“The National Consortium of Breast Center's Board of Trustees has given their consent to the following position statement reflecting their stand on the issue of mammographic screening, in response to the recommendations made by the US Preventive Services Task Force.
National Consortium of Breast Centers, Inc.
Position Statement regarding the Mammography Screening Recommendations of the United States Preventive Services Task Force (USPSTF)
The National Consortium of Breast Centers (NCBC), the largest national organization devoted to the inter-disciplinary care of breast disease, requests the USPSTF rescind their new position on mammography screening.
The U.S. Preventive Services Task Force (USPSTF) published a paper detailing model estimates of potential benefits and harms to women screened for breast cancer with mammography.1 They provided an updated USPSTF recommendation statement on screening for breast cancer for the general population that alters currently accepted guidelines for women over 40 years old.2
The NCBC opposes the new guidelines as written. We cite specific evidence that screening mammography leads to early detection which leads to improved survival.3 In every country starting population screening, mortality declines coincide with onset of screening, not systemic therapy. These USPSTF models are not based on sound data, namely different denominators in the “harms” vs. “benefits” groups leading to invalid comparisons. Recent data from randomized controlled trials reveal significant mortality reductions evident approximately five years after screening programs were initiated. The reductions in age-adjusted, disease specific mortality (30-40%) since 1990 define screening program benefits not seen in the prior six decades. In the United States, these mortality declines continue at a rate of approximately 2% per year. 4 This mortality improvement counts as a remarkable public health achievement.
In addition, the USPSTF panel (comprised almost exclusively of primary care physicians) did not include breast imaging specialists nor was it represented by any of the multiple other specialists who collaborate to optimize patient outcomes. These specialists include pathologists, surgeons, medical oncologists, radiation oncologists, reconstructive surgeons, technologists, geneticists, nurse navigators, educators and others.
The NCBC does not understand the assumptions used by the USPSTF to value human life. We note the cited literature was selective and failed to acknowledge equally powerful and credible peer-reviewed literature, which supports currently accepted breast cancer screening guidelines.
We would also like to note that quality of life has a significant value, not just survival. It is well established that if we discontinue mammography for women in their 40’s, the cancers eventually detected will be larger, more likely need more aggressive surgery, more likely need chemotherapy and more likely lead to other significant socio-economic concerns.
The NCBC requests input into future guideline development and vows to work with government, scientists and industry to keep the process transparent and keep the focus on the patient. We recommend further efforts target screening, risk assessment, education and awareness regarding the implications of positive and negative screening findings. Funding for further research is imperative and supported by the controversy these articles have generated.
Finally, we note the USPSTF article states, “whether it will be practical or acceptable to change the existing U.S. practice of annual screening cannot be addressed by our models.”1 The NCBC agrees with this comment and finds their screening guideline suggestions unacceptable. The NCBC believes many women’s lives will be placed at risk if current screening guidelines are altered. We respectfully request the Task Force rescind their position on this specific women’s healthcare screening policy.
# # # #
About NCBC: The National Consortium of Breast Centers (NCBC) is the largest national organization devoted to the inter-disciplinary care of breast disease. In keeping with our mission, to promote excellence in breast care through a network of diverse professionals dedicated to the active exchange of ideas and resources including: 1) To serve as an informational resource and to provide support services to those rendering care to people with breast disease through educational programs, newsletters, a national directory, and patient forums; 2) To encourage professionals to concentrate and specialize in activities related to breast disease; 3) To encourage the development of programs and centers that address breast disease and promote breast health; 4) To facilitate collaborative research opportunities on issues of breast health; and 5) To develop a set of core measures to define, improve and sustain quality standards in comprehensive breast programs and centers.
1. November 17th edition of the Annals of Internal Medicine, Vol. 151, Number 10, 738-747.
2. November 17th edition of the Annals of Internal Medicine, Vol. 151, Number 10, 716-726.
3. Tabar L, Vitak B, Chen HT et al. Beyond randomized controlled trials: organized mammographic screening substantially reduces breast cancer mortality. Cancer 2001; 91: 1724-1731.
4. American Cancer Society, Breast Cancer Facts and Figures, 2009-2010.
All content and design © 2009 by the National Consortium of Breast Centers, Inc.”
I was convinced that Milt Freudenheim's glowing, uncritical puff-piece about Epic in the NYT would not provoke any critical blow-back (see: Digitizing Health Records, Before It Was Cool). I was certainly not expecting any criticism from hospital CIOs and CEOs who are anxious to stay within the good graces of the company and are contractually constrained from any visceral outbursts. However, Vince Kuraitis, who blogs over at e-CareManagement, has informed me via a comment that there is a heated discussion going on at Google+ about the NYT article and Epic in general. You may also want to refer to my recent blog note about Epic (non)-interoperability (see: A Reader Comments on Epic Interoperability and Care Everywhere). Here is Vince's comment:
FYI, there is heated discussion going on about Epic (non)-interoperability on Brian Ahier's Google+ post.
