ICD's for the Over-80 Crowd

I call it "device creep:" a form of extrapolation of clinical trial data to justify the addition of more advanced (and expensive) technologies.

It happens all the time in my field.

Start with an 82-year old with sick sinus syndrome and the need for a permanent pacemaker. Before their procedure, the heart's pumping function, or ejection fraction, is evaluated and found to be, say, 31%. Now, based on data from the NIH-sponsored SCD-HeFT trial, an implantable cardiac defibrillator (ICD) is considered to not only support the heart rate, but also to play potential role in the primary prevention of sudden cardiac death in this higher-than-average-risk patient. But why stop there? After all, the EKG was evaluated and demonstrates an underlying left bundle branch block. A quick review of the chart confirms an admission for heart failure in the last year, and voila', a biventricular ICD is justified on the basis of CARE-HF and the MIRACLE trial to provide cardiac resynchronization in hopes of improving heart failure symptoms, too!

A talk then ensues with the patient and their family. The pros and cons of each technology and the limitations of the data are reviewed. Jointly, the group comes to a clinical consensus about which device to receive. Usually (but not always), a "cover all the bases" approach is taken, since cost is usually not considered in these discussions.

And the difference in price between a pacemaker and biventricular pacemaker-defibrillator?

About three-fold.

So what's the best option?

The Heart.org does a nice job reviewing the controversies surrounding "device creep" in those over the age of 80 with sinus node disease as they review a timely article by Dr Michael O Sweeney of the Brigham and Women's Hospital, Boston, MA published before print in the Journal of Cardiac Electrophysiology. Cardiologists, electrophysiologists and heart failure experts weigh in from both sides of the debate: (1) co-morbidities matter, (2)this is a uniquely American debate since other countries already ration these expensive technologies, and (3) the convergence of an aging population and tightening resources will make discussions like these more and more common the field of cardiac electrophysiology. Perhaps Dr. Lynne Warner Stevenson from the Brigham and Women's Hospital said it best:

"As we look at the healthcare problem in the US, we're going to have to make some exceedingly difficult decisions. We're going to have to be either rational or be severely rationed. And a relatively easy target is to reduce the number of expensive procedures that do not provide anticipated benefit."

But in when does a person reach the age where technology provides no "anticipated benefit?" What benefits should we measure?

Read the whole thing. It's worth it. Then ask yourself: what if you were 80 and facing this decision: what would you do?

-Wes

How to Make a Hospital Profit Center Really Profitable

Most of us want change for our healthcare system.

Real change...

... for the better.

But when we think of "change," most of us think of transformation, conversion, correction, or plotting a new course for our healthcare system....

... not adding monetary change to profit centers for hospitals.

So imagine my surprise when across this press release from our newly-christened Democratic Presidential nominee that contained a little pork-spending for a hospital in my state to put up (are you ready for this?) new equipment in a cardiac electrophysiology laboratory.

Okay, let me get this straight.

Cardiovascular disease in virtually every hospital in America is a profit center that helps support other budget-neutral or budget-negative programs. As a case in point, this particular medical center, according to it's Guidestar non-profit Form 990 tax return, performed 4,452 procedures in its labs and spent over $50 million dollars on its "Cardiovascular Product Line" in 2006 and received some $404 million in payments for healthcare rendered.

So why on earth do they decide to tap a political figure for an "earmark" of another $1 million dollars? Well, it seems they do it because they can:

"The Advanced Flatplate Cardiac Catheterization/ Electrophysiology laboratory in Springfield, IL, would perform advanced cardiac catheterizations and interventions, cardiac electrophysiological and mapping studies, and ablation therapy to treat abnormal electrical functions of the heart. The new flatplate delivers less radiation to the patient, produces sharper and clearer images that enhance diagnostic and treatment capabilities, and has the ability to produce 3-D imaging for improved detection and mapping of diseased vessels."

Mind you, in a state teetering on bankruptcy, this request is not to funnel state dollars to bring services to an underserved area or save a financially teetering hospital that a community depends on. Rather, this earmark is aimed at a flourishing regional medical center that already has an electrophysiology laboratory with a second laboratory at the neighboring hospital several blocks away. No, this "earmark" is just to upgrade their equipment. And while they're at it, they decided to ask for upgraded Vascular Lab equipment, too, to the tune of another $1.8 million dollars:

Funding would enable equipment upgrades for vascular disease diagnostics and screening. This would allow Memorial Hospital to offer screening and diagnostic tests for earlier intervention and care locally.

