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Smart Use of Health Services

Get a second opinion

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Whenever you are faced with a new diagnosis of a serious illness such as cancer, it is a good idea to get a second (or even a third) opinion.  There are several reasons for this action.

- Serious illnesses are often complex to treat and it is good to get the best advice.

- A second opinion can stimulate discussion among your doctors which can lead to better care.

- You should find a doctor who has a communication style which makes you comfortable.

You don't need to be afraid to seek a second opinion and you should do this openly with your doctors so that they can work together.

Here is a good article by an oncologist (and cancer survivor) Elaine Schattner on this subject:



For Those With Diabetes, Older Drugs Are Often Best

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From the NY Times 28 May 2011:

For Those With Diabetes, Older Drugs Are Often Best

WHEN it comes to prescription drugs, newer is not necessarily better. And that’s especially true when treating diabetes.

One in 10 Americans has Type 2 diabetes. If the trend continues, one in three will suffer from the disease by the year 2050, according to the federal Centers for Disease Control and Prevention.

Most Type 2 diabetes patients take one or more drugs to control blood sugar. They spent an estimated $12.5 billion on medication in 2007, twice the amount spent in 2001, according to a study by the University of Chicago. (That figure does not including drugs that diabetics are often prescribed for related health conditions, like high blood pressure and high cholesterol.)

Why the increase? More diagnosed patients, more drugs per patient and an onslaught of expensive new drugs, according to Dr. G. Caleb Alexander, assistant professor of medicine at the University of Chicago and lead author of the study. Since 1995, several new classes of diabetes medications have come on the market. Diabetes drugs are important to the pharmaceutical industry, more lucrative than drugs for many other chronic diseases, Dr. Alexander noted in an interview.

Simply put, many of these drugs help the body produce less glucose or more insulin, the hormone that shuttles glucose into cells for use as energy, or they increase the body’s sensitivity to its own insulin.

Patients and health care professionals have long hoped that as pharmaceutical companies found ways to help the body lower blood sugar, they would produce safer and more efficient alternatives to older medications. But a true breakthrough doesn’t seem to have happened yet.

A report released in March by the federal Agency for Healthcare Research and Quality and conducted by researchers at Johns Hopkins University reviewed data from 166 studies to evaluate the effectiveness and risks of various diabetes medicines. The researchers concluded that drugs that have been around for years are more effective at lowering blood sugar and often work with fewer side effects than the newest drugs. And because so many older drugs now are available as generics, they often cost just a fraction of the price of newer brand-name drugs.

Low-cost treatment is imperative to turning back the diabetes epidemic, said Dr. Wendy L. Bennett, assistant professor of medicine at Johns Hopkins University School of Medicine and the lead author of the A.H.R.Q. study. Experts estimate that only 25 percent of diabetic patients are getting the treatment they need, and expense is a big reason. Even well-insured patients may reel when confronted with the $6,000 a year it takes on average to manage the disease (not counting the costs of such complications as heart disease, stroke, and liver and kidney damage).

Becoming educated is the most important thing a person with diabetes can do to help stem the cost of medications as well as avoid complications, said Dr. Bennett. Here, three crucial things you should know.

Step 1: Fight diabetes with lifestyle changes.

Cost: Free or low cost.

If you are pre-diabetic or recently diagnosed, you may be able to dodge the expense of drug treatment with exercise and a better diet and by quitting smoking. None of this has to cost a fortune, and in any event healthier foods and, if necessary, a gym membership or other exercise program are well worth the investment. Even if you are taking medication, these lifestyle changes can help the medicine work better and longer.

For more information go to and the Web site for the American Diabetes Association,

Step 2: If you need to begin taking a drug to control blood sugar, start with metformin, the most common and one of the least expensive diabetes drugs.

Cost: $36 for 100 pills (500 milligrams); usually taken twice a day. Prices may be even lower at Wal-Mart, Target and other discount pharmacies.

Metformin almost always works as a first-line drug, except for patients suffering from severe kidney disease, said Dr. Bennett. What’s more, metformin generally does not cause hypoglycemia, a common and dangerous side affect of many diabetes drugs.

It also does not seem to cause weight gain, as some other diabetes drugs do, said Dr. Bennett. “The last thing you want if you’ve been diagnosed with diabetes is additional weight,” she added.

A study published in Consumer Reports Health in February 2009 also found that older, less expensive diabetes drugs were just as effective as the new ones. Better yet, they have established safety records, while some newer diabetes drugs have been found to increase cardiovascular and other health risks.

