We had our 4th meeting of doctors and staff interested in improving access, cost and overall quality at our hospital. It was well attended, but mostly by staff and board members rather than physicians. I guess we doctors think we are too busy to talk about health care reform. We had me, an internist, a psychiatrist, a radiologist and and emergency doc. Thinking was clear and focused, and the meeting was productive, as much as talking can be. We came up with several items needing action, and discussed several items that are moving solidly in the right direction.
1. My Own Home: an organization is being born which provides all sorts of resources to older folks wanting to stay in their own houses rather than moving to retirement homes. It will be supported by grants and will require membership payments. It will probably really start functioning in the next year. It is moving in the direction of getting up and running as fast as is practical.
2. Direct or prepaid medicine: there is quite a bit of interest by the hospital leadership in looking at some sort of community based prepaid health care. This would involve using the money that is already being spent on health care, by individuals and insurance companies, to provide comprehensive health care for the whole community. There are models for this elsewhere. Grand Junction, Colorado, has a system that provides affordable health care for the whole community, and we are a good size and makeup for that sort of thing.
3. Physical therapy--appropriate utilization and rapid transition to exercise programs: This is already happening. There is room at the hospital wellness center and costs are low, so many people who go to physical therapy multiple times because that is the only exercise they every get can be transitioned into something much cheaper and more appropriate.
4. Information systems: The hospital just made the decision to buy an electronic medical record system, and will start using it, ever so gradually, in the next few months. This will make monitoring of costs and outcomes much simpler.
5. Radiological testing--making it more appropriate to avoid excess radiation exposure and monetary costs: This will be aided a great deal by the computer ordering of tests. Criteria for appropriateness can be evaluated at the time the test is ordered, and duplication can be avoided.
6. ER use: There is still a great deal of money spent due to patients being seen in the emergency department when seeing a primary care doctor would be more appropriate. This involves excessive testing and insufficient followup, and is associated with higher costs than appropriate care would have generated. This will require a work group to figure out the best approaches. Some suggestions included diverting patients to primary care providers who indicate in some way that they are available and willing to work with these patients for a reasonable fee. Another helpful service would be 24 hour van transportation to get patients home after treatment and evaluation are completed. This kind of service would more than pay for itself, and the hospital CEO said he would move on that.
7. Cost-of-care clinical conferences: I would really like to present case conferences which look at the costs incurred at all stages of a patients hospital stay, along with the clinical outcomes. This can probably be done, with attention to confidentiality, and would really inform some of our choices. I will work on this.
8. Cost transparency for patients: the billing department is working on this, but the progress is slow. They really need more staff to get an efficient interface working.
The hospital has been very receptive to ideas that involve streamlining care and costs, which initially surprised me. They are aware of a new climate of belt tightening, though, and would like to be involved in the process as much as possible.
Tuesday, June 29, 2010
Wednesday, June 23, 2010
CT scans--why not?
The New England Journal of Medicine this week published two articles on imaging technology. The first was about the safety of CT scans and the second was about the indiscriminate use of radiological imaging of all kinds. Imaging of the human body is big business and important in the progress of diagnosis, but once a machine or technique is invented, its use is mostly unregulated and largely up to our discretion, without supporting scientific evidence of usefulness.
CT scans do cause cancer. This is because ionizing radiation causes cancer and CT scans carry lots of that. Every year 10% of Americans get a CT scan, and many people have multiples. Each CT scan carries 100 to 500 times the radiation dose of a standard chest x-ray if done properly. If an error is made, much more radiation can be delivered. Sometimes a patient might find out about such an error, but most often there would be no symptoms and no recognition.
CT scans also do save lives. They detect problems that would require emergency surgery before they are life threatening. They detect conditions which would remain painful or disabling mysteries for years without imaging. The trick is using them appropriately.
CT scans of the abdomen and pelvis usually carry the greatest radiation dosage because there is so much tissue that has to be penetrated in order to get a good picture. In this New England Journal article (http://content.nejm.org/cgi/content/full/NEJMp1002530?query=TOC) the patient in question got 2 CT scans of the head in short succession, arguably for no good reason, and one of them carried an erroneously high dose of radiation, resulting in significant brain toxicity. It could have happened to anyone.
