Life Extension Magazine

Life Extension Magazine August 2006

Report

Death by Medicine

By Gary Null, PhD; Carolyn Dean MD, ND; Martin Feldman, MD; Debora Rasio, MD; and Dorothy Smith, PhD

By Gary Null, PhD; Carolyn Dean MD, ND; Martin Feldman, MD; Debora Rasio, MD; and Dorothy Smith, PhD

Overmedicating Seniors

Dr. Robert Epstein, chief medical officer of Medco Health Solutions Inc. (a unit of Merck & Co.), conducted a study in 2003 of drug trends among the elderly.136 He found that seniors are going to multiple physicians, getting multiple prescriptions, and using multiple pharmacies. Medco oversees drug-benefit plans for more than 60 million Americans, including 6.3 million seniors who received more than 160 million prescriptions.

According to the study, the average senior receives 25 prescriptions each year. Among those 6.3 million seniors, a total of 7.9 million medication alerts were triggered: less than half that number, 3.4 million, were detected in 1999. About 2.2 million of those alerts indicated excessive dosages unsuitable for seniors, and about 2.4 million alerts indicated clinically inappropriate drugs for the elderly. Reuters interviewed Kasey Thompson, director of the Center on Patient Safety at the American Society of Health System Pharmacists, who noted: “There are serious and systemic problems with poor continuity of care in the United States.” He says this study represents “the tip of the iceberg” of a national problem.136

According to Drug Benefit Trends, the average number of prescriptions dispensed per non-Medicare HMO member per year rose 5.6% from 1999 to 2000, from 7.1 to 7.5 prescriptions. The average number dispensed for Medicare members increased 5.5%, from 18.1 to 19.1 prescriptions.137 The total number of prescriptions written in the US in 2000 was 2.98 billion, or 10.4 prescriptions for every man, woman, and child.138

In a study of 818 residents of residential care facilities for the elderly, 94% were receiving at least one medication at the time of the interview. The average intake of medications was five per resident; the authors noted that many of these drugs were given without a documented diagnosis justifying their use.139

Seniors and groups like the American Association of Retired Persons (AARP) have accepted allopathic medicine’s overriding assumption that aging and dying in America must be accompanied by drugs in nursing homes and eventual hospitalization.140 Seniors are given the choice of either high-cost patented drugs or low-cost generic drugs. Drug companies attempt to keep the most expensive drugs on the shelves and suppress access to generic drugs, despite facing stiff fines of hundreds of millions of dollars levied by the federal government.141,142 In 2001, some of the world’s largest drug companies were fined a record $871 million for conspiring to increase the price of vitamins.143

Current AARP recommendations for diet and nutrition assume that seniors are getting all the nutrition they need in an average diet. At most, AARP suggests adding extra calcium and a multivitamin and mineral supplement.144

Ironically, studies also indicate underuse of proper pain medication for patients who need it. One study evaluated pain management in a group of 13,625 cancer patients, aged 65 and over, living in nursing homes. While almost 30% of the patients reported pain, more than 25% received no pain-relief medication, 16% received a mild analgesic drug, 32% received a moderate analgesic drug, and 26% received adequate pain-relieving morphine. The authors concluded that older patients and minority patients were more likely to have their pain untreated.145

What Remains to Be Uncovered

Our ongoing research will continue to quantify the morbidity, mortality, and financial loss due to:

  • X-ray exposure (mammography, fluoroscopy, CT scans).
  • Overuse of antibiotics for all conditions.
  • Carcinogenic drugs (hormone replacement therapy,* immunosuppressive and prescription drugs).
  • Cancer chemotherapy
  • Surgery and unnecessary surgery (cesarean section, radical mastectomy, preventive mastectomy, radical hysterectomy, prostatectomy, cholecystectomies, cosmetic surgery, arthroscopy, etc.).
  • Discredited medical procedures and therapies.
  • Unproven medical therapies.
  • Outpatient surgery.
  • Doctors themselves.