Never mind there has been no proof to date that such screening prevents disease or limits costs.

Remember, too, that new capital equipment like this can be depreciated on their tax return and that patients' Medicare payments contain a specific "technical" fee component to pay for such capital equipment and its staffing when they have procedures in the laboratory already. Yep, that's right. When you have your procedure, a portion of the money pays your doctor, but a much larger portion pays the hospital for all of the lab equipment and overhead inherent to these procedures.

Now I appreciate that hospitals are having a difficult time balancing budgets in this economically challenging time. But each of us are seeing higher co-pays and deductibles to offset employers and insurers' ever-escalating costs as well. And really in the big picture of the US economy, $1 or $1.8 million dollars isn't much.

But if we really want meaningful healthcare reform, then making patients pay twice, once for their procedure and again in the form of a portion of their taxes that pay for these "earmarks," can only mean one thing: nothing, but nothing will change for the little man and our healthcare system.

So go ahead, Barack. Make some "change" for the hospitals.

No doubt the hospitals will appreciate it.

I just wonder about the patients...

-Wes

Eating The Competition

It's happening all over the place.

Cardiology practices being consumed by large hospital systems: Charlotte, North Carolina, Greensboro, NC, Milwaukee, Wisconsin, Tampa/St.Petersberg, Florida, and now, Roanoke, Virginia.

What does this mean for cardiologists, their patients, and cardiothoracic surgery referrals?

Everything.

It is interesting that many of these business plays have occurred in the Southeast, an area known for its large retiree population. Certainly, as Medicare reimbursements decline, administrative and malpractice costs continue to expand, and older cardiologists look for an exit strategy as they near retirement, the selling of their practice might be an attractive option for many.

But such a consolidation is also a strategic move by hospital systems to shore up their most lucrative healthcare "product lines." Acquiring potentially-competing groups adds additional geographic locations to perform cardiovascular testing without the added expense of physician recruitment, while assuring a steady stream of referrals to a fledgling cardiovascular surgery center.

Patients are increasingly moved through a healthcare system unaware of the powerful market currents shaping the direction and costs of their healthcare. A moonscape of larger and larger behemoths of healthcare are slowly taking shape across America as more and more doctors succumb to the inevitable market forces intent on squashing the former entrepreneurial healthcare climate, resulting in fewer patient options for affordable healthcare.

-Wes

What Your Heart Attack Might Be Like

The Brits showed this ad from the patient's perspective:



Although one would hope the symptoms wouldn't get to this extreme, the ad makes the point that heart attacks aren't really just about chest pain: but also chest or arm tightness or a discomfort, dizziness, shortness of breath, nausea, vomiting, sweating, and the like.

But back pain, especially between the scapula, was not mentioned, nor was incessant burping typical with some inferior myocardial infarctions (lower wall heart attacks).

Not only are people unfamiliar with the more common symptoms of heart attacks, but there's a tremendous amount of denial when they happen to one of us. Worse yet, many people I have seen were ashamed to call the ambulance because they didn't like the idea of flashing lights and sirens in front of their residence.

And one more thing to consider: if a friend wants to call an ambulance for you, let them. Remember they are objective observers, and might just save your life even despite yourself.

-Wes

How to Pay for Your $350,000 Bypass Operation

... just screw your fellow man:

Authorities say John Parsons, 57, of Oak Park stole the identity of a mentally disabled friend to pay for heart bypass surgery at Northwestern Memorial Hospital in Chicago in 2007. Parsons allegedly racked up about $350,000 in medical expenses billed to the friend's Medicaid account.

This behavior might help you with the ultimate governmental double-dip: (1) as you tap the government for your health bill and (2) for housing in the slammer after you're caught. But hey, since they can't take back the bypasses, at least you'll be chest pain free!

Sick, just sick.

-Wes

PS: Judith Graham has a nice piece on what to do if you suspect medical identity theft in her blog, Triage.

Doctors' Paycuts Save?