Also an issue for this patient was the fact that a special CT scan called a perfusion scan was done to see if she was having a stroke. I have not ordered these yet myself, and just recently heard about a patient for whom such a scan was suggested as a way to evaluate an odd and transient symptom. These brain perfusion CTs carry a much higher radiation dose than a standard head CT, with the risk of radiation damage to brain and scalp and obvious increased risk of malignancy. Since most of us have, at one time or another, had disturbing neurological symptoms, wooziness, confusion, dizziness and the like, such a scan may gain significant popularity in the future, with results that will be irreversible to the patients who receive them for inadequate indications.
CT scans do cause cancer. This is because ionizing radiation causes cancer and CT scans carry lots of that. Every year 10% of Americans get a CT scan, and many people have multiples. Each CT scan carries 100 to 500 times the radiation dose of a standard chest x-ray if done properly. If an error is made, much more radiation can be delivered. Sometimes a patient might find out about such an error, but most often there would be no symptoms and no recognition.
CT scans also do save lives. They detect problems that would require emergency surgery before they are life threatening. They detect conditions which would remain painful or disabling mysteries for years without imaging. The trick is using them appropriately.
CT scans of the abdomen and pelvis usually carry the greatest radiation dosage because there is so much tissue that has to be penetrated in order to get a good picture. In this New England Journal article (http://content.nejm.org/cgi/content/full/NEJMp1002530?query=TOC) the patient in question got 2 CT scans of the head in short succession, arguably for no good reason, and one of them carried an erroneously high dose of radiation, resulting in significant brain toxicity. It could have happened to anyone.
Also an issue for this patient was the fact that a special CT scan called a perfusion scan was done to see if she was having a stroke. I have not ordered these yet myself, and just recently heard about a patient for whom such a scan was suggested as a way to evaluate an odd and transient symptom. These brain perfusion CTs carry a much higher radiation dose than a standard head CT, with the risk of radiation damage to brain and scalp and obvious increased risk of malignancy. Since most of us have, at one time or another, had disturbing neurological symptoms, wooziness, confusion, dizziness and the like, such a scan may gain significant popularity in the future, with results that will be irreversible to the patients who receive them for inadequate indications.
Saturday, June 19, 2010
The pseudoscience of medicine
The training that leads to becoming a physician is long, taxing and requires academic stamina and intelligence to complete. Nevertheless, most of what we eventually learn is practical: how to take care of patients in sickness and health. This is as it should be, since that is what we mostly do. Nevertheless, because we take many many hours of science related classes, most physicians consider themselves to be scientists. And that we, mostly, are not.
In my years of training I have learned how to construct a hypothesis, test it and use my data to make a conclusion. I know how to document my data, and I know how to perform simple statistical analyses. I know how to interpret statistics I read in other peoples' work, for the most part. But because I am always looking for ways to use the science I read to help me in patient care, I often make inferences that are speculative and probably just plain wrong. It works for me, though. I need to plug the science I read into the craft of medicine I practice in order for it to be meaningful to me, and sometimes my inferences might just be correct.
Take for instance standard clinical trials which look at the effect that a certain intervention, say a drug treatment for cancer, has on a group of people. That clinical trial will show that the in the group getting the drug the cancer will go away for a certain percentage of the people getting it. This result will be compared to results for a placebo group or a group getting a different drug. If the group getting the drug has a higher level of response than the placebo or different drug group, the interpretation will be that the new drug works. This is where the speculation starts to be misleading. I will then tell the patient I see that this new drug works best, and the patient may then choose to take it rather that watching and waiting or taking the other drug. But it isn't necessarily true for this patient that the drug works best, because patients are different, and withing the group that got the new drug, there are very likely patients who would have done better getting no drug or another drug. So I really can't, and shouldn't tell the patient that the drug works better. But just to make it as simple as possible, I do. And most doctors, until they sit down and think about it believe that this is true, that the drug that comes out on top in the clinical trials is the best drug, and they will proceed to use it preferentially.
