Friday, 12 April 2019

Myths about using Suboxone to treat opiate addiction

It used to be that prostate cancer screening was routine for men over the age of 50. Positive results on the prostate-specific antigen (PSA) test would trigger a biopsy, and findings of cancer would lead almost inevitably to treatment.

But recently, the rate of PSA screening in the United States has fallen sharply — and the number of new cases of prostate cancer has dropped, too. That’s according to a pair of studies published together this past November in The Journal of the American Medical Association. The studies couldn’t prove that these two trends are causally related; however, the authors speculate that they are. That is, the drop in the number of new cases likely reflects declines in screening, rather than a drop in the number of men who actually have prostate cancer.

Like some other cancer screening tests, such as mammography for breast cancer, the PSA test has come under growing scrutiny. Experts say that it flags too many low-risk tumors that might never become harmful during a man’s lifetime. Treating those cancers can expose men to a needless risk of impotence, incontinence, and other side effects.
Why the numbers are dropping

In 2008, the United States Preventative Services Task Force (USPSTF), an influential volunteer panel of medical experts, came out against PSA screening in men older than 75. Then in 2012, they issued an updated recommendation against screening for all men, regardless of age, race, or family history. These recommendations are controversial. Even though many experts acknowledge the PSA test’s limitations, they worry that abandoning the PSA test altogether will boost diagnoses of late-stage tumors that may no longer be curable.

One of the newly published studies reviewed national PSA screening data collected between 2000 and 2013. Results showed that screening rates started falling in 2010, but only among men younger than 75, and especially within the 50-54 and 60-64 year age groups. The overall screening rate (for all men combined) fell from 36% to 31%.

The second study detected a similar drop in PSA screening rates — from 37.8% to 30.8% — as well as a 22% drop in new prostate cancer diagnoses. The authors of this study reviewed data maintained by the National Cancer Institute and found the number of diagnoses per 100,000 men ages 50 and older had fallen from 540.8 cases in 2008 to 416.2 cases in 2012. The biggest declines came after the USPSTF released a preliminary draft of its updated screening recommendations in October 2011.

“These are the first national, population-based data showing what appears to be an effect on prostate screening and diagnoses from the Task Force recommendations,” said Ahmedin Jemal, DVM, Ph.D., vice president of surveillance and health services research at the American Cancer Society, and a key author of the first study.
Don’t write off PSA screening just yet

In an accompanying editorial, Dr. David F. Penson, the chairman of urologic surgery at Vanderbilt University Medical Center, cautioned that the “pendulum” of popular opinion might be swinging too far away from screening. But rather than stopping screening altogether, Penson called for smarter, more targeted screening approaches directed mainly at men considered at high risk of developing prostate cancer.

“These new findings are an expected consequence of the Task Force’s conclusion that PSA testing probably causes more harm than good,” said Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of However, Dr. Garnick also called for better screening tests, acknowledging that the number of men presenting with more advanced prostate cancer is now likely to rise. “We also need studies that offer focused screening to those at potentially high risk of more aggressive forms of prostate cancer,” he said. “The research should test whether early treatment saves lives or decreases the rates of prostate cancer mortality. Until we have those data, the true effect of decreasing screening rates will remain unknown, and the debates about PSA testing will continue, with no clear answers in sight.” Traveling with your children can be a great way to explore new places, spend time together as a family, and visit with those friends and family members who don’t live nearby. To have the safest and healthiest trip possible, keep in mind these travel tips.
Bring the important things from your medicine cabinet

    Pack any prescription medicines your child takes. Check to be sure you have enough for the whole trip.
    Bring commonly used over-the-counter medicines, such as acetaminophen (Tylenol) or ibuprofen (Advil, Motrin), antibiotic ointment, cold medications (as recommended by your doctor), and diphenhydramine (Benadryl).
    Carry a thermometer and a few Band-Aids on every trip; they can come in very handy. Consider a pair of tweezers, too, if your child gets splinters often.

Kids need car seats

    Make sure you have the proper seat for your child’s age and weight, and that it’s correctly installed in the vehicle you are traveling in. The website of the American Academy of Pediatrics offers tips on choosing and installing car safety seats.
    If you are traveling by plane, the Federal Aviation Administration strongly recommends bringing car seats for infants and toddlers and fastening them to an airplane seat. Remember that you will have to purchase a separate ticket for the child in order to use the seat. Check with the airline to see if discounts are available. The car seat must be less than 16 inches wide to fit; be sure to measure before you go! Booster seats are not allowed on planes.

