Saturday, February 05, 2011

It's not working that well...

The way it is. It remains a brutal and slow slog for health care reform, now in its ugliest political phase. But reform of access to health care is just one aspect of correcting the problems of a system that is far too costly and far less effective than it could be.

One reason for the ineffectiveness is the powerful profit motive influence on medical research. It's not a inherently bad, but this is what you get when there are no cost controls from either free market forces or regulation: sloppy reports and even sloppier media coverage.
If you follow the news about health research, you risk whiplash. First garlic lowers bad cholesterol, then—after more study—it doesn’t. Hormone replacement reduces the risk of heart disease in postmenopausal women, until a huge study finds that it doesn’t (and that it raises the risk of breast cancer to boot). Eating a big breakfast cuts your total daily calories, or not—as a study released last week finds. Yet even if biomedical research can be a fickle guide, we rely on it.
But what if wrong answers aren’t the exception but the rule? More and more scholars who scrutinize health research are now making that claim. It isn’t just an individual study here and there that’s flawed, they charge. Instead, the very framework of medical investigation may be off-kilter, leading time and again to findings that are at best unproved and at worst dangerously wrong. The result is a system that leads patients and physicians astray—spurring often costly regimens that won’t help and may even harm you. 
But at NIH Ioannidis had an epiphany. “Positive” drug trials, which find that a treatment is effective, and “negative” trials, in which a drug fails, take the same amount of time to conduct. “But negative trials took an extra two to four years to be published,” he noticed. “Negative results sit in a file drawer, or the trial keeps going in hopes the results turn positive.” With billions of dollars on the line, companies are loath to declare a new drug ineffective. As a result of the lag in publishing negative studies, patients receive a treatment that is actually ineffective. That made Ioannidis wonder, how many biomedical studies are wrong? [More of an important article]
Compared to medicine climate science is a model of clarity. But the linkage between research results and product sales is so strong, and as public research funds constitute a smaller part of the support, this problem could get much worse.

Much of the problem comes from our collective math anxiety. We want certainty, not probability statistics. If more of us understood what a standard deviation meant, we could scrutinize flash reports from medical research with more expertise and parse out the meaning for our lives.

Which leads me to this medical report.
Researchers said they have identified a combination of four genes that appear to play a critical role in determining whether prostate cancer in its early stages will go on to become an aggressive, lethal disease.
The information could enable doctors and patients to make better decisions after the diagnosis of prostate cancer, a disease that is commonly overtreated today, researchers said. [More]
It turns out the sample was small (400) and long term studies have yet to be completed.  But my guess is when a test for these genetic markers is available in a few years, guys my age will all be getting one. While I hope it helps and stops the unnecessary interventions now common, it will likely be my sons who really benefit, and only after more and larger tests are completed.

One reason this misapplication of research problem exists could be the self-serving impatience of the aging Boomers. And impatience is very expensive. However it is done, America must come to grips with the idea now clear in other areas of economic activity: you can't have everything. Our system currently tries to finesse that rule, and quietly ration care by capacity to pay or by employer.

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