Friday, November 30, 2007

HIPAA, Guns, and Public Health

A while ago I was called to the Psych floor to see a patient with a cardiac arrhythmia. I thought I would check on the patient’s history via our fancy electronic medical record (EMR) before making the trek to an area rarely visited by this outsider, but I was surprised to see that I could not access charts electronically from outside the Psych ward. It seems there are some checks and balances installed in our EMR to avoid prying eyes. Although I was initially perturbed, I must admit I thought it was a smart move to limit access to psychiatric charts – especially since I might be up there as an inpatient myself given all the bureaucracy surrounding medicine these days.

But then this news appeared today about how the feds have miraculously increased their "Mental Defective File" database size to limit the sales of guns to goofy people. On first blush, I thought, “Thank God! I really don’t one of these crazy people with a gun.”

But then I looked into HOW the FBI expanded their database from 150,000 to over 400,000 people in the blink of an eye:
The vast majority of the individuals who were added to the FBI's list were identified by the state of California, which provided more than 200,000 names to the FBI in October, the Justice Department said. Ohio also provided more than 7,000 new names, and the number of states reporting mental health data to the FBI this year grew from 23 to 32, officials said.
So where did these states get these names from? Well it seems hospitals may have supplied the names:
A Virginia state court found (Seung Hui) Cho (remember, he caused the largest on-campus killing spree of anyone to date) to be dangerously mentally ill in 2005 and ordered him to receive outpatient treatment. But because Cho was not ordered into hospital treatment, the court's order was never provided to the FBI and incorporated in its database, which two gun dealers checked before selling Cho the 9mm Glock 19 and a Walther .22-caliber pistol used in the shootings.
The debate about this has been heated:
House Democrats reached an agreement earlier this year with the National Rifle Association on legislation meant to encourage states to submit timely background check data to the FBI, by offering monetary awards and threatening penalties.

"Our position has always been that those who have been adjudicated as mentally defective or a danger to themselves or to others or suicidal should not have access to firearms" and should be added to the FBI's list, said NRA spokesman Andrew Arulanandam.

The measure passed easily in the House, but it has stalled in the Senate due to a hold by Sen. Tom Coburn, R-Okla. He has said he opposes the legislation because its implementation would cost too much and because it lacks a mechanism to challenge inclusion on the list. He was joined by some veterans' groups, which argued that former soldiers might be denied gun-owning rights without due process.
Now, most of us assume such sensitive health records are protected in the interest of “privacy.” Isn’t that what we’ve been assured by HIPAA? So what’s the loophole that permits the feds access to sensitive hospital records to make their lists? What if I had an anxiety disorder or depression in my medical history requiring inpatient admission. Would I end up on the FBI’s “Mental Defective File?” Would I have any recourse to remove myself from that list if my condition improved? Who’s responsible for this information? If we take this a step further, what’s to stop the feds from forming another database in the interest of public health like, say, an “HIV Defective File” or other “Sexually-transmitted Disease Defective File?”

Probably nothing.

-Wes

Wednesday, November 28, 2007

Hospital Bill Padding Exposed

Hospital bill for compression stockings? $791.
Cost of the same pair on the internet? $12.

Hospital bill for oxygen mask? $2,225 to $6,675 a night.
Cost of the same oxygen mask at home? $250 a month.

Hospital bill to patient AFTER 1.5 million of catastrophic insurance coverage is exhausted? $1.2 million.

Final patient bill after the hospital's billing practices are investigated by the Wall Street Journal? $0.00.

Benefit of these investigations for healthcare reform?

Priceless.

-Wes

New Data on Driving With Defibrillators

Today's post on the above topic can be found over at MedPage Today.

-Wes

14:10 PM CST - Link fixed! Sorry.

Tuesday, November 27, 2007

A New Medical Subspecialty

First there was the internist - available day or night, inpatient or outpatient to care for their patients.

Then there was the hospitalist - available day or night, but only for inpatients.

And now it seems there comes the nocturnist - available only at night and only for inpatients.

I can't believe my eyes...

-Wes

The Deconstruction of Medicare Billing

The Happy Hospitalist demonstrates the mess, vividly.

I find it interesting that CMS wants to improve the quality of health care delivery by evaluating ever-expanding performance measures while ignoring the expense and inefficiencies their own billing morass.

-Wes

Photo credit.

The Collusion between Media and Hosptials

Today, the US News and World Report's Best Hospital issue list appears. Oh, boy! It makes for some great reading. Zzzzzzzzzz.

But what's funny is that the Big Boy winners are now in bed with US News and World Report - providing content for their issue about all kinds of diseases that they (alone, I'm sure) have mastered.

For instance, look at this page from their website. It lists tons of diseases. Now, click on one of the topics. And look at the top of the page, just to the right of the topic you picked. Who supplied the content "with" US News and World Report? Was it Cleveland Clinic? or Johns Hopkins? or Mayo?

Does anyone else find this conflict disturbing?

-Wes

Monday, November 26, 2007

Vice President Cheney Gets Atrial Fibrillation

Well, it was bound to happen.

Take a man with significant coronary artery disease, a prior history of more than enough cardiac bypass operations, a weakened heart muscle that requires an automatic defibrillator, and a prior deep venous thrombosis (blood clot) in his leg and what to you get? An almost inevitable likelihood that he will develop a heart rhythm disturbance, too.

It seems Vice President Dick Cheney has suffered another common complication of a weakened heart: atrial fibrillation (afib).

Atrial fibrillation, characterized by an irregular heart rhythm disturbance in the upper chambers of the heart (atria), becomes symptomatic in a variety of ways:
  • It can made the lower chambers of the heart (ventricles) race too fast
  • It can cause an uncomfortable irregularity of the heart rhythm that can be disturbing to the individual (called "palpitations")
  • It can reduce the efficiency of the pumping action of the heart, making people feel more short of breath or perhaps develop a slight cough (as the above article suggests)
  • Or, commonly, it can be completely silent and not cause any symptoms.
But by far and away the main concern with afib in someone like Mr. Cheney is its propensity to increase his risk of stroke. Fortunately for Mr. Cheney, however, this risk was minimized because he was probably taking warfarin (Coumadin®) for treatment of the earlier blood clot in his leg. More ominously, however, the presence of his persistent cough may have represented congestive heart failure (where fluid backs up into the lungs) caused by the reduced efficiency of his heart to pump blood in this rhythm.

Afib that occurs in someone who already has an automatic defibrillator presents additional therapeutic challenges. In defibrillator patients, if afib causes the heart to race too fast, the heart rate could exceed the rate limit in the defibrillator's pre-programmed settings that helps it separate normal from abnormal heart rates. If the lower chamber (ventricular) rate exceeds this limit, then the device might detect the rhythm as excessive, charge, and deliver a shock to attempt to correct the rhythm. If the shock encompasses the upper chambers sufficiently, it can restore the atrial fibrillation rhythm back to normal. If not, the lower chambers can be driven progressively faster by the upper chambers again, and additional shocks could occur. To prevent this, rate control medications (such as beta blockers) are an important therapeutic strategy.

So what usually happens next?

First, the White House really doesn't want or need this publicity. So the most logical step will be to convert Mr. Cheney's heart rhythm back to normal quickly. Provided he is on adequate anticoagulation, this could be performed right away, often using his defibrillator to restore his atrial rhythm to normal (an "internal" cardioversion) while sedated. If unsuccessful, a more conventional "external" cardioversion could be performed by applying a jolt of electricity across his chest to reset the heart rhythm - much like one hits "Alt-Ctrl-Del" on a PC to reboot it (sorry, I digress...) If these methods are objectionable to Mr. Cheney, pharmachologic cardioversion with a medication like ibutilide (Corvert®) could also be attempted. By restoring the rhythm back to normal quickly, Mr. Cheney loses his star power before the media and gets back to his business as Vice President. And as predicted, it's already been done.