* Part of our ongoing research will be to quantify the mortality and morbidity caused by hormone replacement therapy (HRT) since the 1940s. In December 2000, a government scientific advisory panel recommended that synthetic estrogen be added to the nation’s list of cancer-causing agents. HRT, either synthetic estrogen alone or combined with synthetic progesterone, is used by an estimated 13.5 to 16 million women in the US.146 The aborted Women’s Health Initiative Study (WHI) of 2002 showed that women taking synthetic estrogen combined with synthetic progesterone have a higher incidence of blood clots, breast cancer, stroke, and heart disease, with little evidence of osteoporosis reduction or dementia prevention. WHI researchers, who usually never make recommendations except to suggest more studies, advised doctors to be very cautious about prescribing HRT to their patients.102,147-151

Results of the “Million Women Study” on HRT and breast cancer in the UK were published in medical journal The Lancet in August 2003. According to lead author Prof. Valerie Beral, director of the Cancer Research UK Epidemiology Unit, “We estimate that over the past decade, use of HRT by UK women aged 50-64 has resulted in an extra 20,000 breast cancers, estrogen-progestagen (combination) therapy accounting for 15,000 of these.”152 We were unable to find statistics on breast cancer, stroke, uterine cancer, or heart disease caused by HRT used by American women. Because the US population is roughly six times that of the UK, it is possible that 120,000 cases of breast cancer have been caused by HRT in the past decade.

Summary

The Office of Technology Assessment (OTA) was perhaps the US government's last honest agency that critically reviewed the state of the nation's health care system. The purpose of the OTA was to provide Congress with objective and authoritative analysis of complex scientific and technical issues. In its final critical report, the OTA concluded:

“There are no mechanisms in place to limit dissemination of technologies, regardless of their clinical value.”

Shortly after the OTA released a report that exposed how entrenched financial interests manipulate health care practice in the United States, Congress disbanded the OTA.

References

1. Available at: http://www.ahrq.gov/data/ hcup/hcupnet.htm. Accessed May 22, 2006.

2. Siu AL, Sonnenberg FA, Manning WG, et al. Inappropriate use of hospitals in a randomized trial of health insurance plans. N Engl J Med. 1986 Nov 13;315(20):1259-66.

3. Siu AL, Manning WG, Benjamin B. Patient, provider and hospital characteristics associated with inappropriate hospitalization. Am J Public Health. 1990 Oct;80(10):1253-6.

4. Eriksen BO, Kristiansen IS, Nord E, et al. The cost of inappropriate admissions: a study of health benefits and resource utilization in a department of internal medicine. J Intern Med. 1999 Oct;246(4):379-87.

5. US National Center for Health Statistics. National Vital Statistics Report, vol. 51, no. 5, March 14, 2003.

6. Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA. 1998 Apr 15;279(15):1200-5.

7. Rabin R. Caution about overuse of antibiotics. Newsday. September 18, 2003.

8. Available at: http://www.cdc.gov/drugresistance/community/. Accessed May 22, 2006.

9. Available at: http://www.ahrq.gov/data/ hcup/hcupnet.htm. Accessed May 22, 2006.

10. US Congressional House Subcommittee Oversight Investigation. Cost and Quality of Health Care: Unnecessary Surgery. Washington, DC: Government Printing Office; 1976. Cited in: McClelland GB, Foundation for Chiropractic Education and Research. Testimony to the Department of Veterans Affairs’ Chiropractic Advisory Committee. March 25, 2003.

11. Suh DC , Woodall BS, Shin SK , Hermes-De Santis ER. Clinical and economic impact of adverse drug reactions in hospitalized patients. Ann Pharmacother. 2000 Dec;34(12):1373-9.

12. Thomas, EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000 Mar;38(3):261-71.

13. Thomas EJ, Studdert DM, Newhouse JP, et al. Costs of medical injuries in Utah and Colorado. Inquiry. 1999 Fall;36(3):255-64.

