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.

 

Back Pain Treatment Trends Worth Reversing

It may just be the American way –pull out all the stops and try anything or everything at great expense when it comes to medical care.

Today’s post takes up how well the United States is doing at providing back pain care in accordance with evidence-based clinical practice guidelines for back pain (including neck pain). In original research and a commentary published online July 29, 2013 in JAMA Internal Medicine, John N. Mafi, MD, and coauthors from Beth Israel Deaconess Medical Center and Harvard Medical School, in Boston, MA, point out troubling trends in back pain care using nationally representative data from the Centers for Disease Control and Prevention’s National Ambulatory Care Survey and the National Hospital Ambulatory Care Survey.

Back pain is common, with surveys showing that 65% to 80% of Americans will report back pain at some point in their lifetime. So understanding what’s going on and managing it with the best science sounds good for patients. Back pain is a loaded category for sure: it involves how well patients can tolerate pain, patience because back pain is often temporary, yet it can be a springboard for all sorts of referrals. There are some relatively inexpensive ways to manage back pain that get a grip on back pain, but the study discussed here suggests that people want to throw everything at it and that the care people are getting is moving afield from science-based guidelines.

Prescribing Patterns

oxycontinBetween 1999 and 2010, opioid use for back pain climbed substantially from 19.3% to 29.1%, while recommended nonsteroidal anti-inflammatory drugs (NSAIDs: e.g. ibuprofen) and acetaminophen have declined by nearly half, from 36.9% to 24.5%.  The latter two drug categories are recommended as first-line for patients with back pain. Additionally, doctors in the south and west prescribed narcotic medications about 1.5 times more frequently than doctors nationally.

Not everyone gets opioids prescribed. The odds that women, black, Hispanic, and other racial/ethnic groups, and the uninsured were prescribed opioids was significantly lower. Commenting on this disparity, Richard Deyo, MD, MPH, Kaiser Permanent Professor of Evidence-Based Family Medicine, Oregon Health Sciences University, Portland, OR, said: “I think this is a situation where good insurance – and greater affluence – make overuse more likely. This may be a case where underinsurance has a protective effect!”

Imaging

MRI machine

MRI machine

Subgroup analyses revealed that neurologists and orthopedic surgeons had a far greater odds of ordering CT and MRI: more than 3.5 times higher than primary care doctors. MRI scans and CT scans rose between 1999-2000, at 7.3% to 11.3%, in 2009-2010.

Referrals

Physical therapy referrals remained constant over the ten-year period, but referrals to other doctors, especially neurologists and orthopedists, doubled by 6.8% in the first year of data collection to 14.0% in 2009-2010.

One Limitation: No Surgery Data

 The data are limited in that this data set cannot be used to see whether or not people got surgery.  However, lots of previous research suggests that with the cascade of advanced imaging and physician referrals, people are getting surgery more frequently.

What About Patients?

 In this study, trends in management of back pain suggest care is moving away from science-based medicine. Many of us have endured back pain that feels acute or chronic. Some of us know people who have had back surgery, seen lots of doctors, and gotten imaging studies. As I write this post, the news is calling attention to premiums perhaps not being that high as predicted with Obamacare. But you have to wonder: if these patterns of overuse to no good end for patients persist, the costs are going to get thrown back to patients. I’ve said this before, but I think we are at a standstill. We need to move beyond documenting overuse and inappropriate use and come up with ways to get doctors and patients on board with what works and does not.

Stand Up and Learn the Tradeoffs
Of Using Medical Imaging for Your Kids

MRI machine

MRI machine

My last post raised questions about the overuse of CT imaging in children, which researchers projected could prove hazardous to kids in the form of excess solid tumors at some point in the kid’s lifetime. It’s one study, but as the study shows, a growing peer-reviewed data base points towards hazards that could be avoid.

Key issues that the researchers and editorialists raised include:

  • Around the country, pediatric radiation doses are not standardized and they could be reduced substantially to improve patient safety;
  • CT hits kids with 100 to 500 times as much radiation as standard x-rays.
  • In what cases, is sending your kid for another test distracting from real care and helping them get well?
  • What questions should parents ask to determine the tradeoffs in having their kid imaged or going through any test, or not?

Of all medical imaging tests, so far, CT stands out for the most compelling projection of harm –spelled out in terms of projected excess solid tumors that could have been avoided in a child’s lifetime if careful referral and dosing protocols were in place.

“It’s very well shown that CT scans for minor head injuries are usually of no benefit,” Ricardo Quinonez, MD, Director of Research and Quality, Pediatric Hospital Medicine, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas, and Executive Chair, American Academy of Pediatrics, Section Chair of Hospital Medicine, said in an interview. “For simple abdominal pain, simply watching it is best.

Excess CT Scans Not Only Concern

Quinonez also addressed use of magnetic resonance (MR) imaging in children under age 7. “Most kids need sedation and safety is not a completely settled question, with anesthesia having negative consequences on brain function.” Quinonez questioned whether MR is being overused more and more. Even though no negative consequences from the magnets have been observed directly, there are downstream risks, potentially unnecessary surgeries.”

Another concern is the use of chest x-rays for asthma and bronchulitis. Quinonez stressed that diagnosing these problems can be done clinically, meaning hands-on physical exam of the patient. Chest x-rays subject kids to radiation. Depending on where it is done, the dose may be adjusted to the child’s weight, which should be standard, but you may not be assured of that outside of a children’s hospital. Quinonez also pointed out that if you give a chest x-ray to three radiologists to read, you may get three different interpretations. Armed with results from a chest x-ray, kids may end up with unnecessary antibiotics. When this happens often enough, antibiotic resistance may develop.

Repeat imaging is also widespread. How many times have you gone to one doctor, mentioned that you or your child had a specific study done, and you have been stonewalled, told: “We like to do our own.” Again, you have to wonder whether the second or third repeat study in a short interval was really necessary.

Resources You Can Use 

Projects aimed at dialing back unnecessary imaging are getting around. However, from the response to my first post, the news is not getting around enough. For example, the American Board of Internal Medicine/Society of Pediatric Hospital Medicine Choosing Wisely campaign has prepared a tip sheet listing 5 Things Physicians and Patients Should Question. An American Academy of Pediatrics tip sheet provides additional information.

The Image Gently campaign, organized by pediatric radiologists concerned with safety, has a slew of materials that you may find helpful when deciding whether or not to have an imaging study.  Included on their page is a link for a sheet you can use to track all of your child’s medical imaging studies.

The National Cancer Institute has a sheet for health care providers on appropriate use of CT in children. It includes issues that pediatricians and parents should discuss.