Be aware of common travel health problems

    If your child easily gets carsick, make sure she is high enough in the car to see out the window, as this can help. Keep a window cracked open for a breeze, and have some light snacks such as pretzels available; both can help nausea go away. If your child has particularly bad carsickness (for example, she vomits every trip), talk to your doctor about medications she might take.
    Ear pain can be a problem when people fly. Having an infant nurse or take a bottle during take-off and landing is a good idea, as swallowing helps combat ear pain. For older children, try having them drink, chew gum (sugarless, of course!), or play a yawning game to prevent their ears from blocking up.
    Since schedules and what you eat when traveling are often different than when you’re home, constipation (not having a bowel movement as often as usual) may happen. Give your child plenty of fluids, and make sure there is fiber (fruits, vegetables, whole grains) in his diet.
    Germs can be anywhere when you travel. Carry hand sanitizer with you at all times, to help you bring fewer of them along with you!

Don’t forget about childproofing

    Bring along a childproofing kit with outlet covers, cabinet locks, and whatever else you use at home.
    If staying at someone’s house, you may not be able to childproof the entire place. Ask if there is one room you can completely childproof, so you can relax better while your child is there. Think about the biggest dangers, such as medications, cleaning fluids, knives, and potential choking hazards. Ask if those and any other particularly dangerous things can be moved and/or locked out of reach during your stay.
    For infants and toddlers, a portable crib can serve as both a bed and a safe place to play.
    Consider bringing safety gates with you to block stairs or to help keep your child in a safe room. Your host may appreciate it if you use the kind that open out, as opposed to ones that need to be climbed over.

Do your homework

    Write down your child’s medical information, especially medication allergies (if you forget the name of the antibiotic that gave him the rash, find out before you go!), health problems, and prescription medications. Keep it with you at all times. If your child needs to see a doctor while you are traveling, she’ll need to know these things.
    Bring the names and phone numbers of all doctors your child sees, including specialists, in case you or a doctor you see needs to contact them.
    Ask your doctor about the best hospitals in the area where you are traveling, so you’ll know where to go if necessary.
    Make sure you bring your health insurance cards, and check with your insurance company about coverage out of your area. Most companies will cover emergency care if your child needs it, but you may need to call for approval or go to a particular hospital.

If traveling outside of the country…

    For travel to certain countries, your child may need special vaccines. To find out the latest recommendations, visit the Traveler’s Health section at the U.S. Centers for Disease Control and Prevention (CDC) website. Do this at least six to eight weeks before traveling, as many of the vaccines need to be given at least a month before travel and you may need an appointment at a special travel clinic to get certain vaccines.
    Find out about the particular health risks, such as malaria or dengue, in the country where you will be traveling so that you can talk to your doctor before you go about how to prevent them. The CDC’s website can help with this. It also has lots of useful, practical information about topics such as safe food and water and traveler’s diarrhea.

It sounds like a lot, but mostly it’s just a matter of planning. And it can make a big difference when it comes to making your trip memorable for all the right reasons. In the United States, depression is the top cause of disability, but only 21% of patients diagnosed with major depression get treatment that meets the guidelines of the American Psychiatric Association. Of people seeking depression treatment, those who’d like to be treated with live psychotherapy outnumber those who’d like to be treated with medication three to one, but those who want live therapy often don’t receive it. Access to psychotherapy is limited by the number of professionals in one’s region, cost, and logistics — not to mention stigma. And when people do get therapy, therapists may not provide care that is evidence-based.

One way to get high-quality psychotherapy to people who need it is to automate and computerize the treatment process and deliver it through websites and apps. This could potentially offer guidelines-based treatment to anyone, anywhere, anytime, at a modest cost. Stand-alone computerized cognitive behavioral therapy (CCBT) has been found to be effective for the treatment of depression, and is already available from a few entities. But it’s still not known how much, if at all, CCBT would improve treatment of depression in primary care, so a group of researchers in the United Kingdom recently tested the advantages of adding CCBT to standard treatment. They randomly assigned 691 people with depression into three different groups. One group received standard care, and the others received standard care plus one of two online CCBT programs.
Comparing CCBT with standard care for depression

As it turns out, standard depression treatment in UK primary care centers is quite good. Citizens are routinely offered antidepressant medications, psychotherapy, and access to community mental health teams, psychologists, psychiatrists, and counselors — a range of resources seldom available in US primary care practices.

There was a lot of crossover between the study groups. In the “standard care” group, 19% ended up using CCBT even though they weren’t specifically assigned to that treatment. Between 77% and 84% of all three groups used medication to treat their depression, and “live” mental health specialists were seen by 17% of one and 24% of the other CCBT group.