Kevin Pho, MD makes some salient points about the implications of cutting physicians' Medicare payments in his op-ed piece in USA Today.

-Wes

How to Make an Expensive Procedure Even More Expensive

... just add a robot.

(At least the pictures are pretty cool... Now, looking at slide 10, I don't see atrial fibrillation, so I wonder what was ablated? An atrial tachycardia?)

-Wes

Change of Shift is Up

The next edition of Change of Shift, this week's compilation of the best of nursing's blog posts, is up over at Emergiblog.

-Wes

CMS-Mandated Mortality Data: Whoop Dee Do

I wonder how much money was spent to collect, collate, process and puree the hosptial mortality rates of heart attacks, pneumonia and heart failure in our nation's hospitals, and plotting these data nice little graphs on a website?

I looked at data from most of the hospitals near our facility and was not surprised to find that there was really no big difference in mortality between centers.

So I guess what this data tells us is this: all hospitals are pretty good at collecting data. Whoop dee do.

Now, can we get back to treating patients?

-Wes

The Psychopathology of Healthcare Reform

It seems the healthcare debate has recently fallen off the political map:

The continual tussle between the two presumptive presidential nominees — Obama and McCain — has largely centered recently on national security and the high price of gasoline. Public opinion polls have shown that among the top issues of concern to Americans, health care is languishing far behind the economy, the war and the price of gas. One CBS poll from July put voter interest in health care at just 3 percent. In August, it was at 8 percent.

Is this such a surprise? Gas prices are easy to understand. But start talking deductibles, copays, income deductions to pay for a new public plan or making patients choose an insurance plan with tons of fine print, it's no wonder no one wants to stay focused on healthcare. Hell, it's just too messy! It's a whole helluva lot easier to understand if 70 bucks is in your pocket to fill up your gas tank.

Americans are like that. And politicians and policy makers know it.

So the politicians and policy makers read their tea leaves and go with what's hot at the moment.

And we ignore it.

In the same way that we have not really begun a "national conversation about race," we have not had a "national discussion about healthcare." It's just too emotional, personal and too politically charged. So we should ask ourselves if we, in fact, choose to "believe" in electing politicians who pitch complicated healthcare policy to us as if it were a peaceful bedtime story.

The American soul has been described aptly by one author as full of contradictions:

Americans carry a simultaneous embrace of holiness and hedonism, while pining for the love of tradition as we carry on our headlong romantic affair with progress, (and) as our extreme individualism courses beside a gigantic, gaping yearning for community.

Perhaps because of this American psychological personality, we will choose to believe in someone who will save us from our contradictions.

This is why we can see the new “evidence-based design” architecture for our radiation treatment rooms and cancer treatment centers, along with multi-million-dollar hospital additions full of "woo" promising complete “wellness” whose “extra expense isn’t passed along to patients.” Just like we can see and expansion of healthcare coverage for young adults that will be free, too!

And yet, can we really afford to ignore the debate?

But we do.

Our American psychopathology gets the best of us.

Americans fervently believe in "health care for everyone." We also fervently believe in the truth of government corruption and inefficacy and the truth of corporate self-interest. Most of the time, we're not too crazy about leaving kitchen-table decisions to the Big Boys in Washington. We believe the homeless person should get the million-dollar cancer treatment and we also believe Aunt Molly should be able to get the best health care possible because she's earned it. We believe lots of things. All of these are on the table right now as we continue to gorge ourselves silly with the latest technologies, unfettered hospital construction projects, and limitless end-of-life care.

We have not had a serious national conversation. And if we buy a salesman's pitch on healthcare without dealing honestly with our own psychosocial contradictions, the morning after will not be pretty.

Or it will be pretty, but only for bureaucrats, politicians, and corporate healthcare interests.

-Wes

Gone Hiking...

I'm off to places where computers can't go for the rest of the week... hiking in the Porkies. It's been a while since I've done this, but my soon-to-be-freshman-in-college decided it'd be fun for one last outing... Back Monday. Hope I can still walk...

-Wes

Oh, and where's the sailing beach shown above? On the west shore of Lake Michigan, of course...

Grand Rounds Is Up

This week's Grand Rounds wrap-up of the best of the medical blog-o-sphere is up at the Medical Humanities Blog.

