In "Big Med," his latest article on health care in The New Yorker, surgeon-writer Atul Gawande added the Cheesecake Factory to his running list of health care analogies (which have included, among others, farming, pit crews, and airline safety). Observing that the Cheescake Factory and other upscale restaurant chains successfully lower costs and improve quality by "studying what the best people are doing, figuring out how to standardize it, and bringing everyone in to execute," Gawande asked why this strategy couldn't be applied to fix the shocking amount of disorganization and waste that exists in U.S. health care:
This is not at all the normal way of doing things in medicine. ... But it’s exactly what the new health-care chains are now hoping to do on a mass scale. They want to create Cheesecake Factories for health care. The question is whether the medical counterparts to Mauricio at the broiler station—the clinicians in the operating rooms, in the medical offices, in the intensive-care units—will go along with the plan. Fixing a nice piece of steak is hardly of the same complexity as diagnosing the cause of an elderly patient’s loss of consciousness. Doctors and patients have not had a positive experience with outsiders second-guessing decisions. How will they feel about managers trying to tell them what the “best practices” are?
The Cheescake Factory model of quality and cost control may work well in intensive care units, where, despite the how sick the patients are, there are a finite number of clinical situations that are for the most part amenable to evidence-based protocols (e.g., how to safely insert or remove a central line, what to do for a patient in respiratory failure). That's not the case for much of family medicine, where aside from health maintenance and hospital follow-up visits, patients generally present with undifferentiated problems. (See my previous post on how checklists could be used to avoid diagnostic errors.)
I have spent time in one area of family medicine that functions with restaurant-ish efficiency, however: the urgent care setting. In between leaving my non-clinical position at AHRQ and returning to academic medicine full-time, I moonlighted at a respected chain of urgent care centers, where patients receive walk-in care for minor illnesses such as respiratory infections, sprains and strains, and uncomplicated lacerations. The layout of each facility was identical, so that a clinician, nurse, medical assistant, laboratory assistant, radiology technician, etc. could seamlessly fill in at any location. Senior physicians had integrated evidence-based protocols into the electronic medical record for almost every conceivable clinical situation that physicians might encounter, suggesting medications, follow-up studies, and referrals depending on the diagnosis. Physicians regularly received feedback on their quality of care and were sometimes followed on selected shifts by an "efficiency expert" (typically a registered nurse) who observed them in action and made suggestions about how to improve their performance.
Most patients, accustomed to long waits for doctors' appointments and the glacial speed of the emergency room for non-critical medical problems, left the center satisfied. So why not extend this model to non-urgent primary care? Well, we profited for the most part from dealing with patients with clearly defined complaints who wanted quick fixes rather than long-term healing relationships. Put another way, seeing me for care was something like visiting a McDonalds - a predictable and satisfying experience, but one that you don't want to have on regular basis (much less every day for a month, like Morgan Spurlock in the 2004 documentary Super Size Me).
Like entering a sit-down restaurant that you've never visited before, meeting a new primary care physician is more of a gamble than going out for fast food. Your expectations are higher, and the possibility of disappointment far greater. But the payoff, if you're fortunate, will be better health and improved quality of life, as documented in detail by researchers such as the late Barbara Starfield. The trouble is that today's U.S. health environment consistently pays the best family physicians (Gawande's equivalent of Cheesecake Factory managers) the equivalent of McDonalds wages: my hourly take-home pay was about one and a half times higher doing urgent care than it is today, doing mostly primary care. So it's no wonder that medical students continue to pass on family medicine.
Monday, August 13, 2012
Sunday, August 12, 2012
The best recent posts you may have missed
Every other month or so, I post a list of my top 5 favorite posts since the preceding "best of" list on this blog, for those of you who have only recently started reading Common Sense Family Doctor or don't read it regularly. Here are my favorites from the past few months:
1) Changing unhealthy habits requires changing environments (6/4/12)
2) The best colorectal cancer screening test is the one that gets done (5/21/12)
3) The end of the line on PSA screening (7/11/12)
4) How would you rate your health care team? (6/7/12)
If you have a personal favorite that isn't on this list, please let me know. Thanks for reading!
1) Changing unhealthy habits requires changing environments (6/4/12)
2) The best colorectal cancer screening test is the one that gets done (5/21/12)
3) The end of the line on PSA screening (7/11/12)
4) How would you rate your health care team? (6/7/12)
If you have a personal favorite that isn't on this list, please let me know. Thanks for reading!
