Getting Clarity About What s Right for You OLLI 2017

Transcription

1 Gettig Clarity Abut What s Right fr Yu OLLI 2017 Keeth Brummel-Smith, MD Charltte Edwards Maguire Prfessr f Geriatrics Flrida State Uiversity Cllege f Medicie

2 I a stuig display f peer review fraud, the jural Tumr Bilgy is retractig mre tha a hudred articles whse authrs faked the peer review prcess. These authrs gave the jural editrs sham addresses, which led t a third party wh wuld submit a favrable review. Hw were the scammers fud ut? The editrs became suspicius whe may f the peer reviewers respded time, a rarity i the academic wrld. This icidet is yet ather reas the peer review prcess eeds t be mre trasparet.

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4 Recap f Where We ve Bee Ifrmed cset Uderstadig gals ad targets Recgizig the differece betwee symptm treatmet ad preveti Kwig what is really recmmeded (ad NOT recmmeded Uderstadig hw mey iflueces medical care

5 Elemets f Ifrmed Cset The recmmeded treatmet Beefits ad harms The alterative treatmets Beefits ad harms f each The beefits ad harms f treatmet Drs. discuss harms ad beefits ly 9% f the time They assess uderstadig ly 2% f the time Braddck, J Ge Iter Med. 1997;12:

6 Gettig True Ifrmed Cset Ask Dr. t use cmm wrds ad terms. Summarize back what yu heard. Request writte materials, r eve pictures r vides. Ask fr best-case, wrst-case, ad mst likely scearis, alg with the chace f each e ccurrig. Ask if yu ca talk t smee wh has uderge the surgery r received the chemtherapy. Explre alterative treatmet ptis, alg with the advatages ad disadvatages f each.

7 Gettig True Ifrmed Cset (3) Ask if yu ca talk t smee wh has uderge the surgery r received the chemtherapy. Explre alterative treatmet ptis, alg with the advatages ad disadvatages f each. If I saw 10 differet experts i my cditi, hw may wuld recmmed the same treatmet yu are recmmedig? Ifrmed Patiet? D t Bet O It. MA Sekeres, TD Gilliga, NY Times March 1, 2017

8 Defiitis Symptms abrmal sesatis felt by the pers NOW Ofte a sig f disease Immediate relief r reducti i symptms usual gal Preveti dig smethig t prevet a prblem which may ccur LATER Ofte related t risk factrs

9 Tw Kids f Treatmets Treatmet f symptms Pai, shrtess f breath, ski itchig, paiful feet What is the gal? Preveti f diseases r bad utcmes Primary prevet a disease frm happeig Secdary prevet a cmplicati Tertiary prevet a prgressi r imprve fuctiig

10 N-drug Appraches t Pai Cgitive behaviral therapy Massage Heat Ice Acupucture TENS uits Tpical creams PT/OT Chirpractic Distracti Laughter Prayer

11 Preveti Meds Risks/Beefits Medicati Beefit # f peple ut f 100 wh will have a evet preveted # ut f 100 wh will be harmed Statis (5 yrs) Reduced heart attack (MI), strke 1-4 if risks 5-7 if risks BP meds Reduced MI, strke if BP>160 Metfrmi (5yrs) Reduced MI, strke 5 (1 meta-aalysis says beefit) 5-10 muscle aches 2 liver prb 5/10,000 muscle damage 10 lw BP, falls 10 stmach itlerace Other glucse pills Reduced MI, strke 0 10 hypglycemia 10 wt gai Warfari fr a.fib fr 1 yr Reduced strke severe bleed

12 Preveti Meds Risks/Beefits Medicati Beefit # f peple ut f 100 wh will have a evet preveted # ut f 100 wh will be harmed ACE/ B Blcker fr heart failure fr 3 yrs HF, death 7 10 lw BP Bisphsphates fr 2-3 yrs PPI (Nexium) fr 8 wks SSRI fr depressi fr 8 wks Chliesterase ihibitrs 1 yr Fractures Healig/decrease symptms Nt depressed Better day t day fucti 5 spie 1 hip 1-2 stmach symptms 1-2/1000 steecrsis due t side effects Icreased risks? 0 if mild t md 7 if severe 2-5 due t side effect Icrease mrtality? 0 10 stmach side effects

13 Itesive Ctrl f Risks 25,966 patiets ver 80 fllwed 2 years Mrtality was lwest with: BP 150/90 155/95 Ttal chlesterl A1C % Mrtality was highest with: BP < 130/70 Ttal chlesterl < 116 A1C < 6.0 Hamada S, J Amer Geriatr Sc, 2016;64:1425

14 Cl Screeig Oly fecal ccult bld testig has bee shw t reduce mrtality Clscpy has ever bee shw t reduce mrtality i a radmized trial Risk f harms frm clscpy rise with age Perfrati 4/10,000, majr bleed 8/10,000 Sedati Cst eprgsis: Cacer Screeig

15 Useless r Questiable HRT hrme replacemet therapy Asymptmatic bacteriuria Atidepressats fr mild depressi Arthrscpic debridemet f OA kee Crary stets fr stable crary artery disease MRI i ucmplicated acute back pai Tsillectmy Rutie heria repair i lder me PSA testig