14. Xakellis GC, Frantz R, Lewis A. Cost of pressure ulcer prevention in long-term care. Am Geriatr Soc. 1995 May;43(5):496-501.

15. Barczak CA, Barnett RI, Childs EJ, Bosley LM. Fourth national pressure ulcer prevalence survey. Adv Wound Care. 1997 Jul-Aug;10(4):18-26.

16. Weinstein RA. Nosocomial infection update. Emerg Infect Dis. 1998 Jul-Sep;4(3):416-20.

17. Fourth Decennial International Conference on Nosocomial and Healthcare-Associated Infections. Morbidity and Mortality Weekly Report. February 25, 2000, Vol. 49, No. 7, p. 138.

18. Available at: http://www.cmwf.org/programs/elders/burger_mal_386.asp. Accessed May 22, 2006.

19. Starfield B. Is US health really the best in the world? JAMA. 2000 Jul 26;284(4):483-5.

20. Starfield B. Deficiencies in US medical care. JAMA. 2000 Nov 1;284(17):2184-5.

21. Weingart SN, McL Wilson R, Gibberd RW, Harrison B. Epidemiology of medical error. West J Med. 2000 Jun;172(6):390-3.

22. Available at: http://www.ahrq.gov/data/ hcup/hcupnet.htm. Accessed May 22, 2006.

23. Available at: http://www.ahrq.gov/news/ ress/pr2003/injurypr.htm. Accessed May 22, 2006.

24. Nationwide poll on patient safety: 100 million Americans see medical mistakes directly touching them [press release]. McLean, VA: National Patient Safety Foundation; October 9, 1997.

25. Leape LL. Error in medicine. JAMA. 1994 Dec 21;272(23):1851-7.

26. The Society of Actuaries Health Benefit Systems Practice Advancement Committee. The Troubled Healthcare System in the US. September 13, 2003. Available at: http://www.soa.org/sections/troubled_healthcare.pdf. Accessed December 18, 2003.

27. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA. 1995 Jul 5;274(1):29-34.

28. Vincent C, Stanhope N, Crowley-Murphy M. Reasons for not reporting adverse incidents: an empirical study. J Eval Clin Pract. 1999 Feb;5(1):13-21.

29. Bates DW. Drugs and adverse drug reactions: how worried should we be? JAMA. 1998 Apr 15;279(15):1216-7.

30. Dickinson, JG. FDA seeks to double effort on confusing drug names. Dickinson’s FDA Review. 2000 Mar;7(3):13-4.

31. Campbell EG, Weissman JS, Clarridge B, Yucel R, Causino N, Blumenthal D. Characteristics of medical school faculty members serving on institutional review boards: results of a national survey. Acad Med. 2003 Aug;78(8):831-6.

32. Possible conflict of interest within medical profession. HealthDayNews. August 15, 2003.

33. World Health Organization. Press Release Bulletin #9. December 17, 2001.

34. Angell M. Is academic medicine for sale? N Engl J Med. 2000 May 18;342(20):1516-8.

35. McKenzie J. Conflict of interest? Medical journal changes policy of finding independent doctors [transcript]. ABC News. June 12, 2002.

36. Crossen C. Tainted Truth: The Manipulation of Fact in America. New York: Simon & Schuster; 1994.

37. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991 Feb 7;324(6):370-6.

38. Wald H, Shojania KG. Incident reporting. In: Shojania KG, Duncan BW, McDonald KM, et al, eds. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Rockville, MD: Agency for Healthcare Research and Quality; 2001:chapter 4. Evidence Report/Technology Assessment No. 43. AHRQ publication 01-E058.

39. Grinfeld MJ. The debate over medical error reporting. Psychiatric Times. April 2000.

40. King G III, Hermodson A. Peer reporting of coworker wrongdoing: a qualitative analysis of observer attitudes in the decision to report versus not report unethical behavior. Journal of Applied Communication Research. 2000;(28), 309-29.

