Off-Label Communications: Is More Less?

Allergan corporation has filed a law suit against the Federal government challenging the FDA’s limits for companies discussing or promoting off-label uses of approved medicines.  This is not a new issue, but the news reports indicate that Allergan is going very old school and basing their legal challenge on Constitutional freedom of speech rights.

The issue is not can doctors and patients use approved medicines for conditions, (or in ways), which are not specifically approved by the FDA, but can companies discuss these off-label uses with physicians or provide them with published information about these off-label uses?

Competing Risk-Benefit Perspectives
The competing risk-benefit perspectives that surround this issue are nearly identical to the trade-offs that all stakeholders in biomedical research and development face – including the FDA, companies, patients, clinicians, and legislators:

  • Creating a landscape that protects individuals and public safety
  • Being flexible enough to provide clinicians and patients access to the best available treatment possibilities
  • Providing companies a reasonable market environment that creates incentives for developing new treatments and investigating new uses for already approved medicines, which also has marketing rules that are as clear as possible so companies can conduct business without being excessively concerned about straying into regulatory gray zones

Off-label use is common in clinical practice – particularly for disease areas like cancer – because it often represents the standard of care. …

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Encouraging Communications About Patients’ Goals

I attended a great event yesterday where experts discussed how to improve healthcare quality and safety by increasing patients’ involvement in making healthcare decisions.

This seminar, “Patient-Centeredness and Patient Safety: How Are They Interconnected,” was organized by the Kenneth B. Schwartz Center and sponsored by the Massachusetts Medical Society and CRICO/RMFDon Berwick (President & CEO of the Institute for Healthcare Improvement) was the main speaker followed by a panel consisting of two patient safety leaders from local hospitals and a patient involved with promoting patient engagement in quality improvement.

To start the event, Dr. Berwick discussed how his thinking about healthcare quality had evolved over several decades, and his increasing belief in the importance of patient involvement.…

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Miscommunicating Health Reform

Anyone following the debate about health reform knows that the discourse has become increasingly uncivil.  While it is easy to blame those opposing the proposals being developed in Congress for this situation, supporters of the proposals have been validating their adversaires’ messages by repeating the misrepsentative labels in their rebuttals.

Specifically, critics of the overall proposal have mischaracterized a provision that would pay clinicians for discussing end of life care preferences with their patients enrolled in Medicare.  (See below for information about the provision.)  Unfortunately, in responding to these attacks, health reform supporters have repeated the false claims about the provision, (and the label “Death Panels”), and thus perpetuated the fear their opponents have created.…

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Unfortunate Diversion from Health Reform Message

It was unfortunate that President Obama answered the question about Professor Gates at his news conference last night because it has dramatically diluted the focus of his message from health care reform to this unrelated story.  Many news organizations are covering his remarks on that one subject with less recognition of his health care reform message.  While the Washington Post and NY Times lead with the health message, they also include articles about the Professor Gates.  Conversely, the Boston Globe (not surprisingly) and CNN.com highlight the Professor Gates story over healthcare.  (MSNBC.com and cbsnew.com have health reform coverage more prominently that the Professor Gates story, while abcnews.com…

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Diabetes Updates – New Diagnostics, Increasing Rates, and Implications for Health Reform, CER, etc.

Changes in the diagnosis and treatment of diabetes is a great example for understanding how healthcare delivery constantly evolves based upon new discoveries.  And the history of these changes may help illuminate some thinking about health reform and the development and use of comparative effectiveness research (CER).

First, a little background on diabetes.

Diabetes Background
Diabetes mellitus (or “sugar diabetes”) occurs when the body has problems regulating the level of sugar (specifically glucose) in the blood.  This can be because the body’s pancreas doesn’t produce enough insulin, or for some reason the person’s organs become resistant to the actions of the insulin that is present – or sometimes both occur simultaneously. …

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Savings from Comparative Effectiveness Research

The May 23rd issue of National Journal has two very interesting pieces about Comparative Effectiveness Research.

