It’s one thing for medical researchers to suspect an answer they set out to prove is within the scope of the methods by which they conduct the study. It’s quite another when the results of said study give a totally unexpected conclusion. This is perfectly illustrated in this week’s NEJM, in which investigators show that cardiologists are essentially inappropriately heading right for the high-cost (and apparently low-value) procedure known as the angiogram in attempting to diagnose coronary disease.
Out of almost 400 000 patients studied, investigators found that 4 out of every 10 patients who underwent this procedure (which involves invasive catheterization) had absolutely no findings of disease (blockages). Not exactly half, but you get the idea. Although it’s clear that these subspecialists must do a better job in stratifying the most appropriate patients for this procedure, what’s even more salient is the fact that coronary angiograms — being an invasive procedure — are not without risk. Their implementation carries an approximate risk of 1% of an acute coronary event (ie., heart attack), not to mention the amount of radiation exposure involved. | LINK
I’m not a big fan of medical dramas. From my earliest memory as a child, I can recall my mother’s whimsy with the TV show “Medical Center”. At the tender age of five, I never really understood her fascination with the show at that time (although I’m sure the eye candy was a big part of the draw for her, if you know what I mean); perhaps it was the fact that she was a registered nurse and could relate on some visceral level. Okay, that’s probably stretching things a bit — as medical dramas in the 1970s didn’t utilize the high-powered medical knowledge and muster of physician consultants in the manner they do today.
Well, one would think in this age of “transparency” and disclosure among source materials for dramatization, consultants would make sure medical pathology portrayed on television would be as accurate as possible. Don’t they owe it to the audience (along with a riveting storyline)? According to a study getting some Internet meme ink, they do.
There were 59 seizures in the 327 episodes included in the study. Inappropriate responses — such as holding a patient down, trying to stop involuntary movement, or putting something in the person’s mouth — occurred in about 46 percent of the seizure depictions. Appropriate first-aid management was shown about 29 percent of the time, while the appropriateness of first aid couldn’t be determined in 25 percent of the seizure scenes, the study authors noted.
Using current and relatively recent dramas as subjects for the study, the authors note that emergency first aid for seizure was appropriately given about 50% of the time. Perhaps the bigger issue here is why this was studied in the first place. If society relied on medical drama to provide the appropriate instruction rather than, say, medical school; then healthcare reform would probably take on an entirely different meaning. | LINK
In the upcoming NEJM, a large prospective study makes the case for the consideration of dementia as a certain cause of death for the mostly elderly patients who suffer from it. Ever since the disorder was first described by its namesake Alois Alzheimer, MD 102 years ago; it has always been thought of as an unfortunate comorbid “condition” of which advancing age itself was a risk factor. The complexity of the diagnosis made early attempts to formulate effective treatments virtually impossible. Toward the middle of the 20th century the focus of caring for the patient who suffered from dementia shifted to palliation and suppression of other comorbidities which could hasten its clinical effects.
At the end of the last century, breakthroughs in neurobiological research opened the doors to classes of drugs that have largely been successful for controlling debilitating symptoms — without, however, effecting retardation of the disease, or even a cure. Thus the stage was set for a redefinition of sorts for this illness. Authors of the study have delineated the course of dementia (not necessarily following Alzheimer patients, but studying the constellation of disorders that make up its syndrome — Parkinson’s, stroke related dementia, and other organic causes) as one of a terminal nature. They are sounding a clarion call for re-education of the public on what they call a termainal condition which requires effective palliation, at the very least.
At the moment, treatment (which may include some reversal of the pathology) of Alzheimer dementia is being heavily researched. Until the time comes for a certain cure for all causes of dementia, the importance of accurately diagnosing and crafting essential care plans for those who suffer from its horrible effects is the most effective treatment there is. Hopefully, by mid century, the estimated 17 million who will fall prey to dementia will have not only the treatments but also the resources to prevent its early mortality so prevalent in this population today. | LINK
A pregnant Pakistani mother who has just given birth via Caesarian section fights for her life as her child loses his, the product of a completely avoidable obstetrical outcome and a case study in the lack of reproductive rights for women in this culture.
Typically, treatment for hepatitis C comprises at least 48 to 50 weeks of intense intravenous chemotherapy — a mixture of potent antivirals and immunosupressive agents that is as unrelenting on the patient as it is on the virus. This treatment modality even takes into account that the patient is otherwise healthy and free of other significant systemic illness. Hepatologists often have to use serial invasive mechanisms (principally liver biopsies) to monitor treatment progress, adding insult to patient “injury”.
It is also known, albeit for reasons that are still largely unknown, that certain demographics — generally racial ones — determine the degree of treatment success. Now, scientists have taken a step in the direction of predicting treatment outcomes before antiviral chemo has even begun. It all has to do with the way a patient’s genetic code is “read”. This information would then be used by patients and physicians to choose the most appropriate therapies — many of which are apparently safer, but still in development. | LINK
Recently, CMS published data on the readmission rates for hospitals as part of an ongoing effort to make transparent quality indicators from which hospitals could improve healthcare delivery. A recent U of MN study which just wrapped shows how focusing on patients at risk of rehospitalization can cut those potential costs by directly screening for and averting those risks in the nursing home following discharge.
One of the study participants, Theresa McCarthy MD (under whom I once trained), hails the results as they apply to future cost savings in geriatric care. By utilizing a transitional care team made up of the geriatrician, pharmacist, and critical ancillary staff, rates of readmission from patients in this particular care facility fell by 20 per cent. Not only are unnecessary costs averted, potential lives are saved (as many readmitted elderly may become sicker and more susceptible to preventable problems once back in the hospital), but new treatment paradigms are also possible. Smart. | LINK
Should patients with cognitive impairment be given caffeine supplements to stave off the typical short term cognitive deficits seen symptomatically with the disease? Well, while the jury is still out on that count, there’s no denying that for us coffee achievers on a Monday morning after a long holiday weekend, the news of this study is somewhat compelling.
