcome. Truly equality of outcome – both bad.

Tim’s other point is superficially more worrying:

Furthermore, those patients paying in public hospitals simply to get the best treatment option will become more and more resistant to funding anything other than pure “safety net” bargain basement treatment for the non-paying patients out of their taxes.

This also has been occurring for a long time already. What do you think the phrase “value for our tax dollars” really means? Does anyone really think that the current public health system funds anything more than “bargain basement” treatment? (Unless by the phrase “bargain basement” you really mean “inadequate”; because that is a whole different ball of wax). There is and will always be a limited amount of money in state-provided health care. We will always be making decisions about rationing health resources. Allowing private patients into public facilities is not going to change this in any way. It is even possible that the extra funds may provide better health care for state patients.

The Two-Tier system is a present day reality. Instead of having angst about it, we should be trying to make it work for us.

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Sounds Familiar Jim McVeagh Dec 03

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This is the section on health from the 2025 Task Force summary:

10. Health:

a. A funder-provider model should be reintroduced in the hospital sector, allowing much greater private sector involvement in the provision of taxpayer-funded services.

b. Universal (unrelated to income or health status) subsidies for doctors’ visits should be abolished.

c. Subsidies for prescription pharmaceuticals should be substantially reduced, with those in generally good health and not on low incomes paying the full price up to a cap.

I’ve read the full section as well. These are the only three real ideas in it. This is all the much-vaunted task force could come up with for health. It is quite sad.

For a starter, Dr Brash would like to go back to the funder/provider split that worked so well in the 1990s </sarc>. All this shows is that he and his compatriots have no understanding of health care at all and are merely advocating ideology again.

The problem with the health reforms of the 1990s were that they were too timid. The then National government attempted to graft a mock free market onto socialised medicine with predictably disastrous consequences. Attempting to run a state-owned hospital as a business is lunacy. A private medical concern is extremely efficient: these are two words that do not describe state hospitals. Consequently, the attempt by the lumbering administration of state hospitals to become efficient, saw them cutting corners in all the wrong places while increasing their bureaucratic requirements exponentially. This process of cost cutting slowed under the DHB system, but all that achieved was rapidly rising costs.

What was really required was for the National government to grasp the nettle of health care and completely privatise the system, ensuring that the poor had access to health care by providing them with fully or partially subsidized insurance. The bizarre limbo we find ourselves in at the moment, where people are denied healthcare or delayed to death by the system is due solely to the attempt by the State to provide universal socialised health care alongside a fully functioning private system. You only need to pop along to South Africa to see the end result of this dual system: a decaying public service unable to cope with the sheer volume and a private health service costing a large fortune, simply because it is underutilised (driving up costs).

I do not expect the current government nor any future one to actually privatise health. Most people react with horror at the suggestion because they associate privatised health with the US system. In fact the problems with the US system are almost entirely related to the combination of too much state intervention and the pernicious effect of tort law. But the left have taught us that the US problems are due to “privatisation” and we have learned this untruth too well.

It should be obvious from what I have said that I think the second and third suggestions miss the point as well. In addition, reduction of doctor’s visit subsidies brings a clear problem at the margins where people earn $10 dollars a week more than their neighbour, yet pay the full price for doctor’s visits. A similar problem can be found with subsidies for pharmaceuticals, but here the problem is worse. With a dual (subsidised, non-subsidised) system, drug companies are incentivised to drop their prices dramatically for Pharmac, but increase their prices at pharmacies, effectively taking all their profit from the non-subsidised sales. This effectively locks out competition (because they take the volume), ultimately reducing choice and raising prices.

Because New Zealand is a small country and most places have no choice of medical facility, it should be possible to move to a privatised system in stages. Initially, withdraw funding from hospitals and place it into a universal insurance scheme. The scheme should NOT be government run but merely offer a universal subsidy to insurance companies, allowing people to buy more expensive coverage with their own money if they desire. Patients then immediately get a choice in the larger centers. Small hospitals can then be offered privately, initially to locals, then New Zealanders and finally overseas investors. Only the tertiary hospitals would remain and should be taken over by the universities (though the New Zealand universities do not appear particularly business orientated and would be better off having separate companies running the hospitals while retaining a major shareholding in the companies).

All this is doable, but requires enormous political will. It would fix the health system permanently, providing better access and proper cost containment. You could get your cancer therapy in 6 days time, instead of 6 weeks. You could get your hip replacement next week. It would actually matter if ED throughput and hospital bed turnover was managed properly.  Doctor’s pay scales would be contingent on the number and complexity of patients seen, rather than whether they fill a place on a roster.

Ah, well. I can’t dream, can’t I?..

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Obamacare Wins (Maybe) Jim McVeagh Nov 08

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The House of Representatives has just approved Obama’s healthcare bill 220 -215. The bill will now go to the Senate where the Democrats may have the numbers to pass the bill – assuming all Democrats and the two independents vote for it. Obama needs to get everything passed before the mid-term elections. It is highly likely that the Democrats will either lose control of one or both houses or, at least seriously erode their margin. Obama can then kiss his healthcare bill goodbye. Effectively, he probably needs to have it enshrined in law by the end of the year as Congressmen and Senators become increasingly nervous as the mid-terms approach and don’t like being asked to vote on controversial issues.

Of course, if he gets it passed, there is no way that the Republicans will be able to do anything about it. History shows that engineering a perceived reduction in health care is a fine way of getting yourself voted out of office. Once Obamacare is in, it will be impossible to move and it will be practically impossible to prevent the inevitable socialisation of US healthcare.