Friday, August 10, 2012
The FDA, social media, and Big Pharma - Part 2 of 2
This is the second of two posts that outlines my view of the approach that the FDA should take in regulating pharmaceutical promotion in social media. Part 1 is available here.
Another critical element that may determine how involved the industry can be in promoting products through social media outlets is the FDA’s interpretation of manufacturers’ obligations to report prescription adverse events in online discussions that they monitor. The scope of such a task may be more manageable than it seems. In 2008, the Nielsen Company analyzed 500 randomly selected healthcare-related messages on non-pharmaceutical social media sites and found that only one satisfied the FDA’s four standard adverse event reporting requirements (specific medication, adverse experience, identifiable patient, and identifiable reporter). A subsequent analysis estimated that social media generate only 166 reportable adverse events per day across the entire industry, with even the best-selling brand name medications generating fewer than 100 “mentions” each day.
AstraZeneca recently distributed a “white paper” on social media that proposed five principles for guiding the company’s social media activities: ensuring truth and accuracy; respectful participation; protection of patient health; transparency; and tolerance of differing views. It also suggested that in regulating social media activities, the FDA should distinguish between three levels of communications: company-controlled and hosted, such as on company websites; company-controlled communications provided on other websites; real-time communications such as chat rooms and blog comments. AstraZeneca argued that in general, manufacturers should be held most accountable for the first two types of communications and least accountable for the latter.
Ultimately, the FDA’s decision will depend on its assessment of the potential public health benefits and harms of allowing limited or unlimited engagement of pharmaceutical companies in social media for product promotion purposes. As was the case in 1997, when the FDA modified its stance on broadcast DTCA, there is little empiric evidence to indicate that the benefits will necessarily outweigh the harms, or vice versa.
Policy Options
1) Outright Ban – This option would prohibit pharmaceutical companies from using social media for direct product promotion. Companies would be allowed to host and/or support websites that provide news about company activities or general disease information that does not reference particular products.
2) Restrictive Option – Pharmaceutical companies would be permitted to advertise products via social media, but all such activities would be subject to strict FDA oversight and approval, guided by existing regulations regarding “fair balance” in broadcast DTCA. All company communications, on sponsored or independent websites, must be transparent about their source. In addition, companies that chose to engage consumers in conversations about their products would take on the responsibility of monitoring for, and reporting, all adverse events on those websites.
3) Permissive Option – This option would permit pharmaceutical companies to promote their products in any social media outlet without limits, as long as the content provided was factually accurate. “Fair balance” rules would only apply to content posted on company-sponsored websites. Adverse event reporting to the FDA from other websites would be encouraged, but voluntary.
Discussion
The Permissive Option, by continuing the status quo of no explicit FDA regulation of social media, is administratively the most feasible. However, it is likely to have a significant public health impact by encouraging pharmaceutical companies to intensify DTCA of products via social media, increasing requests for (and, probably, prescribing of) promoted medications. The experience of DTCA broadcast ads suggests that health professionals will have mixed responses, and patients will generally support having access to more information about diseases and treatments.
The Outright Ban Option would require a greater investment in administrative resources initially, as many current pharmaceutical industry activities would need to be discontinued to comply with the new policy. In addition, there would be a continuing need to monitor health care social media sites to enforce the blanket restrictions. The public health impact of this option is uncertain, and it may prove unpopular with patients.
The Restrictive Option would require a substantial investment in administrative resources, since it contains the most specific guidance and would require staff to create and apply objective criteria to determine if a specific social media activity is permitted or not (rather than “all are permitted” or “none are permitted”). Although the rationale for regulating product promotions is to encourage social media activities that are likely to benefit the public health and discourage harmful activities, these benefits and harms would be theoretical and initially very subjective. I anticipate that health professionals and patients would be for the most part satisfied with this option. I recommend that the FDA Administrator select the Restrictive Option. Although it poses some administrative challenges, it strikes a balance between too much and too little regulation and is most likely to lead to improvements in public health.
