AARP: Stakeholder for Waste and Moneyed Interests?

AARP, you lost whatever presumed credibility you thought you had with one article in the current issue of your magazine. I am talking about the hard copy of “All the President’s Scans: Our Commander in Chief Regularly Gets An Extensive Physical: Should You?” – part of your Spring 2016 Health Special in AARP: The Magazine, out this weekend. The hard copy is far more slick and glossy than what’s online, replete with pics of the three most recent presidents getting comprehensive physicals for everything under the sun, with smiles on their faces. These were not online. BTW, readers, you can get a copy of it at your local library if you don’t see it at your doctor’s office or are not getting it as an AARP member. Readers note: to get a Medicare Supplement, AARP requires that you join AARP.

 

Pitching High

 

Readers over age 50 (AARP’s target audience) might be tempted to look for an executive physical after reading this article. AARP tells you right away where to go for it in the first paragraph: “Cooper Clinic, Cleveland Clinic, UCLA, Duke and many other major hospitals offer them,” the author writes, warning you that “you could pay upward of $2,000 to $3,000 out of pocket for this.”

Like concierge care before this, executive physicals can embellish a doctor’s base considerably and enlarge what people pay for healthcare. First, a sliver of the upper middle class is conned to pay for these tests because, after all, what’s more important than your health? Pretty soon, demand increases broadly and prices go up for all.

As Good as a Cruise

The nuts and bolts of this executive physical are written about like brochures for a cruise. Nothing but upbeat information, you’ll find here. No downsides. It’s clear that AARP will satisfy many of its funders: for example, academic medical centers, providers looking for volume, and purveyors of imaging and screening tests. But those groups have their own stake and it conflicts with that of aging Americans, no matter what their health status.

Here’s the potpourri of tests that AARP claims “could help” you and provide superlative care:

  • Blood pressure readings taken all day long;
  • Blood test and urinalysis;
  • A thorough head-to-toe physical exam instead of the “old-fashioned once-over;”
  • Specialist exams all done in one day;
  • Multi-expert Q&As;
  • Body fat tests;
  • Cancer screenings, including mammography, colon, and PSA – and even a total-body CT scan, with the caveat that “some detractors think that ultra-early detection can lead to unnecessary treatments.”
  • Eye exams, which could lead you to “new medications that may help stop the spread of macular degeneration, one of the leading causes of blindness in older people” and blood vessel changes in the eyes, suggestive of uncontrolled hypertension.
  • Strength and flexibility assessment, which can lead you to physical therapy for pain relief, balance improvement, and strength improvement;
  • A stress test – EKG showing early heart problems;
  • A sit-down to summarize all the above.

Harm and The “Detractors”

The absence of attention to how so many of these tests have been demonstrated to be wasteful and even harmful is concerning.

AARP, you owe it to your readers to not masquerade advertisements as journalism. Aging Americans have shrinking pocketbooks and this “advice” is a disservice to readers. You scoff at the so-called “detractors,” as if they are few when they are many, completely overlooking the body of scientific research, clinical practice guidelines, and state of knowledge about these tests, which many, as opposed to few, question. Major health authorities question many of these tests, discussed a bit in this blog in numerous posts, and many other places. Overuse is concerning, harms are unacceptable.

For policymakers looking for stakeholders to represent aging Americans, please look outside of AARP. It does not represent us. I submit that AARP’s voice is with waste and the moneyed interests in healthcare, the providers, the establishment, and white Americans aspiring to be part of it.

 

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Readers might be interested in more nuanced discussion of these issues, as covered previously in this blog:

Cardiovascular Care and the Bush Effect

MR Imaging, Electronic Test Ordering Creates Waste

Back Pain Trends Worth Reversing

 What’s Next for Prostate Cancer Screening and Treatment?

Caveat Emptor: Testosterone Replacement Therapy Ads Soar

 

..and many more.

 

Finally, my shameless self-promotion here, but PLEASE take this seriously.

 

I need more paid, honest work to do! Please contact me! I am not ready to retire.

 

Economic Repercussions Prove Powerful in Stopping Hateful Public Health/Quality of Life Laws

It’s hard to keep up with the regressive state laws that threaten the people’s health and quality of life. Women, LGBT individuals, and people of color are popular targets. There may be a silver lining though. Just this morning, the NY Times reported corporate sponsors are thinking twice as groups mobilize to #dumpTrump, demanding that corporations separate themselves from Trump and the Republican National Convention. Coke already shrunk its $  substantially. More sponsors are expected to join in. Kind of makes me hungry for a Coke, all that sugar and all. This is special.

