In a recent article in JAMA Oncology there is a study about the alleged usefulness of PSA tests. Simply stated they did the following:
1. Examined 18 variations on a theme, namely PSA levels and duration between tests.
2. Costs associated with procedures resulting from the tests.
3. Determined the cost of each life year saved compared to not testing.
The result if the QALY measure, that generally useless, essentially banned by the ACA from use in any medical care. But alas, here it comes.
Their conclusion is simple:
For
PSA screening to be cost-effective, it needs to be used conservatively
and ideally in combination with a conservative management approach for
low-risk disease.
We know that PSA is problematic. But we also know:
1. That PSA testing makes sense if and only if we examine it over time, specifically over a 5 year window of annual data at the very least. It goes up and down and it changes as the prostate grows. So like fasting blood sugar it all too often just tells us what happened last night.
2. Family history is also a significant factor. If you have no relatives with PCa then you have a good chance that you will not have it. Bayes to the rescue. But the corollary is not really true. Namely if you have a first degree relative you may have an increased risk. To be determined.
4. PCais not simple. It is a complex genetic disease and it is highly heterogenetic in its spread.
5. PCa is all too often not that serious but when it is it really is. Yet we do not know that boundary.
6. Calculating QALYs without taking the above into account is really really bad in my opinion.
Thus the more of these results that get published the more we confuse the patient. We just do not really know. Remember, if all else fails, listen to the patient. Let them be part of the informed decision process and please keep the QALYs in the UK whee they belong!
Sunday, March 27, 2016
Forces on the Nano Scale
The book by Butt and Kappl is a must have for anyone working
in the field of surface interactions, especially the developments of nano
technologies. The classic work was done to understand colloidal solutions and
their dynamics, often lasting many decades, and also the issue related to van
der Waals forces. The development of the quantum understanding expressed in
London forces as well as the various varieties developed over the past few decades
are both highlighted and detailed in this work.
The first major Chapter is on van der Waals forces and its
derivatives. The authors have a wonderful style combining simple explanations
along with detailed but readily understandable derivations. The clarity of the
work is truly exceptional. One can almost see the Gecko feet adhering to the
walls as they climb!
The Third Chapter details measurement techniques. Again the
authors present the principles employed in a clear and readily understandable
manner and then progress to explain the actual implementation.
They then move through electrostatic forces, capillary
forces, hydrodynamic forces, and inter facial forces. All are explained simply
and then in detail. They continue with such topics as friction and polymers
surface energies.
Although this is presented as a text book it is truly an
exceptional reference work because of both its breath and depth.
My only issue is that perhaps they could have discussed some
of the specific applications to nano materials. Specific materials such as nano
Selenium where one tries to best understand the surface stickiness on the one
hand and the bacteriostatic behavior on the other.
Overall this book is a necessity for anyone working in the
area of intermolecular forces and their impact on adhesion and interaction.
Understanding Cancer Signalling
The book by Robert, the Textbook of cancer signaling, is one
of the best works on cell signaling available as an introduction. As the author
indicates in the preface the intent is for oncologists to obtain a better
perspective of the issues associated with the wealth of new therapeutics as
well as some of the key issues behind their introduction. For the most part the
work is a high level, but not simplistic, organization and presentation of the
key signaling paths. The general approach is to detail one class of paths after
another and describe in excellent detail the elements of those pathways and how
they function. Then there is a brief exposition of how aberrations in the
pathways lead to oncogenic effects and then a discussion on pharmacological
possibilities. This is done chapter by chapter.
The author’s collection and organization is superb and it
presents the reader with an organization that they can come back to time and
time again. He covers kinases, including MAP and other elements, cytokines,
TGF, G protein, Wnt, Notch, and Hedgehog. He also discusses integrins and a
collection of adhesion molecules. There is a discussion of B and T cell issues
including Toll Like receptors and lymphocytic receptors. He ends with excellent
discussions on cell cycle control as well as apoptosis.