**
Another critical element that may determine how involved the industry can be in promoting products through social media outlets is the FDA’s interpretation of manufacturers’ obligations to report prescription adverse events in online discussions that they monitor. The scope of such a task may be more manageable than it seems. In 2008, the Nielsen Company analyzed 500 randomly selected healthcare-related messages on non-pharmaceutical social media sites and found that only one satisfied the FDA’s four standard adverse event reporting requirements (specific medication, adverse experience, identifiable patient, and identifiable reporter). A subsequent analysis estimated that social media generate only 166 reportable adverse events per day across the entire industry, with even the best-selling brand name medications generating fewer than 100 “mentions” each day.
AstraZeneca recently distributed a “white paper” on social media that proposed five principles for guiding the company’s social media activities: ensuring truth and accuracy; respectful participation; protection of patient health; transparency; and tolerance of differing views. It also suggested that in regulating social media activities, the FDA should distinguish between three levels of communications: company-controlled and hosted, such as on company websites; company-controlled communications provided on other websites; real-time communications such as chat rooms and blog comments. AstraZeneca argued that in general, manufacturers should be held most accountable for the first two types of communications and least accountable for the latter.
Ultimately, the FDA’s decision will depend on its assessment of the potential public health benefits and harms of allowing limited or unlimited engagement of pharmaceutical companies in social media for product promotion purposes. As was the case in 1997, when the FDA modified its stance on broadcast DTCA, there is little empiric evidence to indicate that the benefits will necessarily outweigh the harms, or vice versa.
Policy Options
1) Outright Ban – This option would prohibit pharmaceutical companies from using social media for direct product promotion. Companies would be allowed to host and/or support websites that provide news about company activities or general disease information that does not reference particular products.
2) Restrictive Option – Pharmaceutical companies would be permitted to advertise products via social media, but all such activities would be subject to strict FDA oversight and approval, guided by existing regulations regarding “fair balance” in broadcast DTCA. All company communications, on sponsored or independent websites, must be transparent about their source. In addition, companies that chose to engage consumers in conversations about their products would take on the responsibility of monitoring for, and reporting, all adverse events on those websites.
3) Permissive Option – This option would permit pharmaceutical companies to promote their products in any social media outlet without limits, as long as the content provided was factually accurate. “Fair balance” rules would only apply to content posted on company-sponsored websites. Adverse event reporting to the FDA from other websites would be encouraged, but voluntary.
Discussion
The Permissive Option, by continuing the status quo of no explicit FDA regulation of social media, is administratively the most feasible. However, it is likely to have a significant public health impact by encouraging pharmaceutical companies to intensify DTCA of products via social media, increasing requests for (and, probably, prescribing of) promoted medications. The experience of DTCA broadcast ads suggests that health professionals will have mixed responses, and patients will generally support having access to more information about diseases and treatments.
The Outright Ban Option would require a greater investment in administrative resources initially, as many current pharmaceutical industry activities would need to be discontinued to comply with the new policy. In addition, there would be a continuing need to monitor health care social media sites to enforce the blanket restrictions. The public health impact of this option is uncertain, and it may prove unpopular with patients.
The Restrictive Option would require a substantial investment in administrative resources, since it contains the most specific guidance and would require staff to create and apply objective criteria to determine if a specific social media activity is permitted or not (rather than “all are permitted” or “none are permitted”). Although the rationale for regulating product promotions is to encourage social media activities that are likely to benefit the public health and discourage harmful activities, these benefits and harms would be theoretical and initially very subjective. I anticipate that health professionals and patients would be for the most part satisfied with this option. I recommend that the FDA Administrator select the Restrictive Option. Although it poses some administrative challenges, it strikes a balance between too much and too little regulation and is most likely to lead to improvements in public health.
References
1. AstraZeneca. White paper: social media in the pharmaceutical industry. December 2010. Available at: http://www.astrazeneca-us.com/_mshost795281/content/media/AZ_Social_Media_White_Paper.pdf. Accessed February 14, 2011.
2. Davies, M. White paper: listening to consumers in a highly regulated environment: how pharmaceutical manufacturers can leverage consumer-generated media. The Nielsen Company, August 2008. Available at: http://blog.nielsen.com/nielsenwire/wp-content/uploads/2009/11/Nielsen-Online-Healthcare-Practice_Social-Media-Adverse-Event-Reporting_nov09.pdf. Accessed February 14, 2011.
3. Donohoe, J. A history of drug advertising: the evolving roles of consumers and consumer protection. Milbank Quarterly 2006;84:659-99.
4. Frosch DL, Grande D, Tam DM, Kravitz RL. A decade of controversy: balancing policy with evidence in the regulation of prescription drug advertising. Am J Public Health 2010;100:24-32.
