changes in mammogram screening – here we go again

As a follow up to my post yesterday on dense breasts, the US Preventative Services Task Force issued draft recommendations on Monday for mammogram screening.

The panel recommended that while routine screening brings little benefit to women in their 40’s, routine screening should begin at age 50 and occur every two years.  Screening at age 40 is a personal choice, should be determined based on a woman’s risk, and that women should weigh the pros and cons of screening in concert with their physician.  Furthermore, the panel stated that there was no evidence to suggest that women with dense breasts need extra testing.

The draft is largely a rewording of the controversial 2009 recommendations that questioned the usefulness of mammograms in the 40s.  Compared with biennial mammograms for average-risk women, starting at age 40 instead of 50 could prevent one additional death but lead to 576 more false alarms for every 1,000 women screened. Age aside, the report from the US Preventative Services Task Force estimated nearly 1 in 5 women whose tumor was detected by a screening mammogram may be overdiagnosed.

In other news, the American Cancer Society currently is updating its own mammography guidelines, due out later this year, to include the latest evidence on age questions.

Monday’s task force recommendation is a draft open for public comment through May 18, at http://www.screeningforbreastcancer.org.

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You Have Dense Breasts. Now What?

Last week, Kaiser Health News shed the light on a little known law that requires women who have undergone a routine screening mammogram to be notified if they have “dense breasts”.  Written by Barbara Feder Ostrov, the article titled “So You Have Dense Breasts.  Now What?” stems from the growing controversy over dense breast notification laws which are currently in place in 21 states, under consideration in another 11 states, and even reaching Congress.  The laws raise any many questions as they answer, but the ultimate question of what happens next is vexing policy makers, physicians, and most importantly the very women the law was meant to aide.

In 2004, Nancy Cappello was diagnosed with stage 3 breast cancer.  Cappello hadn’t been told that her mammograms showed dense breast tissue, and since her diagnosis she strongly advocated for a new law in her home state of Connecticut.  The new law was the first of its kind, defining dense breasts as containing more than 50% fibroglandular (as opposed to fatty) tissue, requiring physicians to offer supplemental whole-breast ultrasound to women with dense breasts, and mandating that insurers cover the additional screening.  Ever since there has been a growing movement to educate women about breast density, the risk of breast cancer with dense breasts and the potential role of supplemental screening for breast cancer.  About 40% of women have dense or extremely dense breast tissue, which can obscure cancer that might otherwise be detected on a mammogram.  The laws therefore have the potential to affect thousands of women.

Advocates have hailed the laws as empowering women to take charge of their own health and note the benefits that additional screening may have for these women.  Critics, on the other hand, see numerous flaws in the new laws despite their good intentions.  Among the critiques include higher costs, unnecessary anxiety, increasing numbers of unnecessary invasive testing, and treatments that may not save lives or benefit patients.  Some worry that the laws may be doing more harm than good.  Additionally, the laws vary from state to state; for example, California and many other states require notification but do not require supplemental screening – leaving a woman who received a notification letter in limbo about what to do next.

The root of the problem?  There is no medical consensus on whether routine supplemental screening for women with dense breasts is worthwhile. For example, a study in Connecticut performed shortly its notification law went into effect found that supplemental screening was successful in finding more cancers; however, only about three cancers were discovered per 1000 women screened, and the likelihood was low of finding life-threatening cancers.  Critics point out that testing different approaches for screening women with dense breasts should be done first and then pass legislation once a consensus has been reached, and not the other way around.

Notification laws add to the already super-charged controversy over breast cancer screening ever since 2009 when the US Preventative Services Task Force changed its recommendations and voted against yearly mammography.  Organizations like the American Cancer Society and the American College of Obstetrics and Gynecology viewed the move as “rationing” women’s health care, stating that mammography should begin at 40 and continue annually.  These aren’t trivial matters either, breast cancer is the second most common form of cancer among American women and the second leading cause of cancer death. An estimated 231,840 U.S. women will be diagnosed with invasive breast cancer in 2015, and women with moderately dense breasts have about a 20% higher chance of getting breast cancer than women who don’t. Those with the highest-density breasts have about double. To put the numbers into perspective, if an average 50-year-old woman has a 2.38% change of getting cancer in the next 10 years of her life, a woman with the highest density breasts would have a nearly 5% chance of being diagnosed.