The Appendices are superb summaries of DNA control, gene
expression and protein activity. Overall this is a book that should be on the
desk of almost every oncologist and it is an excellent summary for those
involved in pathway analysis and their implications.
The most important elements of the book are the author’s
organization and integration. It is simple, straightforward and touches on all
the current elements under consideration.
This is not a book for the specialist but it is worth
reading by those deeply involved in that work to see haw one person who truly
understands the depth and breadth sees it structured.
On the side of a critique, and this is hard given the superb
effort displayed, issue such as epigenetic factors should have gotten some bit
of discussion. Specifically the issue of methylation and miRNA silencing need
to be integrated into the overall signaling fabric. However that would clearly
have extended and expanded the work
Also the reader should not look at this as a reference book,
it was not intended as such.
Finally my only one negative is the lack of an Index. That
most likely is a publisher problem and not the author’s problem. The lack of an
index is not that serious since the author has organized the book so well it is
almost not necessary.
I would strongly recommend this book for anyone seeking to
learn pathway issues in cancer and those who are deeply involved already. The
logical wholeness of the work is worth understanding by all.
Friday, March 25, 2016
The Three Horsemen
In a set of recent JAMA Viewpoints three of the key players
in the delivery of the ACA are giving their updates on the progress of the
bill.
First is the assessment from the one who seeks to just pass
on when he turns 75 I believe[1]. His
assessment is mixed but full of praise. What is most telling is his last set of
comments. He states:
Even though the ACA is not a perfect bill, it has
improved the US health care system. If venture investing is a trustworthy
indicator and if additional reforms enabled by the ACA, such as more payment
change and drug cost controls, are implemented, Americans can be optimistic
about the future of the US health care system.
This single paragraph is in my opinion the most telling.
First he admits the ACA is not perfect. Far from it. As we have already noted
it has added some 15 million new participants costing the taxpayers about
$15,000 per year per participant. This is more than Medicare participants who
being older should have been costlier albeit having paid some 50 years’ worth
into the system. The conclusion of efficacy is not justified. Second the grab
to venture investing as a proof of success is truly mind blowing! There is no
basis for this assertion. Why not indicate the rise of ISIS as well?
Coincidence is not correlation is not a proof!
The second horseman is the fellow who brought us Meaningful
Use and the EHR[2].
As we have seen since its inception the CMS mandated HER has in my opinion led
to higher costs, less patient interaction, and less inter physician
communications. The design in my opinion is fatally flawed by setting up
islands of non-interconnected data elements with the patient nowhere to be
found. As he states as a key step in his proposal[3]:
Third, Shift the Business Strategy From Revenue to
Quality: Maximizing revenue continues too much to dominate the business models
of health care organizations. That reflects short-term thinking. A better, more
sustainable route to financial success is improving quality. This requires
mastering the theory and methods of improvement as a core competence for health
care leaders. It also requires that the CMS and other payers continue to unlink
incomes from input metrics, such as “relative value units” for specialists’
incomes, which are not associated with quality and drive volume constantly
upward.
Now as we have noted frequently the term Quality is in the “eye
of the beholder”. Quality means what and to whom? The CMS has also promulgated
mandatory “quality” measures. If one looks at them there is nothing more than a
useless list of check marks adding costs and detracting from the delivery of
services!
Now the third horseman. He was the strategists again on
health care information. As he stated just after the ACA[4]:
The widespread use of electronic health records (EHRs) in
the United States is inevitable. EHRs will improve caregivers' decisions and
patients' outcomes. Once patients experience the benefits of this technology,
they will demand nothing less from their providers. Hundreds of thousands of
physicians have already seen these benefits in their clinical practice.
And how did that work out for us. More cost and less care.
We have physicians becoming typists or if they can’t type hiring a third party
to sit in the examining room typing away and interfering with patient-physician
contact. The result, better patient care and lower costs, it does not seem so.