Long-term, there will be a discussion if Mr. Cheney should remain on an anti-arrhythmic medication. This will most likely depend on the severity of symptoms he experienced with his afib. If the symptoms were deemed severe enough, he might placed on a medication to attempt to maintain normal atrial rhythm. The efficacy of these anti-arrhythmic medications are at best about 60% effective long-term at maintaining normal rhythm after one year. On the other hand, if his symptoms were minimal, then a rate-control medication (i.e., beta blocker) coupled with anticoagulation might be the better long-term option.

It would seem unlikely that Mr. Cheney would opt for primary catheter ablation of his atrial fibrillation right now, especially given the inherent risks to the procedure, but should the medicines prove ineffective at managing his symptoms, or if his atrial fibrillation rates prove difficult to control with medications alone, then catheter ablation might offer some effective therapeutic options.

No matter how you cut it, though, this rhythm disturbance is likely to be a recurrent problem for Mr. Cheney. Hopefully, its effects can be minimized with close management and follow-up.

-Wes

MedTees in the News Again

Pretty cool. Our health-related t-shirt website, MedTees.com, was in the Dallas Morning News on 6 November 2007, this time for our diabetic shirt line.

-Wes

Sunday, November 25, 2007

More Direct-to-Consumer Insanity

Now it's Johnson and Johnson's turn: starting on Thanksgiving Day, coronary stent (specifically Cypher stent) advertisements began airing on television directly to "consumers," our patients, promoting the ability of stents to "prop up your life" that has been "narrowed" by coronary blockages. "Life wide open" is the tag line.

It's so catchy. As though our patients can go down to the corner store and pick one of these up for their heart. I guess J&J feels patients can discern when a drug-eluting stent is preferred over a bare metal stent, or better yet: when a stent is appropriate and when it is not. Why didn't their ad mention that other non-invasive options might be more appropriate before stenting in some circumstances?

Well, it's simple. The best medical care isn't important to J&J. What is important is that J&J sells more stents. To that end, what's really important to J&J is that patients ask their doctors why their life isn't "wide open" and full throttle yet. As if we don't have better things to discuss.

But I guess J&J figures our patients' wallets are wide open, given the cost of such advertising, especially in prime-time TV slots. This advertising, by the way, is in addition to an already re-worked website and other print media that has appeared in major newspapers.

And J&J seems to be taking a path that is in direct conflict with their own credo, their guiding mission statement, that has hung on their walls for over 60 years:
"We believe our first responsibility is to the doctors, nurses and patients, to mothers and fathers and all others who use our products and services. In meeting their needs everything we do must be of high quality. We must constantly strive to reduce our costs in order to maintain reasonable prices."
And where's the FDA who promised to monitor such advertising to our patient "consumers?"

Oh, I forgot - they're enjoying "monitoring" the commercials with a beer in their hand in front of the TV.

-Wes

Image credit.

Thursday, November 22, 2007

NFL Rushes to Lose Image

Here I was, enjoying my Thanksgiving football, and on comes the NFL's compelling commercial promoting kids to "Play 60." Minutes, that is. It's a new campaign by the NFL to promote exercise in kids and reminds us that, according to their ad, 1 in 3 children are obese. 60 minutes of exercise per day will help, the ad claims. I suppose anything to get kids away from the TV makes sense. And they must be serious after spending $1.5 million for their "What Moves U" ad campaign, right?

But where does the ad direct the kids? To NFLRush.com, a cute kid-friendly website full of games and sound bites where our heavy-tushed youth can sit their butts down and be entertained and mesmerized by all kinds of cute games and football statistics that sound more like an NFL "get-'em while their young" ad campaign, rather than a bonafide health initiative:
"...the NFL has created NFLRUSH to provide young football fans with a refuge where they can celebrate their expanding interest in the game of football.

This site is filled with a great volume of up-to-the-minute statistics, data and information that will increase your child's understanding of the game of football, with connections to teams, player profiles that provide positive role models and inside information that will give your child a sense of mastery of the sport.

The site also delivers high-quality, football-themed, casual computer games and activities that are fun and often specifically educational, as well as contests that make the site even more exciting and vibrant for young football enthusiasts. We have tried to strike a balance between information and game play because we believe that an important part of growing up is just having fun."
But to partake, your child must register their name and e-mail, Mom and Dad. No doubt lots of NFL paraphernalia will be hawked in the future through direct-to-consumer advertising and reminders to come back and shop, er, play often.

Now while the message of getting off your butts is a good one, maybe they should rethink the credibility of their message by having their players lose weight and decreasing (rather than increasing) screen time in front of a computer as their way of "playing 60."

-Wes

Wednesday, November 21, 2007

The End of Delayed Gratification

Perhaps no greater stimulus for performing difficult tasks exists that are to become a person's vocation is that of delayed gratification. Successful lawyers, financial analysts and business people know this. But few are more a master of delayed gratification than a physician with their long, poorly-paid residencies - even more: surgeons.

The profession of surgery, after all, is a hands-on endeavor, involves countless hours at the patient's bedside and even more in the operating room to perfect the craft. The weeding process of individuals to find those with the "right stuff" to become a surgeon is remarkable: only the strong survive. Admittedly, that "worth" to some is just to have a nascissitic "bragging right" to calling themselves "surgeon" or the altruistic and admiral goal of being skilled at helping one's fellow man. But in the end to many, it is the hope that some day their efforts will pay off personally and financially. To this end delayed gratification, the hope that some day it will all be worth it, plays a significant role is helping an individual complete the training gauntlet.

But these times are difficult for anyone contemplating becoming a physician, let alone a surgeon. The commoditization of the profession, the ever-increasing regulatory environment, the decline of revenue, and the rise of liability - all serve to remove the carrot of delayed gratification dangling before the horse.

Josef Fischer, MD's excellent commentary appearing in the Journal of the American Medical Association last week illuminates the issues:
In the United States, approximately 1000 general surgeons complete their residency training each year. These surgeons have completed 4 years of medical school and 5 clinical years of residency, and during residency many also have spent 1 or 2 years in a research laboratory. Thus, these physicians enter the workforce between the ages of 33 and 35 and usually have $150 000 to $250 000 in educational debt. (editor's comment: some have suggested this number is MUCH higher) The training of surgeons has been stable since the early 1970s, and the number of general surgery residency training programs will not likely increase. Even if new medical schools were established the number of surgeons trained would not likely increase much, because many medical students have lost interest in pursuing a career in surgery.

In small urban or rural hospitals, which care for approximately 54 million patients, general surgeons care for emergencies and trauma and perform a variety of operations. They are essential to the provision of adequate health care and often are the most well-rounded surgical clinicians in the area. Therefore, training only 1000 general surgeons per year will not meet demands. Specialization also affects the general surgical workforce. Presently, approximately 70% of graduating surgical residents pursue specialized surgery training, and this percentage may be increasing. Thus, only about 300 to 400 of the 1000 general surgeons completing residency each year will choose general surgery practice.
But the historical and future impacts of reimbursement for surgical services is articulated nicely by Dr. Fischer and spells the end of any hope of delayed gratification for surgeons:
In 1993, Congress declared a redistribution of funds from proceduralists to primary care physicians.10 Initially there were 2 conversion factors—1 for medicine and 1 for surgery. The conversion factor, ie, the multiple of the RVU for payment, had the added advantage of demonstrating where costs were increasing. The 2 conversion factors demonstrated conclusively that surgeons did not increase their utilization when reimbursement decreased (because, for example, patients have only 1 gallbladder, and the indications for its removal remain constant). Other specialties increased their utilization, a process that continues to this day.11 In a refining effort to shift money to primary care, a third and separate conversion factor was developed in 1995. By 1997, it was clear that separate conversion factors were not controlling utilization of primary care and medicine services, causing these 2 conversion factors to decrease. The 3 separate conversion factors were eliminated in 1998, resulting in a decrease for surgery and an increase for medicine and primary care. In addition, more surgeons' practice expense reimbursements are included under the indirect category, now reimbursed at 35% of cost; internists and primary care physicians have a higher percentage included as direct expenses, which are reimbursed at 66%.