Economic boycotts have also been announced following North Carolina’s passage of the egregious HB2, which eliminates all new LGBT protections.  Although it’s been oversimplified into the “bathroom bill”because it disallows transgender people from entering bathrooms of the gender they identify with,it is more wide-reaching, and also takes away legal protections for LGBT individuals in the state. Last February, Charlotte NC passed a nondiscrimination ordinance. That will be made moot with NC Governor Pat McCrory signing the law.

New York State, Vermont, Washington, the City of Seattle, have announced boycotts against the state, and by the time you read this, we’ll see many more. The City of Atlanta has come out punching, saying the NBA’s All-Star Game should be moved out of Charlotte to Atlanta. Tourism, sports money are at stake.

North Carolina is already facing economic woes as a result of its outrageous positions on abortion rights. The Women’s Right to Know Act, passed in 2011, forced women opting for abortions to listen to a narrated ultrasound within 4 hours of a scheduled abortion. The good news is that the State lost a Federal lawsuit to stop this, and they now must pay out $1 million from savings in an emergency fund for legal fees, according to a News & Observer report.

Economic sanctions are proving  a lever for change, for getting corporations on the side of the people’s health. Interestingly, Atlanta was at risk of losing rights to the upcoming Super Bowl, given fair warning that passage of its regressive anti-LGBT bill would have repercussions. Then, last week, that bill was not signed into law, a victory for the people of Georgia, and LGBT health and safety.

I always think about the people in states proposing regressive legislation. The Moral Monday movement in North Carolina has been out front for quite awhile objecting to these horrendous laws that harm the public’s health. I applaud the movement. Although I wish that there was a better way than boycotts, I have to say I am delighted that people have been organizing successfully, that businesses are taking note, and that we just might stem the tide of the nasty rhetoric and legislation afoot in many parts of this nation.

Do you have thoughts on how we can restore protections now endangered? Please join the discussion below.

 

 

 

 

 

 

 

Homeless Youth and the Chicago Youth Storage Initiative: This Project Needs Your Support

Sleep Out Chicago, Nov. 20, 2015. Credit: Kat Ferguson.

Sleep Out Chicago, Nov. 20, 2015. Credit: Kat Ferguson.

Homelessness may seem remote to you today as you lounge around a comfortable home celebrating Christmas, with presents and ease. Even if you are not celebrating Christmas, this week and next, many of you are likely to spend time in someone’s home, taking for granted that you have a chance to relax comfortably. But the economy, housing, and jobs have not been kind to many. Today, I ask you to give back to homeless organizations, specifically highlighting the Chicago Youth Storage Initiative, which is raising money so that homeless youth can safely store their belongings in lockers.

Several thousand dollars has been raised for the project, but your donation will help move this program forward.

Your donations accepted thru Dec. 31:  fighting youth homelessness. Pick one of the agencies working on this and donate at link here. http://events.aidschicago.org/site/TR?fr_id=1260&pg=teamlist

Over the next 18 months, the Youth Storage Initiative is putting 250 lockers into drop-in centers and shelters across Chicago. Each locker will be large enough to hold three suitcases.
  Why the Youth Storage Initiative?

“For young people experiencing homelessness and housing instability, access to safe and secure storage options for personal belongings – such as clothing, school books, keepsakes, and legal documents – is a daily, often hourly, stressor,” says Lara Brooks, Director of the Chicago Youth Storage Initiative. As for the magnitude of the problem, the Chicago Coalition for the Homeless estimated that in the 2014-2015 school year, 13,054 families were homeless, with fewer than 125 families finding permanent affordable housing annually, with about 22,000 homeless students. Imagine where you can keep important documents and valuables, job-interview clothes, or textbooks if you don’t have your own home or safe place to leave them.

 The Youth Storage Initiative grew out of an LGBT Homeless Summit, organized by Windy City Times and its publisher and Executive Editor Tracy Baim. Although LGBT youth have special problems, the Youth Storage Initiative is available to all youth, regardless of gender identity.

Storage Initiative Backers

Fundraising for the project was buoyed by Sleep Out Chicago, held Nov. 20 this year, in Chicago. The program would not be possible without the generous support of Marianne Philbin of the Pierce Family Foundation, Debbie Reznick of the Polk Brothers Foundation, Tracy Baim, Publisher, Windy City Times, Lara Brown, the Chicago Youth Storage Initiative, and a much-needed grassroots campaign in Chicago.