In his most recent paper he states[5]:
Given some Americans’ skepticism of
foreign experience, home-grown examples may be more compelling. The
Commonwealth Fund State Scorecard suggests that
(1) if US health spending per
person averaged the same nationally as among the 5 lowest-cost states (Utah,
Arizona, Georgia, Idaho, and Nevada), an estimated $535 billion (approximately
20%) less would have been spent on personal health services in 2014;
(2) if rates of health insurance
coverage averaged the same nationally as among the 5 areas with the highest
rates (Massachusetts; Vermont; Hawaii; Washington, DC; and Iowa), an estimated
20 million more Americans would have been insured in 2014; and
(3) if the national levels of
mortality amenable to health care averaged the same as among the 5 states with
the lowest rates (Minnesota, Vermont, New Hampshire, Utah, and Colorado), an
estimated 77 000 fewer deaths would have occurred in 2014.
Let’s look at the above and examine it
for facts. First the states of Utah, Nevada, and Arizona have high Mormon
populations. Mormons live health life styles. So perhaps it would cost less.
Georgia just has less access.
Second, Massachusetts has world class
hospitals that do leading edge care. Idaho does not. Vermont is a socialist
state in many ways and people pay for that. Hawaii always has high costs, buy a
gallon of milk!
Third, look at the demographics of the
states with lowest mortality. I reside part time in New Hampshire. It soon will
see a rise as obesity takes its toll but for the most part it is rural and of
modest income.
Frankly in my opinion this type of
sweeping ad hoc propiter hoc argument is baseless. One must ask why. But that
does not seem to be in the vocabulary.
It is worth reading the comments of
these three who played so much of a role in what has happened. This is the left
wing of medicine, yet they managed in my opinion to set the agenda for the next
generation, and the cost may be overwhelming.
Then of course one asks who is the Pale Horse?
Thursday, March 24, 2016
Doing What You Were Not to Do
In a recent Healio piece they describe a study evaluating QALY on PCa. This was frankly expressly prohibited by the ACA for any service provided thereunder. But the cat is out of the bag. The study states:
Under selective therapy, men with lower Gleason scores (< 7) and clinical stage cancer ( T2a) would only receive treatment after clinical progression. All other cases underwent contemporary treatment practices. Key study endpoints included life-years (LY), quality-adjusted life-years (QALY), direct medical expenditures, and cost per LY and QALY gained. Researchers evaluated cost-effectiveness as willingness-to-pay thresholds ranging from $50,000 to $150,000 per QALY. When compared with no screening, all screening strategies increased LYs (range, 0.03-0.06) and costs (range, $263-$1,371). Costs ranged from $7,335 to $21,649 per LY gained.
Not really clear what was concluded. Was the cost low compared to the benefit? They conclude:
“Our work adds to the growing consensus that highly conservative use of the PSA test and biopsy referral is necessary if PSA screening is to be cost-effective,” Roth and colleagues wrote. “Among the strategies considered, less frequent screening and more restrictive criteria for biopsy resulted in greater chances of PSA screening being cost-effective — particularly when combined with selective treatment strategies that do not immediately treat low-risk, screen-detected cases.”
This of course is studying on the basis of past practises and having not a clue what causes or differentiates the disease.
Under selective therapy, men with lower Gleason scores (< 7) and clinical stage cancer ( T2a) would only receive treatment after clinical progression. All other cases underwent contemporary treatment practices. Key study endpoints included life-years (LY), quality-adjusted life-years (QALY), direct medical expenditures, and cost per LY and QALY gained. Researchers evaluated cost-effectiveness as willingness-to-pay thresholds ranging from $50,000 to $150,000 per QALY. When compared with no screening, all screening strategies increased LYs (range, 0.03-0.06) and costs (range, $263-$1,371). Costs ranged from $7,335 to $21,649 per LY gained.
Not really clear what was concluded. Was the cost low compared to the benefit? They conclude:
“Our work adds to the growing consensus that highly conservative use of the PSA test and biopsy referral is necessary if PSA screening is to be cost-effective,” Roth and colleagues wrote. “Among the strategies considered, less frequent screening and more restrictive criteria for biopsy resulted in greater chances of PSA screening being cost-effective — particularly when combined with selective treatment strategies that do not immediately treat low-risk, screen-detected cases.”
