Sunday, September 6, 2009

Various “Factoids” from Medical Journals

Those of you who have read my blog and who have read other past efforts I have made to make medicine understandable know that I tend to follow three themes in these writings.  One is understanding health policy and the impact health care has on economics and policy, the second is bringing understanding of the care function of health that must be delivered hand in hand with the scientific aspect and lastly reporting on the new science which is published on an almost daily basis.  Ultimately, these three aspects must come together in a caring health care system that is based on sound science and is supported by valid economics.  In this posting I want to focus on a few of the scientific studies that were discussed in recent medical journals.

Personalized Genomic Medicine

In a recent blog I wrote about some of the controversies in the use of personalized genomic medicine.  In this week’s New England Journal of Medicine, there are two articles and an editorial about the selection of the right chemotherapy based on the presences of a gene.  The studies and the editorial point out that, at least in cancer treatment, the promise of using a person’s genetic makeup is a powerful way of guiding the best therapy.  Whatever controversy does exist about other uses, and potential misuses of genetic testing and analysis, it is clear that research such as this is guiding the way for using personal genomics in medical care.

Chronic Lyme Disease

There are certain diseases in our society that gain popularity as they seem to explain the problems of people with vague symptoms that no other diagnosis seems to explain.  Since Lyme disease is a multisystem inflammatory disease that can potentially cause many symptoms, there are those who believe they have this disease when they have diffuse aches and pains and fatigue.  In a study in the American Journal of Medicine, the researchers recruited 240 patients from an area that is endemic for Lyme disease.  Each of these people believed or were told by local doctors that they had chronic Lyme disease.  Less than 20% of these people had any evidence of any sort of Lyme disease either in the present or past (and standard medicine does not recognize chronic Lyme disease as a disease) however most did have a different medical illness or what is now called Chronic Multisystem Disease (meaning they hurt all over and we don’t know why).  Depression and anxiety were very common as were other personality defects.  The authors summarize by saying “multidisciplinary treatment addressing the physical and often emotional suffering of such patients will be more effective than perpetuating the diagnosis of “chronic Lyme disease”.  In my words, we often overemphasize a diagnosis when appropriate care in the absence of a firm diagnosis is really indicated.

Retail Clinics and Cost and Quality of Care

In the Sept 1 issue of the Annals of Internal Medicine, a study was described that looked at the quality and cost of care in retail clinics of the type found in pharmacies for three simple illnesses, pharyngitis (a sore throat), urinary track infection and otitis media (ear ache), compared to the cost and quality in physician offices, urgent care centers and emergency rooms.  Overall the cost of care was 30-40% lower in the retail clinics than in urgent care centers and physician offices and 80% lower than in emergency rooms.  The quality was care in the retail clinics was just as good as in the other settings.  The lower costs were due to lower unit costs since the retail clinics are usually staffed by nurse clinicians rather than doctors, and due to less lab tests being done.  Before we get too enthusiastic about this, this was a study of the costs for a comparable visits, not a study of total costs from the illnesses.  Since most sore throats just get better on their own as do some ear aches, the question is whether people who would have stayed home and just waited to get better went to a retail clinic instead, raising the total number of people being served and thus raising the total costs.  That is not known from this study.  But it does show that these retail clinics fulfill their promise of lower costs and high quality.