Vaness Davis, Credit: Hal Baim photography.

Vaness Davis, Credit: Hal Baim photography.

Wishing all a happy and healthy 2016 – and a permanent, affordable housing for all in 2016!

Blowing the Whistle on Toxic Toys
& Why I Am Giving Back

Toxic toysPhoto: Toxic toys for sale this holiday season in New York City. Credit: WE ACT for Environmental Justice, New York, NY.

It’s 36 hours before I go to a Christmas dinner, where I plan to bring gifts to two lovely girls. After buying books for the occasion, I had second thoughts, thinking that books might bore them. So I added in an inexpensive, make-your-own jewelry kit and another kit with lots of paint. Then this happened. Those girls will never see those kits because I fear that they are probably toxic. I worry about the people who manufactured them, who will surely have longlasting toxic effects like the “radium girls,” who made radium watches.  The toys look a lot like some of the items pictured above, demonstrated to be loaded with toxic metals, by WE ACT for Environmental Justice, the Center for Environmental Health. The toys are for sale in New York City stores this holiday season and they are toxic. A coalition of these groups, together with parents, and business representatives released their report Dec. 17 on New York City’s City Hall. I applaud them. It’s likely toxic toys are for sale in your community too.

I am making a tax-deductible charitable donation to WE ACT for Environmental Justice. You can donate here.

Readers, this post is not something that I planned with them at all, but stems from considering forward-thinking groups that engage the public and communities around important issues in the public’s health. You’ll be hearing about other groups from me here until the end of the year. I suggest that you poke around WE ACT’s website to see what valuable work that they do. You can read about their theory of change here. WE ACT is far from a single issue group. Its work encompasses environmental justice in the broadest sense: clean air, indoor exposures, reducing waste, pests, and pesticides, affordable, equitable transit, good food in schools, open and green space, as well as stopping toxic products from going to our communities. WE ACT’s work extends to Washington DC, where they are making a dent on the national dialogue on the public’s health.

It’s time we gave back to the groups that have been organizing for the public’s health and protecting the public’s health. If we don’t join forces for change, we are going to be living with more toxicity than we can stand. The Flint Michigan water supply never should have poisoned kids with lead. Donating is love, I read somewhere this week.

Enjoy the holidays! Make your tax-deductible donation to WE ACT here.

DCIS: Overdiagnosis for Some,
But Breast Cancer Death Rates in Young and Black Women Troubling

Ductal carcinoma in situ – known more by its abbreviation DCIS – has been a term mired in controversy for decades. Over the years, it’s been termed “stage 0” breast cancer, “precancer”, and skeptics have gone so far as to say it is perhaps not much of anything. Before the advent of mammography, the proportion of women with DCIS was as low as 3%, but now 20% of women diagnosed with breast cancer have DCIS. That’s why this morning’s news, about the evolution of DCIS, should give women and their doctors pause about how they have approached a DCIS diagnosis.

In short, Steven A. Narod, MD, and colleagues, analyzing retrospective data on nearly 109,000 women from the Surveillance, Epidemiology and End Results (SEER) database, found the following after a diagnosis of DCIS:

  • Overall, 20 years later, the breast cancer mortality rate was 3%, whereas, ten years after, it was 1.1%;
  • Black women were an exception, with a 7% mortality rate;
  • Women diagnosed before age 35 also had a higher rate of 7.8%;
  • Using radiation or mastectomy did not prevent deaths;
  • Preventing an invasive cancer on the same breast as the DCIS did not prevent death from cancer

The researchers analyzed data from a large database of women diagnosed with DCIS between 1988 and 2011 using data from cancer registries across the United States, The paper is published online today in the peer-reviewed JAMA Oncology.

Addressing the big picture, Dr. Susan Love, Dr. Susan Love Research Foundation, told PatientPOV: “This is yet another argument that we shouldn’t be overtreating. this is more support for doing less.” However, she added: This clearly does not apply to every woman. This is just an observational study, not a randomized study. You also have to study what accounts for the higher death rates in young and black women. Further research should explore what accounts for this difference, including looks at the anatomy, biology, and screening practices.”

An inadvertent casualty of the fight against overdiagnosis is that patients who do not fit that profile are overlooked. Just as overdiagnosis can spell waste and harm, the health care community must no longer sweep under the rug bad health outcomes for subgroups. It’s not just a footnote. Failure to delve deeper inadvertently fosters continuing health disparities and inequality.