41. Gilman AG, Rall TW, Nies AS, Taylor P. Goodman and Gilman’s The Pharma-cological Basis of Therapeutics. New York: Pergamon Press; 1996.

42. Kolata G. New York Times News Service. Who cares when our drugs fail? San Diego Union-Tribune. October 15, 1997:E-1,5.

43. Melmon KL, Morrelli HF, Hoffman BB, Nierenberg DW, eds. Melmon and Morrelli’s Clinical Pharmacology: Basic Principles in Therapeutics. 3rd ed. New York: McGraw-Hill, Inc.; 1992.

44. Cullen DJ, Bates DW, Small SD, Cooper JB, Nemeskal AR, Leape LL. The incident reporting system does not detect adverse drug events: a problem for quality improvement. Jt Comm J Qual Improv. 1995 Oct;21(10):541-8.

45. Cohen JS. Overdose: The Case Against the Drug Companies. New York: Tarcher-Putnum; 2001.

46. Stenson J. Few residents report medical errors, survey finds. Reuters Health. February 21, 2003.

47. Survey by Henry J. Kaiser Family Foundation, Harvard School of Public Health. Methodology: Fieldwork conducted by ICR - International Communications Research, April 11- June 11, 2002.

48. Bond CA, Raehl CL, Franke T. Clinical pharmacy services, hospital pharmacy staffing, and medication errors in United States hospitals. Pharmacotherapy. 2002 Feb;22(2):134-47.

49. Barker KN, Flynn EA, Pepper GA, Bates DW, Mikeal RL. Medication errors observed in 36 health care facilities. Arch Intern Med. 2002 Sep 9;162(16):1897-903.

50. LaPointe NM , Jollis JG. Medication errors in hospitalized cardiovascular patients. Arch Intern Med. 2003 Jun 23;163(12):1461-6.

51. Gandhi TK, Weingart SN, Borus J, et al. Adverse drug events in ambulatory care. N Engl J Med. 2003 Apr 17;348(16):1556-64.

52. Medication side effects strike 1 in 4. Reuters. April 17, 2003.

53. Vastag B. Pay attention: ritalin acts much like cocaine. JAMA. 2001 Aug 22-29;286(8):905-6.

54. Rosenthal MB, Berndt ER, Donohue JM, Frank RG, Epstein AM. Promotion of prescription drugs to consumers. N Engl J Med. 2002 Feb 14;346(7):498-505.

55. Wolfe SM. Direct-to-consumer advertising—education or emotion promotion? N Engl J Med. 2002 Feb 14;346(7):524-6.

56. US General Accounting Office. Report to the Chairman, Subcommittee on Human Resources and Intergovernmental Relations, Committee on Government Operations, House of Representatives: FDA Drug Review Postapproval Risks 1976-85. Washington, DC: US General Accounting Office; 1990:3.

57. Available at: www.msnbc.com/news/ 937302.asp?cp1=1. Accessed May 22, 2006.

58. Agger WA. Antibiotic resistance: unnatural selection in the office and on the farm. Wisconsin Medical Journal. August 2002.

59. Nash DR, Harman J, Wald ER, Kelleher KJ. Antibiotic prescribing by primary care physicians for children with upper respiratory tract infections. Arch Pediatr Adolesc Med. 2002 Nov;156(11):1114-9.

60. Schindler C, Krappweis J, Morgenstern I, Kirch W. Prescriptions of systemic antibiotics for children in Germany aged between 0 and 6 years. Pharmacoepidemiol Drug Saf. 2003 Mar;12(2):113-20.

61. Finkelstein JA, Stille C, Nordin J, et al. Reduction in antibiotic use among US children, 1996-2000. Pediatrics. 2003 Sep;112(3 Pt 1):620-7.