This of course is studying on the basis of past practises and having not a clue what causes or differentiates the disease.
The Cost of the ACA
The CBO has a report describing the anticipated costs of the ACA, exclusive of Medicare for those who have paid in and are over 65.
We depict this above. It will soon exceed $200B annually and that is for an increase of some 14-15 million people. That amounts to an insurance premium of some $15,000 per person enrolled! Now the Medicare participant over 65 has paid in some 50+ years worth at 3% of their gross income plus some $2,400 per year plus a Medigap plan and a Part D plan costing an additional $4,500, plus a deductible, at a total in excess of well above $7,500. That is in addition to what they paid for 50 years!
So who are these people. Read the report and moan!
So who are these people. Read the report and moan!
Tuesday, March 22, 2016
Why People Buy Apple Computers
For the past few weeks, yes weeks, I have been struggling with a dying W7 computer. Each death is different. In this case it was a result of what we think is registryoma, a malignant condition in the Microsoft Registry. We all know that Microsoft has designed this devilish system to control its world but one small base pair mismatch and if you think melanoma is bad try this on for size. There is no immune therapy available and there is not way to block the pathways.
The first symptoms are insidious. Google desktop stops. It just disappears. It was akin to a small mole, just a small change, just a little sensitive. So you do a work around. Then Quick Books fails. The mole starts to bleed. Maybe I scratched it, denial. Another work around. I will do my books on another machine. No problem. Put another bandage on it, how bad can it be.
Then the web systems fail to connect. No problem I can use Filezilla, another work around. It is another mole popping up where there was none before. I do not see lungs becoming engorged with metastatic patches.
Then I try Skype. Dead. It will not even load. It has spread to the brain. The patient does not know it yet. But Office is not loading properly, it freezes up all the time. Firefox has to be loaded 2 or 3 times before it starts. The patient has a seizure.
At this point I would say the patient is a goner! Well I got another machine. Started all over again. New patient, left the old one in the basement. Not totally dead but it is hospice care for the dying!
Microsoft has with its Registry invented a malignancy that makes cancer seen benign. It starts slowly and then spreads and infirm the "patient" and the user. There is no cure, just put the old guy in a hospice and let him die. Kind of like the ACA approach. Thanks Microsoft, you make cancer research looks trivial!
The first symptoms are insidious. Google desktop stops. It just disappears. It was akin to a small mole, just a small change, just a little sensitive. So you do a work around. Then Quick Books fails. The mole starts to bleed. Maybe I scratched it, denial. Another work around. I will do my books on another machine. No problem. Put another bandage on it, how bad can it be.
Then the web systems fail to connect. No problem I can use Filezilla, another work around. It is another mole popping up where there was none before. I do not see lungs becoming engorged with metastatic patches.
Then I try Skype. Dead. It will not even load. It has spread to the brain. The patient does not know it yet. But Office is not loading properly, it freezes up all the time. Firefox has to be loaded 2 or 3 times before it starts. The patient has a seizure.
At this point I would say the patient is a goner! Well I got another machine. Started all over again. New patient, left the old one in the basement. Not totally dead but it is hospice care for the dying!
Microsoft has with its Registry invented a malignancy that makes cancer seen benign. It starts slowly and then spreads and infirm the "patient" and the user. There is no cure, just put the old guy in a hospice and let him die. Kind of like the ACA approach. Thanks Microsoft, you make cancer research looks trivial!
Monday, March 7, 2016
Spy vs Spy
Ad Blockers have become a common thing. I use Badger on Firefox. One can see masses of white space where the ads were before being blocked. I now see that Wired senses the ad blockers and then blocks the page. Cute game, but I just switch to somethi9ng else.
The worst of these techniques is the pop up video, silently I work, check out a headline on Feedly and then WHAM! Blasting video. Now stopped by Badger.
Do these people really think that if I accept the ads I will in any way be persuaded. Rather to the contrary.
