TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week.
This week's topics include Medicare negotiation on drug price comparison, messaging to improve adherence to cardiovascular disease (CVD) medications, maternal cancer detection, and vigorous intermittent lifestyle physical activity (VILPA).
Program notes:
1:02 Incidental detection of maternal cancer
2:02 Have abnormal blood tests
3:04 Call into question what to do with the findings
3:50 Text messaging to improve adherence to CVD medications
4:51 Get generic reminders
5:50 Wide age range and conditions
6:50 Does help in some circumstances
7:26 Physical activity and cardiovascular events
8:26 Vigorous intermittent lifestyle activity or VILPA
9:30 U.K. Biobank population
10:30 At least some brief intermittent activity
10:44 US drug prices under Medicare negotiation compared with peers
11:43 8% to 42% compared to before negotiation
12:43 Net spending reduced 22%
13:23 End
Transcript:
Elizabeth: How do drug prices negotiated by Medicare compare with other peer countries?
Rick: Does brief, but vigorous physical activity improve outcomes?
Elizabeth: Can we use personalized patient data and behavioral nudges to get people to take their cardiovascular meds?
Rick: And incidental detection of maternal cancer.
Elizabeth: That's what we're talking about this week on TTHealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I'm Elizabeth Tracey, a Baltimore-based medical journalist.
Rick: And I'm Rick Lange, president of Texas Tech University Health Sciences Center in El Paso, where I'm also dean of the Paul L. Foster School of Medicine. Before we get started, we just closed the Thanksgiving holiday and I just want to give thanks for the fact that we're now entering our 20th year of podcasting together. Thank you very much, Elizabeth.
Elizabeth: Thank you very much, Rick. Any listener who would like to weigh in on that, we would deeply appreciate it. Thanks to all of you who also listen to us. On that note, which of these would you like to start with?
Rick: The incidental detection of maternal cancer.
This is an article in the New England Journal of Medicine. Blood is routinely drawn in pregnant women looking for what's called fetal aneuploidy, evidence that the fetus has abnormal chromosome numbers. Most DNA is contained in cells, but this is looking for cell-free -- that is, circulating -- DNA, which approximately 10% comes from the placenta and about 90% comes from the blood system of the pregnant person.
Use of this blood test has replaced invasive diagnostic procedures such as amniocentesis, but occasionally when they do the blood test it comes out as non-reportable or it indicates an abnormality that just doesn't mesh with what we're seeing in a sonogram. What exactly does that mean?
Let me take a step back. About 1 in 1,000 women who are pregnant have incidental cancer. An observation made a long time ago with individual patients was oftentimes these cancers, which otherwise a mother may not have symptoms of or may attribute the symptoms of pregnancy, would have abnormal blood tests, and perhaps this prenatal cell-free DNA sequencing can detect incidental maternal cancer.
They looked at 107 participants that had abnormal cell-free DNA sequencing -- it wasn't aligned with any fetal abnormality -- and then said, "Gosh, I wonder if that could indicate some underlying malignancy?" In fact, in half the women that's exactly what happened. Secondly, they said, "Well, how would we detect where that malignancy is?" Whole-body MRI imaging was the most sensitive and specific way to pick up this cancer.
Elizabeth: It's an interesting thing to me looking at this study, first of all, that half of the women who demonstrated this issue with their cell-free DNA assessment sure enough turned out to have cancers. You may know that even while cancer during pregnancy is rare, it's becoming more common. Just like a lot of these other -- colorectal cancer, for example, in younger people, this is something that definitely concerns me.
Now, the editorialist with regard to this study does call into question what do we do with these findings because whole-body MRI is expensive. It is not indicated under the usual care of pregnant persons and there are going to be a lot of places where it's not going to be available.
Rick: You wouldn't do it in every woman, but you would target it to those women that have abnormal cell-free DNA testing. The false-positive rate is relatively low. Again, what the editorialist suggested is we need to incorporate this into our guidelines. Almost all women in the United States receive cell-free DNA testing. When it comes back abnormal, but inconsistent with what you know about the fetus, that's when we need to take it further in terms of additional testing.
Elizabeth: Let's turn from here to JAMA. This is a look -- and it's a rather disappointing look -- at whether utilizing personalized patient data and behavioral nudges can improve people's adherence to chronic cardiovascular medications.
This study aimed to compare different types of text messaging strategies with usual care to see whether folks would refill their medicines prescribed for cardiovascular indications or not. Over 9500 were enrolled and they represented a large slice of the population. They looked at a generic reminder, a behavioral nudge, and a behavioral nudge plus a chatbot to see, "Does any of this stuff really make any difference?" The bad news was, it really didn't make any difference no matter which of those things you selected. Their medication adherence was not improved over 12 months.
Rick: Many of us that have prescriptions get these generic reminders from Walmart or CVS or the local pharmacy saying, "It's time to refill your medication." This study shows that that's not really beneficial.
Now, these are people that are on chronic medications. They have not picked up their medication for at least 7 days and at that point they gave them the generic reminder. Then they thought, "Well, okay, that didn't work." Well, a little behavioral nudge is encouraging. "Well, that didn't work." Then a chatbot where it is actually interactive with the individual. Well, that didn't work either.
In some ways, in some particular cases, these text messages -- especially the ones that are personalized -- can help; for example, with diabetes management it's shown to be helpful. The assumption is if it's helpful there it's helpful for everything.
I appreciate the journal for publishing this negative study because it shows you can put a lot of effort into this in terms of refilling medications. In this particular circumstance, it's not helpful. We have got to find some other way to improve medication refill adherence. This won't be it.
Elizabeth: I thought it was really interesting because this patient population was aged 18 years to less than 90 years and they also had one or more cardiovascular conditions, including high blood pressure, hyperlipidemia, diabetes, coronary artery disease, or atrial fibrillation. It was a wide slice of folks and many of them were on more than one medicine for these particular indications. What I would be interested in would be drilling down into this data and seeing if you were just on one medicine and it was for mildly elevated blood pressure, is that the population who really were completely not moved at all by any strategy? I'd like to hear some more about all of that.
Rick: Yeah. Unfortunately, it doesn't provide as much information. What it does say is we found 9,500 people that weren't refilling their medications and, by the way, had a cardiovascular condition, which most of us would assume can be life-threatening. You would think that these are the people that were highly motivated to do that, but unfortunately that's not the case.
Elizabeth: I just want to note that a Hopkins study that was recently published also in JAMA was taking a look at these personalized text messages for helping inform parents so that the trajectory of childhood obesity could be avoided. It was a positive study -- and it was really pretty profoundly positive -- and so I'm not sure abandoning the strategy of text messaging is the thing. I think maybe it's a more personalized identification of, "Hey, what works for you?"
Rick: Yeah. What certain conditions is it helpful? Again, we talked about the fact that it may help in diabetes and it may help with weight management. In terms of medication compliance, it doesn't seem to be helpful. You can't take the results of one study and extrapolate them into another.
Elizabeth: Turning to The BMJ.
Rick: We know that from many studies higher levels of physical activity are associated with reduced risk of many cardiovascular events. The recommendation of the American Heart Association is 150 minutes of exercise over a week. I usually tell people that's 30 minutes for 5 days a week. While many individuals are able to incorporate that into their daily routines, a lot of people don't.
Some will take place in what's called vigorous intermittent physical activity, and that's planned short bouts of exercise -- instead of 30 minutes, maybe 5 or 10 or 15. But there are some individuals that don't even do that. The only vigorous lifestyle physical activity they do is what occurs during their routine activities, for example, climbing up stairs or walking very quickly. These activities, by the way, occur in very brief periods of time, up to 1 minute long. We call this vigorous intermittent lifestyle physical activity (VILPA). You really can't record vigorous intermittent lifestyle physical activity. It has to be measured by a device.
What this study tried to assess is, do these short, very brief lifestyle physical activities that are vigorous improve cardiovascular events, and is there a difference between men and women? They examined over 13,000 women and over 9300 men over an 8-year follow-up and looked at the device-measured vigorous intermittent lifestyle physical activity to find out if there was any relationship between that and major adverse cardiovascular events.
Compared with women that had no vigorous activity, even activity of 3.4 minutes per day was associated with a 45% lower risk of these major cardiovascular events and a 67% lower risk of heart failure. There was a linear relationship. The more vigorous activity, the lower your risk. You started to receive some benefit at a little over a minute and a half per day. The results were much more noticeable in women than they were in men.
Elizabeth: Which seems somewhat inexplicable. This is our U.K. Biobank population, of course. Gosh, those poor people are going to be so intensively studied as they age out, or whatever, out of that study. I find it amazing. Wasn't there also some notion about the VILPA -- one more acronym to add to our acronym vocabulary -- was most beneficial for those folks who were largely sedentary?
Rick: All of these individuals, their comparison were those individuals that were sedentary, so sedentary versus those that had this vigorous intermittent physical activity -- that is, up to 1 minute long. With respect to the difference between men and women, in general women have lower cardiorespiratory fitness on average than men at any given age. What that means is that any physical effort they give for any given physical task is higher for women than it is for men. That may be an explanation for why women received more of a benefit than men.
Elizabeth: I'm seeing a prescription for VILPA in the future.
Rick: Yeah. Elizabeth, let me put that in context. For those people that are sedentary and can't find the time to put routine exercise into their schedule, at least do some brief intermittent vigorous activity. That means park far away and walk quickly to the store. That means take the stairs instead of taking an elevator. Even these short bursts of vigorous physical activity can be extremely beneficial in women.
Elizabeth: Okay. Finally, let's turn back to JAMA. This is a research letter -- something that, of course, I find outrageous -- and that's the fact that in the United States we pay so much more for prescription drugs than other peer countries. What this letter examines is since Medicare has been empowered to negotiate drug prices, how do they compare with six other high-income peer countries?
They identified these negotiated prices using a published list from CMS. They then compared these things to Australia, Canada, France, Germany, Switzerland and the U.K. They looked at all kinds of initial net prices, ceiling prices, and prices in the non-U.S. countries are estimated, and then looked at the most recent year with complete data. All of these were converted to 30-day equivalents.
Basically, what they found is that these negotiated prices were 8% to 42% lower than the net prices before Medicare's negotiation. However, all of them are still significantly more expensive domestically than they are in any of these peer countries. This is apart from insulin, which had a voluntary price reduction in 2024. All of them are more expensive in the U.S. than in other countries.
Rick: Yeah. Elizabeth, again, as a result of the Inflation Reduction Act, Medicare is now able to negotiate prices of some of the top-selling drugs and set ceilings on what these negotiated prices are. This is Medicare negotiating with pharmaceutical companies and they pick the medications that are either most frequently used or are the most expensive in terms of their output.
I agree with you. Even after negotiation, the fact that we're paying 2 to 3 times more than in other countries around the world is a problem to me. In fact, CMS estimated that if they had negotiated these prices in 2023 and not waited until now, the net spending would have been reduced by about 22%. The fact that our negotiated prices all remained higher than in our peer countries and we're paying a lot more should bother all of us.
Elizabeth: I would urge people to bring this issue up because it's something that impacts all of us and definitely impacts the bottom line for many, many people.
Happy 20-year anniversary! That's a look at this week's medical headlines from Texas Tech. I'm Elizabeth Tracey.
Rick: And I'm Rick Lange. Y'all listen up, as you have for the last 20 years, and make healthy choices.