Proton Beam Therapy For Prostate Cancer
As of this writing, there is insufficient evidence to conclude that proton beam is more effective in treating prostate cancer than conventional radiation therapy; and there is no evidence of significant differences between proton therapy and radiation therapy in total serious adverse events. Readers may be interested in a recent article where the investigators point out that patients diagnosed with prostate cancer and living in areas where proton beam therapy is readily available are more likely to be treated with this new technology than with conventional radiation therapy. The cost of treating prostate cancer with proton beam therapy can exceed $50,000 per patient which is twice the cost of radiation therapy. Increasingly, we are seeing new technologies with staggering costs. In prostate cancer, for example, as we write this, proton centers are being built all over the country at a cost of up to $200 million.
Aaronson DS, Odisho AY, Hills N, Cress R, Carroll PR, Dudley RA, Cooperberg MR. Proton beam therapy and treatment for localized prostate cancer: if you build it, they will come. Arch Intern Med. 2012 Feb 13;172(3):280-3. PubMed PMID:22332166.
Caution About Screening Tests
Dr. John Henning Schumann has written an informative article about screening tests: On the Sordid Sale of Screening Tests, by John Henning Schumann, MD, The Atlantic, October 2012.
A Performance Measure for Overuse? The Loosening Of Tight Control In Diabetes
Performance measures for tighter glycemic control appeared following the DCCT trial (Type 1 diabetes) in 1993 and the UKPDS trial (type 2 diabetes) in 1998., About 7 years ago groups recommended that glycohemoglobin concentrations be less than 7%, even though clear evidence of improved net outcomes was lacking.
Now in an editorial in the online version of Archives of Internal Medicine, Pogach and Aron have nicely summarized details of this journey into overuse of hypoglycemic agents resulting in the problem of harms probably outweighing benefits—at least for some diabetics—in an editorial entitled, The Other Side of Quality Improvement in Diabetes for Seniors: A Proposal for an Overtreatment Glycemic Measure.
The authors review the ACCORD, ADVANCE and VADT trials and remind readers that tight glycemic control did not yield cardiovascular benefits in these trials and that severe hypoglycemia occurred in the intensive treatment groups of all three trials. Of concern was the finding that ACCORD was terminated early because of increased mortality in the intensive glycemic treatment group. These trials appear to have increased concern about the risks of severe hypoglycemia in elderly patients and patients with existing cardiovascular disease, and the National Committee for Quality Assurance Healthcare Effectiveness Data and Information Set (HEDIS) modified its glycohemoglobin goal to less than 7% for persons younger than 65 years without cardiovascular disease or end-stage complications and diabetes and established a new, more relaxed goal of less than 8% for persons 65 to 74 years of age.
Kirsh and Aron took this a step further in 2011 and proposed a glycohemoglobin concentration of less than 7.0% as a threshold measure of potential overtreatment of hyperglycemia in persons older than 65 years who are at high risk for hypoglycemia. They point out that the risk for hypoglycemia could be assessed by utilizing data from the electronic medical record regarding prescriptions for insulin and/or sulfonylurea medications and retrieving information on comorbidities such as chronic kidney disease, cognitive impairment or dementia, neurologic conditions that may interfere with a successful response to a hypoglycemic event.
This commentary is worth reading and thinking about. We agree with them that the time has come to take more actions to prevent the risk of possible overtreatment in diabetes.
 The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. N Engl J Med. 1993 Sep 30;329(14):977-86. PubMed PMID: 8366922.
 Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998 Sep 12;352(9131):854-65. Erratum in: Lancet 1998 Nov 7;352(9139):1558. PubMed PMID: 9742977.
 Pogach L, Aron DC. Sudden acceleration of diabetes quality measures. JAMA. 2011 Feb 16;305(7):709-10. PubMed PMID: 21325188.
 Published Online: September 10, 2012. doi:10.1001/archinternmed.2012.4392.
 Kirsh SR, Aron DC. Choosing targets for glycaemia, blood pressure and low-density lipoprotein cholesterol in elderly individuals with diabetes mellitus. Drugs Aging. 2011 Dec 1;28(12):945-60. doi: 10.2165/11594750-000000000-00000. PubMed PMID: 22117094.