How do I find things? Well look at Lookeen, I had an indexing problem. Most likely some Microsoft update on W7. Killed Google Desktop. So I searched Google for an alternative and got a better result. Did I ever see them in an ad? No. Would I have responded to an ad? No.
Marketing folks really do not understand the consumer dynamic. Pity!
The worst of these techniques is the pop up video, silently I work, check out a headline on Feedly and then WHAM! Blasting video. Now stopped by Badger.
Do these people really think that if I accept the ads I will in any way be persuaded. Rather to the contrary.
How do I find things? Well look at Lookeen, I had an indexing problem. Most likely some Microsoft update on W7. Killed Google Desktop. So I searched Google for an alternative and got a better result. Did I ever see them in an ad? No. Would I have responded to an ad? No.
Marketing folks really do not understand the consumer dynamic. Pity!
Wednesday, March 2, 2016
Great Product!
I have never endorsed any products before but when my Google Desktop crashed and would not reboot I panicked since my life depends on indexing my some 300,000 files! So after a few tries I stumbled on Lookeen, a German company, and for about $50 you get a fantastic indexing system. It is one of those simple things that you find a better part each time you use it. It is what Google Desktop could have become.
Moreover their customer support is fantastic! Real people answering real questions to make the experience better. So for any of you who want a great indexing system for a PC I would strongly suggest you try them out! No disclosures to make here, just that when one relies on a good indexing system and the only one you had is no more it is a God send to get this one! Hope they do well.
Moreover their customer support is fantastic! Real people answering real questions to make the experience better. So for any of you who want a great indexing system for a PC I would strongly suggest you try them out! No disclosures to make here, just that when one relies on a good indexing system and the only one you had is no more it is a God send to get this one! Hope they do well.
Tuesday, March 1, 2016
How Stupid is the USPTF?
First they did away with mammograms. Women went ballistic. Then they did away with PSA tests. Men were silent. Now they are doing away with vision testing for the elderly. At least the JAMA folks complained.
The USPTF states as of today:
The U.S. Preventive Services Task Force released today a final recommendation statement on screening for impaired visual acuity in older adults. The Task Force concludes that the evidence is insufficient to make a recommendation for or against screening in older adults without reported vision problems within a primary care setting.
In contrast JAMA states:
In 2009, the US Preventive Services Task Force (USPSTF) concluded that there was insufficient evidence to warrant recommending visual acuity screening of older adults. A recent update, published in JAMA,1 reaches the same conclusion. How (one might ask) can that be, especially as the USPSTF also concluded that impaired vision is common among elderly adults and that the major causes of impaired vision that the recommendation targets—refractive error, cataract, and age-related macular degeneration—are prevalent among elderly individuals and responsive (often dramatically) to clinical intervention?
It appears that these medical wizards always come up with recommendations that impair health and reduce costs. Remember we said seven years ago that this would happen!
Have any of these brains heard of ARMD, dry or wet, it leads to blindness! Any second year medical student should recognize drusen on a retinal exam. Did these folks ever do one in their life?
The USPTF states as of today:
The U.S. Preventive Services Task Force released today a final recommendation statement on screening for impaired visual acuity in older adults. The Task Force concludes that the evidence is insufficient to make a recommendation for or against screening in older adults without reported vision problems within a primary care setting.
In contrast JAMA states:
In 2009, the US Preventive Services Task Force (USPSTF) concluded that there was insufficient evidence to warrant recommending visual acuity screening of older adults. A recent update, published in JAMA,1 reaches the same conclusion. How (one might ask) can that be, especially as the USPSTF also concluded that impaired vision is common among elderly adults and that the major causes of impaired vision that the recommendation targets—refractive error, cataract, and age-related macular degeneration—are prevalent among elderly individuals and responsive (often dramatically) to clinical intervention?
It appears that these medical wizards always come up with recommendations that impair health and reduce costs. Remember we said seven years ago that this would happen!
Have any of these brains heard of ARMD, dry or wet, it leads to blindness! Any second year medical student should recognize drusen on a retinal exam. Did these folks ever do one in their life?
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