...which is why Im happy when the media do a good job of covering this underappreciated issue. BBC Radio 4 just broadcast an excellent piece on patient safety in the UK. It focuses on alerts issued by the National Patient Safety Agency to local NHS trusts. The alerts are based in part on aggregated reports of errors - or, as some in the US call them, adverse events, to avoid the language of blame - and are meant to help trusts, which have primary responsibility for delivering safe health care, to implement specific procedures aimed at avoiding errors. Trusts are responsible for reporting back on their progress implementing the alerts; there are, evidently, hundreds of trusts that have not yet implemented at least one, and there are a couple more that have not reported back on over 30. A key problem is that there is no national mechanism or authority for enforcing compliance with the alerts, although they are issued at the national level. The story, about 40 minutes long, did an excellent job of interweaving anecdotes with investigative reporting on NHS policies and procedures. The reporter, Julian OHalloran, spoke with patients family members who have now become active in improving patient safety in the UK, as well as policymakers. One case highlighted was that of a man who was killed by a massive overdose of a painkiller. The media have focused heavily on the fact that the doctor who administered the drug was foreign and had apparently been censured by medical authorities in his home country, that he was unfamiliar with the drug in question, diamorphine, and also that the incident occurred on his first shift working in the UK. What the media have not grasped - until now - was that the drug ampule the doctor used should probably never have been in his medical kit to begin with, because such a high dose has almost no application in day-to-day use. The NPSA had issued guidance in 2006 about safe storage practices for diamorphine, to help clinicians avoid administration errors. OHalloran spoke to the patients son, who is himself a doctor, and who mentioned that he had never even seen such a large dose of diamorphine.

Great stuff from the Centre for Evidence-Based Medicine at Oxford, by Dr. Richard Lehman. Now with recipes! Speaking of which, check out my new food blog - in which I figure out how to feed myself in the UK - at Emily Drinking Tea.

Seriously, what took them so long? Their reluctance to address due caution to the chemical really presented an impression that the Agency was beholden to chemical industry interests.

A Guardian article on a new epidemiologic study looking at a class of blood pressure drugs and dementia started out with a headline that was doubly misleading:

Blood pressure drugs can halve risk of dementia

First of all, this may just be my own reading problem, but when I first saw the word "halve" my brain saw "have" and interpreted it to mean that the drugs increase risk of dementia. But when I slowed down and re-read it, I was not much happier, because Ive developed this intellectual/editorial tic, a tendency to notice and then question statements that imply causation. The Guardian lead reiterated the causal language:

Millions of older people who take drugs for high blood pressure or heart problems can more than halve their risk of developing Alzheimers disease and dementia, according to research.

For the headline and lead to be supportable, there would have to be a clinical trial randomly assigning people (a lot of them) to get ARB drugs, or not. It seemed unlikely, and in fact, it wasnt the case. Here is the original article from BMJ. Sure enough, right in the articles title, it says that its a prospective cohort study - a very good one, Im sure, but designed to look at associations, but not causation. And heres the conclusion of the research article:

Angiotensin receptor blockers are associated with a significant reduction in the incidence and progression of Alzheimer’s disease and dementia compared with angiotensin converting enzyme inhibitors or other cardiovascular drugs in a predominantly male population.

Wordy, but - again - in terms of "association" not an active, causal verb phrase like "cuts risk by half." Regarding expert comments, I thought the article let the head of research of the Alzheimers Association get a little carried away with the conclusions of the study: "The prospect of using already existing drugs to help in the fight against dementia is attractive." The head of another Alzheimers research organization did acknowledge the need for trials to confirm the link.

The whole Facebook bra-color thing. It started out as a silly meme, someone apparently tried to legitimize it by attaching it to breast cancer awareness, breast cancer groups tried to weigh in, and the Washington Post wrote up the whole kerfuffle. I think the best thing to come out of the phenomenon, which was over and done with in not much more than 24 hours, was not increased breast cancer awareness - I mean really, arent we aware enough? - but awareness of and attention to the concept of awareness: What does it mean, where does it get you, and where do we go from here? Breast cancer awareness needs to go way beyond a mass adolescent giggle about the color of underwear. The timing coincides nicely with the release of Barbara Ehrenreichs new book, a polemic against the feel-good-about-cancer movement. You can read an excerpt of it in the Guardian. She has this to say about awareness:

The first thing I discovered as I waded out into the relevant [breast cancer] sites is that not everyone views the disease with horror and dread. Instead, the appropriate attitude is upbeat and even eagerly acquisitive. There is, I found, a significant market for all things breast cancer-related. You can dress in pink-beribboned sweatshirts, denim shirts, pyjamas, lingerie, aprons, shoelaces and socks; accessorise with pink rhinestone brooches, scarves, caps, earrings and bracelets; and brighten up your home with breast cancer candles, coffee mugs, wind chimes and night-lights. "Awareness" beats secrecy and stigma, of course, but I couldnt help noticing that the existential space in which a friend had earnestly advised me to "confront [my] mortality" bore a striking resemblance to a shopping centre.