5. Greene JA, Kesselheim AS.
6. Kravitz RL, Epstein RM, Feldman MD, et al. Influence of patients’ requests for direct-to-consumer advertised antidepressants: a randomized controlled trial. JAMA 2005;293:1995-2002.
7. Kupchuk A, Madagan K. FDA policy on social media and product promotion. Corporate Compliance Insights Blog. Posted June 7, 2010. Available at: http://www.corporatecomplianceinsights.com/2010/fda-policy-social-media-product-promotion/
8. Richman, J. Monitoring adverse events for pharma’s biggest brands: hopeless task or simple project? Dose of Digital Blog. Posted December 8, 2009. Available at: http://www.doseofdigital.com/2009/12/monitoring-adverse-events-social-media-pharmas-biggest-brands/
9. Richman, J. Dose of Digital Pharma and Healthcare Social Media Wiki. Last updated September 10, 2010. Available at: http://www.doseofdigital.com/healthcare-pharma-social-media-wiki/
10. Webb, S. Drug marketing and the new media. Nature Biotechnology 2010;5:396-98.
Thursday, August 9, 2012
The FDA, social media, and Big Pharma - Part 1 of 2
Last December, more than two years after first holding public hearings on the promotion of medical drugs and devices via social media, the U.S. Food and Drug Administration finally released draft guidance to pharmaceutical companies on the very narrow topic of responding to unsolicited requests for information on off-label uses of their products. Citing limited resources to explain their glacial progress on this critical guidance, the FDA's website states:
Taking into consideration the input from within and outside FDA, ... we have identified the following issues that are important to address: responding to unsolicited requests; fulfilling regulatory requirements when using tools associated with space limitations; fulfilling post-marketing submission requirements; on-line communications for which manufacturers, packers, or distributors are accountable; use of links on the Internet; and correcting misinformation. We are developing multiple draft guidances to address these topics to benefit industry and the public by ensuring that these draft guidances are meaningful and well thought out when they are issued.
Direct communication between the pharmaceutical industry and patients is increasingly common. An important milestone in direct-to-consumer advertising (DTCA) was the 1995 FDA hearings, at which pharmaceutical companies requested that the FDA clarify the conditions under which broadcast advertisements need not include a brief summary of benefits and risks from the approved product label. The FDA subsequently stated that these advertisements could instead send consumers to a website, toll-free telephone number, print advertisements, or health professionals for this information. Overall pharmaceutical spending on DTCA then shifted from predominantly print to broadcast advertisements and rose from $1.3 billion in 1998 to $4.9 billion in 2007.
While the pharmaceutical industry has consistently argued that DTCA empowers patients by providing information on potentially undiagnosed health conditions and enabling them to initiate conversations with their physicians about treatments, physicians and physician groups have expressed concerns that DTCA would lead patients to request, and doctors to fulfill, inappropriate prescriptions. Limited evidence on the effect of DTCA on prescribing practices, including a single randomized controlled trial of DTCA for antidepressants suggests that DTCA increases prescribing of advertised medications in general, both for appropriate and inappropriate indications.
A survey conducted by the National Consumers League in 2002 indicated that most consumers did not agree that ads for prescription drugs should be restricted to medical journals. These results may reflect changing societal attitudes about the extent to which patients ought to be involved in making their own health care decisions, and the degree to which health information needs to be filtered through physicians.
Social media websites such as blogs, Facebook, and Twitter differ from static web pages in allowing multiple participants to exchange information, ideas, and opinions in real time. The proliferation of social media tools over the past decade has created new opportunities for unmoderated dialogue between health professionals, pharmaceutical companies, and the public, as well as the rapid dissemination (“going viral”) of health-related content to a broad and diverse audience.
Despite the FDA’s stated intention to issue guidance on permissible uses of social media, the pharmaceutical industry has already established or is involved in many online communities relevant to their products. Some examples of pharmaceutical-sponsored social media websites are a Pfizer-authored blog “forum about science and medicine,” Think Science Now; a GlaxoSmithKline-supported “community” for users of its over-the-counter weight-loss drug Alli; and a Boehringer Ingelheim Facebook page that “is not intended as a forum to discuss technical queries regarding specific pharmaceutical products.” Every major drug manufacturer has an active Twitter account, and most have created one or more mobile phone applications.