I have been attempting to explain this sort of thing to my patients more often since I have been thinking about it, but I think it just makes them uneasy. They want an answer from me: what choice is best. Now that is not true of all patients. Some of my more thoughtful patients are glad to have many options open to them. It is more honest to discuss these things, but they are complicated and definitely not reassuring. The use of estrogen is a frequent subject for these discussions. Estrogen causes various harms in some people, including increasing the risk of breast cancer and vascular events when combined with progesterone, but it also saves people from breaking their hips and reduces the risk of colon cancer. It definitely helps relieve the sleeplessness and hot flashes of menopause as well. So is it good for a woman or bad for her? I guess it depends on what she values.
Another thing that physicians do that makes us feel like scientists is we measure things. We measure how much pressure it takes to stop the blood flowing in someone's arm. We call that the blood pressure. We measure the number of blood cells in a cubic centimeter of blood. We measure weight, temperature, height and head circumference. We count the number of times we feel the blood pulsing in someone's wrist per minute. We are reassured of a person's health based on these numbers. The numbers themselves may be misleading, as in the case of the blood pressure. The pressure it takes to stop the blood flow in the arm can go up if the arteries are particularly tough and springy. We don't necessarily know that this is a bad thing. The blood pressure can vary depending on recent exercise, time of day and emotional state. But that really isn't the most basic problem. What I think is more basic is the fact that we have decided that the things we can measure, and routinely do measure, are the important things, and we mainly base our studies on these pieces of data that we have decided are important because we can quantify them.
I recognize that medicine has, at times, significantly improved the quality and quantity of peoples' lives, so disrespecting it based on its fallacies is unkind and unfair. I would really just like to see my medical profession lighten up and recognize that much of what we see as fact is not. This could nicely dovetail with the recent emphasis on what is called "shared decision making." We have come a long way from the paternalistic past of medicine, and have another long way to go.
In my years of training I have learned how to construct a hypothesis, test it and use my data to make a conclusion. I know how to document my data, and I know how to perform simple statistical analyses. I know how to interpret statistics I read in other peoples' work, for the most part. But because I am always looking for ways to use the science I read to help me in patient care, I often make inferences that are speculative and probably just plain wrong. It works for me, though. I need to plug the science I read into the craft of medicine I practice in order for it to be meaningful to me, and sometimes my inferences might just be correct.
Take for instance standard clinical trials which look at the effect that a certain intervention, say a drug treatment for cancer, has on a group of people. That clinical trial will show that the in the group getting the drug the cancer will go away for a certain percentage of the people getting it. This result will be compared to results for a placebo group or a group getting a different drug. If the group getting the drug has a higher level of response than the placebo or different drug group, the interpretation will be that the new drug works. This is where the speculation starts to be misleading. I will then tell the patient I see that this new drug works best, and the patient may then choose to take it rather that watching and waiting or taking the other drug. But it isn't necessarily true for this patient that the drug works best, because patients are different, and withing the group that got the new drug, there are very likely patients who would have done better getting no drug or another drug. So I really can't, and shouldn't tell the patient that the drug works better. But just to make it as simple as possible, I do. And most doctors, until they sit down and think about it believe that this is true, that the drug that comes out on top in the clinical trials is the best drug, and they will proceed to use it preferentially.
I have been attempting to explain this sort of thing to my patients more often since I have been thinking about it, but I think it just makes them uneasy. They want an answer from me: what choice is best. Now that is not true of all patients. Some of my more thoughtful patients are glad to have many options open to them. It is more honest to discuss these things, but they are complicated and definitely not reassuring. The use of estrogen is a frequent subject for these discussions. Estrogen causes various harms in some people, including increasing the risk of breast cancer and vascular events when combined with progesterone, but it also saves people from breaking their hips and reduces the risk of colon cancer. It definitely helps relieve the sleeplessness and hot flashes of menopause as well. So is it good for a woman or bad for her? I guess it depends on what she values.