A lot of breast-cancer awareness focuses on unproven buddy-check programs and mammography promotion. How about more awareness of what we mostly dont know about breast cancer - what causes it and how to prevent it, not just detect it earlier?

According to the Washington Post, Maine is considering adding a warning about cancer risk to cell-phones. A state legislator claims that there are "numerous studies" to support such a risk. To be fair, Im not really current with the literature, but I do wonder: do cell phones also come with a warning about risks of crashing your car? For that matter, how about absolute risks of cancer, contrasted with absolute risk of crashing your car? Anyone seen these numbers?

Today, after watching last evening this rather moving program in which someone called Gerry Robinson visits and tries to fix dementia care in the UK, I found out that Mr Robinson (actually Sir Gerry) was a businessman. That might explain why he just threw up his hands when confronted with pretty clear evidence that one of these homes was owned and run by two people who couldnt see past making a profit to the well-being of the residents (or the staff, for that matter). Robinson just wasnt ready to admit that capitalism might not always be a sustainable model for the provision of dementia care. But thats what we have, for now. Measuring and improving quality of care for dementia is, according to the program, in its infancy, but developing measures and benchmarks based on quality of life would be a big step forward.

Cochrane reviewers have concluded in yesterdays British Medical Journal that there is little evidence that antiviral drug oseltamivir, or Tamiflu, stops flu complications in otherwise healthy people. The BMJ has a number of related articles as well. BBC News today had a great investigative piece on the story behind the evidence; there is one crucial, oft-cited dataset belonging to Tamiflu manufacturer Roche, which Roche has not released to the Cochrane reviewers. The BBC has not yet posted a link to the story but Ill up date this when its available. Meanwhile, the Guardian has also covered the story. flu Tamiflu health news Cochrane

Check out this Tom Toles cartoon.

Contrast the conciliatory tone of this editorial co-authored by Eric Winer, MD, Medical Director of the Susan G. Komen Breast Cancer Foundation with the gloom and doom expressed by Komens president Nancy Brinker, as quoted in this op ed piece by Washington Post writer Dana Milbank. Per Winer:

Fourth, we must be careful not to send a message that screening and early detection are of no value: there is no doubt that early detection of breast cancer can save lives. We are particularly concerned about the perceptions of women who are members of disadvantaged minority groups and those who lack education and health insurance. It would be lamentable if progress made in breast-cancer awareness were reversed as a result of this debate. Efforts to educate the public about breast cancer must be maintained and, in some areas, increased.

and Brinker:

The recommendations "have taken a tremendous toll, and I believe they set us back," Brinker told reporters at the National Press Club on Monday afternoon. "The women I have heard from, thousands and thousands and thousands, are justifiably outraged and worried and angry."

Oh, and heres a quote from a statement by Winer on Komens website:

Susan G. Komen for the Cure wants to eliminate any impediments to regular mammography screening for women age 40 and older. While there is no question that mammograms save lives for women over 50 and women 40–49, there is enough uncertainty about the age at which mammography should begin and the frequency of screening that we would not want to see a change in policy for screening mammography at this time.

What do you think? Are the substance of what Winer and Brinker said similar enough that Winer will keep his job? (Note that Milbank himself is probably just as angry as Brinker, yet he claims he has no problem with the science, just in the way the recommendations were rolled out.) Does Winers official Komen statement waffly enough to accommodate both his view of the uncertainty of the science and Komens aggressive pro-screening stance? And will women reading the recommendations - or more importantly the docs who are recommending screening - really take home the message that mammography screening is useless? Id love to hear the behind-the-scenes discussions at Komen as they proceed.

this one from Michael Power, one of my colleagues from a great evidence-based-medicine listserv out of Oxford University.