But advocates for the US Preventative Services Task Force’s move point out that mammography is far from perfect.  Older studies of women who had mammograms in their 40’s suggest that the test reduces mortality by as much as 30 to 40%, but newer research has decreased that benefit to around 15%. Researchers broke down the numbers as follows: if 10,000 women aged 40 have mammograms every year for ten years, an estimated 190 will be diagnosed with breast cancer. Of those, the test will save about 5. Roughly 30 will die because their cancer will prove too aggressive. For the rest, mammography won’t make a difference, in large part because their cancers are slower growing, will never become invasive, or because treatments have improved, making early discovery through mammography less urgent. Due to the false positive rate of mammography, more than 6,000 of the cancer-free women will be called back with at least one false positive in ten years likely resulting in unnecessary biopsies. Any abnormalities that are found will almost certainly be treated as if they could be deadly, exposing women to radiation, surgery, chemo, and hormone therapy, all of which have their own set of risks.

The bottom line is that informing women of breast density may empower them and create informed decision makers, but on the other hand being informed requires telling them the risks and benefits of that new knowledge.

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Grading your doctor/hospital may be killing you

The Atlantic recently released an article “The Problem With Satisfied Patients” written by Alexandra Robbins covering the idea that patient satisfaction should be used as a indicator of health care quality.  In the era of increasing focus on “patient centered care”, the Centers for Medicare and Medicaid Services (CMS) decided rather reasonably that the “delivery of high-quality, patient-centered care requires us to carefully consider the patient’s experience in the hospital inpatient setting.”  Like many of the government’s ideas with regard to health care, the intent was good but the consequences potentially dire.

In order to enforce the idea, CMS decided that a proportion of hospitals’ Medicare reimbursement would be based on patient satisfaction survey scores.  This was codified into law with the Affordable Care Act, which implemented a policy withholding 1% of total Medicare reimbursements to the tune of roughly $850 million.  Hospitals with high satisfaction scores would earn the money back, the top performers would received a bonus, and poor performers would lose out on a significant portion of revenue.

It really does make sense – patients receiving high quality care must be satisfied with the care they are receiving.  Right?  Well… not exactly.  Listen, no one doubts the importance of satisfaction surveys, but if you’ve ever browsed through Yelp or TripAdvisor – you’ll notice a wide variety of what people consider to be “quality” when it comes to commercial services like restaurants or hotel stays.  The problem is that we aren’t talking about the amount of cheese on your pizza or what the thread count of hotel linens but rather your health and safety.  No one is arguing that healthcare needs to be drastically improved, but you can imagine the great variety of subjective scores hospitals receive – and the resulting financial implications.  The problem ultimately is that the scores are leading hospitals to shift the focus from a patient’s health to patient satisfaction, and that patient satisfaction surveys may actually be negatively affecting patient care and therefore people’s lives.

The majority of the patient satisfaction survey, known as HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems), addresses care provided by nurses or nursing ancillary staff.  As Robbins points out in The Atlantic, one of the questions on the survey asks, “During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?”  But the question doesn’t specify why help was needed and if that help was medically necessary.  Certainly, a patient having chest pain would require help right away, while one requiring an additional pillow may be able to wait a few minutes. Alexandra Robbins notes,

Patients have complained on the survey, which in previous incarnations included comments sections, about everything from ‘My roommate was dying all night and his breathing was very noisy’ to ‘The hospital doesn’t have Splenda.’ […] An Oregon critical-care nurse had to argue with a patient who believed he was being mistreated because he didn’t get enough pastrami on his sandwich (he had recently had quadruple-bypass surgery).

Ok, so maybe the survey became a forum for people to complain, much like lacking Splenda may negatively affect the rating at a restaurant or Starbucks.  But satisfied patients may not be suffering only from unrealistic expectations for their care, they may be suffering from overuse of the medical system.  Studies have noted that patients who report being more satisfied with their physician have higher healthcare and prescription costs, are more likely to be hospitalized, and are significantly more likely to die within the next four years.  Putting too much focus on what patients want may mean they get more of what they don’t need and not enough of what they do.  But when reimbursement is closely tied to patient happiness, it begs the question… does patient-centeredness really mean that clinicians should give patients what they want even if they don’t need it?  And at what other cost?  Evaluating care in terms of its ability to make patients happy may force systems to do things they cant at the expense of what they should.

