November 27th, 2008 · Comments Off
Because of the response to the previous post, Clinicians Can Choose How, Not If, They Influence Patient Compliance, I am posting references to two recent publications that address issues raised in that entry.
Microsoft has published the results of a study of cyberchondria, the behavior of individuals who use the Internet to gather information on health or healthcare. The Microsoft study tallies data from health-related Web searches on popular search engines (a 40 million page anonymized sample) as well as a survey of 500 Microsoft employees about their own health-search experiences.
The New York Times summarized the report’s findings:
The study suggests that self-diagnosis by search engine frequently leads Web searchers to conclude the worst about what ails them. … Mr. Horvitz, an artificial intelligence researcher at Microsoft Research, said many people treated search engines as if they could answer questions like a human expert. “People tend to look at just the first couple results,” Mr. Horvitz said. “If they find ‘brain tumor’ or ‘A.L.S.,’ that’s their launching point.” … They found that Web searches for things like headache and chest pain were just as likely or more likely to lead people to pages describing serious conditions as benign ones, even though the serious illnesses are much more rare. For example, there were just as many results that linked headaches with brain tumors as with caffeine withdrawal, although the chance of having a brain tumor is infinitesimally small.
The study can be downloaded at Microsoft Cyberchondria Report
Survey Of Placebo Prescribing
Last month, BMJ published the results of a survey of the habits of American physicians re the prescription of placebos.The abstract follows:
Prescribing “placebo treatments”: results of national survey of US internists and rheumatologists
Objective To describe the attitudes and behaviours regarding placebo treatments, defined as a treatment whose benefits derive from positive patient expectations and not from the physiological mechanism of the treatment itself.
Design Cross sectional mailed survey.
Setting Physicians’ clinical practices.
Participants 1200 practising internists and rheumatologists in the United States.
Main outcome measures Investigators measured physicians’ self reported behaviours and attitudes concerning the use of placebo treatments, including measures of whether they would use or had recommended a “placebo treatment,” their ethical judgments about the practice, what they recommended as placebo treatments, and how they typically communicate with patients about the practice.
Results 679 physicians (57%) responded to the survey. About half of the surveyed internists and rheumatologists reported prescribing placebo treatments on a regular basis (46-58%, depending on how the question was phrased). Most physicians (399, 62%) believed the practice to be ethically permissible. Few reported using saline (18, 3%) or sugar pills (12, 2%) as placebo treatments, while large proportions reported using over the counter analgesics (267, 41%) and vitamins (243, 38%) as placebo treatments within the past year. A small but notable proportion of physicians reported using antibiotics (86, 13%) and sedatives (86, 13%) as placebo treatments during the same period. Furthermore, physicians who use placebo treatments most commonly describe them to patients as a potentially beneficial medicine or treatment not typically used for their condition (241, 68%); only rarely do they explicitly describe them as placebos (18, 5%).
Conclusions Prescribing placebo treatments seems to be common and is viewed as ethically permissible among the surveyed US internists and rheumatologists. Vitamins and over the counter analgesics are the most commonly used treatments. Physicians might not be fully transparent with their patients about the use of placebos and might have mixed motivations for recommending such treatments.
The citation and links to the abstract and full text (available without charge) follow:
Tilburt, J. C, Emanuel, E. J, Kaptchuk, T. J, Curlin, F. A, Miller, F. G (2008). Prescribing “placebo treatments”: results of national survey of US internists and rheumatologists. BMJ 337: a1938-a1938 [Abstract] [Full Text]
March 6th, 2008 · Comments Off
A study published this week in The Journal of the American Medical Association indicated that expensive placebos were more effective than cheaper placebos.
An article from the March 5, 2008 New York Times, More Expensive Placebos Bring More Relief, summarizes the study:
The investigators had 82 men and women rate the pain caused by electric shocks applied to their wrist, before and after taking a pill. Half the participants had read that the pill, described as a newly approved prescription pain reliever, was regularly priced at $2.50 per dose. The other half read that it had been discounted to 10 cents. In fact, both were dummy pills. The pills had a strong placebo effect in both groups. But 85 percent of those using the expensive pills reported significant pain relief, compared with 61 percent on the cheaper pills. The investigators corrected for each person’s individual level of pain tolerance.
Inevitably, some readers felt obliged to make comments along the lines of “I’m going to sell a pill for a gazillion dollars that will cure everyone.”
Ron Winslow, at the Wall Street Journal was more on point with his headline, Placebos Might Work Even Better With a Brand Name. He went on to observe
The results may help explain, among other things, why some patients report worsening symptoms when they switch from a brand-name drug to a cheaper generic version of the same medicine, principal investigator Dan Ariely tells the Health Blog. “The placebo effect is really about the body’s ability to heal itself and prepare for a future that it expects to happen,” says Ariely, a behavioral economist who took time out from a tour for his book “Predictably Irrational” to talk with us. The findings suggest that factors well beyond what people think is in a pill can have an impact on the medicine’s effectiveness.
Still, this is the more of the same sort of thinking that has led to the current crisis in American healthcare. The brand names Mr. Winslow references are, after all, those of the same old pharmaceutical manufacturers.
Pharmaceutical manufacturers manufacture pharmaceuticals. The cognitive dissonance of “pharmaceutical manufacturers manufacture placebos” alone would wash out any potential benefit. Besides, if you’re selling Buicks, you can’t just double or triple the price of Buicks and hope that the customers will accept that increase without demanding an explanation.
One must give the customer/patient extra value for the extra price – which brings us to the new AlignMap business enterprise:
Placeboutique - The Home Of High Priced & Highly Effective Placebos
The Clinical Retail Strategy
First, The AlignMap research staff carefully leeches out any potential chemically-mediated physiological effect from the products while retaining and, in some cases, expanding the expense of producing these placebos.
The key to the placeboutique business plan, however, is offering really prestige name brands. Check out these samples:
Now, those are names that are worth the extra dollars that will make these pseudo-pills expensive enough to be effective.
While the initial iteration of the placebotique tactics limited inventory exclusively to designer brands, we soon realized our humanitarian responsibilities obligated us to carry more affordable generics.
Consequently, we have developed an in-house category of drugs that lack the designer flare and logo but make their own distinctive, low-key statement by virtue of each pill and capsule bearing an embedded blue star diamond.
Remember: At Placeboutique, the diamonds are real; only the drugs are fake
These are quite presentable and, because they do not incur the cost of a designer, can be offered at a substantial savings. While some placebo categories, such as fake immunosuppressive drugs, may remain beyond the reach of a small percentage of the impoverished, more common remedies, such as the fake antibiotics in this line, are widely available at less than $1,000 per dose.
Several other affiliate deals are in the works. While royalties are still being negotiated, a Grey Goose branded bowel prep, for example, could be on the shelves by the end of the year.
Finally, all placebos sold at the placeboutique carry our unique clinical-fiscal guarantee: if the first course of a placeboutique pill does not result in a cure, we will provide a second course of even more prestigious pills at at least twice the price and effectiveness.