From Bleak House to My House: A Second Look at Vitamin D

This morning, I noticed that UK news was alight with stories about how the UK National Health Service and NICE are recommending daily vitamin D. In the UK, they are giving out low-dose vitamin D like chocolate at drugstores, groceries, and at your PCP. So it gave me pause after my last post.

First, I wondered: is it really that much more bleak in the UK that the evidence-based authorities are pushing vitamin D so aggressively with certain high-risk groups? Then I thought: did the University of Wisconsin study on postmenopausal women that I wrote about really pan vitamin D supplements? Could the researchers have done better in informing the public. I doubt the public got the story clearly.

I reached Deborah Grady, MD,Professor and Associate Dean of Clinical and Translational Research, at University of California San Francisco,  today, who wrote a companion short commentary in JAMA Internal Medicine on the University of Wisconsin study. I asked her for clarification on the UK/US points of view. She responded: “I don’t think that there is much argument about low-dose vitamin D. [400 IUs per day] of vitamin D is safe, pretty cheap, and might be helpful. The argument is really around much higher doses.”

Meanwhile, today’s US papers were less favorable on vitamin D, referencing  the JAMA Internal Medicine paper.. I asked BMJ’s Richard Lehman for his take on this. He responded: “I have some vitamin D on my desk and I take it occasionally. That’s what they call a British compromise.” That’s an unfamiliar term for me, but a UK-trained doc explained it to me this way: “it’s a political compromise that gives everyone a little bit of what they want and holds the peace for a very long time, but offers no real solution.”

I have spent most of today diving through arcane medical stories that probably could have been more useful for readers.  Perhaps it is unrealistic to hope that vitamin D advice could be as clearcut as the bulleted list from NICE below.

According to NICE (National Institute for Health and Care Excellence), the listed groups below are high-risk groups for vitamin D deficiency and it is these groups that UK public health authorities are reaching out to with enhanced vitamin D access:

  • All pregnant and breastfeeding women, particularly teenagers and young women
  • Infants and children under 5 years
  • People over 65
  • People who have low or no exposure to the sun. For example, those who cover their skin for cultural reasons, who are housebound or confined indoors for long periods
  • People who have darker skin, for example, people of African, African–Caribbean and South Asian origin.

All this input and I haven’t been away from my desk all day. I mean zero time outside, in the sun. It’s just about sundown. Perhaps it’s tantamount to living in the UK. I suppose I should try to change that – although I am not sure how.

 

Vitamin D and Postmenopausal Women:
Another Case of Overuse?

If you talk to postmenopausal women, you learn that a large proportion of women are told to take vitamin D to bolster bone health, prevent osteoporosis, and fractures. This was used so widely in New York City that a doctor said to me two years ago with a straight face: “There’s something about postmenopausal women in Manhattan that the vast majority of women have low vitamin D.”

In today’s JAMA Internal Medicine,  University of Wisconsin researchers report results from a randomized, double-blind, placebo-controlled trial, refuting the target of 30 ng/mL and questioning the benefit of both low-dose and  high-dose vitamin D therapy on enhancing bone mineral density, muscle function, muscle mass, and falls – finding that it was no better than placebo. The study tested outcomes at one year with high-dose, low-dose, and placebo.

Adequate vitamin D levels are controversial, but this study rejected a target of 30 ng/mL.

It may be a hard pill to swallow for women, who have long feared potentially disabling hip fractures. Many think with aging, more medications are needed.  I spoke with a few friends diagnosed with low vitamin D about the research. They told me that they would rather be safe than sorry and would consult with their doctors.

Documenting no added benefit to a widely used drug is an important first step in changing practice. However, I wonder if more research needs to be conducted on patient perceptions of aging, hazards on the horizon, and imperatives for prevention. Simply documenting inappropriate use or overuse without attention to widely held beliefs may not be sufficient to guide change.

On the Skyrocketing Costs
Of MS Drugs: A Patient Point of View

Last week, Daniel M. Hartung, PharmD, MPH, and coauthors, published an open-access article in Neurology on astronomical increases in disease-modifying drugs for multiple sclerosis (MS) –many developed decades ago. Notably, they report that first-generation drugs — now cost about $60,000 per year, when they originally cost about $8,000 to $11,000. Copaxone is an injection-based therapy. The original Copaxone came out in the 1990s and was part of the first-generation of disease-modifying therapies for MS. It required daily injections. Within the past few months, Teva-Sandoz introduced a new longer-acting brand formulation. The new version is injected three times per week and the company hopes to switch all on the older brand to the new short-acting brand. In fact, an ad on the Copaxone home page makes a compelling argument for the new brand: “With the 3-times-a-week dose, experience 208 fewer injections per year than with daily COPAXONE® 20 mg.” Yet just as this was going on, Teva-Sandoz got FDA approval for a generic version of Copaxone. Yet, Teva had long been adamantly opposed to a generic. What will happen to the pricing and affordability of MS drugs like Copaxone? When will the generic become available?