An even greater peril in basing quality on care on patient satisfaction is that patient’s don’t actually know what constitutes quality care.  That’s not meant to be insulting or denigrating to the public at large.  The problem stems from a few reasons – one is that government, hospitals, and providers already struggle with defining “quality of care” and then turning those definitions into quantities that can be measured and acted on.  The other is due to the natural imbalance of information between patient and provider – patients don’t know what they need.  Obviously, a quality physician/nurse/etc should provide that information, thereby creating an informed, prepared patient – but sometimes that information may not be received so well.  Sometimes hearing bad news is not going to result in a satisfied patient but at least they are well-informed.

Perhaps the biggest downside of patient satisfaction surveys is that they turn patients into customers.  Don’t get me wrong, on some level this is a good idea, especially when the discussion revolves around the cost of care compared to the quality of care; in fact, turning patients into consumers is one of the avenues to reducing the overall costs of care.  That of course requires greater transparency in medicine, but the idea of focusing on “patient experience” has, as Robbins points out “mischaracterized patients as customers and nurses as automatons.”  By treating patients like customers, hospitals are inadvertently making patients feel like “the customer is always right.”  Due to the information imbalance in medicine, the patient actually cannot always be right.  Hospitals have spent thousands of dollars on hiring “customer-service representatives” in order to ensure the comfort of their patients, yet the unfortunate truth is that medicine isn’t always comfortable; in fact it can often be painful both mentally and physically, and sometimes necessarily so.

The ultimate tragedy is that some hospitals receive high patient-satisfaction ratings and unfortunately offer extremely poor care.  In her article, Robbins researched the hospitals that perform worse than the national average on three or more patient outcome measures – things like being readmitted to the hospital, suffering serious complications during an inpatient stay or mortality rate.  Nearly two thirds of those poorly performing hospitals scored higher than the national average on the key HCAHPS question; their patients reported that “YES, [they] would definitely recommend the hospital.”

While they are undoubtedly an important piece of the puzzle, patient satisfaction surveys alone will not drastically or directly improve healthcare.  An over-reliance on them may lead to hospitals focusing on “smiles over substance” and pandering to patients’ desires rather than their needs, perhaps ultimately achieving an unintended opposite goal.

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Elmo knows to just “Shake It Off” when it comes to vaccines

I posted this video to Facebook the other day, but felt the need to put it on the blog as well.  This adorable video features Elmo and Surgeon General Vivek Murthy talking about the importance of vaccination, and for all you Taylor Swift fans, Elmo breaks out into a cute rendition of “Shake It Off”.

Proving that getting vaccinated is less painful than Taylor Swift.

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Monday blues

It’s a cloudy and rainy Monday here in Boston, and while thousands of people will be running the Boston Marathon today, the rest of us at work will not have that kind of energy.

monday blues workplace energy someecards

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overread

You know you’re in love when you can’t fall asleep because reality is finally better than your dreams.

~Dr Seuss

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Uninsured rate continues to decline

The uninsured rate among US adults continues to decline, currently standing at 11.9% for the first quarter of 2015.  The rate is 1 percentage point lower than the fourth quarter in 2014 and is 5.2 points lower than 2013, when the Affordable Care Act went into effect.  It’s also the lowest since 2008.

Percentage Uninsured in the U.S., by Quarter

The percentage of uninsured Americans peaked in 2013 at 18% of adults and has dropped sharply since the most significant change to the U.S. healthcare system in the Affordable Care Act – the individual mandate – went into effect in 2014.  Experts also point to an improving economy and an improved unemployment rate as having accelerated the steep drop in the percentage of uninsured over the past year. However, the uninsured rate is significantly lower than it was in early 2008, before the depths of the economic recession, suggesting that the recent decline is due to more than just an improving economy.

While the rate declined across a broad swath of demographic groups, more importantly, the uninsured rate dropped the most for lower-income Americans and for Hispanics – two groups with traditionally low rates of insurance. The uninsured rate among Americans earning less than $36,000 annually dropped 8.7 points since the end of 2013, while the rate among Hispanics fell 8.3 points. The significant drop in uninsured Hispanics is a key accomplishment for the Obama administration, which led targeted efforts to insure this group as they had the highest uninsured population of all key subgroups. However, despite the gains in insurance coverage among Hispanics and lower-income Americans, these groups still have higher uninsured rates than other key subgroups.

Americans aged 26 to 34 have also seen gains in coverage since the healthcare law went into effect — the uninsured rate among this group is down 7.4 points since the end of 2013, the largest drop among any age group. Blacks have also seen a substantial drop in their uninsured rate since the fourth quarter of 2013 at 7.3 points.

Percentage of Uninsured Americans, by Subgroup

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