docThe Clinical Application of Genetic Testing in Type 2 Diabetes
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The Clinical Application of Genetic Testing in Type 2 Diabetes
HARVARD MEDICAL SCHOOL Back Pain Blues or What Happens When You Try to Cure a Chronic Condition Steven J. Atlas, M.D., M.P.H. General Medicine Division HARVARD MEDICAL SCHOOL Low Back Pain Management from 30,000 feet • Almost everyone will have low back pain at some point in their life – For most its episodic, for some it is a chronic problem • It can be severe in its intensity but rarely represents a serious, life-threatening condition • What do patients want/expect? – Explanation → Diagnosis – Cure → The doctor to “fix” them • What can doctors provide? – No explanation → Diagnostic uncertainty – No cure → Actively involve patient in care plan, control pain, improve function, prevent disability HARVARD MEDICAL SCHOOL The State of Back Pain Care in the U.S. • Non-evidence based, highly variable care that is expensive and rarely better than simple, less risky alternatives • My Goals – Highlight trends in back pain care – Focus on technology that has run amok • Specific Topics – Diagnostic testing – Medications: narcotics – Invasive, non-surgical procedures: vertebroplasty, injections – Surgery: minimally invasive, fusion, disc replacement HARVARD MEDICAL SCHOOL The Need to Improve Back Care “Somebody has to do something, and it’s just incredibly pathetic that it has to be us.” The late Jerry Garcia of the Grateful Dead HARVARD MEDICAL SCHOOL Ratio of Spine Fusion Rates to the U.S. Average by Hospital Referral Region (2002-03) 1.30 to 3.80 (79) 1.10 to < 1.30 (48) 0.90 to < 1.10 (47) 0.75 to < 0.90 (46) 0.24 to < 0.75 (86) Not Populated HARVARD MEDICAL SCHOOL Spine fusion per 1,000 Medicare enrollees Spine Fusion per 1,000 Medicare Enrollees (2002-03) 6.0 5.0 4.0 3.0 2.0 Arlington, VA Victoria, TX Milwaukee, WI Washington, DC Tuscaloosa, AL Minneapolis, MN Kansas City, MO Monroe, LA McAllen, TX Boston, MA Philadelphia, PA 2.15 1.80 1.71 1.64 1.55 1.51 1.31 1.14 0.81 0.67 0.67 1.0 0.0 HARVARD MEDICAL SCHOOL HARVARD MEDICAL SCHOOL HARVARD MEDICAL SCHOOL Trends in Imaging of the Spine Deyo, J Am Board Fam Med 2009 HARVARD MEDICAL SCHOOL HARVARD MEDICAL SCHOOL HARVARD MEDICAL SCHOOL HARVARD MEDICAL SCHOOL Vol 373 February 7, 2009 HARVARD MEDICAL SCHOOL DISCOGRAPHY HARVARD MEDICAL SCHOOL HARVARD MEDICAL SCHOOL HARVARD MEDICAL SCHOOL HARVARD MEDICAL SCHOOL Ad in Boston Globe – Fall 2007 HARVARD MEDICAL SCHOOL NON-SURGICAL MANAGEMENT Oral Drugs Physical Measures Stimulation Anti-inflammatory Analgesics Antidepressants Muscle relaxants Bed rest Exercise Manipulation Local heat/cold Massage Acupuncture TENS PENS TMS Injection Drugs Ultrasound Local heat Corsets Traction Yoga Other Epidural steroid Epidural anesthetics Discal chymopapain Biofeedback Back school Behavioraltherapy HARVARD MEDICAL SCHOOL INCREASING USE OF NARCOTICS Deyo, J Am Board Fam Med 2009 HARVARD MEDICAL SCHOOL Estimated Pharmacy Expenditures for Prescription Medications in US Adults With Spine Problems, MEPS 1997-2005 Martin, B. I. et al. JAMA 2008 HARVARD MEDICAL SCHOOL HARVARD MEDICAL SCHOOL Vertebroplasty HARVARD MEDICAL SCHOOL Kallmes D et al. N Engl J Med 2009;361:569-579 HARVARD MEDICAL SCHOOL Buchbinder R et al. N Engl J Med 2009;361:557-568 HARVARD MEDICAL SCHOOL “Before publication of these 2 trials, vertebroplasty had been used for almost a decade, with little evidence to recommend it. As a society, we can surely do better for our patients.” Carey TS. Ann Intern Med. 2009 Dec 15;151(12):JC6-9 HARVARD MEDICAL SCHOOL INCREASING USE OF INJECTIONS Deyo, J Am Board Fam Med 2009 HARVARD MEDICAL SCHOOL HARVARD MEDICAL SCHOOL DISCECTOMY HARVARD MEDICAL SCHOOL Minimally Invasive Spine Surgery HARVARD MEDICAL SCHOOL HARVARD MEDICAL SCHOOL NON-INSTRUMENTED FUSION HARVARD MEDICAL SCHOOL INSTRUMENTED FUSION HARVARD MEDICAL SCHOOL HARVARD MEDICAL SCHOOL HARVARD MEDICAL SCHOOL LAMINECTOMY HARVARD MEDICAL SCHOOL Surgical Procedures for Lumbar Stenosis per 100 000 Medicare Beneficiaries 65 Years or Older HARVARD MEDICAL SCHOOL Complications of Fusion Surgery Compared to Laminectomy for Spinal Stenosis Deyo, R. A. et al. JAMA 2010 HARVARD MEDICAL SCHOOL HARVARD MEDICAL SCHOOL Artificial Disc Replacement HARVARD MEDICAL SCHOOL Evidence Supporting Disc Replacements • For patients with chronic discogenic low back pain – No reliable way to identify the disc as the pain generator – Discography hasn’t been shown to work • Treatment options – Interdisciplinary rehabilitation and fusion surgery better than “usual care” – Interdisciplinary rehabilitation and fusion surgery have similar outcomes – Fusion and disc replacement surgery have similar shortterm outcomes • Disc replacement failure rate ~30% within 3-5 years – Ideal candidate is patient 40-50 years old HARVARD MEDICAL SCHOOL So, How Are We Doing? • Hopefully I’ve shown that low back pain care is – – – – Highly variable Not evidence-based Using up a lot of our nation’s health care resources Really expensive • Implications of this “natural” experiment – Less pain, better function? – Less chronic disability? HARVARD MEDICAL SCHOOL Freburger, J. K. et al. Arch Intern Med 2009;169:251-258. Copyright restrictions may apply. HARVARD MEDICAL SCHOOL Percentage of Individuals with Permanent Work Disability (SSDI beneficiaries) Deyo, J Am Board Fam Med 2009 HARVARD MEDICAL SCHOOL “I don’t believe there’s any problem in this country, no matter how tough it is, that Americans, when they roll up their sleeves, can’t completely ignore.” Comedian George Carlin HARVARD MEDICAL SCHOOL “The Americans always do the right thing, after they have exhausted all the other alternatives.” Sir Winton Churchill HARVARD MEDICAL SCHOOL