A recent Medicare Program review focused on concern about patients with chronic conditions and on compensating the physicians who care for them, not on the technical aspects of Current Procedural Terminology. Seventy-eight percent of Medicare beneficiaries have 1 chronic condition. By contrast, 63% of beneficiaries have 2 or more chronic illnesses; caring for such patients accounts for 96% of Centers for Medicare & Medicaid Services expenditures. It was proposed that patients with chronic disease were not receiving care because physicians were underpaid. The most frequently billed code in the physician fee schedule was revalued upward, and payment was increased by 37%. This year, the estimated $4 billion impact of the proposed changes in work RVUs resulting from the 5-year refinement will require that a budget neutrality adjustment be made.16 Fees for certain procedures, specifically for malignancies in women such as hysterectomy (–4.7%), partial mastectomy (–5%), and resection of ovarian carcinoma (–2.9%), decreased between 2006 and 2007.

In addition, the 90-day global period means that no additional payments will be made for any physician services that can be associated with the initial procedure, regardless of how much work the follow-up entails. Other physicians can see patients daily for the same illness or situation and can bill and collect each time.

No other profession or situation apart from medicine experiences denial of payment for services already performed. (ed: emphasis mine) At times, it seems that health insurance companies employ staff whose only goal appears to be to deny payment for services already performed.

These sequential decreases in reimbursement provide a substantial disincentive to enter these branches of surgery and may have profound future consequences. The self-designated specialties of internal medicine, medicine, and pediatrics have substantially increased members since 1985, while general surgery membership has remained level.
While I appreciate all of the new health care proposals to provide univeral health care (and certainly our system is broken), unless we address the shortages of physicians in general, we won't have professionals where the rubber meets the road: that is, physicians capable of performing the remarkable skills to which we and our health care system have become accustomed. Without them, the final policy enacted won't be worth the pile of paper upon which it is penned.

-Wes

Reference: Josef E. Fischer, MD. "The Impending Disappearance of the General Surgeon." JAMA. 2007;298(18):2191-2193.

Image.

Tuesday, November 20, 2007

Things to Be Thankful For

I found this on our refrigerator:

I am thankful for the teenagers who are complaining about doing chores -- that means they are home and safe.

... for homework. It means we live in a country where education is valued and encouraged for all.

... for the taxes I pay; it means I have income.

... for the mess that I have to clean up after parties, because it means I am surrounded by friends.

... for the clothes that fit a little 'too snug' because it means I have enough to eat.

... for the lawn to mow, windows to wash and gutters to clean; it means I have a home.

... for the parking spot I found at the far end of the parking lot, because it means I am capable of walking and am blessed with transportation.

... for my huge heating bill, because it means I am warm.

... for the person behind me in church that sings off key, because it means I can hear.

... for the pile of laundry and ironing, because it means I have clothes to wear.

... for all the complaining I hear about the government; it means we have freedom of speech.

... for the alarm that goes off early in the morning because it means that I am alive!
Author unknown
For those leaving early to be with family or friends:

Happy Thanksgiving.

-Wes

Heretic

Though I was born and work in Illinois, my money's with the Blue Devils.

Monday, November 19, 2007

Fire Drill

It was a clinic day like any other - seeing too many patients in too little time. But remarkably, today I was on time, efficiently finishing with one patient and moving seemlessly to the next. It was poetry in motion - an accomplishment rarely achieved these days in the clinic.

I had just completed examining a patient and asked our nurse to assist with an EKG while I obtained headed outside to check on the next patient. The poor thing was disrobed when it happened.

Brrrrrring. Brrrrrrring. Brrrrrrrrrring. Brrrrrrrring.

What the...?

Brrrrrring. Brrrrrrring. Brrrrrrrrrring. Brrrrrrrring.

It was deafening.

I looked down the hall of the clinic and a sea of humanity slowly emptying into the halls. Disbelief surrounded us. The office manager looked perplexed and slightly anxious.

"I think it's the real thing," she whispered.

"Really? Damn. To think I was finally on time." She smiled and glaced toward the clinic exit as if to say, "You too, chump."

We checked each room. My patient was getting clothed again and shuffled out the door, somewhat excited at the prospect of finally adding some entertainment to her day.

"Isn't this exciting?" she exclaimed.

"Move along Ms. Jones," I said. Her Parkinsonian shuffle hastened toward the stairwell just outside our clinic. My eyes caught my colleague's gaze and they rolled upward, exasperated.

And then it dawned on me. A hoard of individuals were patiently waiting for the all-to-narrow stairwell to clear as an elderly man supported by a nurse and a doctor struggled to descend the stairs. The doctor held the man's armpit in one hand and his folded walker in the other. One slow step at a time. Step by painful step. My clinical acumen lept to action - no smell of smoke was detected. Patience. Patience. I looked behind me. Eyes glared. It was as if I was caught in Chicago's E2 niteclub disaster or decending the stairs from the World Trade Center before it collapsed. I tried to smile back. No one seemed amused. The pace was glacial. Finally after descending two floors, the old man touched down on the ground floor. People scurried past.

The fire department arrived, their flame-retardant jackets, fire-hoses and oxygen tanks in tow. They swam upstream to the sounding alarm location. Two seconds later: "All clear! Just a broken switch! Joe, call dispatch."

We shuffled back to clinic, this time taking the elevator and remembering.

No one said a word.

-Wes

Image credit.

Sunday, November 18, 2007

deCodeJeans4Me.com

Dear Gullible Consumer,

Thank you for allowing me to introduce my new company, deCodeJeans4Me.com, where we promise to tell you if you’re at high risk of all kinds of scary diseases as well as determine your ancestral roots, by looking at your jeans. You see, we have a patented way to predict what diseases you might contract by merely having you send us a pair of your jeans from the privacy of your own home to our fancy multi-zillion dollar laboratory. We will run over a million tests to identify small imperfections in the color and contour of your jeans that we have been carefully correlated to your jean-etic risk factor for hundreds of ailments. Using fancy machines, our well-meaning staff will determine your Every Disease Known Score (EDKS) that no one else understands but us. And once we see what your EDKS looks like, we’ll tell you, based on the world’s literature, what your chances of getting a disease might be so you can be “empowered” and “network” with other like-minded suckers souls on our fancy web site. All it will take is for you to register your name, rank, serial number, number of children, address, pant size, height, weight, your e-mail address PLUS a mere $900 (we want to undercut our competitors) and we’ll send you a pre-addressed mailer in which to place your jeans.

By the way, the federal authorities think this is a great idea, too! We’ll be sure to save your jeans in our secure warehouse so the feds can examine them carefully with a court order, especially in times of National Security breeches.

So go ahead, sign up, and send us those jeans!

Yours in blue –

-Wes

P.S. Please send jeans only. Underwear present unique biohazards that we are not yet prepared to handle.

P.P.S.: Be sure to see our competitor's website, too, for an informative link to their video to see an example of how this is done!

Photo credit.

12:30 19 Nov 2007 CST: Addendum - Oh, no! Even more competition! (Glad I still have a cheaper price...).

Leisurely Physician Pastimes

At first it's faux poo, now it's rocket lauchers. What will ImpactEDNurse think of next?

-Wes

Saturday, November 17, 2007

Orchestral Interlude

Wonder where I was? Well I was uploading this video from a week ago to YouTube. Nothing like the french composer, Hector Berlioz, to make your day. What's funny, is that Mr. Berlioz started to study medicine before beginning his musical career:
In 1821 at the age of eighteen, Berlioz was sent to Paris to study medicine, a field in which he had no interest, and later, outright disgust towards after viewing a human corpse being dissected, which he later detailed in a colourful account in his Mémoires.
So enjoy. It's another concert by New Trier High School's symphony orchestra, winner of the 2007 National Grammy Signature School award.

Yes, that's right. High School.

Pretty impressive performance.

(And yes, a proud father was in the audience).

-Wes

Other videos can be viewed at NTJazz.com.

Friday, November 16, 2007

Name That Drug - If You Dare

On 9 November, I challenged the blog-o-sphere to associate a pharmacetical's drug marketing image to the some of each drugs' side effects. Although I had over 2063 visits to the blog since that posting, 20 brave souls forwarded their answers (1%). You, my friends, are the elite, the talented, the brave.