Best Care at Lower Cost: The Path to Continuously Learning Health Care in America
“If home building were like health care, carpenters, electricians, and plumbers each would work with different blueprints, with very little coordination.”
“If airline travel were like health care, each pilot would be free to design his or her own preflight safety check, or not to perform one at all.”
The Institute of Medicine (IOM) has just released this latest “state of our health care” report which is well worth reading.  We have a long ways to go before we have a health system. The report, released September 6, 2012, concludes that our dysfunctional health care system wastes about $760 billion each year. Much of the waste is due to inefficiencies and administrative duplications, but $210 billion of the waste is due to unnecessary services (e.g., overuse, unnecessary choice of higher cost services) and $55 billion is wasted on missed primary, secondary and tertiary prevention opportunities.
Here are just a few of the interesting points and recommendations the 18 authors make:
- The volume of the biomedical and clinical knowledge base has rapidly expanded, with research publications having risen from more than 200,000 a year in 1970 to more than 750,000 in 2010;
- We can achieve striking improvements in safety, quality, reliability, and value through the use of systematic evidence-based process improvement methods;
- We need digital platforms supporting real-time access to knowledge;
- We need to engage empowered patients;
- We need full transparency in all we do;
- We need improved decision support; improved patient-centered care through tools that deliver reliable, current clinical knowledge to the point of care; and, organizations’ support for, and adoption of, incentives that encourage the use of these tools.
The pre-publication issue of this IOM report is currently available free of charge at this URL.
 Smith M, Cassell G, Ferguson B, Jones C, Redberg R; Institute of Medicine of the National Academies. Best care at lower cost: the path to continuously learning health care in America. http://iom.edu/Activities/Quality/LearningHealthCare/2012- SEP-06.aspx.
Why People Tend to Overuse Healthcare Interventions
This nice piece in Time Magazine by Maia Szalavitz provides some clues about our major problem of overuse. Ms. Szalavitz documents the convincing power of anecdotes compared to statistics which are poorly understood by most people. She provides a really nice example of decision support from the Harding Center for Risk Literacy for prostate cancer screening that illustrates graphically how prostate cancer screening is likely to create more harms than benefits. For more information go to—
Critical Appraisal Matters
Most of us know that there is much variation in healthcare that is not explained by patient preference, differences in disease incidence or resource availability. We think that many of the healthcare quality problems with overuse, underuse, misuse, waste, patient harms and more stems from a broad lack of understanding by healthcare decision-makers about what constitutes solid clinical research.
We think it’s worth visiting (or revisiting) our webpage on “Why Critical Appraisal Matters.”
Dr. Otis Brawley & Overuse in Healthcare
Everyone will want to listen to Dr Otis Brawley, Chief Medical Officer of the American Cancer Society, discuss why overuse in healthcare is costing us money, jobs and other harms. He talks like a real person—not like a professor and is easy to listen to. Who is at fault for all of our healthcare woes? Watch it and you will see we are all to blame. We need reliable information to make good choices and very few people are getting it.
Unnecessary or Harmful Tests and Treatments You May Wish To Avoid
The Dartmouth Atlas of Healthcare and others have estimated that at least 30% of US healthcare spending is unnecessary. The American Board of Internal Medicine, along with nine prominent physician groups, announced on April 4, 2012 released lists of 45 common tests and treatments they say are often unnecessary and may even harm patients. For example the American Board of Family Practice recommended against imaging for low back pain unless red flags are present. Other items on the lists included avoiding antibiotics for most acute mild to moderate sinusitis symptoms, screening EKGs (or other cardiac screenings) in people without symptoms, DEXA screening for osteoporosis in women younger than 65 and many more. For details go to Kaiser Health News—http://www.kaiserhealthnews.org/Stories/2012/April/04/physicians-unnecessary-treatments.aspx
Efforts at Curbing Excessive Medical Testing
Reuters reports on the efforts of the American College of Physicians (ACP), the largest U.S. medical specialty group, in rolling out guidelines to help reduce overuse.