-Wes

Marketing Accurate Empathy

Meanwhile, back in the AstraZeneca marketing department:

"Hey, Joe, I got an AWESOME idea! We've got a few hundred thousand extra bucks lying around, right? Let's get some trucks! I mean, we could drive 'em around and burn some diesel, and pull right up to hospitals all over the frickin' country, man!"

"Dude, why didn't I think of that? Like, that's so frickin' coooool!"

"Yeah, man, like, we can say things abut heart failure, like:

"It’s the number one reason why people over age 65 are admitted to hospitals. For that reason alone, it’s important to raise awareness of Congestive Heart Failure and help healthcare professionals recognize and understand its symptoms."

"Man, we'd sound so, so, I mean, authoritative, man! And sooo, since doctors have no clue how to diagnose heart failure and since they need to be using more of our drugs like Zestril, Toprol XL, and Atacand, like, DUDE, it'll be frickin' awesome to suffocate them with a pneumatic vest connected to a Mac computer and make 'em beg for our drugs! Then they'd HAVE to use 'em! And once we let 'em tour the driver's front cabin, they'll want to even drive the frickin' truck!" (* giggling loudly *)

"Dude, like, how big a truck's that gonna take for one simulator, man?"

"Like, I dunno, but hey, man, they got these cool expandable sides. Here's an idea that I thought would work, so I had 'em make a prototype..."

"No waaaayyyyy...."

"Waaayyyy!!!! Here, look:"



"Oh, Dude, you're so awesome. Can't wait to see those marketing numbers soar! It's gonna be soooo phat!"

"Dude, can I ride your coattails when you become our next CEO?"

"Heh, yeah man.... Hey, you doin' NASCAR this weekend?"

Meanwhile, back in the heart failure patient's kitchen, the USA Today arrives:

Drug companies are quietly pushing through price hikes of 100% — or even more than 1,000% — for a very small but growing number of prescription drugs, helping to drive up costs for insurers, patients and government programs.

"Whoa, DUDE! Somebody's gotta pay for the truck..."

-Wes

h/t: Medgadget.

Beware of the Simvastatin/Amiodarone Drug Interaction

For electrophysiologists, the drug combinations of amiodarone (marketed as Cordarone® or Pacerone®) and simvastatin (marketed as Zocor®) is a common drug combination. The FDA issued an alert that these two drugs, when taken together, might result in an increased incidence of rhabdomyolysis (injury to muscle cells characterized by muscle aches, weakness and dark urine). It is thought by some that this might result from competition of the two drugs for the same metabolic pathway in the liver:

Statins such as atorvastatin (Lipitor®), lovastatin (Mevacor®) and simvastatin (Zocor®)are metabolised via a cytochrome P450 3A-dependent pathway while fluvastatin (Lescol®), pravastatin (Pravachol®)and rosuvastatin (Crestor®) are metabolised via cytochrome P450 3A-independent pathways. As simvastatin and amiodarone are metabolised by the same isoenzyme, in the present case, the concomitant use of these drugs may have resulted in competition, resulting in excess of free plasma statin and thereby causing myotoxicity. However, there are limited publications on this interaction and the exact mechanism has not been established.

It is recommended to keep the daily simvastatin dose to 20 mg or less to avoid this side effect of the drug combination.

-Wes

h/t: WSJ.

Twitches

When a patient complains of "left shoulder pain which began 30 minutes ago, is pulsitile and sharp, comes and goes, and is associated with a left abdominal pulsation which began yesterday:"

Click image to enlarge

... always check the implanted biventricular defibrillator lead locations.

-Wes

Guaranteed to Increase the Calls to Our Office

... heart rate sensing computer mouse...

-Wes

Dronedarone Granted Reprieve

It seems Sanofi-Aventis's amiodarone analog drug, dronedarone (marketed as Multaq®), was granted a stay of execution by the FDA:

Multaq appeared at one stage to have little future, after an early clinical trial showed excess mortality and the drug was rebuffed by regulators.