Another thing that physicians do that makes us feel like scientists is we measure things. We measure how much pressure it takes to stop the blood flowing in someone's arm. We call that the blood pressure. We measure the number of blood cells in a cubic centimeter of blood. We measure weight, temperature, height and head circumference. We count the number of times we feel the blood pulsing in someone's wrist per minute. We are reassured of a person's health based on these numbers. The numbers themselves may be misleading, as in the case of the blood pressure. The pressure it takes to stop the blood flow in the arm can go up if the arteries are particularly tough and springy. We don't necessarily know that this is a bad thing. The blood pressure can vary depending on recent exercise, time of day and emotional state. But that really isn't the most basic problem. What I think is more basic is the fact that we have decided that the things we can measure, and routinely do measure, are the important things, and we mainly base our studies on these pieces of data that we have decided are important because we can quantify them.
I recognize that medicine has, at times, significantly improved the quality and quantity of peoples' lives, so disrespecting it based on its fallacies is unkind and unfair. I would really just like to see my medical profession lighten up and recognize that much of what we see as fact is not. This could nicely dovetail with the recent emphasis on what is called "shared decision making." We have come a long way from the paternalistic past of medicine, and have another long way to go.
Wednesday, June 9, 2010
800 pound mooses and the American College of Physicians
The American College of Physicians has created an initiative to reduce costs and increase quality. It is called the High-Value, Cost-Conscious Care Initiative, and was launched at the annual meeting in April. They plan to focus on overuse and misuse of ineffective tests and treatments, of which there are many. The congressional budget office estimates that 700 billion dollars yearly is spent on tests and treatments that do not improve health. I suspect they underestimate that significantly. At the same meeting the college revealed plans to lobby for changes in health care policy not quite adequately addressed in the health care reform package, including prolonging salary bonus for primary care doctors treating patients on medicare and medicaid.
This is good! Even great. Why did this take so long?
I expect that part of the problem has been that it is difficult to find consensus in changing a system when there is considerable concern about loss of income and loss of respect.
Issues not mentioned in the articles I have read about the meeting which are difficult to address include the fact that the present 10% bonus for primary care physicians doesn't come close to making the salaries of specialists and family practice or internal medicine doctors equal. Providing adequate numbers of high quality primary care doctors is absolutely necessary to raise the quality of health care and health in general, and the oversupply of specialty physicians pretty much guarantees that too much expensive and unnecessary specialty care will be delivered.
Also, addressing the large and irritable moose sitting in the corner of the room during this discussion, some physicians really do make too much money.
I don't think that physicians should have to take extra jobs as cab drivers to support their families, as happens in Cuba, and there are many issues suggesting that physicians' salaries should be higher than average salaries, but a starting salary of $500,000 for a neuroradiologist is just plain out of balance. A full time primary care doctor can expect to pull in $150,000 at the height of his or her career, and in small towns or if the physician is female, that number is significantly smaller.
It is difficult to address this issue in a group like the American College of Physicians, because most people don't want to see their salaries shrink, and these large organizations are responsible for representing all of their members.
(Note: the 500 pound gorilla has been replaced with an 800 pound moose due to regional differences in fauna. i.e I'm from Idaho.)
This is good! Even great. Why did this take so long?
I expect that part of the problem has been that it is difficult to find consensus in changing a system when there is considerable concern about loss of income and loss of respect.
Issues not mentioned in the articles I have read about the meeting which are difficult to address include the fact that the present 10% bonus for primary care physicians doesn't come close to making the salaries of specialists and family practice or internal medicine doctors equal. Providing adequate numbers of high quality primary care doctors is absolutely necessary to raise the quality of health care and health in general, and the oversupply of specialty physicians pretty much guarantees that too much expensive and unnecessary specialty care will be delivered.
Also, addressing the large and irritable moose sitting in the corner of the room during this discussion, some physicians really do make too much money.
