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A New Drug for the New Year (Jan-04)

Out with the old drugs and in with the new! How is your doctor prescribing for you?

Imagine that you are a physician and your patient is a 55-year-old white male with high blood pressure. He has no other medical problems, is on no medications, and has completed a 1-year program of diet and exercise to control his condition, but his blood pressure remains elevated at 170/105 (140/90 is the definition of high blood pressure).

As his physician, you have to decide on a medication to prescribe him in order to lower his blood pressure. You have the following options to choose from:

Diuretics: Diuretics are medications that lower blood pressure by getting rid of excess fluid in your body, making it easier for your heart to pump. They were first introduced in the 1950s.

Beta-blockers: Beta-blockers are medications that lower blood pressure by helping the heart to relax and pump more effectively, and by also reducing heart rate. They were first introduced in the 1960s.

ACE inhibitors: Angiotensin converting enzyme (ACE) inhibitors are medications that lower blood pressure by widening blood vessels and increasing blood flow. They were first introduced in 1981.

Calcium channel blockers: Calcium channel blockers are medications that lower blood pressure by relaxing blood vessels, reducing the heart's workload, and increasing the amount of blood and oxygen that reach the heart. They were also first introduced in 1981.
 
What type of medication would you prescribe this patient?
 
  • A diuretic
  • A beta-blocker
  • An ACE inhibitor
  • A calcium channel blocker

How do you compare to the physicians surveyed?

Of the physicians surveyed, 18% chose the same medication as you did. 38% chose an ACE inhibitor, 29% chose a beta-blocker, and 11% chose a calcium channel blocker. Most physicians chose an ACE inhibitor, a newer type of medication, rather than beta-blockers or diuretics, which are older types of medication.

Why is this important? When asked how they made their decision, the majority of physicians believed that diuretics were less effective and that beta-blockers were less likely to be tolerated by a patient's body than the other medications. However, a number of important studies have shown that beta-blockers and diuretics are as effective at lowering blood pressure as newer medications like ACE inhibitors and calcium channel blockers. Studies have also shown that beta-blockers and diuretics are equally or even better tolerated than the newer types of medications. Yet, the use of beta-blockers and diuretics has declined steadily in the past 15 years in favor of the newer and more expensive types of medications.

Why do physicians believe these things when the studies say otherwise?

The answer to this question is not fully known. One possibility is that physicians may be prescribing newer medications because these are the medications actively promoted by pharmaceutical companies. By providing free samples of the newer medications for physicians to give to patients, these companies may be influencing which medications physicians actually decide to prescribe. To test this possibility, after physicians had decided between diuretics, beta-blockers, ACE inhibitors, and calcium channel blockers, they were asked if they ever provide their patients with free medication samples from these companies to treat their high blood pressure. It was found that physicians who used free samples were more likely to believe that ACE inhibitors are more effective. This isn't proof that physicians are influenced by pharmaceutical companies when prescribing medication for high blood pressure, but it does urge us to seriously consider if physicians may need to be re-educated about the effectiveness and tolerability of beta-blockers and diuretics.

For more information see:

Ubel, PA, Jepson, C, Asch, DA. Misperceptions about beta-blockers and diuretics. Journal of General Internal Medicine, 18, 977-983. 2003.

 

What is the price of life? (Aug-03)

Do you think that your life is worth more than the amount that the government usually uses as the maximum to spend to provide one year of life?

Imagine that you are a member of a government panel that is trying to decide how cost-effective a medical treatment must be in order for the government to cover the costs of the treatment. Suppose that a certain treatment could provide one additional year of life to an otherwise healthy person. What is the highest amount the government should be willing to pay per person for this treatment?

How do your answers compare?

For the past twenty years, the figure most often used as the maximum amount to spend to provide one year of life has been $50,000. This figure was originally proposed since it was the cost of a year of kidney dialysis, a lifesaving treatment that the U.S. government funds in Medicare.

Should the number be higher or lower than the current standard?

Conventional wisdom would suggest that the number be higher to take into account the inflation that has occurred in the years since the standard was developed. Current practices such as annual Pap smear screening for women with low risk for cervical cancer, which has a cost of $700,000 per year of life gained, also suggest that society is willing to pay more than the current standard for a year of life. The authors of the cited article recommend, based on current treatment practices and surveys of the general public, that the cost-effectiveness threshold should be revised to be around $200,000.

Should the number increase, decrease, or stay the same over time?

Again, it seems that the threshold amount should increase over time due to inflation. However, other factors come in to play that affect the value.

Since new technologies are emerging all the time, some of which will be deemed cost-effective, there will be more and more treatments to be offered in the future. Also, the rate of use of treatments is an important consideration, because even if a new treatment is more cost-effective than an old one, if it is used more often it will end up costing more to society overall. With more treatments becoming available and more people being given treatments, the threshold cost will probably have to decrease so that insurance companies and the government can keep up with the increasing availability and demand.

Why is this important?

Insurance companies and government health care entities face a continuing struggle when trying to determine which medical treatments to cover. Health care costs are increasing rapidly, so these groups will be facing even tougher decisions in the future. Establishing cost-effectiveness guidelines would be extremely helpful as an aid to making the decisions about treatment coverage. Evidence shows that the current threshold is probably not an accurate reflection of the desires of society or actual prescribing practices. It needs to be adjusted to become useful once again, and must be reevaluated periodically to make sure the value keeps up with trends in the health care market, rather than being left alone without question for two decades as is the current situation.

For more information see:

Ubel PA, Hirth RA, Chernew ME, Fendrick AM. What is the price of life and why doesn't it increase at the rate of inflation? Archives of Internal Medicine. 163:1637-1641, 2003.

Mon, January 05, 2015

Reshma Jagsi was interviewed by mCancerTalk for the article, “Is your course of radiation treatment longer than it needs to be?” which focuses on two of her radiation treatment studies. In one of her studies, looking at a national database of patients, she and her colleagues found that hypofractionated radiation therapy was used in only 13.6% of Medicare patients with breast cancer. In Michigan, Jagsi’s other study found, fewer than one-third of patients who fit the criteria for offering this approach got the shorter course of treatment.

Read Dr. Jagsi’s paper about hypofractionation use nationally and in Michigan.

Fri, April 10, 2015

Dr. Jagsi was interviewed by MedicalResearch.com, discussing her study which finds many breast cancer patients have an unmet need to discuss genetic testing with their healthcare provider. The study found that 35 percent of women with breast cancer expressed a strong desire for genetic testing, but 43 percent of those women did not have a relevant discussion with a healthcare professional. "By more routinely addressing genetic risk with patients, we can better inform them of their true risk of cancer returning or of developing a new cancer," Dr. Jagsi explains in the interview. "This could potentially alleviate worry and reduce confusion about cancer risk."

Fri, May 08, 2015

The vaccine appears to slow spread in those with advanced breast cancer. Sarah Hawley was quoted, "The preliminary finding that the vaccine improved progression-free survival in patients with metastatic cancer [when the disease has spread to other parts of the body] is especially exciting because of the lack of good treatments for metastatic breast cancer... If the authors can replicate this result in future trials in metastatic and non-metastatic or newly diagnosed patients, this will represent an important direction for the field of breast cancer treatment research."

CBSSM Seminar: Jacob Solomon, PhD

Thu, November 19, 2015, 3:00pm to 4:00pm
Location: 
NCRC, Building 16, Room 266C

Jacob Solomon, PhD


CBSSM Postodoctoral Fellow

Title:

Designing the information cockpit: The impact of customizable algorithms on computer-supported decision making

Abstract:

Intelligent systems that provide decision support necessitate interaction between a human decision maker and powerful yet complex and often opaque algorithms. I will discuss my research on end-user control of these algorithms and show that designing highly customizable decision aids can make it difficult for decision makers to identify when the system is giving poor advice.

"Still Alice" Film Screening & Moderated Discussion

Thu, October 15, 2015, 7:00pm to 9:30pm
Location: 
Forum Hall, Palmer Commons

"Still Alice" Film Screening & Moderated Discussion

Free Admission

Moderator:    Raymond De Vries, PhD

Panelists:     Nancy Barbas, MD
                  J. Scott Roberts, PhD

Refreshments provided.

Based on Lisa Genova’s bestselling novel. In an Oscar winning performance, Julianne Moore plays Alice Howland, a renowned neurolinguistics professor at Columbia University who is diagnosed with familial, early onset Alzheimer’s Disease. The film provides insight into the patient’s perspective and the challenges patients, families, and caregivers face. The film also raises important bioethical questions related to patient autonomy, genetic testing, and personhood in the face of dementia.

Geoffrey Barnes is lead author on study published in the American Journal of Medicine finding new anticoagulants are driving increase in atrial fibrillation treatment and reducing warfarin therapy use.

“The data provides a promising outlook about atrial fibrillation which is known for being undertreated,” says lead author Geoffrey Barnes, M.D., MSc.,  cardiologist at the University of Michigan Health System and researcher at the Institute for Healthcare Policy and Innovation.  “When we don’t treat atrial fibrillation, patients are at risk for stroke. By seeking treatment, patients set themselves up for better outcomes.”

More details can be found here.

Thu, September 10, 2015

Beth Tarini, associate professor of pediatrics and communicable diseases, is launching a study to see whether the martial art of tae kwon do could be an effective therapy - or even an alternative to prescription medication - for kids with attention deficit/hyperactivity disorder. Dr. Tarini is working with Master Dan Vigil on the “Martials Arts as ADD/ADHD Treatment Trial (aka the MAAT Trial)”

She is using the online crowdfunding site Crowdrise to raise money  for the research.
 

Research Topics: 

Interim Co-Director Brian Zikmund-Fisher was featured in “Medicine at Michigan.” Brian shared his personal experience with risk and probability in medical decision making.  This experience provided him with the personal career goal of improving patients’ lives by making health information easier to understand.

This is the first featured story in the new section “Gray Matters,” which gives our faculty members the opportunity to write about complex issues in medicine, such as ethics and decision-making.

"A Calculation of Risk"

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