Now before I divulge the answers, why did I do this? Well, one reason was because it is fun to try new things. Two, I wanted to see how well Big Pharma is getting their information to the general public about all of the side effects of the drugs. And three, I had an interest in seeing how well the images developed by pharmaceutical companies stick with their viewers.

Unfortunately, the number of respondents was ridiculously low. But being of scientific mind, we must ask ourselves, why? Was it because the images were not well known? Or was it because the stupid physician made a bad test that was just too difficult?

Well, it was probably both. I tested the question on our staff in the local catheterization lab many had no clue what the heck a beaver had to do with a drug. Many of them had never seen the little "pipe man" before. Likewise, many had never heard of drugs causing those side effects. (What, you mean they couldn't cover everything in a 30-seconds commercial?)

But of the low number of respondents, we had a fairly bright crew: 50% of them got the correct answer, "C." Now, seeing as this was an "official, accredited" survey (I made it, so I can call it whatever I want), it is now OBVIOUS that a remarkably HIGH number of people remembered these drugs and (oh, my gosh!) that these ad images clearly work 50 percent of the time! Awesome! But then, many of the people answering this question might be in the pharmaceutical industry or physicians themselves. (Oh, well, they WORK, remember?)

Shhhhh. Now what we DON'T want spread about is that 50% of the time, people have NO CLUE what these drugs really COULD do to them. Half the patients. As studied by the World's Most Accurate Survey (WMAS).

Perhaps the pharmaceutical companies will now reference this blog's WMAS in their next advertisements! Now they have additional data justifying the benefits of advertising like this to the consumer! (I mean, look at what they've LEARNED!) 50% more of them know their drug's name! 50% ALSO know those drug's side effects! Damn. What a GREAT thing! Patients the world over will benefit, thanks to these clever ads.

But then we look at the costs of these drugs (Prices courtesy Costco.com - quantity 30 tabs), we see:

A) Nasonex: elevated intraocular pressure, wheezing, hypersentivity - $144.38 (pro-rated to 30/pkg)
B) Lipitor: chest pain, arthritis, liver failure - $79.12
C) Rozerem: decreased testosterone levels and/or elevated prolactin levels - $106.30
D) Vesicare: prolonged QT interval, dry mouth, constipation - $122.64
e) Lunesta: dysgeusia (bad taste in the mouth), dry mouth - #125.75

Said another way, these pills go for anywhere between $2.64 - $4.19 per pill. More than a cup of coffee at Starbucks per pill, or a Grande Mocha for that matter. Compare that to 13 cents per pill for generics ($4 divided by 30 pills) at Walmart.

How much of these high drug costs come from advertising? Plenty.

Here's what a 30-second spot TV ad costs in 2006-2007 primetime season: between $45,000 and $394,000! Yep, as much as over a THIRD OF A MILLION DOLLARS for a 30-second TV ad at primetime (The super bowl is more than $1 million dollars per 30 seconds - remember the Flomax commercial?). Recall that I recently saw 12 drug commercials during one evening news broadcast. Taking a conservative number above ($150,000), the single news advertisements added $1,800,000 of revenue to the broadcast network from the pharmaceutical companies. And who do you think is paying the pharmaceutical companies' bills?

Yep, you. And me.

-Wes

Update 16 Nov 06 15:42 CST: Updated for 2006-2007 ad cost information.

Wayne Newton's Next Show


Wayne Newton, the entertainer who took over for Bob Hope for the USO tours, announced that he could no longer keep up with his Dancing with the Stars tour due to “cardiomyopathy:”
The famed Las Vegas entertainer told People this week that he has been forced to clear his schedule for the next few months while he undergoes treatment for a recurring case of cardiomyopathy, a viral infection of the heart.

Newton, 65, had to cancel a two-month engagement at Harrahs and he will not be able to perform on the Nov. 27 finale of Dancing with the Stars, though he should be doing well enough to make an appearance.

"This is just another little bump in the road," Newton, who lost 20-some pounds during his run on Dancing, said. "The doctors are a little more concerned than I am. Part of their concern is that I feel so good—I’m not taking this lightly."
Nor should he.

It is difficult to ascertain the type of cardiomyopathy that Mr. Newton suffers from when reporters try to give background to his condition, without really having a clue what they’re talking about. You see there are two types of cardiomyopathy. The first more common form where the heart muscle becomes weakened, dilated, and fails to contract well is called dilated cardiomyopathy. A second, less well-recognized form of cardiomopathy is often a congenital one that causes the heart to thicken so severely that is fails to relax (and therefore fill with blood well) called hypertrophic cardiomyopathy. Either form of heart muscle abnormality can cause the heart to provide insufficient blood to the tissues, the ultimate final common pathway of heart pump failure. My bet, is that Wayne suffers from the more common, dilated form of this heart ailment, especially given the multiple other references in the media suggesting a “viral” cause of his condition.

For Mr. Newton, who has now had two (public) episodes of heart failure, he faces a transition point where the complexities of his condition have begun to interfere with his vocation as an entertainer. It is a difficult period for anyone making this transition. After all for Mr. Newton, entertainment has defined much of his life. But his decision to forego his rigorous schedule and focus on his treatment is a good one. Doctors will adjust his medications (like beta blockers, angiotensin converting enzyme inhibitors or antiotensin receptor blockers, and diuretics) to improve his symptoms, and maybe, just maybe, (dare I say it??) give him an automatic defibrillator, a la Dick Cheney, to protect him against life-threatening, sudden, and unexpected heart rhythm abnormalities. After a two-months recovery, he might be able to return to dancing, perhaps to a scaled back level. And although he might not be “cured,” as the entertainment magazines would like us to believe, he certainly can get back to the business of life.

-Wes

Image reference.

Thursday, November 15, 2007

Wednesday, November 14, 2007

New Help for Pectus Patients?

The San Francisco Chronicle reported on a new device being tested at UCSF that employs powerful magnets to help correct pectus excavatum, a congenital deformity of the chest cavity that is typically indented over the breastbone. The theory is that the magnetic force between a surgically-implanted magnet beneath the breastbone and a second magnet positioned above the implanted magnet and attached to a brace, will slowly permit remodeling of the chest cavity, much like wearing braces on the teeth reshapes their growth pattern.

Although still experimental, it is a clever concept. But future MRI's for these patients? Well, they're out of the question.

My fellow physician-blogger, GruntDoc, will also appreciate the logo of the magnet worn on the first patient's chest, seen in the pictures that accompany the article.

-Wes


h/t: WSJ Health Blog

The device's patent application.

Conflicts

I saw him from the corner of my eye. Reaching slowly to grasp a small edge of the wall as he shuffled from the bathroom, he held a large walking cane in his right hand to steady his gait.

“Honey, thanks for letting me head back to see my parents. I’ve made a casserole for you guys. It’s in the fridge for tomorrow.”

“No problem, dear. I’ve got the kids. Have fun.”

His hair was grey, his clothing looked re-worn, a bit disheveled. Every step looked like an effort. His progress was slow, measured.

“How many patients do we have to round on tonight?”

“We still have to see the four patients from yesterday, but I already took care of Mr. C’s pre-op orders for tomorrow.”

“Thank you. I’ve got the kids tonight because my wife’s out of town.”


He stopped briefly and looked down the long hall, as if to measure his next few steps. The hall stretched before him. He appeared uncertain of his ability to continue as he grasped the enormity of his task.

We headed up for rounds. The mechanical door flew open and there he was, seen from the corner of my eye. It was the end of the day. Cleaning up the last few things before heading home. To the kids. Car-pool. Dinner. Homework. I’ve got to get these rounds done! Will anyone be there when the kids get home? We pressed on, silently passing the old man. Once he was behind us, we forgot about him and continued our rounds.

At least so I thought.


-Wes

Photo credit.

Avoiding Obscurity

Any idea how many of the 109.2 million blogs you track get no hits in the course of a year?"

Just over 99 percent. The vast majority of blogs exist in a state of total or near total obscurity."

