The
information in this column is intended for informational
purposes only, and does not constitute medical advice or
recommendations by the author. Please consult with your
physician before making any lifestyle or medication changes, or if you
have any other concerns regarding your health.
BENEFITS
OF FULL DRUG
COVERAGE FOR MEDICARE RECIPIENTS AFTER HEART ATTACK?
Patient
compliance with medications following a heart attack has been shown to
improve
survival. However,
recent studies (please
see my column for 3-2-08) have pointedly confirmed that many patients
stop
having their heart medications refilled within a year or two of their
heart
attack. With an
estimated 47 million
uninsured people in the United States,
and many millions more with
inadequate healthcare insurance, it is not surprising that many
patients decide
to stop taking costly medications.
A new
study in the journal Circulation
has examined
the potential benefits (in terms of additional years of quality life
added and
costs associated with the treatment of cardiovascular disease) of
eliminating
out-of-pocket medication costs for Medicare beneficiaries.
Using
complex
statistical modeling, the researchers considered the potential benefits
of
providing 100% drug coverage for the following types of cardiac medications: aspirin, beta-blockers,
ACE inhibitors and
blockers, and statins. When
considering
the current Medicare Part D medication coverage plan, patients enrolled
in this
plan at the time of their heart attack were projected to live, on
average, an
additional 8.21 quality-adjusted life-years, while incurring an average
of
$114,000 in medical treatment-related costs.
However, based upon a hypothetical 100% drug coverage
model, which
assumes that all patients will take their medications as prescribed
(i.e.,
because out-of-pocket costs for drugs are eliminated), additional
quality-adjusted life-years following heart attack was estimated to
rise to
8.56, while total costs associated with medical treatment was estimated
to be
$111,600 per patient. Thus,
based upon
this statistical model, switching to a 100% drug coverage benefit for
Medicare
patients, following a heart attack, might be expected to both extend
lives and
decrease the cost of medical care for individual patients (although the
anticipated increase in lifespan, with the addition of 100% medication
coverage, would actually nullify any significant overall cost savings,
according to the results of this study).
Of
course, it is
one thing to try and hypothetically estimate the costs and benefits
that might
arise from a change in existing drug benefits coverage, but the reality
would
almost certainly be a bit more complicated.
First, and foremost, the high cost of medications is not
the only factor
that has been linked to poor patient compliance with medications. Medication side effects
and the inconvenience
associated with taking multiple medications are also well-known
significant
impediments to patient compliance.
It is
unlikely that compliance with medications will ever reach 100% in any
substantial population of patients, even with a 100% drug benefit. Additionally, the
administrative costs
associated with transitioning to this enhanced drug benefit plan, were
it ever
to be enacted, might further siphon off some of the individual patient
savings
projected by this study. Finally,
as a
physician who treats a large volume of patients from socioeconomically
depressed communities, I have to wonder if physician prescribing
patterns might
also change if patient co-pays were no longer required for medications. In my own case, when
presented with the
option of several equally effective drugs for patients, I try to select
older,
generic medications for my patients, in order to reduce their
out-of-pocket
expenses. If
co-pays were completely
eliminated, I wonder how many physicians would then adopt a “sky is the
limit”
approach to prescribing medications.
Despite
my
reservations regarding this study’s projected benefits from
implementation of a
full drug coverage plan for Medicare patients, there is no doubt but
that the
skyrocketing costs of medications, and mandatory patient co-pays for
these
medications, cause many patients to stop refilling their prescriptions. Undoubtedly, the
elimination of patient
co-pays would indeed significantly improve patient compliance with
their
prescribed medications. On
the other
hand, the Medicare entitlement plan is projected to become insolvent if
current
and predicted expenditures are not radically reduced.
Unfortunately, there is no easy answer for
the inherent conflict between limited healthcare budgetary resources
and
spiraling healthcare costs. From
a
purely clinical perspective, however, I would strongly favor 100%
medication
coverage for the poor and elderly, as these are the patients who would
benefit
the most from such coverage.
PARENT-TEEN
CONVERSATIONS
ABOUT SEX
Every parent I
have ever known has dreaded having “The Talk” with their teenage son or
daughter about the birds and the bees.
It is no secret that many parents find the topic
embarrassing and
uncomfortable to discuss with their progeny.
At the same, the pressure on teens to engage in sexual
activity has
never been greater than it is in our current sex- and body-obsessed
culture. Recent
studies have suggested
that as many as 1 in 4 teenage girls have already become infected with
sexually
transmitted diseases in the United States,
and in certain inner city and
minority populations, the incidence of sexually transmitted diseases in
teenage
girls may actually be as high as 50%.
A
great deal has
already been written about the best approach to having this critically
important discussion with your son or daughter, although most of us
parents
already understand that there is simply no perfect way to actually go
about
it. However, a new
study in the journal Pediatrics
does provide some helpful
clinically-based evidence about how to talk to your teenager about
sexual
topics.
