The Managed Care View on the Vioxx Mess

On MedRants, a commentator expressed this "managed care" view of the Vioxx mess:


Payers are frustrated that MDs are prescribing drugs patients don’t need, driving up short term costs with no attendant benefit to patients. Meanwhile, these decisions may very well lead to additional costs, as patients suffering cardiovascular events who also took COX-2s for WC injuries seek compensation from their WC payer.
The net - payers see MD prescribing behavior as abdicating responsibility, and increasing payer costs. Frustration is rampant.
I think there is plenty of blame to spread around for the Vioxx debacle. Physicians' enthuisiasm for Vioxx and other Cox-2 inhibitors clearly went beyond the evidence. And I think some physicians believed that Cox-2 inhibitors are actually more effective than regular non-steroidal anti-inflammatory drugs (NSAIDS), without evidence to support this belief.
However, before 2004, it would have taken some digging to find evidence that suggested Cox-2 inhibitors were actually dangerous. The published VIGOR trial data did show heart attack risk was higher in the Vioxx group, but this could have been due to chance alone.[1] Although the most evidence-based discussions of Cox-2 inhibitors did raise questions about cardiac risk, they offered no definitive conlusions (see the Cochrane Review[2] and ACP Journal Club[3] from 2002.)
Furthermore, even the most evidence-based physician would have had a hard time discouraging a patient absolutely determined to get a Cox-2 inhibitor before 2004, especially in the context of the typical 15 minute visit during which Cox-2 may have been only one of many issues raised. Such patients were not rare, due to vigorous direct to consumer (DTC) advertisements.
Managed care, of course, has to accept some blame for deluging physicians with paper-work and bureaucracy, while cutting reimbursements for office visits, thus making it financially disadvantageous for physicians to spend enough time with patients to discuss benefits and harms of treatments. Managed care, of course, likes to talk about "evidence-based medicine," but has provided little real support for clinical trials, systematic reviews, or educating physicians about evidence-based medicine. And managed care did nothing to counter all those fancy pharamaceutical DTC advertising campaigns that down-played the adverse effects of drugs, including Cox-2 inhibitors.
If managed care organizations really want patients to get the best possible care based on the best possible evidence, they should provide support and incentives for physicians to take enough time with patients, and for physicians to understand, have access to, and be able to use the tools of evidence-based medicine.
References
[1] Bombardier C et al. Comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis. N Engl J Med 2000; 343: 1520-8.
[2] Garner S et al. Rofecoxib for the treatment of rheumatoid arthritis. Cochrane Database Syst Rev 2002; CD003685.
[3] Meyerhoff J. Rofecoxib, 25 md/d, was more effective than rofecoxib, 12.5 md/d, or acetaminophen in osteoarthritis of the knee. ACP Journal Club 2002; 137: 26.

The Doppler Effect on the Fate of NIH Whistle-Blowers

See The Doppler Effect for an expanded discussion of the firing by the NIH of Dr. Fishbein after he raised questions about the Ugandan site of the nevaripine HIV prevention trial. (My discussion of this recent case of whistle-blowing with an unfortunate outcome for the whistle-blower is here.)

Sex Dreams Equal 8% of Adults' Dreams

Antonio Zadra, PhD, asked 109 women and 64 men to keep a dream diary for two to four weeks. Participants were about 30 years old, on average.

According to Zadra, only two other studies have probed the frequency and content of sexual dreams, and both of those studies were done more than 40 years ago.

In Zadra's study, participants jotted down every dream they had, whether it was sexual or not. All in all, they noted 3,564 dreams. Of those dreams, 292 included sexual content.

"Sexual intercourse was the most common type of sexual content, followed by sexual propositions, kissing, and fantasies," Zadra writes.

For men and women alike, sexual dreams accounted for 8% of all reported dreams. Zadra also notes that "masturbation accounted for approximately 6% of both male and female sexual dreams and an orgasm was experienced in approximately 4% of all sexual dreams."

However, there were some gender differences in sex dreams.

By Miranda Hitti

"Men's sexual dreams were more likely to take place in public or unknown settings, to have the dreamer initiate sexual contact, and to involve unknown characters or multiple partners," Zadra writes, adding that "gender differences in the content of everyday sexual dreams may reflect people's waking needs, experiences, attitudes, and concerns with respect to sexuality."

His findings were presented today in Minneapolis at Sleep 2007, a joint venture of the American Academy of Sleep Medicine and the Sleep Research Society.