Patient POV asked a person with MS since the 1990s what he thought of these issues. David asked that his last name not be used. He tried one of the interferons for his MS shortly after he was diagnosed.He has been on Copaxone since 1999 and his MS has been stable. He told Patient POV: “The interferon didn’t help at all. I had side effect and flares with some disease progression.”

Learning that the first-generation MS drug prices are escalating far greater than inflation, what are your thoughts?

These are first-generation drugs that were developed a very long time ago. I don’t think the price hikes are defensible. The research and development costs are long since recovered. The manufacturing costs are not that high. The price in Europe might be a better reflection of the ‘real’ costs of the drug with a reasonable profit. David worries about people without insurance who don’t get the benefit of any reduced price an insurer negotiates. (David knows that his insurer and PBM negotiate the best rates and then establish a copay accordingly.)

David raises another reason why he thinks the price hikes are excessive. It’s not as if these drugs are orphan drugs where the market is so small. There is a significant worldwide patient population.

What do you think about negotiating prices for drugs?

 I know that when the Accountable Care Act was being considered, this came up frequently, but obviously the government has shied away from negotiating best prices, except for state Medicaid. It seems like prices go up as the market can bear and it is very hard to rein in pharma. It’s certainly a deal breaker for the new hepatitis C drugs. I wish that Medicare D would allow negotiation for better prices.

What disease-modifying drug are you on? How long have you been taking them and how interchangeable do you think these medications are?

 I have been on Copaxone since 1999. For two years before that, I tried another drug. Not only did I have terrible side effects, but I continued to have relapses with that drug. I think that patients react differently and should get the drug that gives them the best outcomes and quality of life. It can be hit-or-miss for a person with MS to find the best disease-modifying drug.

A few months ago Teva introduced its three times per week, long-acting Copaxone. Teva hopes to move all Copaxone users to this formulation. Is this something desirable?

Yes. I went on it a few months ago. It helps to not have to inject myself so frequently. I have scar tissue in areas where I have injected frequently. Another advantage of the three-times-weekly dosage is that the shots are less intrusive when I travel. But 99% is getting away from the daily shots that can be uncomfortable.

Teva/Sandoz has not said when it will release generic Copaxone. In fact, there have been numerous attempts to block its introduction. Do you think that generic Copaxone will get much market share?

Teva might have staked out its claim to market share by introducing a new dosage for Copaxone [its brand].  Sandoz has yet to establish a retail price for the generic version.  Also, if PBMs can get better pricing on the generic then there might be pressure to switch.

Have you had to go through any hoops with your insurer to get your Copaxone over the years?

Until quite recently, I needed to get prior approval for Copaxone every year for 15 years. I don’t know what my insurer was thinking. This was very taxing. It took my doctor multiple attempts to get prior approval, sometimes hours on the phone, with faxing, and misplaced papers. There were a couple of years where I was running close to running out of my medicine, which was an additional stressor. Finally, I am at the point with my insurer where the Copaxone goes through year after year without these issues.

That sounds incredibly taxing.

Yes, and if you add to this that many people with MS have secondary conditions and must take additional medications, the red tape to get your needed meds can be endless. Obviously, this can trigger MS symptoms and wipe you out.

Homecare Workers Flood #fightfor15 Rallies,
Wait for President Obama to Act

Home care workers organized by 1199/SEIU march in midtown Manhattan on April 15, 2015.

Home care workers organized by 1199/SEIU march in midtown Manhattan on April 15, 2015.

Homecare and direct care workers were out in droves last night in New York’s #fightfor15 rally that stretched from Columbus Circle to Times Square. Initially billed as an event for fast-food and retail workers, the #fightfor15 day expanded to home care workers, adjunct professors, and low-wage workers in general. In fact, health and home care workers lined up for blocks to participate in this demonstration. So far, home care workers have won the right to unionize in several states. This will clearly be a linchpin in moving this issue forward.