Although the FDA’s experience with regulating DTCA can help inform its guidance to the pharmaceutical industry regarding social media, the scope of social media communication is considerably larger than advertising alone. Social media channels are varied, evolving, and for the most part, not under direct industry control. Other unresolved issues include how and where to draw the line between company-sponsored media and “independent” websites, as well as the difficulty in determining financial or other conflicts of interest held by health bloggers, many of whom are anonymous.
As a result of the above concerns, social media activities of the pharmaceutical industry generally have not included DTCA. Only 4% of the $4 billion that the industry spent on DTCA in 2008 on the Internet. Further discouraging online advertising, the industry’s previously-held assumption that fair balance requirements could be satisfied with a “one-click” rule (including a direct link to a web page that contained full risk and benefit information), was overturned when the FDA sent warning letters in April 2009 to 14 companies that had posted brief online ads without risk information on search engines.
Taking into consideration the input from within and outside FDA, ... we have identified the following issues that are important to address: responding to unsolicited requests; fulfilling regulatory requirements when using tools associated with space limitations; fulfilling post-marketing submission requirements; on-line communications for which manufacturers, packers, or distributors are accountable; use of links on the Internet; and correcting misinformation. We are developing multiple draft guidances to address these topics to benefit industry and the public by ensuring that these draft guidances are meaningful and well thought out when they are issued.
While Big Pharma and other interested observers continue to hold their breath (or not), here is my take on this topic, drawn from a paper I wrote last year. Sources are listed in Part 2 of this post.
**
Direct communication between the pharmaceutical industry and patients is increasingly common. An important milestone in direct-to-consumer advertising (DTCA) was the 1995 FDA hearings, at which pharmaceutical companies requested that the FDA clarify the conditions under which broadcast advertisements need not include a brief summary of benefits and risks from the approved product label. The FDA subsequently stated that these advertisements could instead send consumers to a website, toll-free telephone number, print advertisements, or health professionals for this information. Overall pharmaceutical spending on DTCA then shifted from predominantly print to broadcast advertisements and rose from $1.3 billion in 1998 to $4.9 billion in 2007.
While the pharmaceutical industry has consistently argued that DTCA empowers patients by providing information on potentially undiagnosed health conditions and enabling them to initiate conversations with their physicians about treatments, physicians and physician groups have expressed concerns that DTCA would lead patients to request, and doctors to fulfill, inappropriate prescriptions. Limited evidence on the effect of DTCA on prescribing practices, including a single randomized controlled trial of DTCA for antidepressants suggests that DTCA increases prescribing of advertised medications in general, both for appropriate and inappropriate indications.
A survey conducted by the National Consumers League in 2002 indicated that most consumers did not agree that ads for prescription drugs should be restricted to medical journals. These results may reflect changing societal attitudes about the extent to which patients ought to be involved in making their own health care decisions, and the degree to which health information needs to be filtered through physicians.
Social media websites such as blogs, Facebook, and Twitter differ from static web pages in allowing multiple participants to exchange information, ideas, and opinions in real time. The proliferation of social media tools over the past decade has created new opportunities for unmoderated dialogue between health professionals, pharmaceutical companies, and the public, as well as the rapid dissemination (“going viral”) of health-related content to a broad and diverse audience.
Despite the FDA’s stated intention to issue guidance on permissible uses of social media, the pharmaceutical industry has already established or is involved in many online communities relevant to their products. Some examples of pharmaceutical-sponsored social media websites are a Pfizer-authored blog “forum about science and medicine,” Think Science Now; a GlaxoSmithKline-supported “community” for users of its over-the-counter weight-loss drug Alli; and a Boehringer Ingelheim Facebook page that “is not intended as a forum to discuss technical queries regarding specific pharmaceutical products.” Every major drug manufacturer has an active Twitter account, and most have created one or more mobile phone applications.
Although the FDA’s experience with regulating DTCA can help inform its guidance to the pharmaceutical industry regarding social media, the scope of social media communication is considerably larger than advertising alone. Social media channels are varied, evolving, and for the most part, not under direct industry control. Other unresolved issues include how and where to draw the line between company-sponsored media and “independent” websites, as well as the difficulty in determining financial or other conflicts of interest held by health bloggers, many of whom are anonymous.