As we recall:

Dronedarone is structurally similar to amiodarone but lacking the iodine moiety — a feature of amiodarone that has been linked to many non-cardiac side effects (including pulmonary toxicity, ocular effects, thyroid disease, and hepatic dysfunction). The Dronedarone Atrial Fibrillation Study After Electrical Cardioversion (DAFNE) trial demonstrated the efficacy and safety of dronedarone in preventing AF recurrence after cardioversion in 199 patients. In the EURIDIS (European trial in atrial fibrillation or flutter patients receiving dronedarone for the maintenance of sinus rhythm) and ADONIS (American–Australian–African trial with dronedarone in atrial fibrillation or flutter patients for the maintenance of sinus rhythm) trials, dronedarone was effective in preventing AF recurrence and was shown to reduce the ventricular response during AF relapse. There was no evidence of proarrhythmia (including TdP), heart failure exacerbation, or thyroid, pulmonary, or other organ toxicity. The mortality rate was low (1.0%) and not significantly different from placebo (0.7%) during the 12-month follow-up. However, the Antiarrhythmic Trial with Dronedarone in Moderate-to-Severe Congestive Heart Failure Evaluating Morbidity Decrease (ANDROMEDA) was stopped prematurely because of a trend towards increased risk of death in the dronedarone group, but this numerical increase in mortality was not statistically significant. In 2006, the United States Food and Drug Administration issued a non-approvable letter based on safety concerns. Consequently, the drug manufacturer withdrew an application for licensing to the European Agency for the Evaluation of Medicinal Products.

But new results from the Athena Trial (ppt) that excluded severe (Class IV) heart failure patients were favorable (except for some problems with a slight decline in renal function) suggesting the drug may become a promising new treatment for atrial fibrillation if approved by the FDA (decision expected in late January, 2009).

-Wes

Nurses and Their Pets

One of our EP nurses shared this photo of her pet with me this morning:



Got to admire its choice of uniform, but given the weight of this bunny, it probably should have opted for a Bud Lite.

-Wes

The Marriage of Credit and Medical Histories

Dr. Cory Franklin issues a grave warning in the editorial pages of today's Chicago Tribune:

A political issue that neither Barack Obama nor John McCain has addressed is an emerging development in health care, obvious in retrospect, but with tremendous implications for virtually every patient in America. It is the marriage of credit and medical histories, an inevitable partnership being consummated by at least one company already collecting information about how reliably patients pay their medical bills. Other companies are sure to follow what is essentially a means of creating a credit score related to a patient's health status with the clear goal of predicting his or her future ability to pay.

But as is so often true with the clever new initiatives afoot in healthcare management, it's sold as being good for the patient:

The rationale behind this effort is that the credit profiles are in the best interest of patients. Hospitals and doctors will be able to provide patients with better payment strategies and allocate charity care more efficiently.

This sounds suspiciously like the Orwellian logic that characterizes modern corporate health care. The credit industry's misbehavior in the subprime mortgage debacle certainly leaves open the possibility that any benefits patients may realize could be dwarfed by major obstacles that could stand in the way of medical treatment. This includes fraud, medical identity theft and plain old credit reporting errors.

An even more ominous threat would be prescreening patients before medical treatment is provided. ...

As this blog has demonstrated many times, the obfuscation of medical pricing and insurance payments, coupled with the the growing movement of physician-employees (can you say, "hospitalists?") aligned with the hospitals' financial interests, rather than the patients', focuses our eye on the brewing storm ahead.

-Wes

Change of Shift is Up

This week's edition of Change of Shift, the nursing blog carnival, is up.

-Wes

Co-writer of Boing Boing Interviewed

Cory Doctorow, co-writer for Boing Boing, one of the most popular blogs in the world as ranked by Technorati.com, was in Chicago to promote his new science fiction novel "Little Brother," and has an interview in today's Chicago Tribune.

You'd Better Not Watch the Olympics

... because the media thinks, just like the Super Bowl and World Cup Soccer, doing so might just kill you.

If anyone would like a defibrillator for primary prevention of sudden death... (heh)

... really, why do they print these stories?

-Wes

Hard to Believe

... it's been a year. Time has a way to gain perspective on the loss of a loved one. I'm glad that I have this blog and its postings to look back on.

My mother's been able to move forward now and is doing remarkably well. Thanks to all who were so supportive then and now.

-Wes

Afib Online Chat Reminder

Barring any technical difficulties, I'll be hosting an online chat room for questions about atrial fibrillation tonight at 7PM Central Standard Time over here.