I don't think that physicians should have to take extra jobs as cab drivers to support their families, as happens in Cuba, and there are many issues suggesting that physicians' salaries should be higher than average salaries, but a starting salary of $500,000 for a neuroradiologist is just plain out of balance. A full time primary care doctor can expect to pull in $150,000 at the height of his or her career, and in small towns or if the physician is female, that number is significantly smaller.
It is difficult to address this issue in a group like the American College of Physicians, because most people don't want to see their salaries shrink, and these large organizations are responsible for representing all of their members.
(Note: the 500 pound gorilla has been replaced with an 800 pound moose due to regional differences in fauna. i.e I'm from Idaho.)
Tuesday, June 1, 2010
Antony Jacob throws light on Apollo Munich's Growth Over Next 3 Years
Antony Jacob,Chief Executive Officer,
STANDALONE health insurer Apollo Munich Health promoted by Apollo Hospitals expects to turn profitable in the next three years.
"We hope to break even by 2012-13 and start making profit from 2013-14," Apollo Munich Health Insurance chief executive officer Antony Jacob said.
The company is already making profit so far as retail business is concerned, however, there are under-writing losses in terms of group insurance, Antony Jacob said.
Apollo Munich is a 74:26 joint venture between The Apollo Hospitals Group, and Germany-based Munich Re's newest business segment, Munich Health, which came into being following the reorganisation of business.
As far as capital infusion is concerned, Jacob said, by 2013-14 the company's total paid-up capital would go up to Rs 500 crore from the present level of Rs 225 crore.
Capital infusion will go in for expansion of the business, he added.
Antony Jacob said, the company would invest about Rs 20 crore during the last quarter of 2009-10.
About the rechristening of the firm, he said, the new name is in line with the company's brand strategy to communicate its deep-rooted expertise.
They are: Easy Health standard; Easy Health Exclusive; Easy Health Premium.
On December 29, 2009, the insurance company, has renamed itself Apollo Munich Health
Insurance from Apollo DKV Health Insurance.
Apollo Munich Health Insurance has three options in healthcare insurance products.
Tuesday, May 18, 2010
How Does Cuba Do It?
Cuba has achieved a life expectancy approximately equivalent to the US, despite a long standing embargo on food and medical supplies and despite spending a small fraction of the amount of money per person on health care than we do.
A Stanford social sciences researcher, Paul Drain, has studied Cuba's medical system and has identified a few factors that may be responsible for their success. Cuba completely subsidizes medical training. After high school, students who are interested in medical school and qualify for it attend 6 years of combined college and medical training, complete with a stipend for living expenses and then 3 years of postrgraduate training in primary care medicine. Many do rural health residencies either before or after the postgraduate training. After becoming family practitioners, 35% of them do further specialty training and the rest remain primary care doctors. There are many multi-specialty clinics which provide care in cities, and small primary care clinics that serve small neighborhoods. Their vaccination rate is excellent as is their rate of professionally attended births. Everyone sees a doctor at least once a year and sometimes these are home visits. Doctors are not paid highly, but then they emerge from training without the usual multi-hundred thousand dollars of educational debt that they end up with in the US.
If one were to look at the economic incentives that have lead to our excessive health care expenses and our shortage of primary care doctors and effective preventive medicine, it is not hard to see how we have landed in our present circumstances. It is a bit harder to see how we should escape from them. Certainly subsidizing the training of primary care physicians would be a good start.
Paul Drain was interviewed for Wired, and published an article in the April 30 issue of Science magazine. This is a link to the Wired article.
http://www.wired.com/wiredscience/2010/04/cuban-health-lessons/
A Stanford social sciences researcher, Paul Drain, has studied Cuba's medical system and has identified a few factors that may be responsible for their success. Cuba completely subsidizes medical training. After high school, students who are interested in medical school and qualify for it attend 6 years of combined college and medical training, complete with a stipend for living expenses and then 3 years of postrgraduate training in primary care medicine. Many do rural health residencies either before or after the postgraduate training. After becoming family practitioners, 35% of them do further specialty training and the rest remain primary care doctors. There are many multi-specialty clinics which provide care in cities, and small primary care clinics that serve small neighborhoods. Their vaccination rate is excellent as is their rate of professionally attended births. Everyone sees a doctor at least once a year and sometimes these are home visits. Doctors are not paid highly, but then they emerge from training without the usual multi-hundred thousand dollars of educational debt that they end up with in the US.