Against this backdrop — with many participants in the CCBT groups also receiving mental health specialty treatment and 19% of the standard-practice group receiving CCBT — no significant difference in depression treatment results was found. However, in the US, the findings may have been very different, considering the limited array of mental health resources in most primary care clinics.

It would be most interesting, and more important, to know the benefit of using CCBT for patients who receive nothing else — no medication and no access to mental health specialists. It’s for these patients that CCBT might be the most beneficial.
Challenges in getting people to use CCBT for depression treatment

Both of the CCBT websites had been tested in previous clinical trials and both had been found to be effective treatments — but they’re only helpful if people use them. Even though the two stand-alone CCBT websites were designed to be used over either 6 or 8 “sessions,” most people only used them once or twice, even though the study provided reminder calls to the participants. People with depression can experience fatigue, impaired concentration, and feelings of hopelessness. Getting them to consistently use CCBT websites on their own schedule is a challenge — even if these programs might be helpful in the end. More structure may be needed to keep people using CCBT.

What’s the take-home? The biggest challenge isn’t building a CCBT program that works; it’s building one that people will use. Just as you need to entertain before you can educate, any CCBT program needs to be extremely engaging to users — and to provide immediate value from the first session. And, although the treatment-anywhere-anytime concept is alluring, relying on people to schedule CCBT themselves on their own time, in their own homes, may lead to high levels of drop-off; after all, you can always get around to it later. When I was growing up, my doctor still made house calls when we were too sick to get to his office. But he stopped visiting people at home long before he retired. Both he and his patients realized they were perhaps better served by going to his clean, well-equipped office for whatever care they needed.

So I was more than a little surprised when a woman representing my health insurance plan called to schedule me for a home visit from either a nurse practitioner or physician. I have a Medicare Advantage plan, and I thought I was being offered this visit because the caller assumed I was frail and house-bound. I assured her I could easily get to my doctor’s office if I needed to. I’d also just had my annual physical, my immunizations and screenings were up to date, and I felt great. Why would I need a home visit?

The only reason she could give was that the clinician would have more time to spend with me than my own doctor did. The home visit would last 45 minutes to an hour and would include a health history, a physical exam, screenings, and health advice. Since I work full-time, I could schedule the visit for a weekend. And she’d even throw in a $25 Walmart gift card if I completed the exam.

I declined, feeling a little creeped out — especially after checking with my doctor and learning that she knew nothing about this. So I did a little research.

I learned that these visits are legitimate — in fact, over a million patients have signed up for them so far. And I learned that the extra exam had reduced hospitalizations, primarily for patients with diabetes, heart failure, or chronic obstructive pulmonary disease. But what still puzzled me was why my insurer would want to incur the extra expense of duplicating the exam and tests I had just gotten from my doctor. I don’t have any serious conditions and my doctor consistently receives top grades from all the ratings systems.
A method to the supposed madness

Dr. Michael McWilliams suggested an answer. As an associate professor of health policy at Harvard Medical School, he understands the arcane regulations that cover how Medicare reimburses my Medicare Advantage plan for the care I get. He told me that each of us covered by these plans is assigned a risk score. As we develop more health problems, our risk score increases. “The home visits conducted by Medicare Advantage plans allow for the capture of more diagnoses, which in turn increases the risk score that adjusts plan payments from Medicare.  Generally speaking, the more diagnoses recorded, the higher the payment,” Dr. Williams says.

He explains that the risk adjustment system was created to ensure that plans don’t enroll only the healthiest patients, who are less likely to run up charges for expensive procedures and hospital stays. To provide an incentive for insurers to cover sicker patients, the plans are paid commensurately more for their care.

I’ve received two more calls since I first declined the home visit, each more persistent than the last. Now I understand why. If the clinician could diagnose me with a serious health condition, the company could raise my risk score and get a higher Medicare reimbursement each time I visit the doctor.
What to consider if you’re offered a home visit

If you or someone you know is offered a home visit from a Medicare Advantage plan, keep the following in mind:

    If you have a serious health condition, the extra care might help you avoid a hospital stay.
    The care they provide isn’t ongoing. This is the only time you will see the clinician who examines you. The results of the exam and tests will be forwarded to your regular clinician for follow-up.
    If you are healthy and the visit results in an increased risk score, you won’t have to pay more for your care. But the higher Medicare reimbursement your insurer receives may contribute to the nation’s rising health care costs.

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