Here are five snippets from the ongoing Google+ dialogue selected on a semi-random basis:
I guess the sad thing about American health IT is that this -- so far -- is the best we got (Matthew Holt)
OMG! All of this anger can't be healthy. However, don't expect much to change in the real EMR/EHR world as a result of this discussion. Link to Google+ if you want to read more in this thread.
One more thing. Has the NYT totally lost its way amidst the Epic adulatory mist? Here's what I think happened. Judith Faulkner NEVER gives interviews to the press. I suspect that Milt Freudenheim was advised by his editors to pitch only softballs to her in exchange for this exclusive audience. I know that the paper maintains that it never cuts such deals but why don't you read the article and judge for yourself. There must be some teeny, weeny problems somewhere in Verona that Milt could have uncovered.
In response to a recent note about Epic's Care Everywhere (see: Sharing Medical Records across Hospitals with Epic's Care Everywhere), a reader (Open Standards) posted a comment which I thought was instructive and worthy of promotion to the level of a note. I present it below in its entirety:
Per the Epic technical manual, Epic's Care Everywhere is [described in] the following [way]: 1. For Epic institutions, it is an XML file containing Epic proprietary extenstions to the continuity of care document. 2. For non-Epic institutions, it is an XML file containing the standard continuity of care document. Both of the above are variations of the same theme: the CCD document, an XML marked up document with the demographic, medication, medical history, and most recent encounter data abstracted from the EMR.
There is nothing particularly innovative about Epic's Care Everywhere. In fact, it is a Mearningful Use requirement for any EMR vendor to have CCD export capability. In this regard, all the 400+ MU certified EMRs in the U.S. have this functionality. A CCD document is vastly different than an HIE, which is an independent server that acts as a translation broker. The whole point of the CCD is to enable point-to-point transfer of a common standard machine readable summary of the patients data as a handoff document between any and all EMR.
In this regard, EpicCare specifically breaks the standard CCD form, and makes it incompatible with the rest of the 400+ EMRs in the USA by adding their proprietary extensions. This is consistent with Epic's proprietary, one-vendor-shop, non-interoperability stance. The statement that "any hospital can interoperate with Epic's Care Everywhere - just so long as they are an Epic institution" aptly summarizes this. Again, the proprietary extension to the CCD by Epic means that the 400+ certified EMR's in the USA won't interoperate with Epic's EMR, because these 400+ EMRs adhere to the government mandated open standard CCD XML form and Epic doesn't.
I would appreciate any further comments if this comment is erroneous or misleading in any way. On this basis, it would not be correct to describe Epic's Care Anywhere as a type of HIE. The name of the product is misleading but that nothing new in the software industry. It seems to be a proprietary version of CCD export capability -- a continuation of the Epic's "walled garden" software model.
There are a number of factors contributing to the financial pressures being placed on community physicians. One of the most significant is that the federal government, the most important payer of medical costs, tends to favor inpatient and ambulatory care delivered by hospitals. A recent story provided the details (see: Doctors going broke). Below is an excerpt from it
Doctors in America are harboring an embarrassing secret: Many of them are going broke. This quiet reality, which is spreading nationwide, is claiming a wide range of casualties, including family physicians, cardiologists and oncologists. Industry watchers say the trend is worrisome. Half of all doctors in the nation operate a private practice...."A lot of independent practices are starting to see serious financial issues," said [ a consultant to physician practices]. Doctors list shrinking insurance reimbursements, changing regulations, rising business and drug costs among the factors preventing them from keeping their practices afloat. But some experts counter that doctors' lack of business acumen is also to blame....[A cardiologist] said recent steep 35% to 40% cuts in Medicare reimbursements for key cardiovascular services, such as stress tests and echocardiograms, have taken a substantial toll on revenue. "Our total revenue was down about 9% last year compared to 2010," he said. "These cuts have destabilized private cardiology practices," he said. "A third of our patients are on Medicare. So these Medicare cuts are by far the biggest factor. Private insurers follow Medicare rates. So those reimbursements are going down as well."....Also on his mind, the impending 27.4% Medicare pay cut for doctors. "If that goes through, it will put us under," he said.Changes in drug reimbursements have hurt [oncologists] badly. Until the mid-2000's, drugs sales were big profit generators for oncologists. In oncology, doctors were allowed to profit from drug sales. So doctors would buy expensive cancer drugs at bulk prices from drugmakers and then sell them at much higher prices to their patients. "I grew up in that system. I was spending $1.5 million a month on buying treatment drugs," [an oncologist] said. In 2005, Medicare revised the reimbursement guidelines for cancer drugs, which effectively made reimbursements for many expensive cancer drugs fall to less than the actual cost of the drugs.