62. Linder JA, Stafford RS. Antibiotic treatment of adults with sore throat by community primary care physicians: a national survey, 1989-1999. JAMA. 2001 Sep 12;286(10):1181-6.

63. Available at: http://www.cdc.gov/drugresistance/community/. Accessed May 22, 2006.

64. Available at: http://www.health.state.ok.us/ program/cdd/ar/. Accessed May 22, 2006.

65. Available at: www.bayer.com/social-responsibility/health-projects/libra-initiative/page1193.htm. Accessed May 22, 2006.

66. Ohlsen K, Ternes T, Werner G, et al. Impact of antibiotics on conjugational resistance gene transfer in Staphylococcus aureus in sewage. Environ Microbiol. 2003 Aug;5(8):711-6.

67. Pawlowski S, Ternes T, Bonerz M, et al. Combined in situ and in vitro assessment of the estrogenic activity of sewage and surface water samples. Toxicol Sci. 2003 Sep;75(1):57-65. Epub 2003 Jun 12.

68. Ternes TA, Stuber J, Herrmann N, et al. Ozonation: a tool for removal of pharmaceuticals, contrast media and musk fragrances from wastewater? Water Res. 2003 Apr;37(8):1976-82.

69. Ternes TA, Meisenheimer M, McDowell D, et al. Removal of pharmaceuticals during drinking water treatment. Environ Sci Technol. 2002 Sep 1;36(17):3855-63.

70. Ternes T, Bonerz M, Schmidt T. Determination of neutral pharmaceuticals in wastewater and rivers by liquid chromatography-electrospray tandem mass spectrometry. J Chromatogr A. 2001 Dec 14;938(1-2):175-85.

71. Golet EM, Alder AC, Hartmann A, Ternes TA, Giger W. Trace determination of fluoroquinolone antibacterial agents in urban wastewater by solid-phase extraction and liquid chromatography with fluorescence detection. Anal Chem. 2001 Aug 1;73(15):3632-8.

72. Daughton CG, Ternes TA. Pharmaceuticals and personal care products in the environment: agents of subtle change? Environ Health Perspect. 1999 Dec;107 Suppl 6:907-38.

73. Hirsch R, Ternes T, Haberer K, Kratz KL. Occurrence of antibiotics in the aquatic environment. Sci Total Environ. 1999 Jan 12;225(1-2):109-18.

74. Ternes TA, Stumpf M, Mueller J, Haberer K, Wilken RD, Servos M. Behavior and occurrence of estrogens in municipal sewage treatment plants—I. Investigations in Germany, Canada and Brazil. Sci Total Environ. 1999 Jan 12;225(1-2):81-90.

75. Coste J, Hanotin C, Leutenegger E. Prescription of non-steroidal anti-inflammatory agents and risk of iatrogenic adverse effects: a survey of 1,072 French general practitioners. Therapie. 1995 May-Jun;50(3):265-70.

76. Kouyanou K, Pither CE, Wessely S. Iatrogenic factors and chronic pain. Psychosom Med. 1997 Nov-Dec;59(6):597-604.

77. Abel U. Chemotherapy of advanced epithelial cancer—a critical review. Biomed Pharmacother. 1992;46(10):439-52.

78. Schulman KA, Stadtmauer EA, Reed SD, et al. Economic analysis of conventional-dose chemotherapy compared with high-dose chemotherapy plus autologous hemato-poietic stem-cell transplantation for metastatic breast cancer. Bone Marrow Transplant. 2003 Feb;31(3):205-10.

79. Kaufman, M. Drugmaker to pay FDA $500 million. Manufacturing problems found at Schering-Plough. Washington Post. May 18, 2002:A01.

80. US Congressional House Subcommittee Oversight Investigation. Cost and Quality of Health Care: Unnecessary Surgery. Washington, DC: Government Printing Office; 1976. Cited in: McClelland GB, Foundation for Chiropractic Education and Research. Testimony to the Department of Veterans Affairs’ Chiropractic Advisory Committee. March 25, 2003.