See you then.

-Wes

Interesting Defibrillator Insights

This morning, Google introduced their new "Insights for Search" feature, geared toward marketers who want to see information about specific search terms. Now being the nerd that I am, I decided to take it for a spin and was surprised at what turned up in the area of implantable cardiac defibrillators, or "ICDs", as we call them.

First, what's going on in India?

It seems searching for "ICD" revealed that India is outpacing the US in the use of that search term by a margin of about four to one.

The same holds true if we use the term "cardiac defibrillator."

Maybe this is where the software that drives these babies comes from, so there's lots of technical inquiries there. Or maybe there's a push to market the devices there. I wasn't sure, so I took a look at India here and noted that most of the searches were from the Karnataka region, and within that region, most searches came from Bangalore.

Secondly, within the US, the findings were also interesting. Not surprisingly, Minnesota, home to the "Big Three" defibrillator manufacturers, had the most search terms for "ICD", but was interesting to me, is that Illinois didn't even make the top ten states searching for the term since 2004.

Cool stuff. Try checking terms from your own field...

-Wes

h/t: NYT

Premonition?

Careful when you google yourself. You might find something related to your field from 1897 that you wish you didn't know.

-Wes

Resident Work Hour Restrictions: "Attending" to the Consequences

From the Fellow's Corner:

Question: I'm curious as to what the experience has been, not in terms of the workhour restrictions to which we as cardiology trainees are subject, but rather, do you think that the workhour restrictions on residents has had an effect on what you are expected to do as fellows? Is work flowing uphill? Is it flowing over fellows' heads to attendings? Is it being shifted over the physician extenders? And perhaps most important, do you think that we're at steady state, or are shifts going to continue?

Work hours restrictions have definitely changed the nature of training. The hierarchical roles where attending supervises fellow supervises resident supervises intern is shifting to a divide-and-conquer strategy where housestaff divvy up the work to get everything done at the expense of knowing every patient. Interns were once expected to get all the scut done on all their patients while the senior housestaff managed; now interns/residents/fellows are dividing the scut which comes at the expense of interns learning management of clinical scenarios from their senior housestaff at an earlier point in their training. Meanwhile, attendings still have to manage every single patient, so their jobs have probably become more difficult since the new work hour rules have been put into place. Attendings have to spend more time directly managing more junior housestaff.

The conversation is shifting. Traditional hierarchical patient management is giving way to the need for "scut management" as work hours, thrown in amongst teaching sessions, draw short. Divide-and-conquer. No time for supervision. Hurry up! We've got to get done!

More surprisingly, trainees are now perceiving a tectonic shift in patient care responsibilities as attendings "manage every single patient" and rely less and less on their presence. Housestaff are becoming fearful that they will be marginalized members of the patient care team. Meanwhile, they witness the change in their attending's quality of life. Suddenly, the lure of the title "senior attending" is losing its luster.

And home life for the attending? Well... Oh, geez, I better call home!

"Sorry for calling so late dear. Yes, dear, I should be home soon."

"What's that dear? Why can't the residents finish up? Well, you know, they've left. They can only work so many hours..."

"Say what? Who made those rules? It really doesn't matter... (Holding phone away from ear)... I know you don't give a damn about those residents, dear. But someone has to manage the patients, dear."

"Birthday, whose birthday? You're kidding, right. (Looks at calendar and thinks, "Oh no! I'm so screwed!") I'm so sorry dear. Er, uh, I'll come back later to finish up, dear. No problem, I'll get changed and get home right away..."

-Wes

MD from St. Regis Medical School?

If so, you might be in some hot water:

The network of bogus universities was a family-run venture based in rural Washington state, but the criminal enterprise spanned the globe, with its operators allegedly paying bribes to Liberian officials and selling fake PhDs and MDs as far away as Iran.

They were busted by state and federal officials—among them a Secret Service investigator posing as a shadowy Syrian seeking a bogus chemistry degree—with the help of a local physics professor.

For the last four years, U. of I. at Urbana-Champaign professor and Fermilab physicist George Gollin helped unravel the scheme that has resulted in eight guilty pleas this year and could spark further charges against hundreds of people who may have bought and used bogus diplomas.

...