Scoring Savings from CER:
The first is in an interview with CBO Director Doug Elmendorf which includes this Q&A about scoring savings from CER:
“NJ: In the first five years after studying comparative effectiveness, are the savings that CBO can find relatively small?
Elmendorf: The estimates that we’ve done in the past suggest that by the 10th year, you are saving about as much as the cost of the research itself.  By the fifth year, you are not.  We would expect there to be savings in the private sector. 

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People in Health Reform & Transformation

The importance of the “people factor” in improving the quality and efficiency of healthcare is well understood by experts in health information technology (HIT) and healthcare delivery transformation.  In estimating the time and cost for implementing new technologies or processes, they appreciate how behavior change and technology adoption are very time consuming and expensive – factors that are often glossed over in policy discussions.

David Brooks’ recent Op-Ed in the New York Times about the personality traits of CEOs leading successful companies sheds some light on the people factors in health reform.  Contrary to a lot of the common wisdom about the importance of good personal connections with coworkers for success in the corporate world, Brooks cites information that the most important factors for successful CEOs are “execution and organizational skills.

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Communicating with Clinicians to Improve Quality

At a recent public forum on improving quality and value in healthcare, an audience member asked how can patients know if the treatment or diagnostic test their clinician is recommending is really the best thing for them.  This reminded me that the Agency for Healthcare Research and Policy (AHRQ), recently ppublished a two page tip sheet to help patients talk to their doctors and a web-page that helps people create a set of questions customized for their individual healthcare needs and situations.

While these are obviously useful tools, I realized that emphasizing patient-clinician communications is now more important than ever because of the growing trend toward “consumer directed healthcare” and “patient empowerment.” …

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Medical Case Management – Making It Work

Jeffrey Krasner had a great article in yesterday’s Boston Globe about his experience trying to manage and coordinate his Mom’s care.  As a very experienced health reporter in a city dense with advanced health care delivery and health policy wonks, his story of problems getting care coordinated amongst her physicians and having her medical records transferred is very illuminating.  However, for those of us who have spent time trying to help friends and relatives navigate the medical care maze, it is not surprising.  (I went through a somewhat similar situation with my Aunt several years ago.)

While some people conclude that the solution to this complexity is a national health system, I believe that creating more standardization and accountability within our existing structure is a much more practical answer. …

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Patient-Physician Communications: Sometimes It’s the Small Things

Wide ranging discussions are ongoing about how to systemically improve the collection and analysis of clinical information via electronic medical records and other forms of health IT.  In addition there are more focused discussions about how to improve physician patient relationships.  However, when a friend told me how a communication failure with her physician left her with less than optimal treatment instructions, I was reminded that at the very micro level there are additional communications issues that need to be examined.

Here’s the story:  My friend had a temporary and rather minor – but certainly annoying –  skin problem, and her doctor advised her that hot/moist compresses would be the best thing, and that she should wrap a potato in a paper towel and “zap it,” and then apply this to where she had the skin issue. …

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Controlling Health Care Costs and Improving Quality with Effective Care Coordination

A study published by in the New England Journal of Medicine last week examining the effects of 15 different Medicare care coordination demonstrations received wide coverage by the general media.  Unfortunately, much of this focused on the study’s overall finding that these programs didn’t reduce hospitalizations or Medicare spending.  For example, the AP story’s headline, “Study finds bid to cut Medicare costs failed,” was used by many papers such as the Washington Times.

However, the actual study had much more complex, important, and useful findings, and the paper’s authors from Mathematica, (which Medicare contracted to do the analysis from this project), deserve a lot of credit for extracting meaningful information from this project.…

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Communicating Health Quality Measures

Educating patients, (a.k.a. “consumers”), to make the “best” health care choices has been a fundamental principle in some health reforms schools, including those advocating for more high-deductible health plans.  While this concept makes sense in economic theories, it also requires belief that patients can and will make good use of the information available to them – particularly when they are ill.

Another fundamental necessity for making such consumer-directed healthcare work to improve quality and lower costs is that the information provided to people is meaningful and accurate.  A study published in the November/December 2008 issue of Health Affairs illustrates the complexity of providing accurate information.…

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