81. Leape LL. Unnecessary surgery. Health Serv Res. 1989 Aug;24(3):351-407.

82. McClelland GB, Foundation for Chiropractic Education and Research. Testimony to the Department of Veterans Affairs’ Chiropractic Advisory Committee. March 25, 2003.

83. Coile RC Jr. Internet-driven surgery. Russ Coiles Health Trends. 2003 Jun;15(8):2-4.

84. Guarner V. Unnecessary operations in the exercise of surgery. A topic of our times with serious implications in medical ethics. Gac Med Mex. 2000 Mar-Apr;136(2):183-8.

85. Rutkow IM. Surgical operations in the United States: 1979 to 1984. Surgery. 1987 Feb;101(2):192-200.

86. Rutkow IM. Surgical operations in the United States. Then (1983) and now (1994). Arch Surg. 1997 Sep;132(9):983-90.

87. Linnemann MU, Bulow HH. Infections after insertion of epidural catheters. Ugeskr Laeger. 1993 Jul 26;155(30):2350-2

88. Seres JL, Newman RI. Perspectives on surgical indications. Implications for controls. Clin J Pain. 1989 Jun;5(2):131-6.

89. Chassin MR, Kosecoff J, Park RE, et al. Does inappropriate use explain geographic variations in the use of health care services? A study of three procedures. JAMA. 1987 Nov 13;258(18):2533-7.

90. Office of Technology Assessment, US Congress. Assessing the Efficacy and Safety of Medical Technologies. Washington DC: Office of Technology Assessment, US Congress; 1978.

91. Available at: www.wws.princeton.edu/ ota/disk1/1995/9562_n.html. Accessed May 22, 2006.

92. Zhan C, Miller M. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. JAMA. 2003;290:1868-74.

93. Weingart SN, Iezzoni LI. Looking for medical injuries where the light is bright. JAMA. 2003 Oct 8;290(14):1917-9.

94. MacMahon B. Prenatal x-ray exposure and childhood cancer. J Natl Cancer Inst. 1962 May;28:1173-91.

95. Available at: http://hps.org/publicinformation/ate/q1084.html. Accessed May 22, 2006.

96. Gofman JW. Radiation from Medical Procedures in the Pathogenesis of Cancer and Ischemic Heart Disease: Dose-Response Studies with Physicians per 100,000 Population. San Francisco, CA: CNR Books; 1999.

97. Gofman JW. Preventing Breast Cancer: The Story of a Major, Proven, Preventable Cause of This Disease. 2nd ed. San Francisco, CA: CNR Books; 1996.

98. Sarno JE. Healing Back Pain: The Mind-Body Connection. Warner Books; 1991.

99. Showalter E. Hystories: Hysterical Epidemics and Modern Media. New York: Columbia University Press; 1997.

100. Available at: http://college.hmco.com/history/readerscomp/women/html/wh_001200_alternativeh.htm. Accessed May 16, 2006.

101.Thacker SB, Stroup D, Chang M. Continuous electronic heart rate monitoring for fetal assessment during labor (Cochrane Review). In: The Cochrane Library, issue 1, 2003. Oxford: Update Software.

102.Cole C. Admission electronic fetal monitoring does not improve neonatal outcomes. J Fam Pract. 2003 Jun;52(6):443-4.

103.Nelson HD, Humphrey LI, Nygren P, Teutsch SM, Allan JD. Postmenopausal hormone replacement therapy: scientific review. JAMA. 2002 Aug 21;288(7):872–81.

104.Nelson HD. Assessing benefits and harms of hormone replacement therapy: clinical applications. JAMA. 2002 Aug 21;288(7):882-4.

105.Fletcher SW, Colditz GA. Failure of estrogen plus progestin therapy for prevention. JAMA. 2002 Jul 17;288(3):366-8.