1199/Service Employees International Union (SEIU) led organizing for yesterday’s rally in New York and elsewhere. Ai-jen Poo, Director of the National Domestic Workers Alliance and Co-Director of Caring Across Generations, has been out front on in calling for radically altering the long-term-care infrastructure. In her new book, The Age of Dignity: Preparing for the Elder Boom in a Changing America, she proposes integrating access to care and affordability of care, aligning the interests of the workers, the families that they care for, and the quality of care the workers provide. At the heart of Poo’s work is the recognition that home care and domestic workers are not valued and treated with dignity. Elders don’t fare much better.

Looking at her book and other data, it becomes abundantly clear the nation’s 2-3 million home care workers live in poverty. Home care workers are overwhelmingly women, immigrants, and people of color. The health care industry does not value these workers and the workforce is often transient. According to the National Employment Law Project, in 2013, the average income of home care workers was $18,598. Is it any wonder that quality of care is an issue in elder and long-term care?

Are quality improvement proponents targeting the wrong metrics: would they do better to ensure that workers have a living wage and -fair working conditions before they check whether the elderly suffer from bedsores, get infections, or sustain falls? Are they supervised properly, available in sufficient numbers, or is the industry cutting corners?

Yet despite a mantra in health policy circles to tout value-based care, health care leaders and the medical press have proved somewhat inattentive to these pressing issues, which if addressed, would ratchet up worker quality of life, reduce burnout and workforce transiency, and enhance quality of care for patients.

It would be refreshing for health care leaders and the families to back a decent living wage for homecare and direct care workers.

But many Americans may not realize that ever since the Fair Labor Standards Act went into effect in 1938, home care and direct care workers were excluded from basic minimum wage and overtime protection. As Poo points out, this exemption stemmed from racism in the 1930s, when African-Americans provided much of the nation’s domestic work. Southern legislators refused to sign off on the Fair Labor Standards Act, unless farmworkers, domestic workers, and homecare workers were excluded from labor protective legislation. It needs to be changed.

Finally, in September 2013, the fight seemed to be over, when the Department of Labor issued its Home Care Final Rule that extended these protections to the nation’s 2-million home and personal care workers The law was slated to go into effect in January 2015. However, District of Columbia Judge Richard Leon vacated the ruling in Home Care Association of America vs. Weil. The Department of Labor has filed an appeal and action is expected sometime this summer.

Advocates for enhanced worker protections for homecare and direct care workers are hoping that the Obama administration will push this forward shortly. When President Obama ran for election, he promised prompt action on this. Hillary Clinton offered this comment on twitter last night: “Every American deserves a fair shot at success. Fast food & child care workers shouldn’t have to march in streets for living wages. –H.” Clearly advocates for home care workers will want to hear a heck of a lot more before they see Hillary or any other candidate on their side.

Are Pediatric Guidelines for Statins Too Aggressive?

If, instead of following the adult guidelines, doctors used pediatric guidelines to identify teens with high LDL-levels, and if universal screening was in place, another 400,000 adolescents would be taking statins. Would that increase be good or bad? Doctors disagree. Some suggest that the increased treatment would be premature and dangerous to teen health.  Results from a study, which used the Centers for Disease Control and Prevention’s National Health and Nutrition Examination Survey, published today in JAMA Pediatrics, found that about 2.5% of teens 17-21 would satisfy the pediatric statin guidelines, compared with 0.4% using adult criteria.

“The safety of statins [in this population] is completely speculative and theoretical,” said Rodney Hayward, MD, Director of the Robert Wood Johnson Clinical Fellows Program, at the University of Michigan Ann Arbor. “We really need good evidence of benefit before we take a risk like this with adolescents.”

What concerns Hayward is a trend for specialists, in this case, pediatric cardiologists, to favor aggressive treatment before the burden of proof is satisfied. “There is a tendency to view everything as safe until we have the new Vioxx.” The teen brain is still developing. Given associations between statins and cognitive problems, Hayward questions whether giving statins could have adverse neurologic effects. Statin’s effects on neurologic tissue are also concerning. It would be best if teens were physically active. Adverse muscle effects have also been identified with statin use. This is just at the time when you want kids to be physically active.

One possible exception for statin use that Hayward would use is an extremely high LDL level. He also acknowledged that there is some evidence that testing adolescents once every five years may derive benefit. Hayward still thinks that benefit would be gained if statins were begun later, perhaps at age 35.Statin benefits do not accrue until years later.

The authors urge doctors to use shared decision making in cases of uncertainty because people vary in what risks that they want to take. To my knowledge, no studies of shared decision making in evaluating whether or not to put your kids on statins have been done. I wonder whether prescribing pediatric cardiologists can present the knowns and unknowns without bias.