As a result of the above concerns, social media activities of the pharmaceutical industry generally have not included DTCA. Only 4% of the $4 billion that the industry spent on DTCA in 2008 on the Internet. Further discouraging online advertising, the industry’s previously-held assumption that fair balance requirements could be satisfied with a “one-click” rule (including a direct link to a web page that contained full risk and benefit information), was overturned when the FDA sent warning letters in April 2009 to 14 companies that had posted brief online ads without risk information on search engines.
Tuesday, August 7, 2012
Breastfeeding is the infant's best medicine
In honor of World Breastfeeding Week, which ends today, I am re-posting a post I wrote two years ago about breast milk being the "next all-natural blockbuster drug."
**
Pharmaceutical companies and their shareholders are always looking for the next "blockbuster" drug, the label given to a drug that generates more than $1 billion of revenue per year. Blockbuster drugs don't necessarily have to save many (or any) lives - slick marketing more than compensates for marginal improvements in treatment efficacy - but they do need to target conditions that are common enough that millions of patients will buy them. In adults, such conditions include osteoporosis, high cholesterol, and arthritis.
The reason that there have been few, if any, blockbuster drugs for children is that the vast majority of children are healthy. But what if medical science discovered a drug that was proven conclusively to prevent or reduce the risk of a variety of common and uncommon childhood illnesses, including ear infections, gastroenteritis, respiratory infections, eczema, asthma, diabetes, obesity, and even sudden infant death syndrome? A recent cost analysis published in a leading pediatric research journal suggested that giving this drug to 90% of U.S. children for the first 6 months of life could potentially save the lives of more than 900 infants and $13 billion per year. How much do you think people would be willing to pay for this miracle drug? Enough that it could potentially become the first pediatric blockbuster - that is, if breast milk wasn't already free.
Although the American Academy of Pediatrics recommends that mothers exclusively breastfeed infants for the first 6 months of life, and supports continuing breastfeeding to at least one year of age, data from the 2004-2008 National Immunization Survey document that only 73% of U.S. women attempt to breastfeed after birth, and only 42% and 21% are still breasfeeding at 6 and 12 months of life. The numbers are even more discouraging for Black women: only 54% attempt breastfeeding, and just 27% and 11% are still doing so at 6 and 12 months.
Pediatricians and family physicians work diligently to convince women to breastfeed their babies and to continue as long as they can to reap the numerous health benefits (which include a reduced risk of type 2 diabetes, breast, and ovarian cancer for mom), but they are often frustrated in these efforts by health system and employment obstacles. Hospitals commonly distribute free formula or branded diaper bags (my son, who never drank a drop of infant formula, nonetheless went home with a free bag courtesy of Enfamil) and interrupt critical early attempts at breastfeeding with tests and other procedures. Upon returning to the workplace, many moms find that the only private place to pump and store breast milk is a bathroom.
However, a new provision in the health reform bill will for the first time require that U.S. employers (even those with fewer than 50 employees) provide regular breaks and a private space for female employees who need to express breast milk. Small employers who may initially feel that this new requirement is an "undue hardship" should consider the lower health costs (and lower insurance premiums) that should result from more infants consuming this all-natural blockbuster drug.
**
Pharmaceutical companies and their shareholders are always looking for the next "blockbuster" drug, the label given to a drug that generates more than $1 billion of revenue per year. Blockbuster drugs don't necessarily have to save many (or any) lives - slick marketing more than compensates for marginal improvements in treatment efficacy - but they do need to target conditions that are common enough that millions of patients will buy them. In adults, such conditions include osteoporosis, high cholesterol, and arthritis.
The reason that there have been few, if any, blockbuster drugs for children is that the vast majority of children are healthy. But what if medical science discovered a drug that was proven conclusively to prevent or reduce the risk of a variety of common and uncommon childhood illnesses, including ear infections, gastroenteritis, respiratory infections, eczema, asthma, diabetes, obesity, and even sudden infant death syndrome? A recent cost analysis published in a leading pediatric research journal suggested that giving this drug to 90% of U.S. children for the first 6 months of life could potentially save the lives of more than 900 infants and $13 billion per year. How much do you think people would be willing to pay for this miracle drug? Enough that it could potentially become the first pediatric blockbuster - that is, if breast milk wasn't already free.