In
this study,
312 adolescents, and their parents, participated in a randomized,
controlled
clinical research trial involving structured interventions in
parent-teen
communication about sexual topics.
The
teens completed surveys at the beginning of the study, and then at
additional
specified intervals after the interventions were completed. At each survey, teen
respondents had to
report the extent (if any) of parent-teen discussion of each of 22
specific
sex-related topics. The
study’s two
primary endpoints were the number of times that parents and teens
engaged in
discussion of sexual topics, and the number of times that each specific
topic
was discussed.
Based
upon the
surveys completed by the teens, repeated discussions of sexual topics
with
their parents were associated with a closer relationship between
parents and
their teens, and a higher level of communication between them (both in
general
and in terms of discussing sexual topics).
Teens who reported that they did not have repeated
discussions with
their parents about sexual topics reported a much lower level of
feeling close
to their parents, and a lower level of openness between them and their
parents
in discussing sex-related themes.
Those
adolescents who reported discussing the greatest number of specific
sex-related
topics with their parents also reported a significantly greater sense
of
openness of communication with their parents than did the teens who
reported
that fewer specific topics were discussed.
While
the results
of this study appear rather intuitive, they nonetheless reinforce the
importance of repetitive discussions, between teens and their parents,
about
sex-related topics. In
this clinical
study, both repetition and increased breadth of discussion appeared to
be
associated with an enhanced teen-parent level and openness of
communication,
both with respect to discussing sex-related topics and in general
communication
as well. While
these sensitive but very
important discussions can leave both parents and teens feeling a bit
uncomfortable
initially, an open, honest, and repetitive approach to such discussions
appears
to work the best.
SOY
(GENISTEIN) &
PROSTATE CANCER
The effects of
so-called “natural products” on disease prevention is an area of great
interest
to me, and to millions of other health-conscious people. An area of particular
interest to me is the
prevention of cancer through lifestyle modification, including dietary
habits
and natural supplements. (Estimates
by
public health experts have suggested that up to 80% of all cases of
cancer
might be prevented by lifestyle changes alone.)
At the same time, the dietary and “nutritional”
supplements industry,
with its multi-billion dollar annual sales, continues to promote its
products
as having significant disease preventing properties, even though the
scientific
evidence for such claims is often weak, or altogether absent. With these facts in mind,
one must be very
careful to maintain a healthy level of skepticism about the myriad
claims made
by the manufacturers of many of these supplements, or by enthusiastic
supporters of such products. With
these
cautionary statements in mind, an interesting new prostate cancer
research
study appears in the current issue of the highly respected journal Cancer Research.
Genistein,
which
is found in soy-derived foods and products, has been the subject of
intense
cancer-related research. A
member of a
class of plant-derived substances known as isoflavones, genistein has
been
found to have antioxidant properties, as well as weakly “estrogenic”
effects,
which mimic the effects of the dominant female hormone estrogen. Additional research has
also shown multiple
other biological effects for genistein, as well.
A
great deal of
genistein research has been directed at the two human cancers that are
most
closely linked with exposure to female and male sex hormones: breast
cancer and
prostate cancer, respectively.
Unfortunately, as is very common in clinical research, the
findings of
many of these studies have often provided contradictory results. In this new study, human
prostate cancer
cells were implanted into immune-deficient mice, and the effects of
dietary
genistein supplementation in these mice was then studied.
The
mice were
divided into two groups: one group received genistein supplements and
the other
group was fed only standard “mice chow.”
Blood levels of genistein were measured, and the mice
receiving
genistein were confirmed to have circulating blood levels of genistein
comparable
to those seen in men taking genistein supplements.
The
findings in
this animal model were rather dramatic.
Although the implanted tumors in the mice receiving
genistein
supplementation continued to grow just as much as they did in the mice
not
receiving genistein, the spread of tumors to other organs in the mice
receiving
genistein was reduced by an astounding 96% when compare to the mice
that did
not receive this isoflavone supplement.
These
results are
very intriguing as prostate cancer, as with most other types of cancer,
causes
death primarily as a consequence of tumor spreading throughout the body
(also
known as metastasis). Although
genistein
supplementation did not appear to reduce the growth of the implanted
primary
prostate tumors in these mice, a nearly 100% reduction in tumor
metastasis was
observed. Whether
this effect is
long-lasting or not cannot be determined from this clinical study. Just as importantly, this
study cannot tell
us whether or not similar beneficial genistein-associated effects will
also
occur in humans with prostate cancer.
However, ongoing and recently completed human clinical
research trials
will, hopefully, provide important answers to these and other important
clinical questions.
Disclaimer:
As always, my advice to readers is to seek the advice of your physician
before making any significant changes in
medications, diet, or level of physical activity.
