Newscast: Lead Story - Advice for Doctors When Patients Bring Too Much Information to an Office Visit
Rand: Welcome to Healthcare 411 for the week of October 10, 2007
Debra: Healthcare 411 is produced by AHRQ, the Agency for Healthcare Research and Quality, part of the U.S. Department of Health and Human Services. I’m Debra James.
Rand: And I’m Rand Gardner. Coming up: This week’s News and Number is about hospitalizations for kids with cancer.
Debra: A new scientific review of treatments for knee osteoarthritis found some surprises.
Rand: And Dr. Carolyn Clancy gives advice to doctors for when their patients bring too much information to an office visit. More after this message from AHRQ
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Rand: Now the numbers. This week’s News and Numbers finds that hospitalizations for kids with cancer are on the rise. A new AHRQ analysis shows hospital admissions for cancer patients under the age of 18 increased more than 80 percent from 2000 to 2005, from roughly 54,000 to nearly 100,000 admissions. Researchers say the dramatic increase in hospitalizations is due in part to higher survival rates and the need for complex medical treatments. While some children with cancer can get treatment in outpatient settings, other types of care, such as maintenance chemotherapy or radiation therapy, still require that they be hospitalized. Children with leukemia and brain cancer were the most likely to be hospitalized. Hospital costs for children with any type of cancer totaled $1.7 billion in 2005, up from $785 million in 2000. These data are from AHRQ’s Healthcare Cost and Utilization Project.
Debra: Here’s AHRQ’s Research News: About one in 10 Americans over the age of 64 has osteoarthritis of the knee, a condition that wears away the cartilage which cushions the knee joint. The result is often pain and reduced mobility. So many people sought treatment in 2005, in fact, that osteoarthritis and related arthritic conditions totaled more than $81 billion a year in lost wages, medical care and related expenses. But a new scientific review finds a surprising lack of evidence that several common medical treatments for knee osteoarthritis are really very effective. David Samson, Associate Director of AHRQ’s Blue Cross Blue Shield Evidence-based Practice Center, led the review and is with us today to discuss his findings. I think the most surprising finding from your review is about dietary supplements. Please tell us what you found.
Mr. Samson: Glucosamine and chondroitin are two over-the-counter dietary supplements and they’re popular with some people because they believe that they can contribute to cartilage maintenance and repair, and they’re intended to improve the pain due to osteoarthritis of the knee and also improve physical functioning. A review of the scientific evidence found that there was lack of clear evidence to show that these dietary supplements are more effective than placebos. There were some smaller and lower quality studies that suggested that there was some benefit, but the largest and the best designed studies did not show benefit.
Debra: And that was true for other types of treatments that the evidence really isn’t there isn’t that right?
Mr. Samson: Yes, that’s correct. Some people who have osteoarthritis of the knee received arthroscopic surgery that is intended to remove damaged cartilage and other debris. We looked, specifically, at this type of surgery and, again, did not find convincing evidence of benefit. In the area of arthroscopic surgery, there were several observational studies. These are non-experimental studies not the same as clinical trials that suggest a possible benefit, but the best designed trial, randomized study, did not find a benefit. And the difference in these findings might be explained by the possibility that the weaker studies were giving us the wrong results, or that there are particular patients that do better with arthroscopic surgery, but at present, we don’t have a clear indication as what the actual explanation is.
Debra: What about the knee joint injections?
Mr. Samson: The published studies that we looked at on hyaluronic acid injections were intended to show whether or not improved lubrication in the knee joint improves the way that patients rate their pain and function. The evidence is still uncertain whether the study quality was adequate, and it’s difficult to determine whether that the changes in pain and function reported by these patients really constitute a significant clinical improvement.
Debra: So, does that mean that none of these treatments works?
Mr. Samson: No, that’s not what we’ve found. It means that we don’t have enough high quality evidence from well done studies. It’s really important to make a distinction between a lack of evidence and clear evidence that something is ineffective. When evidence is lacking to show that something is effective, it’s not the same thing as saying that we know that it’s not effective, and in this particular case, it’s a lack of evidence to show effectiveness. The most important study on arthroscopy was well done, but it was done by a single surgeon in one clinical center and there are concerns so, we’re still left with one high quality study that does not find evidence of benefit and we would like to see additional studies done in the future that are also well done that might show different results. Our review shows that we need to conduct better quality, randomized clinical trials to show whether these treatments are beneficial or not.