David Rind, an academic physician in Boston, has started a blog called Evidence in Medicine. Rind has a clear, persuasive, honest yet non-sanctimonious writing style. Heres hoping he doesnt get bored or overwhelmed too quickly with the task of keeping up a blog! So far hes covered vitamins, the perils of Pharma, and mammography.

This time from the American College of Obstetrics and Gynecology (ACOG), for later and less frequent cervical screening among young women. A number of people interviewed by the NYTimes once again dont seem to acknowledge that there might be harms from screening; in fact, one of the ACOG guideline authors points out quite a few harms, that she claims makes the case for limiting Pap smears more compelling than that for limiting mammography. cervical cancer screening guidelines

By now youve heard that the US Preventive Services Task Force has updated their recommendations on mammography this week. In fact, the recommendation for women 50-74 is the same as before (B recommendation). The Task Force now recommends against routine screening for women 40-49, and states that the evidence is insufficient either way for women 75 and over. Gary Schwitzers Health News Blog analyzes coverage by the three major network news outlets and found that it was light on evidence. And while waiting for a plane, I caught a glimpse of Florida Congresswoman Deborah Wasserman-Schulz commenting on CNN about the guidelines. The congresswoman earlier this year sponsored legislation, known as the EARLY act, to promote intensive screening and breast self exam training for young women. This legislation has been criticized by cancer experts. Wassermann-Schulz apparently doesnt see any possible downside to screening. In addition, in saying that the guidelines are "patronizing" and that women need more information not less, she apparently ignores the Task Forces statement that

The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patients values regarding specific benefits and harms.

breast cancer screening guidelines

Hi folks, me again; no, Im not dead yet! Anyway, lest it get lost, this NYT Prescriptions blog describes an effort - now in Congress - to introduce charts (drug fact boxes) to drug labeling that present clinical benefit and side effects, side by side, in the form of understandable absolute risks. Seems so simple, but this information usually gets buried in drug-approval applications and doesnt make it into the labeling at all. And all you hear or read in direct-to=consumer drug advertising is rapid-fire or small-print, nonquantitative laundry lists of symptoms that have reported in drug studies, with no indication of whether such symptoms even differed between test and control groups, and they generally carry a legalistic, "FDA made us say this" tone. Sen. Barbara Mikulski (D-Maryland) drafted the legislation. prescription drugs drug labeling FDA

The "Engage with Grace" project was created by Paul Levy, of the Running a Hospital blog, and Matthew Holt of The Health Care Blog:

We make choices throughout our lives - where we want to live, what types of activities will fill our days, with whom we spend our time. These choices are often a balance between our desires and our means, but at the end of the day, they are decisions made with intent. But when it comes to how we want to be treated at the end our lives, often we dont express our intent or tell our loved ones about it.

This has real consequences. 73% of Americans would prefer to die at home, but up to 50% die in hospital. More than 80% of Californians say their loved ones "know exactly" or have a "good idea" of what their wishes would be if they were in a persistent coma, but only 50% say theyve talked to them about their preferences.

But our end of life experiences are about a lot more than statistics. They're about all of us. So the first thing we need to do is start talking.

_Engage With Grace: The One Slide Project_ was designed with one simple goal: to help get the conversation about end of life experience started. The idea is simple: Create a tool to help get people talking. One Slide, with just five questions on it. Five questions designed to help get us talking with each other, with our loved ones, about our preferences. And we're asking people to share this One Slide - wherever and whenever they can…at a presentation, at dinner, at their book club. Just One Slide, just five questions.

Lets start a global discussion that, until now, most of us haven't had.

Here is what we are asking you: Download The One Slide and share it at any opportunity - with colleagues, family, friends. Think of the slide as currency and donate just two minutes whenever you can. Commit to being able to answer these five questions about end of life experience for yourself, and for your loved ones. Then commit to helping others do the same. Get this conversation started.

Lets start a viral movement driven by the change we as individuals can effect...and the incredibly positive impact we could have collectively. Help ensure that all of us - and the people we care for - can end our lives in the same purposeful way we live them.

Just One Slide, just one goal. Think of the enormous difference we can make together.

_(To learn more please go to __www.engagewithgrace.org__. This post was written by Alexandra Drane and the Engage With Grace team)_

Shannon Brownlee, author of Overtreated, and Ezekiel Emanuel, author of Healthcare: Guaranteed, two thoughtful people working toward making our health care "system" more fair, safe, and efficient, have an Op-Ed in favor of health care reform in todays Washington Post. Their goal is to dispel some myths about health care, starting with the canard that the U.S. system is the best in the world. Interestingly, further down, the authors cite survey data showing that 70 percent of Americans feel that the system needs major changes if not a complete overhaul. Still, it helps to repeat outloud and often that our system is not the best - just the most expensive. The comments about the costs of health insurance, and who pays them, are well taken and less obvious. Read my interview with Shannon Brownlee here.