16 Lifestyle versus Medicati Iterveti Icidece (ew cases) Reducti Lifestyle % Metfrmi % Placeb 11.0 (cmparis) Almst 3 year fllw-up Metfrmi side effects stmach (10% - 53%), ervus system (1%-5%), weakess (10%) Kwler WC, NEJM 2002;346

17 Attributable Fractis fr All-Cause Mrtality Me Wme Aerbics Ceter Lgitudial Study,

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19 Pre-Operative Testig SGIM STS ACP ACR

20 LDL Chlesterl ad Mrtality i Older Peple Jural f the America Geriatrics Sciety 53: , 2005

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22 8 Times t Questi Yur Dr s Decisi Imagig fr first-time lw back pai Aual r biaual detal x-rays Aual PAP smear CT sca fr headache FSH test t diagse perimepause Ultrasud t scree fr varia cacer Yearly vitami D test Aual CBC ad chlesterl test

23 Chsig A Dctr Call the ffice fr ifrmati Gives a gd idea f what they are like! Csider a get acquaited appitmet Ask fr it specifically Be prepared t pay Ask questis: D yu have may lder patiets? D yu wrk with family? Ca I call r yu? Other special questis

24 Preparig fr Appitmets Make a PRIORITIZED list f ccers Take ifrmati with yu Keep yu w medical recrds Up-t-date list f medicatis Visits t ther dctrs Ask fr cpies f tests Take yur glasses (ad hearig aids) Csider brigig a family member r fried (Need a iterpreter???)

25 Givig Ifrmati Share ay symptms Whe it started, what is it like, what makes it better r wrse, des it affect yur daily fuctiig? Review yur medicatis ALL OF THEM! (Thse frm ther Drs, verthe-cuter, alterative remedies) Be hest abut symptms ad habits (smkig, drikig, exercise, sleep)

26 Ctrl Yur Prescriptis Keep a list f yur drugs shw it every visit Use ly e pharmacy D t ask fr, r accept, ay drug that is advertised TV r i magazies Ask hw lg the drug has bee the market D t take ay drug util it s bee ut fr at least 2 years Ask if there are ther thigs besides takig a drug yu ca d Ask if yu ca stp ay curret drugs

27 Medicatis Fial Questis Are yu sure there s thig else I ca d istead f takig this medicie? Whe ca I stp it? What side effects ca I expect? Will it iteract with ay f my ther medicies?

28 Gettig Ifrmati Tests Why is it imprtat? Hw will the result affect my treatmet? What are the risks? What will it cst? D I eed t prepare?

29 Gettig Ifrmati Diagsis What caused this? Is it permaet? Hw is it treated? Aythig I ca d ther tha a medicie? Hw will it affect my life? Hw ca I lear mre abut it?

30 Keepig Ifrmati Take tes Keep a health tebk Keep recrds If ucertai ce yu get hme, call r the dctr s ffice Sig up fr a prtal (if available)

31 Makig Decisis Tgether Ask abut ptis Discuss the beefits Discuss the risks/harms Thik abut yur w values ad gals Ask abut preveti Ask abut supprt grups ad cmmuity services

32 Referral t a Specialist Ask that yur recrds be set befre yur visit Have yur w cpies Ask whether ay tests he r she rders have bee de befre. If s, des it really eed t be repeated? Ask same questis abut treatmet. Ask him r her t talk t yur primary care dctr

33 Seeig a Surge Hw may have yu de? What are the success & cmplicati rates? What prblems ca I expect? Hw much pai r discmfrt will I have? What kid f aesthesia? Ay risks i lder peple? Hw lg will I be i the hspital? Will I eed rehabilitati?

34 Gig T The Emergecy Rm Take yu isurace ifrmati List f medicatis List f medical prblems ( Prblem List ) Names ad phe umbers f yur dctrs Names ad phe umbers f family members (ctacts) Advace directives (if applicable)

35 Helpful Decisi Sites Heart risk calculatr The Number Needed t Treat Medstpper Decidig cacer screeig

36 Resurces

37 Helpful Sites Medicatis Therapeutics Iitiative: Evidece Based Drug Therapy OHSU Drug Effectiveess Review Prject

38 Thigs t Csider Ji the Right Care Alliace Kw mre abut yur dctr

39 Great Bks Overtreated, Sha Brwlee, Blmsbury, 2007 The Truth Abut The Drug Cmpaies, Marcia Agell, MD, Radm Huse, 2004 Overdsed America, Jh Abrams, MD, Harper Cllis, 2004 Wrst Pills, Best Pills, Sidey Wlfe, MD, Pcket Bks, 2005 Overdiagsed, Gilbert Welch, MD, Beac Press, 2011 Wrried Sick, Nrt Hadler, MD, UNC, 2008 The Last Well Pers, Nrt Hadler, MD, McQuee s, 2011

40 Is Medicie Wrthless? Hw d yu wat t gamble?

41 Asymmetry Priciple The amut f eergy eeded t refute bullshit is a rder f magitude bigger tha t prduce it.