Debra: So, for now, how should people with osteoarthritis of the knee make treatment decisions?
Mr. Samson: We weren’t addressing all of the options that are available to people with osteoarthritis. We were focused on the three that I mentioned before. Some options that are available include non-steroidal anti-inflammatory drugs, like Ibuprofen or Naproxen. People can also seek out injections of cortical steroids, and there are additional surgical options, up to and including knee replacement. It’s really important for patients to work closely with their own physicians to decide on their treatment plans. But, we have an aging population, and it’s clear that we not only need to clarify the effectiveness of current approaches to treatment we also need new research to find additional approaches to prevent and treat osteoarthritis of the knee.
Debra: Mr. Samson, thank you for being with us.
Mr. Samson: It’s been my pleasure.
Debra: David Samson is the Associate Director for AHRQ’s Blue Cross Blue Shield Evidence-based Practice Center which led a scientific review of treatments for osteoarthritis of the knee.
Rand: As more and more patients use the Internet to research their medical issues, doctors are taking on an additional role that of interpreter. According to an independent study by Pew Internet & American Life, 80 percent of American Internet users have searched for health information on the Internet, but only a small fraction of them check the source of that information. Doctors are reporting that patients arrive for appointments armed with stacks of information, but they can’t discern what information is helpful and which is not relevant and misleading, or just plain wrong. Is the Internet revolution helping or hurting doctor’s medical practices? Joining us now to talk about what doctors can do about helping their patients avoid information overload is Agency for Healthcare Research and Quality Director Dr. Carolyn Clancy. Welcome, Dr. Clancy.
Dr. Clancy: It’s good to be here.
Rand: There’s a lot of medical information out there on the Internet. Do you think it is helping or hurting how we deliver health care?
Dr. Clancy: The clear answer to that question is, it depends, and there is not an easy way to answer the question overall. Sometimes information that people read points them in the direction of asking their doctor more specific questions or realizing that they have failed to share information that’s relevant you know, that they automatically discounted because they thought it wasn’t terribly important. Doctors, I know, can feel pretty overwhelmed when patients arrive with big piles of paper that they’ve dutifully printed out. On the positive side, it’s important for patients to be active in their health care, and the more patients understand their medical conditions, the better off they will be. We know that studies show that patients who become involved in their health care, especially those who ask a lot of questions, are more likely to follow their doctor’s advice and report better results. Patients may have more confidence about asking some of those questions when they’ve done that kind of research on the Internet. On the other hand, patients and doctors together can waste an awful lot of time if patients read something on the Internet and become firmly convinced that they know what the diagnosis is even when, in fact, that’s inaccurate. So, it’s kind of a mixed blessing.
Rand: Well, then how should a doctor handle the patient who may come in with a stack of papers several inches thick wanting to discuss it all?
Dr. Clancy: First of all, unless this is a brand new patient, most doctors usually have a general sense about individuals and how much information he or she wants and can usually handle at a time. And just because patients have done a lot of online research doesn’t mean that they’re actually looking for you to be a librarian and go through every page with them. One option is to ask patients to prioritize their concerns and, indeed, some practices actually let patients know that as a, sort of, standing policy. We may not be able to get to all of your issues in a single visit, so it’s helpful if you tell me what’s most important today, so that we can schedule another visit to discuss other issues that we didn’t have time for today.
Rand: What is it, you think, that patients are trying to accomplish by gathering all of that information?
Dr. Clancy: It’s really important to find out the answer to that question. And I think one of the first issues is, why actually is a patient doing research? In some cases, patients are using information to educate themselves so that they can ask better questions. So, if they ask you a question and you give an answer that they don’t understand they’ll know what to say next, because they will have done some background reading. Clearly, the most problematic situation for any doctor is when a patient uses information to self-diagnose, becomes quite convinced that they’re right, and then challenges the doctor’s advice or opinions. And, the reason this is important, of course, is that part of what makes a doctor relationship work is trust trust in a physician’s knowledge and the ability to work with the patient, as a partner, to make the right choices. If that relationship becomes adversarial or very defensive and stressful, it’s going to be very difficult for physician and patients to work together.
Rand: How can a doctor handle that situation?
Dr. Clancy: Well, clearly, it’s not a good idea for doctors to be dismissive of the fact that their patients have been looking for information online. It’s not really a great way to start the conversation and it’s more likely to lead to a scenario that becomes a little bit adversarial. In the best case, it’s a good idea to listen, to be open to new ideas and to be receptive to questions that patients ask. Sometimes they find really interesting material online and we can always learn something. And, ultimately, doctors can point patients in the direction of reputable sources and good places to go for information when they have questions.
Rand: Do you have any suggestions to help doctors tell their patients whether their online research is reliable?
Dr. Clancy: It’s important to emphasize to the patients that reliable sources are those that are based on the best possible science, that are updated, and that communicate their information clearly. If you look at information on a site and can’t tell where that information came from, what science it’s based on that’s something a patient should know to be looking for that this site may not be reliable. For example, in general, government sites, like the Agency for Healthcare Research and Quality, the National Institute of Health sites, or the National Library of Medicine’s Midline Plus and sites sponsored by non-profit organizations are likely to provide reliable information, but many other sites do that as well. And many patients are very appreciative of being told the following sites I have found to be very helpful and I know that they’re reliable. Doctors can also help patients understand that some sites are clearly going to favor one treatment or diagnostic option over another. The information, before that recommendation, may be pretty accurate, but if someone tells you there’s only one treatment or one solution for any medical condition, it might be a good idea to start asking why, or to start connecting the dots that if this is sponsored by a company that makes medications, for example, it’s likely that the first recommendation they’re going to make is going to be that the problem is treated with medications. Doctors should advise their patients, who haven’t figured this out for themselves, and a surprising number do to be careful for sites that appear to be informative, but keep pointing the user back to a commercial product or solution. The commercial product may be terrific, but again, individuals should question whether the claims are based on the best possible evidence, and reliable sites will make it very clear where they got their information.
Rand: So, what about other sources of online information?
Dr. Clancy: Other good sites are those sponsored by relevant disease organizations that actually use their website as a vehicle to communicate the scientific information that they helped to develop for example, the American Heart Association, the American Diabetes Association and many, many others. They take very seriously their responsibility to make sure that the public is well informed and kept up to date, and informed on scientific advances. Increasingly, librarians, medical librarians of course, but even librarians at the local public library are incredibly helpful in helping to identify good sources of health information.
Rand: Getting back to the office visit itself, how can you help your patients prioritize why they’re there to see you?
Dr. Clancy: You know, many practices have information sheets that they give out to all of their patients information about when phone calls are returned, who to call for medication refills, how the practice handles other people seeing the doctor’s patients, and so forth, who’s available after hours. It seems to me that it would be, actually, a very helpful thing to say if we get crunched for time, it’s always a great idea to have been very clear up front what are the most important issues we need to address today, so that we can then make a follow-up appointment to discuss any issues that we didn’t have time for.
Rand: Any other advice for doctors, Dr. Clancy?
Dr. Clancy: As always, it’s important to be patient with our patients. We’re likely to learn something from them. It’s also a great opportunity to let patients know about reputable websites that you, yourself, have found to be very helpful, in terms of the patient information they provide. And this interaction can actually be a very powerful way to help build a better doctor-patient relationship, one in which the doctor and patient are working together for common goals.
Rand: Dr. Clancy, thanks for joining us.
Dr. Clancy: You’re welcome.
Debra: That’s it for the week. For more information on these and other health-related stories and topics go to www.ahrq.gov. Healthcare 411 is produced by AHRQ, the Agency for Healthcare Research and Quality, part of the U.S. Department of Health and Human Services. For Rand Gardner, I’m Debra James. Please join us for the next edition of Healthcare 411.