106.Rossouw JE, Anderson GL, Prentice RL, et al; Writing Group for the Women’s Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. JAMA. 2002 Jul 17;288(3):321-33.

107.Rutkow IM. Obstetric and gynecologic operations in the United States, 1979 to 1984. Obstet Gynecol. 1986 Jun;67(6):755-9.

108. Family Practice News. February 15, 1995:29.

109. Sakala C. Medically unnecessary cesarean section births: introduction to a symposium. Soc Sci Med. 1993 Nov;37(10):1177-98.

110. VanHam MA, van Dongen PW, Mulder J. Maternal consequences of cesarean section. A retrospective study of intra-operative and postoperative maternal complications of cesarean section during a 10-year period. Eur J Obstet Reprod Biol. 1997 Jul;74(1):1-6.

111. Weiner J. Smoking and cancer: the cigarette papers: how the industry is trying to smoke us all. The Nation. January 1, 1996:11-18.

112. Available at: www.tobacco.org/resources/history/tobacco_history.html. Acccessed May 22, 2006.

113. Lasser KE, Allen PD, Woolhandler SJ, Himmelstein DU, Wolfe SM, Bor DH. Timing of new black box warnings and withdrawals for prescription medications. JAMA. 2002 May 1;287(17):2215-20.

114. Available at: http://www.injuryboard.com/ view.cfm/Article=3005. Accessed May 22, 2006.

115. Blendon R, Schoen C, Des roches LM, et al. Iniquities in health care: a five-county survey. Health Aff. 2002 May-Jun;21(3):182-91.

116. Institute of Medicine. Care Without Coverage: Too Little, Too Late. May 21, 2002. A Shared Destiny: Community Effects of Uninsurance. March 6, 2003.

117. US Department of Health and Human Services and US Department of Justice. Health Care Fraud and Abuse Control Program Annual Report for FY 1998. April 1999. Health Care Fraud and Abuse Control Program Annual Report for FY 2001. April 2002.

118. Available at: http://www.house.gov/waxman. Accessed May 22, 2006.

119. Mitka M. Unacceptable nursing home deaths unautopsied. JAMA. 1998 Sep 23-30;280(12):1038-9

120. New data is in on North Carolina’s nursing home residents. Medical Review of North Carolina, Inc. July 21, 2003.

121. Centers for Medicare & Medicaid Services. Report to Congress: Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes: Phase II Final Report. December 24, 2001.

122. Consumer group criticizes Thompson letter dismissing report on dangerous staffing levels in nursing homes [news release]. Washington, DC: National Citizens’ Coalition for Nursing Home Reform. March 22, 2002.

123. Bergstrom N, Braden B, Kemp M, Champagne M, Ruby E. Multi-site study of incidence of pressure ulcers and the relationship between risk level, demographic characteristics, diagnoses and prescription of preventive interventions. J Am Geriatr Soc. 1996 Jan;44(1):22-30.

124. Miles SH. Concealing accidental nursing home deaths. HEC Forum. 2002 Sep;14(3):224-34.

125. Corey TS, Weakley-Jones B, Nichols GR 2nd, Theuer HH. Unnatural deaths in nursinghome patients. J Forensic Sci. 1992 Jan;37(1):222-7.

126. Lloyd-Jones DM, Martin DO, Larson MG, Levy D. Accuracy of death certificates for coding coronary heart disease as the cause of death. Ann Intern Med. 1998 Dec 15;129(12):1020-6.

127. Thomas DR , Zdrowski CD, Wilson MM, et al. Malnutrition in subacute care. Am J Clin Nutr. 2002 Feb;75(2):308-13.

128. Robinson BE. Death by destruction of will. Lest we forget. Arch Intern Med. 1995 Nov 13;155(20):2250-1.

129. Capezuti E, Strumpf NE, Evans LK, Grisso JA, Maislin G. The relationship between physical restraint removal and falls and injuries among nursing home residents. J Gerontol A Biol Sci Med Sci. 1998 Jan;53(1):M47-52.

