by Scott MacStravic
September 26, 2007 at 10:50 pm · Filed under Hospital and Health System CEOs, Sickness care, Treatments and Therapies, Research, Alternative Medicine
It has often struck me as a writer, that once I initiate research into a given subject, complementary and alternative medicine (CAM) most recently (see my posting of Sep 24), I almost always run into a new story on that subject, often in a matter of days. This time it was: C. Johnson “Study: Acupuncture Works for Back Pain”, Washington Post Sep 24, 2007.
The article is an example of both scientific and economic reasons to consider at least the specific CAM treatment involved, namely acupuncture. Analysis by German researchers indicated that acupuncture works significantly better than conventional medications and other traditional Western treatments. Over 1100 patients were randomly assigned to 1) acupuncture; 2) sham acupuncture, or 3) conventional therapy. In the acupuncture group, 47% of patients improved, compared to only 27% in the conventional group.
One of the particularly interesting findings from this study was that sham acupuncture, i.e. where the treatment is “faked” by not inserting the needles as deeply as acupuncture requires, achieved almost as good results as the real thing, with 44% of patients getting the sham version improved. While Dr. James Young of Rush University Medical Center, who was involved in the research, says that we don’t know precisely why acupuncture works, and often treats his own patients that way, it is clear that it does work.
When dealing with pain, the patient often wills improvement, by believing there will be an effect, or where the sham treatment creates such a belief. This “placebo effect” is particularly strong in pain management, and if it occurs with sham treatment, it makes sense to use it as well. Apparently, in this research, at least, the conventional medical treatment did not produce nearly as great a placebo effect, or else its objective medical effect was so low that even with its placebo effect, improvement was still significantly less than for either sham or true acupuncture.
Dr. Heinz Endres of Ruhr University Bochum, in Bochum, Germany, reported in an e-mail that “patients experiences not only reduced pain intensity, but also reported improvements in the disability that often results from back pain, and therefore in their quality of life.” He noted that these findings are in line with a theory that pain signals to the brain can be blocked by competing stimuli, such as the needles used in both forms of acupuncture.
It could be, as Dr. Brian Berman at the University of Maryland’s center for complementary medicine suggested, that acupuncture changes the way the brain processes pain signals, or by releasing natural painkillers in the body. If this is the case, then there is a logical physiological, as well as psychological reason for the reported success.
The “conventional” treatment includes traditional prescription painkillers, injections, physical therapy, massage, heat therapy, or other treatments, with all patients in the study receiving about ten sessions lasting a half-hour each. Many include both massage and heat therapy in the CAM category, so even when these were included, the acupuncture as a specific therapy appears to work better, though no results specific to these therapies alone were reported.
Because CAM is such a “loose” category of solutions, and because there are so many different specific therapies and therapists that may offer and deliver treatments, this finding cannot be seen as proof that CAM, in general, works – either this treatment for all problems and all patients, or even for all patients with this problem. As has been demonstrated many times already, people’s genetic differences often create vastly different levels and types of response to traditional medications and treatments, so it should not be a surprise if the same is true for CAM in general, and for acupuncture treatment of back pain in particular.
Of course, to employers or insurers who are looking for the best and least expensive way to manage workers’ or covered members’ back pain, these findings may provide both a scientific and an economic reason to not only accept acupuncture for back pain, but even to recommend it over conventional treatment. In the spirit of competition, we should look forward to seeing conventional medicine fight back, perhaps by identifying one particular treatment that does better than acupuncture did in this case. The more we have rigorous science applied to questions of what works, as contrasted to the sophistry of both politics and the market, the better we will all be in the long run.
by Scott MacStravic
September 10, 2007 at 8:05 am · Filed under Chief Medical Officers, Disease Management, Population health management, Treatments and Therapies
A report yesterday indicated that there is a strange chicken or egg question about how at least one medical diagnosis is made. The issue is: Does the diagnosis precede the choice of treatment, or does the choice of treatment come first, then cause the diagnosis in order to justify the treatment?
It has long been known that physicians are idiosyncratic in their approach to diagnosing patients. In some cases, they prescribe a treatment in the hopes that it will show what the diagnosis was by either working or not working. The character “House” in that eponymous TV show is fond of this approach. And it makes sense when the risks and side effects of the treatment are minimal, and no other approach to diagnosis has worked.
Physicians’ diagnoses and treatment choices are also understandably influenced by their specialty training and experience. Just as the “law of the hammer” notes that when you have a hammer in hand, more things begin to look like nails, so when you specialize in one kind of treatment, such as surgery vs. chemotherapy vs. radiation therapy for cancer, the choice of treatment is bound to be influenced by which the physician specializes in.
But “scientific evidence” for the dynamic “loop” of mutual causation emerged in a review of the rate of diagnosis of depression before vs. after “black box” warnings were issued by the Federal Drug Administration about the use of the class of anti-depressants called SSRIs. In the five years before the warning that these drugs can cause teen suicide, the depression diagnosis rate had climbed from 6 to 11 per thousand, among managed care plan members. Then when the FDA warning was issued in 2005, the rate decreased significantly, from 8.0 to 5.8 for men, and from 17.4 to 12.4 for women.
The use of SSRIs understandably dropped, as well, from 53% of depression episodes to only 22% and even non-SSRI anti-depressants were used less often. On the other hand, the number of patients who received at least some psychotherapy and alternatives to anti-depressants did not decline, as should be the case given that the warning only applied to anti-depressants. [“Depression Diagnoses Down After Drug Warning” MSNBC.comSep 5, 2007]
But what was the cause of the decline in the diagnosis of depression? There appears to be no logical connection between the decline in the use of anti-depressants as a cause of the decline in diagnosis. That is unless physicians were heretofore pressured by patients to prescribe anti-depressants for their depressed feelings, and when the warning was issued, the “popularity” of the diagnosis went down. Or perhaps, physicians were previously prescribing anti-depressants as a diagnostic test, and non longer used this test once the warning was issued.
As patients, we non-physicians may expect, and even prefer that diagnoses come first, and are based on something other than the need to justify a presumption or guess about the diagnosis. The fact that diagnoses of depression decreased so markedly, so fast, after increasing so dramatically before the FDA warning, at least suggests that diagnoses were being made on less than model criteria and using a variety of processes that may not fit “evidence-based medicine”.
There are technologies that can assist physicians in making diagnoses, involving computer programs that work physicians through a differential diagnosis program from symptoms to possible to most likely diagnosis. And physicians have been shown by autopsy studies to misdiagnose patients (at least the ones who die) between 8% and 24% of the time. Given this finding, one would think physicians might welcome technological assistance, but they are often described, and many times dismissed as “cookbook medicine”. [E. Donaghue “For Doctors, Diagnosing Gets a Technological Boost” USAToday.com Sep 5, 2007]
Even though cookbook medicine, where presumably computers take over completely in diagnosing and choosing treatments, is a threat to the “art” of medicine, most physicians are perfectly capable of using the technology as a guide to, rather than a substitute for their own judgment. And given the chicken vs. egg issue illustrated by the depression example, consumers might prefer that technology were used more often.