If one were to look at the economic incentives that have lead to our excessive health care expenses and our shortage of primary care doctors and effective preventive medicine, it is not hard to see how we have landed in our present circumstances. It is a bit harder to see how we should escape from them. Certainly subsidizing the training of primary care physicians would be a good start.
Paul Drain was interviewed for Wired, and published an article in the April 30 issue of Science magazine. This is a link to the Wired article.
http://www.wired.com/wiredscience/2010/04/cuban-health-lessons/
Sunday, May 16, 2010
vitamin D--the controversy
In the last year vitamin D has been making headlines. It is not a new vitamin. It was first synthesized in the 1920s and deficiency of the vitamin was known to be a cause of rickets, a bone deforming disease, associated with reduction of sun exposure with the movement to crowded living conditions with inadequate sun exposure during the industrial revolution. It is important in regulating absorption of calcium in the gut and deposition of calcium in bone as well as having a role in supporting the immune system. Vitamin D2 can be made by plants and was added to milk and cereals in order to prevent rickets in children starting in the late 1920s.
Vitamin D is available in relatively small amounts in various foods, especially fatty fish and beef liver. Normally these food supplement the vitamin D made in the skin when we are exposed to certain wavelengths of sunlight. Dark skinned people are less efficient at producing vitamin D from a given amount of sun exposure, which partly accounts for the fact that evolution has put light skinned peoples at the extremes of northern and southern latitudes. Even so, in the winter at the arctic circle, there is no radiant light sufficient to allow the skin to synthesize vitamin D.
Recently data has been piling up about the benefits of vitamin D and the various forms of ill health associated with vitamin D deficiency. A study in 2008 published in the Archives of Internal Medicine showed a higher death rate in adults with lower vitamin D levels, for instance. Other studies have shown and increased risk of influenza and possibly cancer in patients who are vitamin D deficient. Some high profile studies have shown an improvement in fall risk and fractures in elderly patients who are given vitamin D supplements, with or without calcium, but other studies have shown no effect at all.
I practice medicine in a town which is significantly north of the equator, thus providing little sunlight of a wavelength effective for production of vitamin D in the skin during the winter. This combined with cold temperatures means that when I check the vitamin D levels of patients at the end of the winter, about half of them are significantly deficient. This is huge. It implies that half of the patients I test are ill in some way, are courting fractures and other vitamin D related maladies such as infections and bone pain and overall sickliness.
Just this week an article published in the Journal of the AMA by Kerrie Sanders et al studied a group of community living people, aged 70 and over, who were given a huge dose of oral vitamin D once a year with the expectation that the resultant increase in vitamin D stores would reduce falls and fractures. The results, however, were surprising. Significantly more of the vitamin D treated patients developed falls and fractures, especially in the 3 months following receiving the large dose. Interpretation of this finding included thoughts about odd physiological responses to huge doses of vitamin D, which seems plausible, and less plausibly, that since these people felt so chipper after getting their supplement, that they were out and about more and so fell down and broke bones.
There are many issues brought up by this article, which are especially relevant in this year when vitamin D has ridden into the practice of medicine like a handsome sheriff with a white hat.
1. Do we trust laboratory tests of vitamin D levels to tell us if a person needs vitamin D supplementation? Darker skinned people routinely have lower vitamin D levels, but aren't clearly sick because of it. In my experience, deficient levels of vitamin D are randomly associated with skin color, diet or sun exposure, and not usually associated with overall health of the patient. I have been told that laboratory levels are not necessarily consistent from test to test.
2. How should we supplement vitamin D? The studies that have shown good effects of supplementation used daily doses of around 800 units, yet many of my patients who already take this dose daily are found to be deficient. Normally we replete vitamin D levels with 50,000 units of vitamin D twice weekly for 6 weeks, followed by recommendations to take at least 1000 units of vitamin D thereafter. Is this method wrong?