- from Patrick Reardon of the Chicago Tribune in his interview with Derek Gordon, vice president for marketing for Technorati


Whew! Glad I posted today.

-Wes

Tuesday, November 13, 2007

St. Jude Responds to WSJ Article

Here's a copy of St. Jude's response to the WSJ article regarding their Riata leads. It provides a "sneak preview" into an upcoming December PACE article.

-Wes

The Jiggle Factor

The New York Times today explains:
For many overweight exercisers, every step of a workout comes with an unintended cascade of motion — breasts bounce, belly fat shakes and thighs rub. The added jiggle and friction of moving body fat is more than just bothersome. It can alter people’s gait and make them more prone to injuries and joint problems. The discomfort prevents many overweight people from exercising altogether.
I think they're on to something here. This issue is probably so significant that many would rather have a total knee replacement first.

-Wes

Reference: Browning RC and Kram, R "Effects of Obesity on the Biomechanics of Walking at Different Speeds." Medicine & Science in Sports & Exercise. 39(9):1632-1641, September 2007.

Grand Rounds from the Desert

The best of the medical blog-o-sphere is hosted this week by Dr. Anonymous.

-Wes

Monday, November 12, 2007

Pharma Ad Deconstruction Zone

Consumer Reports deconstructs the drug ad for Requip. Definitely worth a look.

I love it when we fight fire with fire.

-Wes

h/t: Gary Schwitzer of the Schwitzer Health News Blog.

Economic Implications of Medicare's Rule Change for EP's

I just got back from a meeting with our business manager and I'm depressed.

We did some homework regarding the implications of the new Medicare payment rules for our procedure codes no longer being exempt from the "51 modifier" as I mentioned before.

Well, it's huge.

We applied this rule change to last year's billings to determine the impact. Assuming we used the same codes and applied to new rule to Medicare patient's, the drop in the physician portion of Medicare reimbursement will be 18.76% for our procedural compensation. Nearly 20%. Ouch.

Now I have no idea how the technical portion of Medicare payments will be affected. Usually technical payments exceed physician payments 10 to 1. No doubt their cut will be considerable too. But suffice it to say, doctors have a lot less "wiggle room" to their income these days than do hospitals. Yet physician revenue remains an easy target. Our political lobbying is dwarfed by other, better connected, entities. And Medicare is a fixed pot of funds which must be distributed to the masses. Certainly, CMS has found a creative way to implement income redistribution.

But if I were a patient, I'd like to see my doctor, the one doing the procedure, get compensated appropriately for their skill and expertise - the last thing I'd want is a doctor pissed that his time and skill weren't worth the effort to perform my procedure anymore. I'd like to know how much this pay cut will effect the hospitals and insurance companies who continue to demonstrate record-setting revenues.

-Wes

10:46 CST - Addendum: Oh, I forgot: this revenue cut does not include CMS's already-threatened 10.1% physician revenue cuts. Could this mean nearly 30% cut in EP's revenue? If so, the implications for our senior citizens could be profound.

Thin Defibrillator Leads from St. Jude Questioned

Area of a circle equals pi (3.14159...) times the radius squared. I remember that equation from geometry class.

Now, all kinds of engineers are rethinking this equation, too. As are doctors.

Since Medtronic had their recent thin Sprint Fidelis lead (6.6Fr) recalled due to an elevated rate of fractures, new scrutiny is being placed on St. Jude's even thinner (6.3Fr) Riata® ST defibrillator lead. But the concern in this case is less about fractures, but rather heart perforations.

This morning the Wall Street Journal reports that St. Jude's Riata ST lead is being evaluated for an increased cardiac perforation rate compared to conventional thicker defibrillator leads. Cardiac perforations are not new to defibrillator or pacemaker implantations. An example of this can be found on a dramatic case recently published in Circulation (reference below) where a pacemaker lead had punctured a patient's heart and had eroded through his 7th rib. But with the recent FDA hypersensitivity and the concerns about thin defibrillator leads, it is not surprising that such concerns have been raised.

You see in cross section, the thinner a lead becomes, the more force from the lead pressing against heart muscle is concentrated over a smaller area. And unfortunately, as the radius of leads are downsized, the force applied over that area increases geometrically (radius squared, remember?). An example of the difference that surface area makes on pressure to tissues can be felt when you apply the same amount of pressure from a pencil's erasure over your hand versus its sharpened tip.

So when a thin lead has a narrowed diameter, it might be more likely to perforate. And given the concerns aired in the Wall Street Journal article, I bet implanting electrophysiologists will be slow to rush these leads until the dust settles a bit more. After all, we've become a bit sensitized to these issues.

-Wes

References:

Wall Street Journal.

Singhal S, Cooper JM, Cheung AT, Acker MA. "Rib Perforation From a Right Ventricular Pacemaker Lead." Circulation; 115: e391-392.


Update 21:49 CST - The PACE articles with the studies regarding the Riata lead issues are now up. Dr Steven V. Vlay of Stony Brook University, New York in his accompanying editorial states:
"What is particularly troublesome about this lead is not only the perforation but its late presentation. Sometimes the lead perforation does not come to clinical attention until it is well beyond the right ventricular free wall. Furthermore with the Riata, the movement continues until it protrudes out several cm into adjacent tissue. This factor seems to distinguish it from a small perforation in which only the tip of the lead penetrates the right ventricular wall. It could result in ventricular asystole if a patient is pacemaker dependent or in failure to successfully defibrillate, both resulting in sudden death. If perforation does not occur in the first three months, can we stop worrying? We do not yet know the answer to this question.


Here's the references from this issue of PACE:

1. Krivan L, oz M, Viasinova J, Sepšsi M. Right ventricular perforation with an ICD defibrillation lead managed by surgical revision and epicardial leads.

2. Fisher JD, Fox M, Kim SG, Goldstein D, Haramati LB. Asymptomatic anterior perforation of an ICD lead into subcutaneous tissues.

3. Satpathy R, Hee T, Esterbroooks D, Mohiuddin S. Delayed defibrillator lead perforation: An increasing phenomenon.

Sunday, November 11, 2007

Happy Birthday


Single words or short phrases mean the world to others sometimes, so here's a list for you, Mom:

monarchs

guitar

Motor-mouth

Taffy

Trouble

Countryside

The Christmas Play

"Cricket in the Grass"

P-bars

Land Sled

The Nature Center

Kooch

"holding wonder like a cup."

Crab burgers

gobble-de-gook

fingermarks!


It all goes so fast, doesn't it? Have a wonderful day.

-Wes

Colors


To all my friends still working in military facilities around the world and to the others with whom I have had the privilege to work beside: I will never forget.

To all those who have had to pack their sea bag one-too-many times. To all the spouses uprooted from familiarity to uncertainty by "orders." God bless you.

To the corpsman with whom I worked and still see from time to time, who gave countless hours of their time and expertise to strive for excellence every day, provided a role-model for others to emulate, and played AC/DC's "Hells Bells" after every successful catheter ablation: you guys are the best.

To the military nurses who never shied away from putting and admiral in his place when it was the right thing to do, or who cried when their young patient lost their battle with leukemia, or cancer, or a million other ailments that afflict military members just like civilians. Thank you.

To all who stop briefly and salute the flag at "Colors" each day remember this: as you look at that flag, there are untold legions of others saluting back.

-Wes

Friday, November 09, 2007

Another Chapter Closed

It all started 25 June 1984 and ended this month:



Those were some great years. But I won't miss the inspections...

-Wes

Is It Live or Is It Memorex?


Real or not?

Street Anatomy with the answer.

The Power of Marketing: Name That Drug

I like the evening news. Being in the hospital, I never know what's happening in the outside world.

But it's getting harder and harder to watch the news anymore, since most of the news isn't about the outside world anymore, but rather about medically-related drug ads. Go ahead. Count them. I did. 12 drugs in a 30-minute news show (if one includes One-a-Day Viamins for Men as a drug). So here's my revenge...

Below are five pictures of marketing creatures/images developed by the pharmaceutical companies. These companies are required to state their side effects by FDA rules now, so I thought I'd see how well my readership can recall the side effect profiles and see if they can match them with the drug!

