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The Doppler Effect on the Fate of NIH Whistle-Blowers

The Doppler Effect on the Fate of NIH Whistle-Blowers

See The Doppler Effect for an expanded discussion of the firing by the NIH of Dr. Fishbein after he raised questions about the Ugandan site ...

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The Managed Care View on the Vioxx Mess

On <a href="http://www.medrants.com/index.php">MedRants</a>, a commentator expressed this "managed care" view of the Vioxx mess: <blockquote>Payers are frustrated that MDs are prescribing drugs patients don’t need, driving up short term costs with no attendant benefit to patients. Meanwhile, these decisions may very well lead to additional costs, as patients suffering cardiovascular events who also took COX-2s for WC injuries seek compensation from their WC payer. The net - payers see MD prescribing behavior as abdicating responsibility, and increasing payer costs. Frustration is rampant.</blockquote>I think there is plenty of blame to spread around for the Vioxx debacle. Physicians' enthuisiasm for Vioxx and other Cox-2 inhibitors clearly went beyond the evidence. And I think some physicians believed that Cox-2 inhibitors are actually more effective than regular non-steroidal anti-inflammatory drugs (NSAIDS), without evidence to support this belief. However, before 2004, it would have taken some digging to find evidence that suggested Cox-2 inhibitors were actually dangerous. The published VIGOR trial data did show heart attack risk was higher in the Vioxx group, but this could have been due to chance alone.[1] Although the most evidence-based discussions of Cox-2 inhibitors did raise questions about cardiac risk, they offered no definitive conlusions (see the Cochrane Review[2] and ACP Journal Club[3] from 2002.) Furthermore, even the most evidence-based physician would have had a hard time discouraging a patient absolutely determined to get a Cox-2 inhibitor before 2004, especially in the context of the typical 15 minute visit during which Cox-2 may have been only one of many issues raised. Such patients were not rare, due to vigorous direct to consumer (DTC) advertisements. Managed care, of course, has to accept some blame for deluging physicians with paper-work and bureaucracy, while cutting reimbursements for office visits, thus making it financially disadvantageous for physicians to spend enough time with patients to discuss benefits and harms of treatments. Managed care, of course, likes to talk about "evidence-based medicine," but has provided little real support for clinical trials, systematic reviews, or educating physicians about evidence-based medicine. And managed care did nothing to counter all those fancy pharamaceutical DTC advertising campaigns that down-played the adverse effects of drugs, including Cox-2 inhibitors. If managed care organizations really want patients to get the best possible care based on the best possible evidence, they should provide support and incentives for physicians to take enough time with patients, and for physicians to understand, have access to, and be able to use the tools of evidence-based medicine. References [1] Bombardier C et al. Comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis. N Engl J Med 2000; 343: 1520-8. [2] Garner S et al. Rofecoxib for the treatment of rheumatoid arthritis. Cochrane Database Syst Rev 2002; CD003685. [3] Meyerhoff J. Rofecoxib, 25 md/d, was more effective than rofecoxib, 12.5 md/d, or acetaminophen in osteoarthritis of the knee. ACP Journal Club 2002; 137: 26.

The Managed Care View on the Vioxx Mess

On MedRants , a commentator expressed this "managed care" view of the Vioxx mess: Payers are frustrated that MDs are prescribing d...

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AdWords: Code it your way

Despite all the development we've done for our AdWords program, much more remains to be built. Fortunately there's no shortage of good ideas outside the Googleplex -- our community of users is amazingly expert and innovative and knows exactly what features they want. Many successful companies fall prey to the NIH ("Not Invented Here") syndrome, but as hard as we try, not every talented developer is <a href="http://www.google.com/jobs/eng.html">working at Google</a>. Which is why we've just announced the arrival of the <a href="http://www.google.com/apis/adwords/">AdWords API beta</a><a href="http://www.google.com/apis/adwords/">.</a> The AdWords API beta program is an open invitation to developers to explore new concepts (and then write great software) for managing Google AdWords advertising campaigns. Large advertisers can use it for their complex ad management needs, like tying product margins to optimized keyword bids. Third parties can use the API to build new interfaces to manage their client accounts. Best of all, an API enables the creation of all sorts of unanticipated ideas. In our experience, it's better to wear "Not Invented Here" as a badge of honor than as a chip on your shoulder. Come sign up for a developer token and show us what we've been missing. - Josh McFarland, Product Manager - Nelson Minar, Software Engineer

AdWords: Code it your way

Despite all the development we've done for our AdWords program, much more remains to be built. Fortunately there's no shortage of go...

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BMJ Retracts Claim That Prozac Documents "Went Missing"

BMJ Retracts Claim That Prozac Documents "Went Missing"

The British Medical Journal has retracted its claim that documents supplied by Eli Lilly in a civil trial about whether fluoxetine (Prozac) ...

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University Board Defeats Proposal for Chiropractic School

University Board Defeats Proposal for Chiropractic School

See the story here about the defeat of the proposed school of chiropractic at Florida State University. It isn't clear whether this dec...

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Light Up at Home, Lose Your Job

I previously <a href="http://hcrenewal.blogspot.com/2005/01/employers-vs-employees-control-of.html">posted</a> on some fundamental confusions caused by having employers pay directly for their employees health insurance. One was employers thinking that such payments entitle them to control their employees' health-related behavior, even off the job. The <a href="http://www.detnews.com/2005/business/0501/27/A01-71823.htm">Detroit News just reported</a> that Weyco, ironically a medical benefits adminstration firm, fired four workers because they refused to be tested to see if they were smoking during off hours. The company already had stopped hiring smokers, and fined workers who continued to smoke. Weyco President Howard Weyers said his motivation included "saving money on the company's own insurance claims," <a href="http://olympics.reuters.com/newsArticle.jhtml?type=healthNews&storyID=7440773">according to Reuters</a>. An <a href="http://www.timesdispatch.com/servlet/Satellite?pagename=RTD%2FMGArticle%2FRTD_BasicArticle&c=MGArticle&cid=1031780483132&path=!news!columnists&s=1045855935174">editorialist also quoted </a>him as saying, "I don't want to pay for the results of smoking." Next on his agenda, again according to Reuters, is to "tell fat workers to lose weight or else." The trend is spreading locally in Michigan, as Kalamazoo Community College is refusing to hire smokers to "reduce health care claims by 10 percent," per Sandy Bohnet, its Vice President for Human Resources. The federal tax laws allow companies, but not individuals to deduct health insurance payments, so employers take money that could have added to employees' salaries to pay directly for their health insurance. Because they "pay" for employees' health insurance, some employers now seem to think they own their employees' bodies. As a physician, I am no fan of smoking, but firing employees just because they smoke (off the job) just adds insult to injury. Of course, more rational tax laws could let individuals could make their own decisions about health insurance and health-related behavior, and be the ones responsible for their actions.

Light Up at Home, Lose Your Job

I previously posted on some fundamental confusions caused by having employers pay directly for their employees health insurance. One was em...

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The NIH Response to Whistle-Blowing: "Overwhelm with Force"

<a href="http://seattlepi.nwsource.com/national/apwashington_story.asp?category=1152&slug=AIDS%20Whistleblower">A follow-up from Associated Press </a>about the case of Dr. Jonathan Fishbein, who complained about questionable practices at a Ugandan site for a National Institute of Health (NIH) run study on nevaripine for the prevention of transmission of HIV. Fishbein had been praised by the Director of the AIDS Division of NIH, Dr. Edmund Tramont, and recommended for a $2500 bonus to recognize his performance in his first year on the job. But after AP reported his concerns about the Uganda site, (see my post on this <a href="http://hcrenewal.blogspot.com/2004/12/politics-and-nih-nevirapine-study-in.html">here</a>), his immediate supervisor emailed Tramont "how hard would it be to terminate him?" Tramont's response was to fire him, "In Clauswitzian style, we must overwhelm with force." Science, and therefore science based medicine, of course, requires the free communication of research data and results, and the free analysis, interpretation, and discussion of them. The very last place in the world I would have expected to see someone who publicly discussed questionable research methods "overwhelmed with force" is the NIH, formerly one of the world's foremost biomedical research organizations. This story, coupled with previous stories about major conflicts of interest affecting NIH leaders (see previous posts <a href="http://hcrenewal.blogspot.com/2004/12/more-outrageous-conflicts-of-interest.html">here</a> and <a href="http://hcrenewal.blogspot.com/2004/12/anechoic-effect-and-conflicts-of.html">here</a> and <a href="http://hcrenewal.blogspot.com/2004/12/few-echoes-from-allegations-of-nih.html">here</a>) suggests the NIH badly needs new leadership who will respect its mission.

The NIH Response to Whistle-Blowing: "Overwhelm with Force"

A follow-up from Associated Press about the case of Dr. Jonathan Fishbein, who complained about questionable practices at a Ugandan site for...

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