3. Is it cost effective to test for vitamin D deficiency, or should we just supplement everyone's diet with oral vitamin D? Not everyone's insurance pays for a vitamin D level and the test can run up to $150. If we do test for deficiency, do we need to re-test to make sure the person is adequately repleted and if so, how often? If we want to achieve the goal of maximum health for minimum time , money and anxiety spent, how best should we do this with regard to vitamin D?
Vitamin D in a form that a person with a healthy liver and kidneys can use is inexpensive, but the widespread treatment of what may or may not be a disease is presently consuming huge amounts of resources of time and perceptions of health.
Vitamin D is available in relatively small amounts in various foods, especially fatty fish and beef liver. Normally these food supplement the vitamin D made in the skin when we are exposed to certain wavelengths of sunlight. Dark skinned people are less efficient at producing vitamin D from a given amount of sun exposure, which partly accounts for the fact that evolution has put light skinned peoples at the extremes of northern and southern latitudes. Even so, in the winter at the arctic circle, there is no radiant light sufficient to allow the skin to synthesize vitamin D.
Recently data has been piling up about the benefits of vitamin D and the various forms of ill health associated with vitamin D deficiency. A study in 2008 published in the Archives of Internal Medicine showed a higher death rate in adults with lower vitamin D levels, for instance. Other studies have shown and increased risk of influenza and possibly cancer in patients who are vitamin D deficient. Some high profile studies have shown an improvement in fall risk and fractures in elderly patients who are given vitamin D supplements, with or without calcium, but other studies have shown no effect at all.
I practice medicine in a town which is significantly north of the equator, thus providing little sunlight of a wavelength effective for production of vitamin D in the skin during the winter. This combined with cold temperatures means that when I check the vitamin D levels of patients at the end of the winter, about half of them are significantly deficient. This is huge. It implies that half of the patients I test are ill in some way, are courting fractures and other vitamin D related maladies such as infections and bone pain and overall sickliness.
Just this week an article published in the Journal of the AMA by Kerrie Sanders et al studied a group of community living people, aged 70 and over, who were given a huge dose of oral vitamin D once a year with the expectation that the resultant increase in vitamin D stores would reduce falls and fractures. The results, however, were surprising. Significantly more of the vitamin D treated patients developed falls and fractures, especially in the 3 months following receiving the large dose. Interpretation of this finding included thoughts about odd physiological responses to huge doses of vitamin D, which seems plausible, and less plausibly, that since these people felt so chipper after getting their supplement, that they were out and about more and so fell down and broke bones.
There are many issues brought up by this article, which are especially relevant in this year when vitamin D has ridden into the practice of medicine like a handsome sheriff with a white hat.
1. Do we trust laboratory tests of vitamin D levels to tell us if a person needs vitamin D supplementation? Darker skinned people routinely have lower vitamin D levels, but aren't clearly sick because of it. In my experience, deficient levels of vitamin D are randomly associated with skin color, diet or sun exposure, and not usually associated with overall health of the patient. I have been told that laboratory levels are not necessarily consistent from test to test.
2. How should we supplement vitamin D? The studies that have shown good effects of supplementation used daily doses of around 800 units, yet many of my patients who already take this dose daily are found to be deficient. Normally we replete vitamin D levels with 50,000 units of vitamin D twice weekly for 6 weeks, followed by recommendations to take at least 1000 units of vitamin D thereafter. Is this method wrong?
3. Is it cost effective to test for vitamin D deficiency, or should we just supplement everyone's diet with oral vitamin D? Not everyone's insurance pays for a vitamin D level and the test can run up to $150. If we do test for deficiency, do we need to re-test to make sure the person is adequately repleted and if so, how often? If we want to achieve the goal of maximum health for minimum time , money and anxiety spent, how best should we do this with regard to vitamin D?
Vitamin D in a form that a person with a healthy liver and kidneys can use is inexpensive, but the widespread treatment of what may or may not be a disease is presently consuming huge amounts of resources of time and perceptions of health.
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