Custom Search

Friday, December 4, 2009

H1N1 Influenza and Gastroenterology

It is not Colonoscopy Chronicles’ intention to provide specific medical advice to users of its blog, instead we provide users with information to help them better understand their health, diagnosed conditions, and the current approaches related to treatment, prevention, screening, and supportive care. Colonoscopy Chronicles urges users to consult with a qualified health care professional for diagnosis and answers to their personal medical questions.

Many of our patients are concerned about the current H1N1 influenza epidemic. As you probably know, both typical influenza and the H1N1 type influenza represent significant health risks. In fact, the Centers for Disease Control has reported their most recent statistics, and as of November 17,2009 there have been 26,315 hospitalizations for influenza and 1,049 deaths from the disease. These statistics include only confirmed cases, proven by laboratory tests. The true statistics are likely quite a bit higher. Naturally, patients want to know what they can do to prevent this illness and whether they should receive the conventional influenza vaccine, the H1N1 vaccine, or both. There is a tremendous amount of information available regarding the current influenza situation on the website of the Centers for Disease control(, a government run health agency that has some of the most up to date information and statistics about the disease.

Since the availability of the H1N1 vaccine has been somewhat limited, the CDC has detailed certain groups of people who they feel are a higher priority for the vaccine. Some of these recommendations include :
• Pregnant women because they are at higher risk of complications and can potentially provide protection to infants who cannot be vaccinated;
• Household contacts and caregivers for children younger than 6 months of age because younger infants are at higher risk of influenza-related complications and cannot be vaccinated. Vaccination of those in close contact with infants younger than 6 months old might help protect infants by "cocooning" them from the virus;
• Healthcare and emergency medical services personnel because infections among healthcare workers have been reported and this can be a potential source of infection for vulnerable patients. Also, increased absenteeism in this population could reduce healthcare system capacity;
• All people from 6 months through 24 years of age
• Children from 6 months through 18 years of age because cases of 2009 H1N1 influenza have been seen in children who are in close contact with each other in school and day care settings, which increases the likelihood of disease spread, and
• Young adults 19 through 24 years of age because many cases of 2009 H1N1 influenza have been seen in these healthy young adults and they often live, work, and study in close proximity, and they are a frequently mobile population; and,
• Persons aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza.

The CDC has stated that when there is an adequate supply of the vaccine, that all people age 25-64 should receive the vaccine.

As far as the "regular" seasonal influenza vaccine, the CDC's recommendations are as follows:
• Children aged 6 months up to their 19th birthday
• Pregnant women
• People 50 years of age and older
• People of any age with certain chronic medical conditions
• People who live in nursing homes and other long-term care facilities
• People who live with or care for those at high risk for complications from flu, including:
• Health care workers
• Household contacts of persons at high risk for complications from the flu
• Household contacts and caregivers of children <5 years of age with particular emphasis on vaccinating contacts of children <6 months of age (these children are at higher risk of flu-related complications

There are some people who should not get a flu vaccine without first consulting a physician. These include:
• People who have a severe allergy to chicken eggs.
• People who have had a severe reaction to an influenza vaccination.
• People who developed Guillain-BarrĂ© syndrome (GBS) within 6 weeks of getting an influenza vaccine.
• Children less than 6 months of age (influenza vaccine is not approved for this age group), and
• People who have a moderate-to-severe illness with a fever (they should wait until they recover to get vaccinated.)

Gastroenterologists recognize that some of our patients may have medical problems that put them at increased risk for influenza-related complications. The best source of advice for whether you should get a seasonal influenza vaccine or an H1N1 vaccine is your primary care physician. However If you have any questions about whether your gastrointestinal or liver related condition puts you at increased risk for flu related complications, please speak to your Gastroenterologist.

Tuesday, November 3, 2009

Obama Health Care Plan-An Ounce of Prevention?