Now, you mustn't cheat. Please try to guess these without doing an extensive literature search. See if you can remember them and then answer the poll in the right sidebar of this blog. I'll post the answers in a few days, after everyone has had a chance.

Have fun!

A


B


C


D


E


Okay, here are the list of side effects, in random order:

(1) dysgeusia (bad taste in the mouth), dry mouth
(2) decreased testosterone levels and/or elevated prolactin levels
(3) chest pain, arthritis, liver failure
(4) prolonged QT interval, dry mouth, constipation
(5) elevated intraocular pressure, wheezing, hypersentivity reactions

Now go the sidebar and place the series of side effects from drugs A through E in the correct order.

Best of luck!

-Wes

Thursday, November 08, 2007

A Face-Lift

I finally got around to converting to the new Blogger template format. I tried not to change too much for starters. Please let me know of there are any problems or recommendations...

-Wes

Other Important Trials from the AHA Meeting

A bunch of important "negatives" were found at the recent American Heart Association meeting:

RethinQ - Do patients with narrow-complex QRS complexes and Class III-IV CHF who are eligible for defibrillator implantation benefit from cardiac resynchronization therapy in regards to exercise capacity? In a word: No. (Published today).

MASCOT - Management of Atrial Fibrillation Suppression in AF-HF COmorbidity Therapy trial - Does atrial overdrive pacing in patients with heart failure reduce one-year development of permanent atrial fibrillation? Answer: No (but only 3.3% of patients in each arm developed atrial fibrillation during the trial, suggesting it was severely underpowered.)

AF-CHF trial - Is a rate control or rhythm control strategy (with anticoagulation) superior to mortality in patients with heart failure? Answer: There was no difference in the primary endpoint of cardiovascular death between the groups or the secondary endpoints of total mortality, stroke, or worsening heart failure.

Oh, and one more: reviewed in abstract form: women had a higher complication rate with ICD implants than did men. The takeaway? Smaller size (in general) means higher risk of ICD implantation.

-Wes

Reference: Cardiosource.com

More Doctor Revenue Cuts

CMS says it's finalized its' decision, now will Congress intervene to halt the cuts? They'd better.

Yet for cardiac electrophysiologists, we will have our procedural revenue drastically cut by a little-known change to our Medicare procedural reimbursements from electrophysiology procedures. This is because catheter ablation procedures will no longer be exempt from needing a "51-modifier" added to procedure billing codes. (I apologize for adding this Medicare mumbo jumbo to my blog, but some EP docs might be interested...) Because I am not a billing nerd, here's the content of a letter e-mailed to all EP physicians from the Heart Rhythm Society explaining the issues:

November 2, 2007

Dear Heart Rhythm Society Member:

The Heart Rhythm Society (HRS) is writing this letter to make you aware of a change in CPT coding that will take effect on January 1, 2008, which will ultimately result in a change in reimbursement for electrophysiological studies and ablation procedures from Medicare and eventually all private insurance third-party payers. The following paragraphs will explain the rationale behind the decision to comply with the change and the consequences of not doing so.

As many of you are aware, within CPT, modifier 51 (Multiple Procedures) is designed to trigger multiple procedure payment reductions when a physician performs separate procedures on the same patient during the same session. These separate procedures are not incidental to the primary procedure and are separately payable. The payer reimburses the highest-ranked procedure at 100 percent and any additional procedures at 50 percent. The vast majority of surgical procedure codes within CPT are subject to the multiple procedure payment reduction rule. Procedure codes that are modifier 51 exempt are not subject to the multiple procedure payment reduction rule and are paid at full rate.

In 2006, the American Medical Association (AMA) CPT Editorial Panel convened a work-group to conduct a review of certain codes. The work-group was instructed to develop recommendations for the 2008 cycle that would eliminate redundancy, inconsistency, and variable interpretations identified for a select group of modifiers and address issues related to modifier 51. More specifically, the work-group was to determine the appropriateness of codes designated as modifier 51 exempt (Appendix E of the CPT book) and develop a set of criteria to use in determining future applications for exempt status.

The work-group felt that the two primary criterion for inclusion of a procedure in Appendix E was that the current RUC values were consistent with exemption from multiple procedure reductions, and the values already had reduced pre- and post-service work and practice expenses, if the procedure was determined to be typically adjunctive or performed with another procedure(s). The work-group's recommendations for 2008 included removal of 151 of the 181 codes currently on the exemption list. It was discovered that many of the services, including certain EP study and ablation procedures, did not meet the new inclusion requirements for retention.

For over a decade, all of the codes in the Intracardiac Electrophysiologic Procedures/Studies subsection (93600-93662) of CPT, with the exception of add-on codes 93609, 93613, 93621, 93622, 93623, and 93662, have been modifier 51 exempt. In the 2008 edition of CPT, the modifier 51 exempt symbol "x" has been omitted from EP study codes 93619, 93620, 93624, 93640, 93641, 93642 and 93660, and ablation procedures 93650, 93651 and 93652. This change eliminates the long-standing exemption status and will result in payment decreases by 50% when multiple procedures are performed by the same physician during the same patient encounter.

From a payment perspective, the rationale is that some of the work for a given procedure is not repeated when two or more procedures are performed simultaneously. Medicare payment rates for EP studies and ablation procedures are based on each service being provided independently. The intra-service work is only a portion of the total work value, while the other portion represents pre- and post-service work. For these procedures, the pre- and post-service work components overlap when multiple procedures are performed on the same patient on the same date of service.

HRS in consultation with the American College of Cardiology (ACC) assessed the impact of this change, and after very careful consideration decided to not object to removal of the codes from the exemption list. While the negative financial impact of removing the codes from exempt status was understood, it was determined that there was greater financial risk in challenging this decision. To maintain exempt status would have required development of rationale to meet the new inclusion criteria. The AMA and the Centers for Medicare & Medicaid Services (CMS) indicated that if all of the inclusion criterion were not met according to the CPT Editorial Panel, then the family of codes (93600-93662) would be sent back to the AMA Relative Value Update Committee (RUC) for complete re-valuation so that CMS payment policy and the modifier 51 exempt status of the codes are congruent. Considering this, HRS and ACC thought it would be counter-productive to the best interest of the EP profession to challenge this decision.

HRS will continue to work diligently with the AMA and CMS to ensure that EP services remain appropriately reimbursed in this politically challenging economic environment.


Well it looks like we're gonna take it in the shorts. Who's next?

-Wes

Genetic Testing for Atrial Fibrillation

It's "Genes Gone Wild."

Trap some Icelanders, swab their cheeks, compare their genes, and make wild predicitions about outcomes. It seems that's all you need these days to tap into the power of fear-based marketing used by genetic testing companies set to bilk gazillion dollars from gullible consumers.

And they'll likely succeed. I mean, after all, what's $200?

In July of this year, a single letter was published in the journal Nature detailing the findings of an "inverse solution" of an Icelandic and Han Chinese population that identified two specific genetic markers from gene 4q25 that suggested a correlation between these genetic markers and the presence of atrial fibrillation. That letter was authored by 19 stake-holders in deCode Genetics (including the principle author), a genetic testing company with more than a minor passing financial interest in performing such testing. They found that 35% of individuals of European descent have at least one of the genetic markers identified and that the risk of atrial fibrillation increases by 1.72 and 1.39 per copy of the gene. The association with the stronger variant was replicated in the Chinese population, where it is carried by 75% of individuals and the risk of atrial fibrillation was increased by 1.42 per copy of the gene. Doctors were even schmoozed to the potential wonders of this testing at the recent American Heart Association meeting. To be sure, it is miraculous what can discovered using their genetic debugging technique these days.

So what does this mean for you and me?

It means that they found a genetic marker that they estimate might be able to identify the development of atrial fibrillation 1.10 years earlier than those in whom the genetic marker is missing.