130. Phillips CD, Hawes C, Fries BE. Reducing the use of physical restraints in nursing homes: will it increase costs? Am J Public Health. 1993 Mar;83(3):342-8.

131. Miles SH, Irvine P. Deaths caused by physical restraints. Gerontologist. 1992 Dec;32(6):762-6.

132. Annas GJ. The last resort—the use of physical restraints in medical emergencies. N Engl J Med. 1999 Oct 28;341(18):1408-12.

133. Parker K, Miles SH. Deaths caused by bedrails. J Am Geriatr Soc. 1997 Jul;45(7):797-802.

134. Katz PR, Seidel G. Nursing home autopsies. Survey of physician attitudes and practice patterns. Arch Pathol Lab Med. 1990 Feb;114(2):145-7.

135. Overmedication of US seniors. Reuters Health. May 21, 2003.

136. Average number of prescriptions by HMOs increases. Drug Benefit Trends. 2002 Sep 12;14(8).

137. Kaiser Family Foundation. Prescription Drug Trends. November, 2001.

138. Williams BR, Nichol MB, Lowe B, Yoon PS, McCombs JS, Margolies J. Medication use in residential care facilities for the elderly. Ann Pharmacother. 1999 Feb;33(2):149-55.

139. Available at: http://www.aarp.org/prescriptiondrugs. Accessed May 22, 2006.

140. California reaches $100 million multi-state settlement with drug giant Mylan over alleged price-fixing scheme [press release]. Sacramento, CA: Office of the Attorney General, Department of Justice, State of California; July 12, 2000.

141. Available at: http://www.wral.com/money/2026364/detail.html. Accessed May 22, 2006.

142. Available at: www.education.guardian.co.uk/ businessofresearch/comment/ 0,9976,606260,00.html. Accessed May 22, 2006.

143. Available at: http://www.aarp.org/Articles/ a2003-03-07-supplements.html. Accessed May 22, 2006.

144.Bernabei R, Gambassi G, Lapane K, et al. Management of pain in elderly patients with cancer. SAGE study group. Systematic assessment of geriatric drug use via epidemiology. JAMA. 1998 Jun 17;279(23):1877-82.

145. Abel U. Chemotherapy of advanced epithelial cancer—a critical review. Biomed Pharmacother. 1992;46(10):439-52.

146. Associated Press. Panel names estrogen as carcinogen. The Washington Post. December 16, 2000:A05.

147. Estrogen hikes ovarian cancer risk. MSNBC staff and wire reports. July 16, 2002. Grady D. Study recommends NOT using hormone therapy for bone loss. New York Times. October 1, 2003.

148. Anderson GL, Judd HL, Kaunitz AM, et al. Effects of estrogen plus progestin on gynecologic cancers and associated diagnostic procedures: the Women’s Health Initiative randomized trial. JAMA. 2003 Oct 1;290(13):1739-48.

149. Chlebowski RT, Hendrix SL, Langer RD , et al. Influence of estrogen plus progestin on breast cancer and mammography in healthy postmenopausal women: the Women’s Health Initiative randomized trial. JAMA. 2003 Jun 25;289(24):3243-53.

150. Wassertheil-Smoller S, Hendrix SL, Limacher M, et al. Effect of estrogen plus progestin on stroke in postmenopausal women: the Women’s Health Initiative: a randomized trial. JAMA. 2003 May 28;289(20):2673-84.

151. Shumaker SA, Legault C, Rapp SR, et al. Estrogen plus progestin and the incidence of dementia and mild cognitive impairment in postmenopausal women: the Women’s Health Initiative memory study: a randomized controlled trial. JAMA. 2003;289:2651-62.

152. Beral V; Million Women Study Collaborators. Breast cancer and hormone-replacement therapy in the Million Women Study. Lancet. 2003 Aug 9;362(9382):419-27.