One of the critical questions that remains to be answered in the current healthcare debate is that of preventive services. Preventive services are those that are designed to maintain wellness, and to screen people for conditions that-if caught early-are more likely to be cured than if caught when they are more advanced. It is a commonly held belief that preventive health services can lead to better health outcomes, and can save money along the way. While this statement would seem self-evident, it is not quite as simplistic as it may seem. For example, an editorial in the New England Journal of Medicine from February 14,2008 calls into question whether preventive medicine truly results in economic savings, and the conclusion of the authors is that it does not necessarily. The authors included the director of the Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts–New England Medical Center, as well as a professor of health policy and management at the Harvard School of Public Health, -not exactly academic lightweights.

While one measure of success for preventive health programs is cost savings, surely another is a better health outcome. Even if there is a net increase in overall cost for implementing preventive health programs, such as cancer screening, there may be enough of a societal justification to implement them.

Not all preventive services were created equal.It turns out that some preventive services give a “better bang for the buck” than others. Some of these “high value” services include smoking cessation, counseling for use of aspirin, colorectal cancer screening, and appropriate vaccination for influenza. These services are currently underutilized. It is estimated that 90% utilization of such measures would result in 100,000 lives saved each year.

Where does President Obama stand on the matter? Is the current climate in Congress one which will expand preventive services regardless of the cost and the cost effectiveness involved? Or will Congress give only lip service to preventive services (as seems to be the case with malpractice reform)? While we may never know the inner thinking of some of the key politicians involved, including President Obama(a sad commentary on transparency in government!), at least we can try to read the tea leaves based on some of their public comments.
President Obama, in his speech to the joint session of Congress in September of this year certainly talked a good game regarding prevention. The President argued that "there's no reason we shouldn't be catching diseases like breast cancer and colon cancer before they get worse. That makes sense." This endorsement of colorectal cancer screening was welcomed by the American College of Gastroenterology. "We know screening for colorectal cancer is good health policy, and makes good economic sense," commented ACG President Dr. Eamonn Quigley. Studies have shown that for every dollar spent by Medicare for this life-saving test cuts about $3 in long-term medical costs. The New England Journal of Medicine says that a colonoscopy colorectal cancer screening is one of the few preventive services shown to reduce future health care costs. "That's a good return on investment in any business - especially when you're saving lives. When screening procedures detect colon cancer early, nine of ten patients beat the disease. In the absence of screening, colon cancer is usually found too late and many patients die. Those are starkly different outcomes that we have the power to change," added Dr. Quigley. Will Congress exercise good judgment regarding preventive health services? Let us hope that they expand those preventive services that have proven benefit, and shun those that do not. This is a tall order-when even the medical community is divided about which services are worthwhile. However, there is little question that colonoscopy for colorectal cancer screening is effective in saving both lives and money. Let us hope that our political leaders put the appropriate resources into this type of preventive services. Now would be a great time to contact your Senator and Congressman to urge them to include colon and rectal cancer screening as a priority in any health care bill that emerges.

Fielding J. Does Preventive Care Save Money. N Engl J Med 2008;358: 2847-2848

Cohen J, Neumann P, Weinstein M. Does Preventive Care Save Money? Health Economics and the Presidential Candidates. N Engl J Med 2008; 358:661-663
Preventive care: a national profile on use, disparities, and health benefits. Washington, DC: Partnership for Prevention, 2007.

Wednesday, October 14, 2009

Healthcare Reform

Healthcare Reform

The Colonoscopy Chronicles-a Baby Boomer’s Guide to Colonoscopy-has so far focused on some of the medical nuts and bolts issues related to colon cancer screening, and colonoscopy in general. So today’s posting will be a bit of departure, as I will take this opportunity to editorialize about the healthcare topic of the day-Healthcare Reform. I propose that healthcare reform is necessary, and long overdue. I firmly believe that Congress will pass some form of reform, and it is my hope that it will be the reform that we want and need. Who would have thought that this would have been such a political tinderbox? Well, when you stop to consider it, perhaps it was predictable that healthcare debate would generate a visceral response from Americans. For one thing, many Americans earn their livelihood from the healthcare industry. It is estimated that healthcare comprises about 17% of our economy, thus it stands to reason that about one of every six Americans’ paychecks come from healthcare.

Another reason for the spirited debate that has occurred is that those Americans who are covered by healthcare insurance in one form or another fear, understandably, losing that coverage, or having their coverage seriously altered. Most studies have indicated that those who are covered are generally happy with their coverage and would not want to see it replaced. This is despite the fact that there is widespread agreement that there are serious flaws with the status quo.