Drinking five cups of coffee a day could reverse memory problems seen in Alzheimer’s disease, US scientists say. The Florida research, carried out on mice, also suggested caffeine hampered the production of the protein plaques which are the hallmark of the disease.
Minnesota man gets prison time for trying to scam one of the state’s largest payers out of medical assistance payments.
Reform? What reform? Health insurance premiums via employer-sponsored plans to increase next year.
Andrew Cuomo, NYs’ AG, has completed reform on out-of-network payments to health plans.
The FDA has approved the sale of Novartis’ Ilaris, the first drug the company has developed as part of its new push to focus on the genetic triggers that cause disease.
The House Energy and Commerce Committee, Subcommittee on Health, held a hearing on the regulatory approval process for medical devices Thursday, presumably as preparation for action on H.R. 1346, the Medical Device Safety Act — sponsored by the committee’s chairman, Rep. Frank Pallone (D-NJ). The American Association for Justice certainly regarded the hearing as serving that purpose, specifically citing the legislation in its news release, “Questions about FDA Oversight of Medical Devices Leave Patients Vulnerable.”
If you’re a diabetic who takes pride in the way you take care of yourself without letting the diagnosis essentially run your life, you’re probably the type of person who could serve a stint as the poster person for the entire wellness and preventive medicine movement. Further, if your physician is the type of provider who prides him/herself as the type of medical professional who loves medicine enough to care about its art and the role of solid evidenced-based medical techniques in preventing more expensive treatments like surgery; then today is a massively lucky one for you (although third party reimbursers may have a difficult time compensating cardiac specialty centers for their time).
Prompt bypass surgery holds no advantage over intensive drug therapy in many patients with type 2 diabetes when it comes to dying from strokes or heart attacks, new research suggests.
The study, a multicenter trial led by the University of Pittsburgh Graduate School of Public Health, took place at 49 medical centers in six countries over five years.
“It’s the first time any randomized clinical trial has shown a reduction in non-fatal heart attack rates in stable patients with diabetes and heart disease,” says cardiologist Robert Frye, a professor of medicine at the Mayo Clinic and a study chairman.
The randomized trial is the gold standard of medical research protocol, and this trial essentially says for people with diabetes and mild heart disease medical therapy works, and extremely well at that. | NEJMLINK | LINK
The experts have been toying with this idea for years. Ever since the medical community have taken note of the importance of tight control of diabetes and the universally benefical effect it has on prevention of serious cardiovascular, kidney, and ocular problems; the role of the much touted test in question — the A1C — has been at the center of the controversy surrounding the best method for “labelling” patient a diabetic.
To be fair, it’s obvious that this diagnosis is much more than a label. Methods which are in use now (fasting glucose blood checks, oral glucose tolerance tests) are universally accepted, sensitive, specific, and validated as true documents of the presence of the disorder. But, according to an expert collective which spoke this week at the American Diabetes Assn. convention, the A1C (currently seen as measure of antidiabetic treatment control) should be considered as a diagnostic tool. The physician and research group, of which the ADA is just one part, stopped short of officially endorsing this line of thinking, rather, stating that the A1C diagnostic guideline would need to be referred to a practice committee before an official statement could be rendered.
The only question now is, what took them so long? | LINK
Music soothes the savage beast. We all know how beneficial it is when it is involved with certain facets of our lives, such as during workouts, high stressful periods in our (love) lives, and in many other scenarios when our emotions need something personal, private, and meaningful. Some physicians are taking this a step further and incorporating the soothing sounds of melody into actual, active procedures as part of treatment intervention — such as during neurosurgery. | LINK
What’s even more interesting than having your craniotomy uploaded live to YouTube? Being wide awake and talking to your surgeon while you’re having it done. In this new (and largely uncharted) intersection of medicine, ethics, and patient confidentiality, social networking is recognizing the beck and call of medical procedures and the healthcare organizations which perfrom them. Surprisingly, there’s a lot of “buy in” by providers and facilities alike. | LINK
AL lawsuit against six pharma production firms results in settlement for state’s Medicaid program.
From the WaPo: Profile of MT Sen. Max Baucus of the Senate Finance Cmte. and his leadership on congressional healthcare reform in the Obama administrati0n.
Speaking of Baucus, he states that illegals will not reap the benefits from pending legislative healthcare reform.
Fair and balanced? A Wash. Times op-ed speaks of discrimination faced by pro-life healthcare providers.
… [Thirty-nine] percent said they already had experienced discrimination because of their beliefs. For example, one doctor said that during her medical residency, she refused to assist in a late-term abortion of a Down syndrome child and was loudly and thoroughly berated in front of her colleagues by the attending physician.
Originating from Saint Paul, Minnesota, [doctorpundit.com] is a weblog about the policy of healthcare and where it intersects with politics and public opinion; it is edited by Michael Douglas, MD, MBA. Welcome, and please consider my take on what is Healthcare 2.0, complemented by a few of my thoughts on my personal avocations and guilty pleasures: music, prose, and writing. Follow Doctor Pundit via RSS above.
DOCTOR PUNDIT @ ONE YEAR
Announcing a year-long series here at Doctor Pundit which reviews healthcare policy trends over the previous year and compares them with current issues. Catch the archives here.