Just noticed a new series exposing health care interventions that dont work, in the NYtimes... not in the health section, but in the business section. The first article is on an apparently dangerous prosthetic hip socket, and highlights the US failure to implement device registries that could allow the identification of faulty implants of various kinds. Heres the blurb:

The Evidence Gap: An Imperfect Picture Articles in this series will explore medical treatments used despite scant proof they work and will consider steps toward medicine based on evidence.

I dont know how many of these are planned, but I imagine they could fill a couple years worth of weekly columns. Regarding this article, Id quibble with the idea that registry data are evidence, per se; the problem with interpreting the data is that there are no controls. One application for registry data stems from the fact that pre-market randomized trial data that provide actual evidence for devices (and drugs for that matter) are inadequate. In this case, the faulty devices in question were found to be contaminated with oil, more of a manufacturing quality-control issue than a general validity issue. The former point still holds, but registries can still provide a useful function in pointing to problems.

Thanks to my friend Pam Marcus for passing this along. I thought it was an appropriate way for me to celebrate my reentry into blogging.

Lacasse A, Rey E, Ferreira E, Morin C, Bérard A: Validity of a modified Pregnancy-Unique Quantification of Emesis and Nausea (PUQE) scoring index to assess severity of nausea and vomiting of pregnancy. Am J Obstet Gynecol. 2008 Jan;198(1):71.e1-7.

California HealthLine today reports on a new Congressional Budget Office Report that finds that inefficient delivery of health care, and delivery of interventions of dubious value, will swamp the effect of the aging of the population in increasing health care costs over the foreseeable future.

"The nature of the long-term fiscal problem has been misdiagnosed," Orszag said, adding that the aging population "is not by any means the main factor" behind the projected rise in cost growth. He noted that many new medical treatments and tests are "of dubious value." He said that in their efforts to stem the growth of health care costs, Congress and federal policymakers need to promote cost effectiveness and "evidence-based" medicine (Reuters, 11/13).

Obviously Congress needs to take the lead in addressing this struggle. Senate Finance Committee chair Max Baucus pledged to address the problem aggressively; I hope he does, and I hope Budget Chief Orszag doesnt lose his job saying what needed to be said.

Natural does not equal healthier, nor does it even equal, well, natural. An article in todays Times skewers the marketing ploys of a variety of beauty products available at stores like Whole Foods, and reiterates that theres no evidence that individual ingredients benefit health or beauty, or that claims of their natural or organic provenance are even necessarily true. Manufacturers profit handsomely on consumers emotional beliefs that natural is somehow better.

"We’re seeing an increased consciousness that what you put on your body is as important as what goes in your body,” said Jeremiah McElwee, the senior coordinator in charge of personal care at Whole Foods, which is the company’s fastest-growing department. “The biggest impetus for buying natural or organic body care is the perceived health benefit.”

Emphasis on "perceived."

The Equator website serves as a resource for consistent, accurate reporting in the literature of new research in a variety of health disciplines (e.g., systematic reviews, clinical trials, observational studies). Several of these disciplines have their own guidelines (e.g., the CONSORT guidelines for clinical trials), which are enforced by some of the leading journals. The site provides resources for authors, editors, and guideline developers. reporting guidelines

This one is from the University of North Carolina Health Sciences Library (my favorite library in the whole world, as it happens...) and the Duke University Medical Center Library. (The photo is of UNCs Old Well, which is more photogenic than the library...)

Robert Wachter, professor at UC San Francisco, author of Internal Bleeding, and patient-safety leader and innovator, has a new blog. This post nicely illustrates the health care quality learning curve as experienced by interns.

The Kaiser Daily Health Policy Report has a piece today about an effort to survey Wellpoints many (35 million) about their physicians in order to provide consumer-based rankings, also to include comments. All together now: "The plural of anecdote is not data." Indeed, as one consumer group interviewed by Kaiser said, these rankings are likely to be skewed to the negative by patients who have had bad experiences. There are better ways to collect consumer-centered data - for example, AHRQs CAHPS measures - than mass rants of the type Wellpoint proposes. I dont have much use for Zagats restaurant reviews, either, for the same reason.