The deCode company would like to think that they can better target patients who would benefit from prolonged cardiac monitoring after ischemic stroke, but there are no data to support this assumption. The deCode company further believes that their genetic determinant can predict who is at greater risk in the real wide world at developing atrial fibrillation and who might benefit from being on coumadin after a stroke or transient ischemic attack, but again, there are no data to support this claim. The presence of this genetic marker does not mean you can predict if you will develop atrial fibrillation in your lifetime. It does not mean that it can predict if a cardiac monitor will be able to detect any atrial fibrilaltion earlier because you have the gene or not. In short, there are no prospective data regarding the application of the results from this genetic test as a prevention strategy for atrial fibrillation in humans.

What it will do is set you back $200.

You see, their study determined a correlation, but not causation. The two are very different. Just because there is a correlation of the presence of a genetic marker and atrial fibrillation, this correlation does not, in itself, say anything about the cause or etiology of atrial fibrillation in an individual patient.

What the marketing of these tests does do is misinform and confuse the general public as to the potential uses and pitfalls of this technology.

-Wes

18:10 CST: This just in, another late-breaking trial from the American Heart Association meeting using genetics to determine who will develop out-of-range blood thinning levels (INR's) showed a similar lack of clinical relevance.

Vindicated

Sorry, but after all the trash-talk I received from members of a certain financial board regarding my decision not to purchase Cambridge Heart's T-wave alternans test previously, I'm feeling a bit vindicated right now.

Wednesday, November 07, 2007

Why Medical Errors are Good for You

“… the majority of medical errors can be prevented.”

- Agency for Health Care Quality, US Department of Health and Human Services

Well, I politely and respectfully disagree. Medical errors, most of them, are NOT prevented and they can't be prevented.

There, I said it. While none of us wants to be the recipient of a medical error, medical errors might just be good for you.

Now before you call the Illinois Department of Regulation and ask that my medical license be revoked, hear me out.

Most of us have heard ad nauseum "that as many as 44,000 to 98,000 people die in hospitals each year as the result of medical errors." It came from an authoritative and trusted source: the Institute of Medicine's November 1999 report entitled "To Err Is Human: Building A Safer Health System." Clearly, there is a political motive to reduce these errors and certainly, if even one death can be prevented, that is a good thing.

But the Institute of Medicine never examined the number of errors ultimately prevented by institutions reviewing the circumstances that surrounded each of these deaths. Medicine, after all, will never be "perfect" in preserving the sanctity of life since life is never limitless. Unfortunately, medicine has been so erroneously marketed as infallible and full of limitless potential to preserve life, that the media, including our own authoritative WebMD, feel that medical errors are "now a 'leading cause' of death and disability."

But medical errors serve as an invaluable resource and irreplaceable learning tool for our housestaff, physician attendings and nurses. For instance, most medical school and hospital medical and surgical programs are required to have "Morbidity and Mortality" conferences as part of their ongoing training curricula. Here, surgical mistakes and deaths are reviewed critically by scores of those involved in a patient's care. To avoid total humiliation, the responsible doctor usually reviews the literature about the problem that occurred and summarizes the case and its relevancy to that literature. Often the doctor is coarsely questioned by his colleagues, often to his embarrassment to be sure, but also to the benefit of scores of other physicians watching and listening to the conference. The beneficial amplification factor of a single medical error, in this instance, in terms of training and ultimately avoiding further errors, might be 100 to 1. In other words, in the ideal setting, 100 future errors might be prevented because the one error was reviewed critically with 100 other people.

Autopsies are another valuable and irrevocable teaching aide, but sadly, are rarely performed any more. A myriad of questions arise in the course of a complicated and challenging illness - particularly when maladies befall an individual after a single medical error. The opportunity to understand the cause of illness or consequences of our actions proves invaluable to score of others involved in a single patient's fatal medical error. Without reviewing, without examining critically or foibles as human beings, we will never improve our "practice" of medicine.

I look back at errors I have made in the past and how they have influenced the way I perform procedures. In my early electrophysiology career, I would always perform a subclavian approach (in the upper chest) or internal jugular approach (in the neck) for placing an electrophysiology wire into the coronary sinus (the main cardiac vein that returns blood from the heart to the right atrium). Anatomically, I felt in the past, it was easier to gain access to the coronary sinus from these superior approaches. And that was how I was taught. But long ago, I had a pneumothorax, a punctured lung, from trying to gain access to the subclavian vein. I had explained to the patient beforehand that this might happen, but I still felt horrible that the "error" had occurred. I lost countless hours of sleep worried that the patient would not recover. (They ultimately did fine). But what did I learn? I learned that I better check the x-ray after such a procedure. I learned that if there was another way to avoid this complication, I would like to learn it. I later learned how to place coronary sinus catheters from the leg while observing others in a different clinical setting. As such, I have never had a pneumothorax from a routine electrophysiology since and no longer require chest x-rays following these procedures as a result.

Was this error useful? Absolutely. I would even say it was critical to shaping my clinical approach for hundreds of other patients. Errors, as difficult and as unfortunate as they may be, remain critical to our development as doctors. Although no one wants them to occur, they do have benefits to developing a mature perspective and technique to medical practice. Critical review of inevitable medical errors should remain a critical part of our medical school curricula.

After all, how will we really learn?

What I tell my medical students, residents, and fellows is this: it's okay to have a medical error once, just never make the same error twice.

I can live with that.

-Wes

Tuesday, November 06, 2007

Grand Rounds, Anesthesia-Style

It's up and rendered pain-free to read with great art and great medical blogging as organized by Counting Sheep.

-Wes

One Lucky Guy

...to have survived this.

Go Navy!

-Wes

Why the ICD Market is Underpenetrated

Some blame the slow ICD market on the recalls, or cost, but Dr. Rich has his own theory.

-Wes

Another Portal

I have joined the dinosaurs. Today, without coersion or prompting by my wife, I used reading glasses to peruse the Wall Street Journal. I felt, well, old. My wife suggested the better word is "mature." But I felt old.

In my younger years, my 20/10 vision was a source of pride in the military. I would revel at the fact that I could always ready the line below what was required to have 20/20 vision on the eye charts. I was invincible. I was super-human because I oould "boldly read where no man has read before." Now, I'm old and need reading glasses. Sheesh.

But in another way, maybe this is a rite of passage, a great portal to the human condition. Like the birth of a child or the death of a parent, it is a universal inevitability that comes with the passing years and of growing intellectually. It is an experience like this that gives a brief glimpse into what it means to be fallible, finite, and vulnerable. It is a portal to more than just knowledge, it is a portal of empathy, a portal to an ever-so-brief encounter with wisdom.

Perhaps this is precisely why it is so scary.

-Wes

Monday, November 05, 2007

She's Back

First she blasted the AMA, now she's back to blast the whole healthcare system as it exists in favor of consumer-driven healthcare: Harvard professor Regina Herzlinger promotes her new book. Here, here!

But she's not the only one singing this tune.

-Wes

Never Mind You Can't Pay - Charge It!

"Never mind that you can't pay for your health insurance, charge it! We'll make it so e-a-s-y to spend your money, and then we'll even compound the interest for you! Hell, if your ailment won't kill you, your payments will! So go ahead, give a Healthcare Visa® gift card for Christmas."
-Brought to you by Highmark Inc., the One-Stop-Shop® for all your insurance and bankruptcy needs.
-Wes

h/t: The Wall Street Journal.

The Missing Kaplan Meier Curve

With all the buzz this week about the potential approval of prasugrel (Eli Lilly), it was interesting to note that the study published in the New England Journal of Medicine failed to have one important Kaplan Meier Curve: that of overall mortality. Certainly the benefits of the drug were shown for death from cardiovascular causes, nonfatal myocardial infarction [MI], or nonfatal stroke, but this advantage was offset by an increased risk of fatal bleeding. But when one looks at the TOTAL mortality from death by ANY cause (non-fatal MI, non-fatal stroke, or non-CABG-related nonfatal TIMI major bleeding), there were 249 deaths in the prasugrel group and 239 deaths in the clopidogrel group (p=0.43).