Let’s face it, when those of us with health insurance receive the estimate of benefits letter from our insurance company, we see the initial charge by the provider or institution, and then we see how our insurer has negotiated a more favorable rate for us, and finally we see how much of this negotiated rate the insurance company will pay, and how much we are responsible for. This last number, our ultimate patient financial responsibility, is generally a far cry from the initial charge. This fact is not lost on patients, and the last thing they want to see is that they are now on the hook for the total charge. This potential hit to the pocket book is bound to provoke a powerful reaction.

Another reason people are loathe to see anything that compromises their health insurance coverage is the fact that most covered patients have significant choice in terms of choosing their doctor, and are afraid that this freedom would vanish under healthcare reform.

Finally, most of us have had either personal experience or have had a loved one experience a catastrophic injury or illness. We all know that without coverage we or someone close to us would have been devastated financially, on top of the effects of the illness.
So yes, it is completely understandable that those who currently have health insurance in one form or another are willing to fight to maintain the status quo-or at least some semblance thereof. American medicine-despite the potshots it takes in the media-has much to be proud of. American research in medicine and pharmacology has produced advances that were practically unthinkable. To put things into perspective, when I was a medical student in the early 1980’s, AIDS was first recognized. Within a matter of only a few years, the virus responsible for AIDS was identified, and treatments developed. Now, what was once a uniformly rapidly fatal disease has been transformed into what is largely a controllable chronic illness-all within an approximately 20 year time frame. This is not to say that we have cured HIV. I also recognize that there are huge numbers of patients that cannot afford antiviral drugs in order to keep the virus in check. But the point is, that the speed and effectiveness with which medicine has advanced is remarkable. Death rates from cancer are declining in America, and people are living longer than ever.

So, why does healthcare in America need reform? First of all, there are vast numbers of Americans who do not have healthcare insurance. While the estimates vary, most would agree that approximately 10-15% of Americans are not covered. What is not exactly clear is why these patients have no coverage. Most certainly, some of them simply cannot afford medical insurance due to a low income, but yet are not eligible for Medicaid-the government healthcare for the indigent. Still others are not able to afford healthcare insurance, not because of a substandard income, but because they have a pre-existing medical condition that makes their insurance rates impossibly expensive. Finally, there are many who can afford health insurance, but simply choose not to. Any meaningful reform in healthcare would have to address all of these underlying reasons for lack of healthcare insurance. Those who truly cannot afford insurance due to low income should get some form of subsidy. Those who have pre-existing conditions should not become healthcare pariahs. Those who can afford insurance but choose not to must be mandated in some way to purchase it.

In addition to reform ensuring that all Americans are covered, it must address the issue of runaway costs. Clearly, the rise in healthcare cost has oustripped rate of inflation. The reasons for this are complex, but certainly include massive profits by health insurance companies. When the insurers offer patients fewer services at a higher premium each year, and pay healthcare providers less each year, it doesn’t take a math genius to see that it is a recipe for steadily increasing profits for the insurers. United Healthcare, just to cite one example, earned nearly 5 billion dollars in profits in 2008, while Aetna earned about 1.5 billion in 2008 profits. No one begrudges them an opportunity to turn a profit, but the insurers must be regulated so they cannot cherry pick the healthier more profitable patients and refuse to cover the higher risk individuals.

Another reason for spiraling costs is the litigation-crazy society in America, and the constant threat that doctors will be sued for malpractice for any sort of negative patient outcome. Beleaguered doctors, fearing lawsuits, often resort to ordering tests that they know are unlikely to be fruitful just to cover the remote possibility that something could have been missed, or to mollify patients. This wasteful process results in huge, essentially worthless, healthcare expenditures. Reforming the malpractice laws could result in a system that no longer promotes this futile spending, yet still protects patients. Yet the current healthcare reform bills that are being proposed do nothing to promote malpractice reform. The trial lawyers have too strong a lobby, and they are not about to allow this source of windfall profits to slip through their fingers.

