Endodoc

My wife sent me an e-mail this morning to let me know about an article published on-line at Salon.com entitled “Growth Hormone For Kids,” written by Rahul Parikh. The article addressed the question of whether short children who have no specific medical condition to explain their short stature should be treated with growth hormone injections. So, the question is whether children who have so-called “idiopathic short stature” should be treated with growth hormone with the intention of making them taller adults than they would otherwise be without the injections. The author comes down on the side of not treating such patients but the issue is actually rather complex and, in my opinion, there are no easy answers.

In 2003, the U.S. Food and Drug Administration (FDA) approved the use of growth hormone injections in idiopathic short stature with several caveats: the child must be short and growing at a rate that would not likely result in their achieving an adult height in the normal range, defined as 59 inches for a girl and 63 inches for a boy. In addition, the bone growth centers must be still open and the child must not have some medical condition that would explain the short stature.

I have no idea how many children in the U.S. have been and are currently receiving growth hormone injections for idiopathic short stature. I do not know of any insurers that cover the treatment, which can be quite expensive- as much as $50,000 or more per year. There is no consensus among pediatric endocrinologists (the docs who mostly deal with growth hormone treatment for short stature) whether short stature per se is a disease worthy of treatment with growth hormone or merely a cosmetic condition for which use of growth hormone should not be considered medically necessary (“medically necessary” is a term I discussed in one of my earlier entries and I would refer you to that in case you have forgotten what I wrote- actually, I can’t even remember what I wrote). Anyway, the article is interesting and the accompanying letters to the editor are particularly interesting. I even wrote a letter, which didn’t make the editor’s list of “the best 3 letters,” but you can find it on page 3 or 4 of the letters.

In my last posting I delved briefly into the politics (nonpartisan, of course) of health care issues in the upcoming presidential election. In that posting (10/10/08) I should have provided some information about the health care proposals put forth by the 2 major candidates, but I wasn’t sure how to do it.

Now I know. To my surprise (and pleasure), the current issue of the New England Journal of Medicine (October 9, 2008) has reasonably detailed statements by Senators Barack Obama and John McCain describing their health care proposals; the editors of the journal had asked the candidates to describe their plans for reforming the U.S. health care system, and voila.

If you want to learn more, the journal sponsored a symposium in which representatives from each of the campaigns participated and which is available as a video at www.nejm.org.

In my opinion the two biggest problems with our health care system (it might be a stretch to call it a “system”) are access and costs. Our collective health care woes cannot be solved without a coordinated effort to attack both problems; I do not believe we can realistically improve access without controlling costs and vice versa. How well do the candidates and their representatives tackle these barriers to a better health care system? I will offer no opinions in this matter until after the election, and you need to sort this out for yourselves anyway. Good luck.

I do promise to get back to health care policy as it affects the health of patients with various endocrine disorders, particularly diabetes mellitus, but only after the election.

This political season I have tried to “sit on my hands” and stay out of the various health care debates until after the presidential election which will finally happen in a few weeks. But, I can’t contain myself. The other day, I read an article in the New York Times entitled “Campaign Myth: Prevention as Cure-All,” written by H. Gilbert Welch, M.D. (NYT, Tuesday, October 7, 2008, page D6). Dr. Welch is a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice in Hanover, N.H. His article, which was labeled an “essay,” addressed the question of whether the presidential candidate claims that improving preventative health efforts will save money and improve health care.

What does Dr. Welch think?

Basically, Dr. Welch writes that preventative health these days is mostly overdiagnosis and not worth pursuing. He contends that the issue “boils down to encouraging the well to have themselves tested to be sure they are not sick. And that approach doesn’t save money; it costs money.” Wow, that’s interesting. But is Dr. Welch correct?

A critique of Dr. Welch’s thesis

In my opinion, Dr. Welch is guilty (very guilty) of generalizing to such an extent that his argument is at best misleading, and at worst, very misleading. Let me defend my position with one simple example- screening for diabetes mellitus. First of all, it is important for you to understand that screening IS defined as testing asymptomatic people for the presence of disease. Diabetes mellitus is incredibly common and we SHOULD encourage people to be tested for the disease. Why? We know that many millions of people in the U.S. (to say nothing about the rest of the world) have diabetes and don’t know it. Studies have shown that the average duration of diabetes prior to its discovery is 9 years; patients not infrequently learn that they have had diabetes for years when their eye doctor asks them after a routine eye exam how long they’ve had diabetes? Furthermore, we now know that early detection and proper treatment can prevent all diabetes complications, which account for most of the diabetes care costs. So, at least for diabetes, early detection improves health and saves money, lots of money. If you don’t believe me, ask Kaiser-Permanente why they screen for diabetes and have specialized diabetes management teams for patients enrolled in one of their health care plans.

Maybe I shouldn’t be so hard on Dr. Welch?

I do agree with Dr. Welch that for some disorders, early diagnosis does not improve health outcomes and save money. I also agree that screening for disease needs to be done in a way that few false positives (people who have positive screens but do not really have the disorder) and false negatives (people who really do have the disease but are missed by the screening test) result from the screening. It is also important in making a decision to screen for a disease that an effective treatment for the disease exists. One last thing- it is possible that for some diseases that not making a timely diagnosis saves money by not having to treat the patient with an expensive drug or procedure; but that’s an ethical/moral question that I’m not in a mood to discuss today.