Sunday, April 8, 2012

A Potpourri of Recent Research on Improving Patients' Health Sensibly

I've had occasion several times to shout out for my friends Drs. Rick Bukata and Jerry Hoffman's Primary Care Medical Abstracts. It slowly dawned on my dim wits recently that it had been several months since I had gotten my monthly audio CD in the mail, and I had to have a talk with their normally on-the-spot crew at their headquarters at Creamery, PA (I have always imagined that your cholesterol goes up 50 points just by entering the city limits). But all is now well and a backlog of several months' CDs duly arrived, which I am working my way thru. Several papers they discussed specifically about the Pharma-medicine interface will be the subject of later posts. But the theme for this post is several studies they reviewed in a 3-month period about non-drug management of common medical problems, as summarized briefly below (journals require subscriptions for access).

  • A Swedish randomized trial in irritable bowel syndrome showed that a program of regular physical activity, instructed by a physiotherapist, dramatically reduced symptom scores, and three-quarters of the patients were able to stick with the program (Johannesson E, Simren M, Strid H, et al. Physical activity improves symptoms in irritable bowel syndrome: a randomized controlled study. American Journal of Gastroenterology 106:915-922, May 2011).

  • A randomized trial out of Pittsburgh involved older adults (mean age 72) with chronic insomnia--an important age group both because insomnia is common and because the risks of side effects of drugs is higher. The experimental group were given 2 sessions with individualized instructions regarding behavior changes to manage insomnia. The number reporting no insomnia at the end of the study were 55% who got the experimental intervention vs. 13% for the controls (Buysse DJ, Germain A, Moul DE, et al. Efficacy of brief behavioral treatmen for chronic insomnia in older adults. Archives of Internal Medicine 171:887-895, May 23, 2011).

  • A Brazilian group looked at a meta-analysis of 47 previous trials of exercise in Type 2 diabetes. (Another meta-analysis recently showed that almost all drugs now prescribed for diabetes reduce glycohemoglobin, the standard measure of blood sugar control, by about 1 point at best.) If physical activity was of greater than 150 minutes per week duration, it reduced glycohemoglobin by 0.89 points, while lesser amounts of exercise reduced glycohemoglobin on average by 0.36 points (Umpierre D, Ribeiro PA, Kramer CK, et al. Physical activity advice only or structured exercise training and association with HbA1c levels in type 2 diabetes: a systematic review and meta-analysis. JAMA 305:1790-1799, May 4, 2011).

  • A group at the American Cancer Society looked at a group of folks who reported in 1992-3 whether they adhered to cancer prevention guidelines calling for weight control, exercise, diet, and moderate alcohol consumption. The authors excluded tobacco avoidance since we all know how huge that is in preventing cancer. They then looked at the 14 years of follow-up and found that among those reporting a high level of adherence to these guidelines, the chance of dying of any cause was reduced by 42%, the chance of dying from a cardiovasculoar cause was reduced by about 53%, and the risk of dying from cancer was reduced by about 27% (McCullough ML, Patel AV, KushimLH, et al. Following cancer prevention guidelines reduces risk of cancer, cardiovascular disease, and all-cause mortality. Cancer Epidemiology, Biomarkers, & Prevention 20:1089-1097, June 2011).
These studies remind me of an old friend, Dr. David Sobel, who for many years did preventive medicine with the Kaiser organization in California. He would do talks for physicians and say something like,"I want to tell you about a new pill that has just been developed. If you give it to people with irritable bowel syndrome, their symptoms will dramatically decrease. And the pill has almost no side effects, and it's very cheap." The docs would jump up and down in their chairs and demand to know more. Then Dr. Sobel would deliver the punch line: "Oops, I made a mistake. It's not a pill after all. It's a simple exercise program." At this point the docs would groan and shake their heads and lose interest.

One of the standard rationalizations that physicians report when asked about bias from getting most of their information from drug reps is, "But I cannot be biased. I see reps from all the different companies, so whatever bias each one introduces must be cancelled out in the end." I will lay dollars to donuts that none of those reps came by the office touting exercise or simple behavioral treatment for irritable bowel or insomnia or diabetes. Yet the effect sizes seen in the studies above are so impressive that any drug company would kill to have one of its drugs perform anywhere near so well in a controlled trial. The conclusion that our society is overdrugged and that we underuse nonpharmacological tools for disease management and prevention seems hard to avoid.

No comments: