Transcript Document

Transforming America’s Healthcare
Edward E. Partridge, MD, Director
UAB Comprehensive Cancer Center
Professor of Gynecologic Oncology
Evalina B. Spencer Chair in Oncology
Alternate Title
The Budget Deficit
US Healthcare
This Disparities Thing
The American Cancer Society
We are dedicated to helping People:
• Get Well
• Stay Well
• Find Cures
• Fight Back
How Can We Provide Adequate
High Quality Care (to Include
Preventive Care) to a Population
That Has So Often Not Received It?
All Sites - Mortality Rates
By Year of Death - All Races, Males and Females
2015 Goal – 50% Reduction from Baseline
1991 Baseline
215.1
220
210
200
190
180
170
160
150
140
130
120
110
100
90
80
( 17.2% from
baseline)
2007
178.2
2015
Projected
Rate – 150.6
(Current trend to 2015 -  30.0% from baseline)
(The latest joinpoint trend (2001-2007) shows a
-1.6 APC in age-adjusted rates)
2015 Goal
107.6
Incidence and mortality rates per 100,000 and age-adjusted to 2000 US standard population
SEER Cancer Statistics Review 1975-2007.
75
78
81
84
87
90
93
96
99
'02
'05
'08
'11
'14
Deaths averted from 1991-2020
The blue solid line represents the actual number of cancer deaths recorded and the blue dashed line represents
projected cancer deaths based on decreasing trends in cancer death rates during 2003-2007. The green dashed line
represents the projected number of cancer deaths if rates continue to decline at twice the current rate (2003-2007)
beginning in 2013. The red line represents the expected number of cancer deaths if cancer death rates had remained
the same since 1990 (males) and 1991(females).
Beyond Healthcare Reform
• What was that Debt Limit Debate
really about.
• Federal Medicare/Medicaid costs are
spiraling out of control
• In 2010, 23% of the $3.456 Trillion
Federal budget ($793 Billion)
Beyond Healthcare Reform
• Medicare, Medicaid, and Social Security account
for all of the projected increase in Federal
spending over the next 40 years.
• For the past 30 years, costs per person throughout
the health care system have been growing
approximately two percentage points faster per
year than per-capita GDP.
• Most projections assume this pattern will continue
through 2050. Over time, the fiscal consequences
of this rate of growth in health costs aremassive.
Factor Increasing Cancer
Risk in U.S.
• The Aging of the population
– 30 million over age 65 in 2000
– 71 million over age 65 in 2030
• Western diet/high in calories
• Lack of exercise
• Smoking/Tobacco use
True Healthcare Reform
Requires:
• Broad critical thinking
• The use of “Evidence Based Care and Prevention”
That is:
 the rational use of medicine
 not the rationing of medicine
• We do what we know works and often do not do
• We stop doing what we know does not work
Toward an Efficient Healthcare System
• Some consume too much
– (Unnecessary care given)
• Some consume too little
– (Necessary care not given)
• We could decrease the waste and
improve overall health!!!!
U.S. Health Care Spending
In 2009, the U.S. spent
$2.53 TRILLION
on Health Care
U.S. Health Care Spending in Context
•How Big is a Trillion?
1 million seconds
Last week
1 billion seconds
Richard Nixon’s Resignation
1 trillion seconds
30,000 BCE
Spending in Context
2009
$2.53 trillion
$1.4 trillion
17.30%
$1.1 trillion
Gross Domestic
Product
* Excludes alcoholic beverages ($150 billion) and tobacco products ($92 billion)
Source: Bureau of Economic Analysis; National Bureau of Statistics of China, MGI analysis
American Healthcare
•
•
•
•
16.2% of GDP in 2006
17.3% of GDP in 2009
19.3% of GDP by 2019 (projected)
25% of GDP by 2025 (projected)
Spending: US vs. Other Countries
Per capita health care spending, 2006
$ at PPP*
Per capita GDP ($)
* Purchasing power parity.
** Estimated Spending According to Wealth.
Source: Organization for Economic Co-operation and Development (OECD)
US Healthcare Outcomes
• Are generally worse than in other
western countries
• True for cancer and other chronic
diseases
• Canada is a wonderful place!!!!
Healthcare in Three Countries (2010)
Canada Switzerland U.S.
•
•
•
•
•
Infant Mortality
White Male Life Exp
Per Capita Costs
Proportion of GDP
5.04
78.0
3173
9.6%
4.53
79.7
4011
11.2%
6.22 per 1000 live births
76.8 Years
6096 US Dollars
17.3%
Overall Quality: Life Expectancy at 65
The US is ranked 12th for Males and 16th for Females
Source: OECD, 2006 data
U.S. vs. Canada
• CT Scanners per million population.
U.S. dominates by 3 to 1 ratio
• MRI Scanner per million population.
U.S. dominates by 5 to 1 ratio
True Healthcare Reform
(An Efficient, Value Driven Health System)
• Rational use of healthcare is
necessary for the future of the U.S.
economy (an issue of U.S. security)
• It is possible to decrease costs and
improve healthcare by using science
to guide our policies
• We need to be smart about health
Adjusted Colorectal Cancer Survival by Stages and Insurance Status, among Patients
Diagnosed in 1999-2000 and Reported to the NCDB
Equal Treatment Yields Equal Outcome
There is not Equal Treatment
Studies suggest that disparities in treatment may
be due to:
• Cultural differences in acceptance of
therapy.
• Disparities in comorbid diseases (including
obesity) making aggressive therapy
inappropriate.
• Lack of convenient access to therapy.
• Racism and SES discrimination.
How Can We Provide Adequate
High Quality Care (to Include
Preventive Care) to a Population
That Has So Often Not Received It?
The Future of Healthcare
Are American’s willing to be scientific, accept
scientific reality and
Give up “faith based medicine”
and
Adopt and appreciate “evidence based medicine?”
Medical Gluttony
• Screening tests of no proven value
• Treatments of no proven value
• Laboratory and radiologic imaging
done for convenience.
•
-Cannot find original.
•
-Legal defense (real or imagined).
•
-Tradition.
Treatment versus Prevention
• Our healthcare system is heavilly
focused on addressing illness.
• The system needs to transform to one
that places more value on prevention
and early detection of disease!
Clinical Lessons Learned Late
•
•
•
•
Postmenopausal Hormone replacement therapyLidocaine after MI
Hyper-vitaminosis (Vit E, Beta Carotene, Selenium)
Rofecoxib and Celecoxib for arthritic pain
– (Vioxx and Celebrex)
• Rosiglitazone (Avandia) for diabetes
• Erythropoetin
Clinical Lessons Learned Late
•
•
•
•
•
•
Hysterectomy
Caesarian section
Carotid endarterectomy
Coronary Artery Bypass Grafting
Tonsillectomy
Tympanostomy
Clinical Lessons Learned Late
•
•
•
•
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Chest X-ray screening for lung cancer
Urine screening for neuroblastoma
Cryotherapy for prostate cancer
Halsted mastectomy
Adjuvant bone marrow transplant for breast cancer
Screening
• Breast - Mammography and Clinical
Examination
• Colon – Stool Blood Testing,
Sigmoidoscopy, Colonoscopy
• Cervix – Pap smear (conventional or wet)
Screening
• Lung – Spiral CT, 20% decrease, significant side
effects of screening`
– 99.5% saw no benefit
– 0.5% were helped (death prevented)
– 3.5% were harmed (unnecessary surgery)
– 0.6% were harmed (complication of surgery)
Screening
• Lung – Spiral CT, 20% decrease, significant side
effects of screening`
– 1 in 217were helped (death prevented)
– 1 in 4 were harmed (false positive CT)
– 1 in 30 were harmed (unnecessary surgery)
– 1 in 161 were harmed (complication of surgery)
Fact
• Smoking cessation is more powerful
at preventing lung cancer death than
spiral CT screening.
• It is also cheaper!!!
Screening
• Prostate – PSA, effectiveness is a question
mark and still the focus of study
ACS Leadership Roles
Prevention and Early Detection
Leadership Roles
• Breast cancer
• Colorectal cancer
• Reduce tobacco use
• Nutrition and physical activity
Breast Cancer
There has been a 30% decline in breast cancer
death rate since 1991 (57,000 deaths averted)
• Treatment has improved dramatically
• Screening Rates:53% by NHIS
62.1% by BRFSS
• A substantial number of women get less than
high quality healthcare.
Prevention and Early Detection
Leadership Roles
• Breast cancer
• Colorectal cancer
• Reduce tobacco use
• Nutrition and physical activity
Colorectal Cancer
There has been a 30.4% reduction in
colorectal cancer mortality since 1991 (77,000
deaths averted)
• Treatment has improved dramatically
• About half of Americans over 50 get any screening.
• A substantial proportion of Americans get less than
high quality screening and treatment.
Breast Cancer
The Reality
• From 1993 to 1997, 561 Black women died of breast
cancer in Atlanta.
• If Atlanta’s Black population had the Department of
Defense Health System Black rate, 330 would have died
(231 less)
• Lund et al, Cancer 2004
Prevention and Early Detection
Leadership Roles
• Breast cancer
• Colorectal cancer
• Reduce tobacco use
• Nutrition and physical activity
Trends in Cigarette Smoking Prevalence* (%), by Sex, Adults 18
and Older, US, 1965-2008
Men
Women
*Redesign of survey in 1997 may affect trends. Estimates are age adjusted to the 2000 US standard population using five
age groups: 18-24, 25-34 years, 35-44 years, 45-64 years, and 65 years and over.
Source: National Health Interview Survey, 1965-2008, National Center for Health Statistics, Centers for Disease Control and
Prevention, 2009.
Lung Cancer
•14.1% reduction in mortality to 2009
–2009 adult smoking prevalence of 20.6% (CDC
National Health Interview Survey)
–2009 teen smoking prevalence of 19.5% (CDC
Youth Risk Behavior Surveillance System)
Prevention and Early Detection
Leadership Roles
• Breast cancer
• Colorectal cancer
• Reduce tobacco use
• Nutrition and physical activity
Poor Nutrition and
Lack of Physical Activity
•Obesity, high caloric intake, and lack of
physical activity is increasing rates of:
• Diabetes
• Cardiovascular Disease
• Orthopedic Injury
• Cancer
Nutrition and Physical Activity
• Obesity, high caloric intake, and lack of physical
activity has the potential of being a greater cause
of cancer in the U.S. than tobacco by 2030
• We are currently not able to model this in an
acceptable fashion but it is causing a rise in cancer
incidence
Summary of Cancer Mortality by
Body Mass Index Women
1.4
Colon & Rectum (> 40)
Multiple myeloma (> 35)
Ovarian (> 35)
Liver (> 35)
All other cancers (> 40)
NHL (> 35)
Breast (> 40)
Gall bladder (> 30)
All Cancers (> 40)
Esophageal (> 30)
Pancreas (> 40)
Cervical (> 35)
Kidney (> 40)
Uterus (> 40)
0
1.5
1.5
1.7
1.9*
2.0
2.1
2.1
2.5*
2.6*
2.8
3.2
4.8
6.3
1
2
3
4
5
6
7
Relative Risk and 95% CI
(based on never smoking women)
Calle et al. NEJM 2001
8
9
10
11
Summary of Cancer Mortality by
Body Mass Index Men
1.3
Prostate (> 35)
NHL (> 35)
All cancers (> 40)
All Aother cancers (> 30)
1.5
1.5
1.7*
1.7
Kidney (> 35)
Multiple myeloma (> 35)
1.7
1.8
1.8
Gall bladder (> 30)
Colon & Rectum (> 35)
Esophageal (> 30)
Stomach (> 35)
Pancreas (> 35)
Liver (> 35)
0
1.9*
1.9
2.6*
4.5
1
2
3
4
5
Relative Risk and 95% CI
(based on never smoking men)
Calle et al. NEJM 2001
6
7
Trends in Obesity* Prevalence (%), Children and Adolescents, by
Age Group, US, 1971-2008
25
20
Prevalence (%)
20
16
18 18
17
16
15
12
10
11
10
11
10
7
5
5
5
7
4
6
5
0
2 to 5 years
6 to 11 years
12 to 19 years
NHANES I (1971-74)
NHANES II (1976-80)
NHANES III (1988-94)
NHANES 1999-2002
NHANES 2003-06
NHANES 2007-08
*Body mass index (BMI) at or above the sex-and age-specific 95th percentile BMI cutoff points from the 2000 sex-specific BMIfor-age CDC Growth Charts. Note: Previous editions of Cancer Statistics used the term “overweight” to describe youth in this
BMI category.
Source: National Health and Nutrition Examination Survey, 1971-1974, 1976-1980, 1988-1994, 1999-2002, National Center for
Health Statistics, Centers for Disease Control and Prevention, 2002, 2004. 2003-06: Ogden CL, et al. High Body Mass Index for
Age among US Children and Adolescents, 2003-2006. JAMA 2008; 299 (20): 2401-05. 2007-08: Ogden CL, et al. Prevalence of
High Body Mass Index in US Children and Adolescents, 2007-2008. JAMA 2010; 303 (3): 242-249.
Trends in Obesity* Prevalence (%), By Gender, Adults Aged 20
to 74, US, 1960-2008†
45
40
35
33
Prevalence (%)
35
34
33 33
31
35 36
28
30
26
23
25
21
20
15
13
16 17
15 15
11
17
12 13
10
5
0
Both sexes
Men
NHES I (1960-62)
NHANES I (1971-74)
NHANES II (1976-80)
NHANES 1999-2002
NHANES 2003-06
NHANES 2007-08
kg/m2 or
Women
NHANES III (1988-94)
*Obesity is defined as a body mass index of 30
greater. † Age adjusted to the 2000 US standard population.
Source: 1976-2006: National Health and Nutrition Examination Survey, Hispanic Health and Nutrition Examination Survey
(1982–84). Centers for Disease Control and Prevention, National Center for Health Statistics, Health, United States, 2008,
With Special Feature on the Health of Young Adults. Hyattsville, Maryland: 2009. 2007-2008: National Health and Nutrition
Examination Survey Public Use Data File, 2007-2008 National Center for Health Statistics, Centers for Disease Control and
Prevention, 2009.
Trends in Consumption of Five or More Recommended Vegetable
and Fruit Servings for Cancer Prevention, Adults 18 and Older, US,
1994-2007
35
Prevalence (%)
30
25
24.2
24.4
24.1
24.4
23.6
24.3
24.7
1994
1996
1998
2000
2003
2005
2007
20
15
10
5
0
Year
Note: Data from participating states and the District of Columbia were aggregated to represent the United
States.
Source: Behavioral Risk Factor Surveillance System CD-ROM (1984-1995, 1996, 1998) and Public Use Data Tape
(2000, 2003, 2005, 2007), National Center for Chronic Disease Prevention and Health Promotion, Centers for
Disease Control and Prevention, 1997, 1999, 2000, 2001, 2004, 2006, 2008.
Trends in Prevalence (%) of No Leisure-Time Physical Activity, by
Educational Attainment, Adults 18 and Older, US, 1992-2008
Adults with less than a high school education
All adults
Note: Data from participating states and the District of Columbia were aggregated to represent the United
States. Educational attainment is for adults 25 and older.
Source: Behavioral Risk Factor Surveillance System CD-ROM (1984-1995, 1996, 1998) and Public Use Data Tape
(2000 to 2008), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease
Control and Prevention, 1997-2009.
The American Cancer Society
We are dedicated to helping People:
• Get Well
• Stay Well
• Find Cures
• Fight Back
Three great threats to America’s
Future
• Apathy
• Ignorance
• Greed
Reforming how healthcare is paid for
Vs.
Transforming how we view and consume it
Transforming American Healthcare
Issues:
• Irrational patterns of consumption
• A lack of basic prevention (obesity, smoking)
• A lack of education (scientific fact)
How Can We Provide Adequate
High Quality Care (to Include
Preventive Care) to a Population
That Has So Often Not Received It?
Breast Cancer Screening
The Reality:
•With maximum use of current technologies.
More than 450,000 women will still die of
breast cancer over the next decade.
•Let us use mammography, but not be content
with it (my opinion).
•Let us support research to improve
mammography, find better tests and better
treatments.
American Urological Association
•
Given the uncertainty that PSA testing results in
more benefit than harm, a thoughtful and broad
approach to PSA is critical.
• Patients need to be informed of the risks and
benefits of testing before it is undertaken. The
risks of overdetection and overtreatment should
be included in this discussion.
•
PSA Best Practice Statement 2009
European Association of Urology
• Recommends against mass screening.
• Recommends for informed decision making within the
physician-patient relationship.
–
–
“Men should obtain information on the risks and
potential benefits of screening and make an
individual decision”
European Urology 56(2), 2009
National Comprehensive Cancer Network
– “There are advantages and disadvantages to
having a PSA test, and there is no ‘right’ answer
about PSA testing for everyone. Each man should
make an informed decision about whether the
PSA test is right for him.”
The American Cancer Society 2010
Prostate Cancer Screening Guideline
“Men should have an opportunity to make an
informed decision with their health care provider
about whether to be screened for prostate cancer,
after receiving information about the uncertainties,
risks, and potential benefits associated with prostate
cancer screening.”