Finally, healthcare should be reformed because, despite the steadily rising costs, we really do not get our money’s worth-partly for reasons mentioned above. In addition, there have not been uniform standards for measuring outcomes and quality. Consumers deserve to know if their healthcare provider follows evidence based medicine, and deserves to know how they perform on a series of universally accepted benchmarks.

There you have it-it is hard to argue against the principles of universally available healthcare this is cost-effective, and promotes quality. The dilemma is in choosing the best path to get there. The reality is that these noble principles will be completely distorted once Congress takes out their toolbox and goes to work drafting a bill. The incredibly powerful special interests who donate millions of dollars to the politicians will really be the ones crafting these bills, and crowding out the interests of the public. The lobbyists that represent the hospitals, the pharmaceutical companies, and the insurance companies will see to it that their interests will be the first priority, and then let the chips fall where they may. They will come out the true winners in whatever reforms come about.

The losers? You guessed it-first and foremost John Q. Public. Sure, on the surface it may seem that there are some gains for the average citizen, but this will come at a gigantic cost in terms of higher taxes and higher public debt. The other big losers will be physicians. As the least powerful link in the healthcare food chain, their interests will be overshadowed by the big bullies on the block-big pharma, insurance, and the hospitals.

What about the “Public Option”? On the face of it, a public option sounds attractive: provide a competitor for the private insurers to let free market forces drive down prices for the consumer. As many have aptly pointed out, it would be one thing if this competition was fair, but it would hardly be a fair fight since the government run option would have gigantic competitive advantages-being subsidized by the taxpayer. What we really need is proper regulation and oversight of the existing private health insurance market. Private profit driven companies will not necessarily do the right thing for society-their principal responsibility is to the shareholder. But that doesn’t mean that every industry needs a government run competitor to force private industry into compliance-that’s what laws are for.

For example, automobile manufacturers knew full well that installing seat belts and headrests in automobiles would prevent injuries and death in car accidents. While the moral imperative would have been to install them, they did not, since it would cut into their profit. So what should the response of government be-to open up a government run automobile manufacturing company and produce cars with seat belts and headrests? Of course not!! Rather, the answer was to federally mandate that these safety measures be implemented by the existing manufacturers.

Creating a public option would entail the creation of a new entity that would bloat the already massive Washington beureucracy and cost the taxpayers beyond their wildest dreams. If the true aim is to achieve universal coverage, with cost reduction, and quality assurance, we can and should do it without a public option. For all of our sake, let’s hope Washington gets it right.

Here’s to good health!


The Colonoscopy Chronicles

Sunday, March 29, 2009

Virtual Colonoscopy-A Primer

Virtual Colonoscopy-What You Need to Know

Note: The Colonoscopy Chronicles attempts to provide information that is as accurate as possible. It is not intended as medical advice. You should consult your personal physician regarding your own medical condition.

So called “virtual colonoscopy” has generated a lot of buzz lately. This is probably because most of us baby boomers fancy ourselves as being a little “tech savvy”, and at the same time are at an age when we have to think about colon cancer screening. Thus, “virtual colonoscopy” would seem like the “perfect storm”- a way to do the right thing, and at the same time use sleek new technology to avoid the indignity of a conventional “optical”colonoscopy. Well, as they say, if it sounds too good to be true, it probably is!

Don’t get me wrong, virtual colonoscopy is definitely an excellent addition to the arsenal of tools we have available for colorectal cancer screening. However, it has to be placed in proper perspective. Virtual colonoscopy is also known as computerized tomographic colography(CTC). For sake of simplicity, I will refer to it as CTC the rest of the way. Well, for starters, what is CTC? Essentially, CTC is a CT scan of the abdomen and pelvis using specialized software that provides detailed images of the colon. A CT scan is a type of x-ray that involves placing the patient in a machine with a flat table, and a doughnut shaped ring that surrounds the area of the body being scanned. In order for CTC to be done properly, the patient has to take a laxative preparation prior to the procedure(just like for conventional colonoscopy). Furthermore, a small tube is placed into the patient’s rectum to inflate the colon with air for optimal results-sometimes a rather uncomfortable maneuver-since the patient is not given anesthesia.