“The expensive drugs are third- and fourth-line drugs,” said Dr. Marvin Lipman, chief medical adviser for Consumer Reports Health and a practicing endocrinologist in Westchester County, N.Y. “If you don’t get results with the less expensive drugs, you go to those. But you shouldn’t start there.”

Avoid: Certain newer diabetes drugs have been associated with heart failure and other risks.

Avandia, for example, has been linked to an increased risk of heart attacks. In September 2010, after years of debate, the Food and Drug Administration severely restricted Avandia’s availability, allowing it to be prescribed only to patients in a special program who had not responded to other drugs and were taking the medicine under a doctor’s strict supervision. This month the agency expanded those restrictions to include related drugs Avandamet and Avandaryl, which also contain rosiglitazone, the active agent in Avandia.

Step 3: Choose combination drugs from among inexpensive generics.

Cost: Glimepiride, $13 for 100 pills (1 milligram). Glipizide, $64 for 100 pills (5 milligrams).

Most diabetics will have to eventually take more than one drug to keep blood sugar under control. The good news here from the Johns Hopkins study is that inexpensive metformin is also quite effective in combination with other generics, such as glimepiride and glipizide.

“Most combinations worked equally well, so when you’re adding a drug, you could choose a generic to save costs,” said Dr. Bennett. She added, however, that some drugs used with metformin might increase the risk of side effects such as hypoglycemia or weight gain. Patients should discuss each drug’s pros and cons, as well as cost, with their doctors.

Avoid: Do not start with one of the more expensive drugs in combination with metformin. In some cases, patients ultimately may need a combination of both generics and the newer drugs, but this usually becomes appropriate only after a less expensive combination has been used for some time or if the patient isn’t responding to the less expensive combination, said Dr. Bennett.


Inappropriate Use of Screening and Diagnostic Tests

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The American College of Physician just published an article in the Annals of Internal Medicine which contained a list of medical screening test and procedures which are of questionable value for various reasons.  Often they are redundant or wouldn't change treatment.  Sometimes they are tests which are more expensive but give no better information than less expensive tests.  If you find yourself in one of these situations ask your doctor if the test is really necessary or if there is a less expensive test which can give the same information.

1. Repeating screening ultrasonography for abdominal aortic aneurysm following a negative study

2. Performing coronary angiography in patients with chronic stable angina with well-controlled symptoms on medical therapy or who lack specific high-risk criteria on exercise testing

3. Performing echocardiography in asymptomatic patients with innocent-sounding heart murmurs, most typically grade I–II/VI short systolic, midpeaking murmurs that are audible along the left sternal border

4. Performing routine periodic echocardiography in asymptomatic patients with mild aortic stenosis more frequently than every 3–5 y

5. Routinely repeating echocardiography in asymptomatic patients with mild mitral regurgitation and normal left ventricular size and function

6. Obtaining electrocardiograms to screen for cardiac disease in patients at low to average risk for coronary artery disease

7. Obtaining exercise electrocardiogram for screening in low-risk asymptomatic adults

8. Performing an imaging stress test (echocardiographic or nuclear) as the initial diagnostic test in patients with known or suspected coronary artery disease who are able to exercise and have no resting electrocardiographic abnormalities that may interfere with interpretation of test results

9. Measuring brain natriuretic peptide in the initial evaluation of patients with typical findings of heart failure

10. Annual lipid screening for patients not receiving lipid-lowering drug or diet therapy in the absence of reasons for changing lipid profiles

11. Using MRI rather than mammography as the breast cancer screening test of choice for average-risk women

12. In asymptomatic women with previously treated breast cancer, performing follow-up complete blood counts, blood chemistry studies, tumor marker studies, chest radiography, or imaging studies other than appropriate breast imaging

13. Performing dual-energy x-ray absorptiometry screening for osteoporosis in women younger than 65 y in the absence of risk factors

14. Screening low-risk individuals for hepatitis B virus infection

15. Screening for cervical cancer in low-risk women aged 65 y or older and in women who have had a total hysterectomy (uterus and cervix) for benign disease

16. Screening for colorectal cancer in adults older than 75 y or in adults with a life expectancy of less than 10 y

17. Repeating colonoscopy within 5 y of an index colonoscopy in asymptomatic patients found to have low-risk adenomas

18. Screening for prostate cancer in men older than 75 y or with a life expectancy of less than 10 y

19. Using CA-125 antigen levels to screen women for ovarian cancer in the absence of increased risk

20. Performing imaging studies in patients with nonspecific low back pain

21. Performing preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology

22. Ordering routine preoperative laboratory tests, including complete blood count, liver chemistry tests, and metabolic profiles, in otherwise healthy patients undergoing elective surgery