There is no question that cutbacks in Medicare and Medicaid reimbursement are hurting many physicians in private practice. However, I also agree with the statement above that part of the problem is many doctor's "lack of business acumen." When times are flush and reimbursement is at a high level, faulty business practices can be glossed over. The same rule does not apply to current conditions. It's easy to manage a business on the way up and hard to manage one of the way down. Physicians spend many years in training but spend almost no time learning how to run a business.
I have posted a number of notes about the so-called oncology concession whereby oncologists purchase expensive cancer drugs at a wholesale price to treat their patients and then mark up the prices when they are administered (see: Academic Oncology and the "Chemotherapy Concession"; The Oncology Concession Under Attack by Health Insurance Companies). I have been told that it's easier to manage the expensive, limited-shelf-life chemothrapy inventory in academic oncology infusion centers with a large number of patients than in smaller private practices. Large cancer hospitals also benefit from the discounted volume purchases of such drugs.
The bottom line is that movement toward Big Medicine (Big Health Systems, Big Payers, and Big Pharma) persists unabated (see: Health Insurance Company to Purchase Troubled Pittsburgh Health System; Hospitals Use Their Medical Schools, Residencies for Later Physician Recruitment).
I’d been meaning to do a post about Emdeon‘s EHR lite ...since I first heard about it at MGMA. While I think that EHR Lite might be some good branding, I’m not sure you can really classify Emdeon’s EHR as lite. I’m sure they’re just trying to differentiate themselves from the 300+ EHR companies out there....I think I found the thing that most differentiates Emdeon from many other EMR companies. it’s their network. Here’s a summary they sent me of their network. Emdeon’s network encompasses:
....I strongly believe that healthcare will be a very heterogeneous environment. ...EHR software is still going to have to connect with hospitals, pharmacies, labs, payers, government entities etc. An EHR is going to be key to integrating with these other heterogeneous software as I do believe the EHR will be the “Operating System of Healthcare.” Today a silo’d version of an EHR is not an issue at all. However, the writing on the tea leaves that I read is that healthcare providers that have a well connected EHR are going to be at an advantage. We’ll see if Emdeon can use their current connections as an advantage in this way.
It's quite clear that hospitals need to be interconnected via multiple networks for the exchange of both clinical and financial information. Whether or not the leading EMR companies will move in this direction and function more as as "operating systems" is another story. Epic, for example, might appear to function as an HIE with its Care Everywhere module (see: Sharing Medical Records across Hospitals with Epic's Care Everywhere). However and given that this interconnectivity is provided only to Epic clients, the software would be better called Care with Epic Clients.
In my opinion, Epic has little interest in mobilizing healthcare information electronically across hospitals within a region that are not its clients. The company is all about domination of the higher end of the hospital market and modules like Care Everywhere have been developed to provide additional client functionality and not to serve as a HIE utility across all hospitals in a region (see: A Fresh Look at Epic from a Financial and Strategic Perspective). Epic's business model can be described as a "walled garden" whereas, I think, Cerner is envisioning the development of an interconnected community with its Winona project as one prime example (see: A Different Paradigm for Analyzing the Competition between Cerner and Epic; The Winona Project: Is This a RHIO Success Story?; Cerner's Winona Health Project Featured on the PBS News Hour).
I have posted notes before about the need for a national, agnostic lab network (see: Interpreting the Tea Leaves: Ten Hot Trends in Healthcare, Lab Medicine, and Pathology Informatics; Predicted Migration of "Some" LIS Functionality from Pathology to Central IT). For the labs, a national network is useful for the exchange of lab data but also as a means to access expertise and talent which may be lacking or insufficient locally. Community hospitals labs, and even academic departments, have always turned to regional and national reference labs to provide esoteric testing services that they can't supply. Any lab or hospital national network needs to be agnostic in the sense that it's open to a variety of companies and service providers. Such an approach stimulates competition on the basis of quality and price and is the antithesis of the walled-garden, vertically-integrated approach which is all about domination of the market by a single company (see: iPhones, Physicians, and the Dilemma of the "Walled Garden").