Although the American Academy of Pediatrics recommends that mothers exclusively breastfeed infants for the first 6 months of life, and supports continuing breastfeeding to at least one year of age, data from the 2004-2008 National Immunization Survey document that only 73% of U.S. women attempt to breastfeed after birth, and only 42% and 21% are still breasfeeding at 6 and 12 months of life. The numbers are even more discouraging for Black women: only 54% attempt breastfeeding, and just 27% and 11% are still doing so at 6 and 12 months.
Pediatricians and family physicians work diligently to convince women to breastfeed their babies and to continue as long as they can to reap the numerous health benefits (which include a reduced risk of type 2 diabetes, breast, and ovarian cancer for mom), but they are often frustrated in these efforts by health system and employment obstacles. Hospitals commonly distribute free formula or branded diaper bags (my son, who never drank a drop of infant formula, nonetheless went home with a free bag courtesy of Enfamil) and interrupt critical early attempts at breastfeeding with tests and other procedures. Upon returning to the workplace, many moms find that the only private place to pump and store breast milk is a bathroom.
However, a new provision in the health reform bill will for the first time require that U.S. employers (even those with fewer than 50 employees) provide regular breaks and a private space for female employees who need to express breast milk. Small employers who may initially feel that this new requirement is an "undue hardship" should consider the lower health costs (and lower insurance premiums) that should result from more infants consuming this all-natural blockbuster drug.
Thursday, August 2, 2012
Making wiser choices about medical tests and treatments
"Sometimes, the hardest thing for a physician to do is nothing," observed my colleague Jay Siwek, MD in a recent editorial in American Family Physician. "And although patients are sometimes a source of excess utilization, physicians, responding to conventional practices, current fads, and the rituals of medicine, often order tests or treatments that don’t stand up to clinical scrutiny. How do we do better? How do we know not only what to do, but also what not to do?"
The editorial compiles family medicine-relevant items from the multi-specialty Choosing Wisely campaign that aims to reduce the provision of "unnecessary" care, defined as medical tests and treatments that offer no health benefits and may result in harm to patients. Based on trusted sources of evidence-based medicine such as the U.S. Preventive Services Task Force, the Cochrane Database of Systematic Reviews, and Essential Evidence Plus, these "don't do" recommendations have the potential to save both lives and money, if they can be effectively put into practice. To inform patients about the campaign, Consumer Reports has created fact sheets about many of the included items.
Reactions to the Choosing Wisely campaign in the blogosphere have been varied. Calling it "the health reform we need," cardiologist John Mandrola writes, "I hope it sticks like super glue." On the other side, emergency physician William Sullivan argues that the campaign "has good intentions, but isn't a good idea," noting that "there isn’t a Suing Wisely campaign for attorneys and there isn’t a Legislating Wisely campaign for Congress." Similarly, family physician Mike Sevilla contends that while Choosing Wisely may "score political points" for sponsoring physician organizations, it is unlikely to change their members' behavior, which is also driven by patient demands and fears of lawsuits over interventions not taken. Where do you stand on this spectrum of opinions? Is the Choosing Wisely campaign good or bad for patients, or perhaps some of both?
**
A slightly different version of this post first appeared on the AFP Community Blog.
The editorial compiles family medicine-relevant items from the multi-specialty Choosing Wisely campaign that aims to reduce the provision of "unnecessary" care, defined as medical tests and treatments that offer no health benefits and may result in harm to patients. Based on trusted sources of evidence-based medicine such as the U.S. Preventive Services Task Force, the Cochrane Database of Systematic Reviews, and Essential Evidence Plus, these "don't do" recommendations have the potential to save both lives and money, if they can be effectively put into practice. To inform patients about the campaign, Consumer Reports has created fact sheets about many of the included items.
Reactions to the Choosing Wisely campaign in the blogosphere have been varied. Calling it "the health reform we need," cardiologist John Mandrola writes, "I hope it sticks like super glue." On the other side, emergency physician William Sullivan argues that the campaign "has good intentions, but isn't a good idea," noting that "there isn’t a Suing Wisely campaign for attorneys and there isn’t a Legislating Wisely campaign for Congress." Similarly, family physician Mike Sevilla contends that while Choosing Wisely may "score political points" for sponsoring physician organizations, it is unlikely to change their members' behavior, which is also driven by patient demands and fears of lawsuits over interventions not taken. Where do you stand on this spectrum of opinions? Is the Choosing Wisely campaign good or bad for patients, or perhaps some of both?
**
A slightly different version of this post first appeared on the AFP Community Blog.
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