23. Performing preoperative coagulation studies in patients without risk factors or predisposing conditions for bleeding and with a negative history of abnormal bleeding

24. Performing serologic testing for suspected early Lyme disease

25. Performing serologic testing for Lyme disease in patients with chronic nonspecific symptoms and no clinical evidence of disseminated Lyme disease

26. Performing sinus imaging studies for patients with acute rhinosinusitis in the absence of predisposing factors for atypical microbial causes

27. Performing imaging studies in patients with recurrent, classic migraine headache and normal findings on neurologic examination

28. Performing brain imaging studies (CT or MRI) to evaluate simple syncope in patients with normal findings on neurologic examination

29. Routinely performing echocardiography in the evaluation of syncope, unless the history, physical examination, and electrocardiogram do not provide a diagnosis or underlying heart disease is suspected

30. Performing predischarge chest radiography for hospitalized patients with community-acquired pneumonia who are making a satisfactory clinical recovery

31. Obtaining CT scans in a patient with pneumonia that is confirmed by chest radiography in the absence of complicating clinical or radiographic features

32. Performing imaging studies, rather than a high-sensitivity D-dimer measurement, as the initial diagnostic test in patients with low pretest probability of venous thromboembolism

33. Measuring D-dimer rather than performing appropriate diagnostic imaging (extremity ultrasonography, CT angiography, or ventilation–perfusion scintigraphy), in patients with intermediate or high probability of venous thromboembolism

34. Performing follow-up imaging studies for incidentally discovered pulmonary nodules 4 mm in low-risk individuals

35. Monitoring patients with asthma or chronic obstructive pulmonary disease by using full pulmonary function testing that includes lung volumes and diffusing capacity, rather than spirometry alone (or peak expiratory flow rate monitoring in asthma)

36. Performing an antinuclear antibody test in patients with nonspecific symptoms, such as fatigue and myalgia, or in patients with fibromyalgia

37. Screening for chronic obstructive pulmonary disease with spirometry in individuals without respiratory symptoms

Appropriate Use of Screening and Diagnostic Tests to Foster High-Value, Cost-Conscious Care, Annals of Internal Medicine, January 17, 2012 vol. 156 no. 2 147-149



Last Updated on Monday, 23 January 2012 18:40

Choosing Wisely - Overused Medical Tests

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Seventeen medical specialty groups have published lists of medical tests and procedures within their specialties which are overuse and of questionable value.  This is a great resource for consumers to use when a doctor advises them to have a test.  They can ask about the value of the test for them and possibly avoid unnecessary, expensive and dangerous procedures which may not provide any health benefit.

Here is a link to all of the tests:

Choosing Wisely Medical Tests

Here is a PDF file of all of the tests:


The US health care system is notorious for ordering too many tests and procedures and for overbilling for these tests.  You as a consumer must take an interest in this issue since you will pay for it in high costs for the test themselves, higher insurance costs, and possible adverse side effects from useless tests.

Time Magazine has just published an excellent article on the subject of high costs for medical care.  You should read this to get a better understanding of the problem:

Time Magazine - Bitter Pill

Last Updated on Sunday, 24 February 2013 17:38

Chest Pain: Best Medical Evidence

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Naomi Freundlich on May 17, 2011 published a good summary article on the "Health Beat" blog about the current (unfortunately sad) state of affairs regarding the best treatment for angina (chest pain).  According to the article titled "Time to Stop 'Resolutely Ignoring' Medical Evidence", there have been a number of large scale medical studies comparing treatment of chest pain by cardiologists.  These studies generally agree that for most people, drug therapy is better than cardiac stents or cardiac bypass surgery (CAB).

However, the problem is that most cardiologists are not following these recommendations.  There does seem to be a conflict of interest where cardiologists and hospitals earn much more money from cardiac stents and that this seems to be influencing their decisions.

This article covers the issues very well and gives references to the original research.  I highly recommend it.

If you find yourself in a situation where you have chest pain and facing the prospect of treatment, the article gives some good guidance on what to ask your cardiologist.  If the cardiologist is recommending a stent, you should question him or her carefully about the necessity for this and inquire about drug treatment instead.  In addition, if bypass surgery is being recommended, there are a few situations where this is the preferred treatment and you should make sure that you fall into this category of patients.




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