The authors looked for the reason why the data were so lackluster in regards to mortality, so they did a multivariate analysis and discovered "high risk" groups: age >=75, body weight <60 kg (135 lbs) or those with higher stroke. Was this study powered to differentiate these end-points in regards to mortality benefit? Of course not. So to make this point retrospectively sounds like data manipulation in the interest of corporate economics, and in the era of an FDA with hypersensitive tentacles to patient safety, the early release of this drug to the market seems suspect.

But then again, certain well-connected people think otherwise.

-Wes

Addendum 2220 CST 19 Nov 2007: The full plenary session at the AHA 2007 meeting.

Sunday, November 04, 2007

47 Million

From HillaryClinton.com:
The American Health Choices Plan gives Americans the choice to preserve their existing coverage, while offering new choices to those with insurance, to the 47 million people in the United States without insurance, and the tens of millions more at risk of losing coverage.
From BarackObama.com:
47 million Americans - including nearly 9 million children - lack health insurance.
From JohnEdwards.com:
The American health care system is broken. It allows 47 million Americans to go uninsured and tens of millions more to remain at risk of losing coverage. It is needlessly expensive, burdening families and businesses without consistently delivering the high-quality care they need. [Census Bureau, 2006]
From RichardsonforPresident.com:
The lack of health insurance by 47 million Americans is a tragedy, Richardson said. He said a third of the cost of health care goes to administration of the HMOs and insurance companies.
So what about the Republicans? A cursory review of their websites seem not to mention this number.

Do these democratic candidates care about the numbers they quote?

Do they lack the staff to cross-check these data?

Or are they more interested in fear-based politics?

Remarkably, this morning's New York Times published a critical analysis of this number from a conservative economist, N. Gregory Mankiw. Mr. Mankiw is a professor of economics from Harvard and was an advisor to President Bush and is advising Mitt Romney, the former governor of Massachusetts, in the campaign for the Republican presidential nomination. Here was the breakdown, as he saw it, of the 47-million number:
Total: 47 million
  • 10 million illegal immigrants
  • The number includes millions of Medicaid-eligible people who have not yet applied for Medicaid
  • 18 million of the 47 million have household incomes over $50,000, which puts them in the top half of the income distribution nationally, suggesting they could buy insurance, but for unknown reasons, do not have insurance. He claims a quarter of the uninsured have been offered employer-based insurance, but have declined.
If 10 million of the disingenuous "47 million uninsured" are in fact illegal immigrants, are we to understand that all of these candidates are actually calling for nationalized health care coverage for illegal immigrants? Perhaps, in our beneficence, we should pay for healthcare for anyone worldwide who comes to our country. If this is what is being suggested in using these numbers, perhaps it needs to be on the table.

Do the candidates that use this number suggest that those who have elected not to have insurance for personal reasons must now purchase insurance? Given the expense of insurance today, should this personal decision now be subject to government mandates?

What has been done so far on providing health care coverage for illegal immigrants? Here's a list of legislation both passed and vetoed for illegal immigrants. Is this a controversial issue? Perhaps it is not. But if the "universal healthcare" imperative will include illegal immigrants, its cost to our system should be estimated as well.

The last time Congress and the public didn't pay attention to the accuracy of data succumbing to fear-based manipulation, we ended up in a war.

-Wes

Evaluation Time

This week several evaluation requests from insurers appeared in my mailbox at work. One from UnitedHealthcare and the other from Blue Cross and Blue Shield of Illinois (BCBSIL). No doubt there will be others.

Most doctors I know ignore these surveys. I, for one, have never filled one out. Usually such notices are relegated to the circular file. Maybe a few physicians are brave enought to turf them over to their already overburdened office managers who could care less about such a survey, scribble a response if required, and move on. But no doubt a few well-meaning individuals complete these - and probably say relatively nice things like "my patients never complain" or "my hospital seems pretty good at what they do." More likely they complete them without ANY data before them, like how many of their patients have been denied payment and how long reimbursement rates for services rendered actually took. And even after the survey is completed (and, if lucky, mailed) we are left to wonder, what's riding on these rarely-completed surveys? So I spent a minute looking at them.

UnitedHealthcare wanted me to sign on to a computer with this survey address: http://www.msisurvey.com/H07162a. They gave me a tip about this address:
TIP: Do not enter the survey web address into a search engine or search function on your browser, as it will not find the survey Web site. Use only the Address or Location line located at the top of your web browser window.
Thanks to web-crawlers, I added it in this little tip into my blog to be SURE to correct this problem. I wonder why they want to keep their UNITEDHEALTHCARE SURVEY so secretive in this era of "consumer empowerment" in healthcare? By the way, the server was down when I tried to log in this morning stating:
The system is unavailable at this time, please try again after 6am EST. We appologize for the inconvenience and appreciate your patience.
That was at 7 am CST (8 am EST) today - maybe because the computer clocks are screwed up due to ending Daylight Savings Time today - but I digress.

Here's a sample of the letter from Blue Cross Blue Shield of Illinois:
"The BCBSIL Quality Improvement Plans require measurement of physician satisfaction with procedures for utilization management, referrals (if applicable), appeals, claim payment, continuity and coordination of care, and various services including BCBSIL services and hospital information."
I'm not good at business double-speak. What is "utilization management?" And since when do insurers perform "referrals" or assure "continuity and coordination of care" for a patient? Is it just me or do insurers now think they are "care providers?"

And the cover letter from BCBSIL says something else:
The Hospital Information section, found on the last page of the Satisfaction Surveys, is important to BCBSIL, as results (will be) analyzed for the BCBSIL Annual Hospital Profile. We strongly encourage you to provide feedback on your primary hospital. Responses are only analyzed and presented at the aggregate level. Therefore, all the individual responses are kept strictly confidential.
The questions for the hospital survey include things like scoring the overall quality of the hospital, timeliness of imaging reports, adequacy of the number of nurses, quality of discharge plans, etc. Wow. Not only do I get to care for patients, but I can be Zagat for hospitals, too!

Or am I being asked to be a mole? Are such "hospital quality" questions really because they care about improving quality in hospitals? Or is there another motivation like: "We want to use your less-than-perfect aggregate responses against your hospital during negotiations with them." At least this would be honest and make more sense why these data are so "important." They are, after all, interested most in their bottom line as a business.

But let's not be quite so negative. No doubt the insurers take the three or four responses (not the real number, mind you, but certainly a minority of the total surveys distributed), and show their leadership and stockholders their beneficience in all things insurable. Surely they raise self-congratulatory data up their PR flagpole and to Congress and CMS as justification of their existence.

All from three or four survey responses.

Ah, the beauty (and shame) of healthcare bureaucracy...

-Wes

Friday, November 02, 2007

Holy Cow!

Pharmalot shows how much money some orthopedists got from the medical device industry:
Zimmer notched 21 payments greater than $1 million and DePuy made the biggest - more than $6.7 million to $6.75 million to Thomas Thornhill, who chairs the department of orthopedic surgery at Brigham and Women’s hospital in Boston.
It's more than I ever imagined.

He adds links to the companies' disclosures as well.

-Wes

The First Angioplasty

Today's post over at MedPage Today.

-Wes

Amish Ingenuity

The Amish are a regilious demonination here in the United States that live the simple life, often without electricity in their home. But they do avail themselves of medical technology on occassion, and to this end, here's a case where technology permitted follow-up of one Amish patient's implantable defibrillator from the countryside, using a telephonic follow-up service from Boston Scientific, called Latitude. (ed. note: Thanks to our local rep, Greg Roth, for providing these images. Please feel free to click them to enlarge).

The patient was a 73 year old Amish man who was implanted in 2003 with a Guidant Ventak Prism II implantable cardiac defibrillator. He traveled 30 miles for his checks from rural Pennsylvania, and then applied his own version of remote follow-up using Boston Scientific's Latitude system:


A view of the countryside.



A view of the countryside from the other angle.
Note the outhouse-style shed.



But is it an outhouse?



A closer look reveals the answer.



Not only is the shed beautifully constructed, using a voltage inverter connected to a car battery, the patient has rigged the Latitude system to a phone line for remote follow-up of his defibrillator. Doctors review the information provided to assure proper functioning of his defibrillator from their office.

Ingenious, indeed.

-Wes