Cleveland Clinic established a ban on hiring smokers more than two years ago and similar policies are now spreading to other hospitals (see: Want a Job at the Cleveland Clinic?: Smokers Need Not Apply; Tobacco-Free Hiring Takes Hold; Both Smoking and Smokers Excluded; The Financial Stakes Escalate for Employees Who Smoke). Geisinger Health System has now introduced a similar policy (see: Hospital Quits Hiring Smokers, Introduces Nicotine Tests For Medical Workers). Below is an excerpt from the story
Smokers in the medical field now have another reason to quit as a Pennsylvania hospital has said it will no longer hire smokers and is introducing nicotine tests in order to enforce the rule....Those exposed to second hand smoke will be exempt from the test, which screens applicants for cigarettes, smokeless tobacco, snuff, nicotine patches, nicotine gum and cigars. For those who fail the test, the hospital says applicants can reapply after six months....According to CNN, Pennsylvania is among 19 states that allow employers to screen job applicants for signs of smoking. While there's certainly an incentive to keep employees healthy for work, the economic benefit of having non-smokers on the payroll is also notable. The U.S. Centers for Disease Control and Prevention (CDC) puts a $3,391 price tag on each employee who smokes: $1,760 in lost productivity and $1,623 in excess medical expenditures.
A few interesting points are brought out in this article relating to the exclusion of smokers as new hospital hires. A twist that was new to me in the article is that a prospective employee can claim an exemption from the hiring ban on the basis of second-hand smoke. I assume that the applicant would show a weakly positive lab test that could be explained by a smoker in his or her household or even in a car pool. I believe that the preferred test for a history of smoking continues to be cotinine (see: Saliva and Urine Tests for Smoking). Secondly and in the article, it seems that there needs to be enabling state laws in place to enable a hospital to pursue a smoking restriction; 19 states currently have such laws in place. I suspect that most of the states that have not yet fallen in line with such legislation will do so shortly. Smokers are becoming an endangered species.
Lastly, there is data presented at the end of the excerpt above that place a cost to employers for employees who smoke, providing convincing financial evidence for the soundness of a "no smokers, no smoking" policy for hospitals. It seems to me that there are three health system that usually take the lead regarding innovative clinical and organizational policies: Cleveland Clinic, Geisinger, and Kaiser. You can now expect many other hospitals, initially in the 19 states, to launch similar policies.
Hepatocellular cancer (HCC) is a common neoplasm in Asian countries because of the high incidence of hepatitis infection. Here are the three most common risk factors for (HCC): (1) alcoholism; (2) hepatitis B; (3) hepatitis C that causes 25% of causes globally (see: Hepatocellular carcinoma). Although HCC has been relatively rare in the U.S., the incidence is now rising quickly (see: Mayo Clinic Studies Identify Risk Factors In Rising Trend Of Liver Cancer). Here's more details from a recent article:
Doctors have known for years that the incidence of deadly liver cancer is on the rise, but what is causing that trend has remained a mystery. Two recent studies...offer a clearer picture of the rise of hepatocellular carcinoma (HCC), or liver cancer, which has tripled in the U.S. in the last three decades and has a 10 to 12 percent five-year survival rate when detected in later stages....[One] study found the overall incidence of HCC in the population (6.9 per 100,000) is higher than has been estimated for the nation based on data from the National Cancer Institute ....The study also found that HCC, which two decades ago tended to be caused by liver-scarring diseases such as cirrhosis from alcohol consumption, is now occurring as a consequence of hepatitis C infection. "The liver scarring from hepatitis C can take 20 to 30 years to develop into cancer," [one study author said]. "We're now seeing cancer patients in their 50s and 60s who contracted hepatitis C 30 years ago and didn't even know they were infected. " Eleven percent of cases were linked to obesity, in particular fatty liver disease. "It's a small percentage of cases overall," [the study author said]. "But with the nationwide obesity epidemic, we believe the rates of liver cancer may dramatically increase in the foreseeable future." Another study looked exclusively at the Somali population, which is growing in the U.S., particularly in Minnesota, where as many as 50,000 Somalis have settled in the last two decades. The East African country is known to have a high prevalence of hepatitis B, a risk factor for HCC. Researchers investigating records in the Mayo Clinic Life Sciences System confirmed that hepatitis B remains a risk factor, but they were surprised to find that a significant percentage of liver cancer cases in the population are attributable to hepatitis C, which had not been known to be significantly prevalent.
What I took away from this article is that the incidence of HCC is rising precipitously due to chronic hepatitis B and C infections in our native-born population, immigrants coming to this country carrying the two viruses, alcoholism, and obesity. It's a "perfect storm." Here's some more information about the relationship between obesity, diabetes, and HCC (see: Obesity and hepatocellular carcinoma):
Both obesity and diabetes are frequently associated with nonalcoholic fatty liver disease, and case reports have shown progression of nonalcoholic fatty liver disease to cirrhosis and hepatocellular carcinoma. Although no study has clearly tied all of these variables together, it is likely that the association of hepatocellular carcinoma with obesity represents the progression of underlying nonalcoholic fatty liver disease to cirrhosis. The mechanism most likely involves replicative senescence of steatotic mature hepatocytes and compensatory hyperplasia of progenitor (oval) cells as a reaction to chronic injury due to ongoing nonalcoholic steatohepatitis and resultant hepatic fibrosis.