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Too Much Care? Newer Treatment for Smoking Cessation

Saturday, October 1, 2011 // Uncategorized

So, actually 52% of physicians thought their patients were getting the right amount of care.

 

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  • September 26, 2011, 4:19 PM ET

Many Physicians Feel They’re Delivering Too Much Care

Your doctor may secretly think you’re making too many office visits and getting too many drugs and tests.

A survey of primary-care doctors conducted in 2009 finds that 42% of the 627 respondents believed the patients in their own practice were getting too much care. Just 6% of doctors believed their patients were getting too little care. (The rest thought the level of care was just right.)

And 28% of the doctors thought they themselves were practicing more aggressively than they would prefer to.

The response rate to the mailed survey was 70%, suggesting this is a topic of interest for doctors — as well as for a health-care system struggling to control costs while helping to improve people’s health.

The survey, the results of which were published in the latest Archives of Internal Medicine, found 76% of doctors blamed malpractice worries for their over-aggressive care. The impact of defensive medicine has been debated, but “it is certainly the most widely endorsed external factor cited by physicians,” says Brenda Sirovich, an author of the study and a staff physician and research associate in the Outcomes Group at the VA Medical Center in White River Junction, VT.

Sirovich, also an associate professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice, notes that 83% of physicians thought they could easily be sued for failure to order a test that was indicated, but only 21% thought they could be sued for ordering a test that wasn’t indicated.

The incentives point toward “when in doubt, do more,” she says.

Some 52% of physicians cited clinical-performance measures, which gauge how closely doctors or institutions adhere to recommended protocols for a certain disease or condition, as a reason for excessive care. “Almost universally, they’re in place to make sure you’re doing enough” for the patient, says Sirovich. Rarely do they attempt to make sure physicians aren’t doing too much.

And 40% of doctors surveyed said inadequate time to spend with patients led them to order tests or refer patients to specialists rather than use other, less-aggressive ways of addressing patients’ issues.

Financial incentives were also cited, but “most thought they affected other physicians,” the study found. Only 3% said financial considerations influenced their own care decisions while 39% said they affected other primary-care doctors and 62% thought they affected sub-specialist physicians.

While the notion that our health-care system delivers too much care to some people is often framed as a cost issue, there’s plenty of reason to believe it can also cause harm, says Sirovich. (Read our Q&A with an author of “Overdiagnosed.” Two of its co-authors, Lisa Schwartz and Steven Woloshin, are also authors of this study.)

Given that so many of these incentives are tied up with the very structure of the malpractice, reimbursement and quality-measurement systems, what can be done? “I don’t think every change has to be sweeping,” says Sirovich. Almost half (45%) of the doctors surveyed estimated that at least 10% of the patients they see on a typical day could be dealt with using an alternative to a full physician’s visit such as a visit with a nurse or an email or phone consultation.

Better reimbursement for those less-intensive ways of following up would help, she says.

And Sirovich notes that “as a profession and as a society, it’s good for us to think about doing a better job of educating patients and the public that more care isn’t necessarily better,” she says. “There’s such a thing as too much.”

Cytisine a Possible Cheaper Approach to Smoking Cessation
Cytisine, a partial nicotine agonist extracted from acacia seeds, sustains smoking cessation better than placebo, according to a New England Journal of Medicine study.
Researchers randomized 740 smokers to 25 days’ treatment with cytisine or matching placebo. The primary outcome, biochemically confirmed smoking cessation at 1 year, was 8.4% with cytisine and 2.4% with placebo.
Gastrointestinal side effects — stomachache, dry mouth, dyspepsia, and nausea — occurred more often with cytisine.
The authors conclude that cytisine’s low cost (about $15 for a course of therapy) “may make it an attractive treatment option for smokers in low-income and middle-income countries.”

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Original Article

Placebo-Controlled Trial of Cytisine for Smoking Cessation

Robert West, Ph.D., Witold Zatonski, M.D., Magdalena Cedzynska, M.A., Dorota Lewandowska, Ph.D., M.D., Joanna Pazik, Ph.D., M.D., Paul Aveyard, Ph.D., M.D., and John Stapleton, M.Sc.

N Engl J Med 2011; 365:1193-1200September 29, 2011

 

Background

Cytisine, a partial agonist that binds with high affinity to the α4β2 nicotinic acetylcholine receptor, is a low-cost treatment that may be effective in aiding smoking cessation. This study assessed the efficacy and safety of cytisine as compared with placebo.

 

Methods

We conducted a single-center, randomized, double-blind, placebo-controlled trial. Participants were randomly assigned to receive cytisine or matching placebo for 25 days; participants in both groups received a minimal amount of counseling during the study. The primary outcome measure was sustained, biochemically verified smoking abstinence for 12 months after the end of treatment. Of 1542 adult smokers screened, 740 were enrolled and 370 were randomly assigned to each study group.

 

Results

The rate of sustained 12-month abstinence was 8.4% (31 participants) in the cytisine group as compared with 2.4% (9 participants) in the placebo group (difference, 6.0 percentage points; 95% confidence interval [CI], 2.7 to 9.2; P=0.001). The 7-day point prevalence for abstinence at the 12-month follow-up was 13.2% in the cytisine group versus 7.3% in the placebo group (P=0.01). Gastrointestinal adverse events were reported more frequently in the cytisine group (difference, 5.7 percentage points; 95% CI, 1.2 to 10.2).

 

Conclusions

In this single-center study, cytisine was more effective than placebo for smoking cessation. The lower price of cytisine as compared with that of other pharmacotherapies for smoking cessation may make it an affordable treatment to advance smoking cessation globally. (Funded by the National Prevention Research Initiative and others; Current Controlled Trials number, ISRCTN37568749.)

 

Supported by a grant from the United Kingdom National Prevention Research Initiative (to Dr. West), which included contributions from the British Heart Foundation, Cancer Research UK, Chief Scientist Office of the Scottish Government Health Directorates, Department of Health, Diabetes UK, Economic and Social Research Council, Research and Development Office of Health and Social Care in Northern Ireland, Medical Research Council, and Welsh Assembly; and by grants from Cancer Research UK (to Dr. West and Mr. Stapleton) and the National Institute for Health Research (to Dr. Aveyard).

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

We thank the members of the Trial Steering Committee (Michael Ussher, Lindsay Stead, Elspeth Lee, Robert Hewings, Martin Edwards, and Dorota Olszak); the members of the Data Monitoring and Ethics Committee (Peter Hajek, Ann McNeill, and Lesley Owen); the doctors (Ewelina Bobek-Pstrucha, Joanna Jonska, Elzbieta Karpinska, Marzena Piasecka, Joanna Surowinska, Ewelina Sliwka, Olga Tronina, and Ewa Wazna), nurses (Teresa Kankiewicz, Mirosława Kleszcz, Katarzyna Marczyk, Elzbieta Milkowska, Malgorzata Pokorska, Dorota Sadowska, and Magdalena Starosciak), psychologists and therapists (Anna Blogosz, Anna Debska, Justyna Koziorowska, Marta Porebiak, Irena Przepiorka, and Agnieszka Smolinska), and secretarial staff (Halina Gaj, Joanna Szwechowicz, and Ewa Tarnowska) who assisted with the conduct of the trial; Ognyan Donev of Sopharma for performing the randomization and providing study medication; and Prof. Piotr Tutka for his help and advice before and during the study.

While this may not seem like an effective treatment, the success of other forms of treatment are similarly dismal( around 23% at 52 weeks for Chantix).  However, if this works for 10% of smokers who try this, the total number is huge and the cost is minimal with few side effects.

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