This is how it will go down. Medicare will be greatly expanded and costs will be tightly constrained in order to price the policy as low as possible. In order to maintain some semblance of a profit margin, healthcare providers will attempt to charge private insurers higher fees. Only the larger insurance companies will have the size and clout to resist this. Private insurance fees will go up, forcing more and more companies (who are now being forced to provide insurance cover) to plump for the cheaper Medicare option, despite the benefits being a limited, one-size-fits-no-one, standardised plan.

  • Job losses are almost inevitable as companies struggle to cope with either new taxes or new healthcare costs.
  • Smaller insurance companies will go to the wall, reducing competition (the exact opposite of Obama’s claim to increase competition)
  • Larger insurance companies will haemorrhage clients, increasing costs

Eventually the system will stabilise with Medicare taking a sizable chunk of the market. This chunk will be too big for the providers to absorb, forcing many into liquidation. The crisis in health care created by this will force the government to buy out major hospital groups (bailouts, anyone?), effectively forming the hub of a new state health care system. Some bright spark in government will point out that owning the insurer and the provider is daft and Medicare will then probably implode, forming a true state health system. This last may not happen, as there may be some incentive for private insurers to buy healthcare from the government providers, if it is cheaper. Moderately well-off people will still be able to insure themselves and access private health care. The wealthy will pay for private health care directly. The poor and the elderly will by then be getting used to the rationing system the state will inevitably put in place.

I hope they don’t mind waiting for their healthcare. A long, long time.

We in New Zealand can tell them how that feels…

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Doctors 4, Labtests 0 Jim McVeagh Nov 04

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Latest update on the game of Auckland pathology football is Doctors 4, Labtests 0 as the DHB , supposedly playing for Labtests, scores an own goal. Last night, Counties Manukau DHB chairman, Professor Gregor Coster, said:

“They led us to believe they had a quality and safety system in place from the outset.

“It proved not to be the case. Frankly they lied to us.”

They lied? Does this man not understand that, in terms of multimillion dollar contracts of public money, “they lied to us” is not a viable excuse. Because what it actually means is “We did not pay due diligence in awarding the contract to a complete unknown“. What is being experienced now is the consequences of not understanding the level of risk the DHBs were embarking upon in awarding this contract to a single unestablished entity. It is also highly unlikely that Labtests “lied” in the sense of deliberately mislead. It is possible they were over-optimistic in their appraisals, in fact, it is more or less certain they were. But that is a long way from lying.

It is also certain that Labtests grossly underestimated the antipathy that both the doctors and DML felt towards them. So far in this game the doctors/DML have:

  1. The scalp of the previous Labtests CEO, Ulf Lindskog.
  2. The takeover of quality control by the DHB.
  3. The removal of 10% of the contract to DML.
  4. The DHBs now trying to make out that Labtests was somehow fraudulent in their bid for the contract.

I hope the DHBs have good lawyers because if I was running Labtests I would be planning legal action at this stage, since the DHB has now provided an excellent prima facie case for defamation.

Absurdly, this statement of the DHB has not bought them any sway with the doctors. Dr Tony Hay, of the Mt Eden Medical Centre, told the meeting the real intention of the doctors:

“I would have thought there were grounds to scrub the contract and go back to where we were.”

At this stage, I wonder if that is even possible, let alone desirable.

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Playing Chicken Jim McVeagh Oct 09

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Apparently, Auckland DHB is now going to play an expensive game of Chicken with Labtests. The Herald reports that “Auckland’s district health boards are considering bringing Diagnostic Medlab back into the provision of community laboratory services because of persisting problems with the newcomer Labtests”.

This is silly. If Labtests are providing an inadequate service, they need to be made to lift their game – if necessary, by legal means. Caving in to DML’s fantasies is not going to help at all. I am fairly certain that any attempt by the DHBs to move part of the contract back to DML will meet with an unpleasant legal response. I find it extraordinary unlikely that the DHBs have a clause in the contract which will allow them to do this unchallenged.

Besides, attempting to split the provision of lab services like this will undoubtably cause far more problems than it will fix. If part of the service (say histology) is transferred back to DML, GPs will now have two sets of forms and two lab numbers to remember. AFAIK, MedTech 32 allows only one lab number, so GP’s will have to remember to fill out manual forms for DML. Currently, only the cervical smears need this and it is already a nuisance. Other services will simply cause more confusion.

The other proposal of giving DML a region is even sillier. A good proportion of my patients live outside of the DHB area I am in. I may, or may not have to fill out manual forms for these people. Worse still, there are a group of people who might choose to get their blood test from their place of work. They now may also need a manual form. Or they may be turned away from the blood depot they choose. Or the blood test result may wind up in the same limbo to which many results with the wrong lab number have gone.

Frankly, the Auckland DHBs have made their bed and should simply lie in it. They have insisted on savings in laboratory testing and now they seem to be attempting to back out of it. This will only cost them every cent that they have saved and then some.

Personally, I would have abandoned the tender system and gone for a negotiated very low fee for service offered to both DML and Labtests with co-payments allowed. At least the cost-shifting to patients would be transparent and the Auckland DHB lab could have taken any people who could not afford even a small co-payment. Or the DHBs could have absorbed these co-payments for high user and community services card holders.

This would have allowed Labtests to enter the market more slowly, one region at a time, and also allowed proper competition. But, of course, competition is a dirty word to most of the people who serve on DHBs.

Ah well, only another 6 year and 8 months to go on the Labtests contract. Then we can try it the proper way.