I think you are getting the picture that virtual colonoscopy is not quite as virtual as you might have thought. It’s not like you just e-mail your information to the radiologist and you get a nice little printout of the results without ever having to step foot into the hospital!! The fact is, the aspect of conventional colonoscopy that tends to aggravate patients the most-the laxative cleanout-is still necessary with CTC.

OK, well then, let’s say it is not quite so virtual. But you’re still interested, because you like to be on the edge of technology. Due to your busy schedule, you don’t want to be sedated for a conventional colonoscopy, which would require that you do not work or drive for the remainder of the day. You want to come in, get your CTC, then head off to the health club and Starbuck’s-right? Understandable. But consider this-what if CTC shows a polyp-a potentially precancerous lesion that will need to be removed via conventional colonoscopy? There would be two options in this situation:
1-Proceed directly to conventional colonoscopy that same day(requiring that you have pre-arranged a ride home. Forget about Starbucks+health club)
2-Arrange conventional colonoscopy for a later date. The downside here is that you would have to repeat the laxative preparation prior to the conventional colonoscopy-again, the aspect that patient’s find the most distasteful.

Well, despite these somewhat confusing logistical issues, you are still fired up for the CTC. The next question to tackle is, how accurate is CTC? This is a question that I could discuss for hours, but I’ll try to distill it into a single sentence: CTC seems generally pretty accurate. It is up to about 95% accurate for discovering polyps greater than 10 millimeters(mm). While some studies have shown a significantly lower detection rate, I think that the bulk of the evidence is that CTC is quite accurate for detecting these larger polyps. Conventional colonoscopy is not 100% accurate for detecting polyps greater than 10 mm, but is more accurate than CTC. As far as detecting polyps less than 10mm, conventional colonoscopy is dramatically better. Does this matter? This is a subject of great debate. Clearly, polyps greater than 10mm are the ones more likely to contain cancer cells, or if not already cancerous, to transform into cancer. So clearly these polyps are more significant than polyps less than 10mm. However, a certain percentage of even these small polyps can contain cancer cells, or transform into cancer.

You, the unapologetic baby boomer, are still enthused about CTC, despite some of its imperfections. The next question is, what about the safety of the exam. CTC is extremely safe. There is radiation exposure involved, which should not be completely dismissed. Furthermore, the American Cancer Society guidelines for colorectal cancer screening(just updated in 2008) advise CTC every 5 years as opposed to every 10 years for conventional colonoscopy. The significance of this radiation exposure every 5 years in a person starting at age 50 and expected to live to at least 75 is not clear. On the other hand, assuming nothing is detected on CTC, the patient avoids the potential hazards of conventional colonoscopy-which, although rare, do exist-including risk of perforation, bleeding, and anesthetic risks.

Now, the quintessential question on a baby boomer’s mind-will insurance cover it? Aha, when the rubber meets the road, we want our technology, but do we want to pay for it? Although CTC has been endorsed by the American Cancer Society as an acceptable colorectal cancer screening alternative, Medicare and most third party payers will not cover screening CTC. This is not likely to change in the near future, since Medicare recently came out with their position-CTC will not be covered for screening. So, unless you are willing to pay out of pocket-it is likely that you will choose conventional colonoscopy- rather than CTC, since the cost of conventional colonoscopy is generally covered by Medicare and most third party payers.

If you choose to have a CTC to evaluate your colon, rather than conventional colonoscopy, I would suggest the following advice:

1. Go to a center that has a reasonable amount of experience in the CTC and a radiologist who has a special interest and training in the procedure

2. Make sure that the center where you do the CTC has a system in place to

a. Read the x-rays promptly
b. Have it arranged so that if a polyp or other abnormality is seen on CTC, you can be assured that a gastroenterologist is available to do a conventional colonoscopy the same day-so you do not have to go through the laxative cleanout process a second time. I would emphasize that you will have to have someone on standby to drive you home in case you should need to have the conventional colonoscopy.

It is worth having a frank, detailed discussion with your physician to see if CTC is a good option in your particular community, as the availability and quality of CTC may vary tremendously. Whether you choose virtual or conventional colonoscopy, make sure you get appropriate colon cancer screening so we can reduce the death rate from the number two cancer killer in America!