Degrees were sold in areas like oncology, dentistry and engineering, and some buyers reportedly worked for state and federal governments, according to the Spokane, Wash., U.S. attorney's office.

I hope those found guilty get their just deserts.

-Wes

Reference: Here's the list of names originally reported by the Spokesman Review.

Press Before Science

It's about 06:10 AM Monday and I'm checking the usual news feeds and stumble across this little tidbit that piques my interest. I read it and move to read the article.

Wait. What article?

It seems the American Heart Association has decided to publish this little "news release" before the article is published online on its Circulation website today.

Wow. Press before science.

One would think our professional organizations would be above this, but alas, no. Publication ratings are at stake, and hence, advertiser's revenue. And although the AHA boasts that only 6% of their revenue comes from corporate sponsors, it must be an awfully important 6%. You see, it's become too important to pre-feed the media and the throngs of news organizations hungry for the latest scientific tidbit with little sound bites from the author like:

“This is the first prospective study to examine light-to-moderate physical activity and the development of AF (atrial fibrillation),” Mozaffarian said. “The focus was on older adults, in whom most atrial fibrillation occurs: after age 65, almost one in five people will develop AF over 10 years.”

just to boost their journal's impact factor. With the wonders of the internet and RSS feeds, no doubt the study will be heralded on this morning's CBS Morning News before anyone with a scientific eye has a chance to read the study.

Hey, it's all about show biz, right?

-Wes

2030 CST Addendum: Here's the study.... finally. My take: The study is a prospective evaluation of the incidence of atrial fibrillation from self-reported questionaires and several spot-checks of EKG's and hospital discharge diagnoses from ICD-9 codes. As such, there are many flaws in the study's methodology, including its means of detecting atrial fibrillation, but the message they convey is: "light to moderate exercise is good in the over-65 crowd:" not exactly earth-shattering, but probably sage advice. Unfortunately, their assertion that such exercise is preventative for the development of atrial fibrillation is a stretch:

Our findings suggest that moderate physical activity may meaningfully reduce this risk and that up to one fourth of new cases of AF in older adults may be attributable to absence of moderate leisure-time activity and regular walking at a moderate distance and pace.

Given the study design, clustering exercise levels into "quintiles," poor sensitivity to the detection of afib (single EKG and chart review?) and the self-reported nature of the questionaire end-points, I'm not sure we should leap to such bold assertions. Still, moderate exercise is good for lots of reasons, folks, so keep at it. -Wes

The Common Cold Added to Medicare's "Never Events" List

That's right folks. It's true.*

Today, the Center for Medicare and Medicaid Services (CMS) added the common cold to its ever-growing list of "never events:"

"Press Release, 3 Aug 2009: The Centers for Medicare & Medicaid Services (CMS) announced today it is taking several actions to improve the quality of care in hospitals and reduce the number of “never events” -- preventable medical errors that result in serious consequences for the patient.

“Never events cause serious injury or death to beneficiaries and result in unnecessary costs to Medicare and Medicaid due to the need to treat the consequences of the errors,” said CMS Acting Administrator Kerry Weems. “There simply is no excuse why health care workers do not cover their nose and mouth when they sneeze. The steps taken today reflect our strong conviction that these events, in fact, should be prevented, and our commitment to protecting Medicare and Medicaid patients from them.”

A final acute care inpatient prospective payment (IPPS) rule that went on display today at the Office of the Federal Register for publication August 18, 2009 updates Medicare payments to hospitals for fiscal year (FY) 2010 and provides additional incentives for hospitals to improve the quality of care provided to people with Medicare. As part of these quality of care incentives, the rule includes payment provisions to provide new attire for all staff who come directly in contact with patients.

In addition to the final rule, CMS today sent a letter to state Medicaid directors providing information about how states can adopt the same never events practices. The letter specifically encourages states to adopt the same non-payment policies outlined in today’s final Medicare rule. Nearly 51 states already have or are considering methods to eliminate payment for some never events."

-Wes

* Well, not quite yet, but it isn't too hard to imagine, now that governmental rationing of health care expenditures continues unabated.

Reference: Never events practices flowchart credit.

Our Medicare Entitlement Crisis

The Happy Hospitalist nails it:

The appropriate course of action should be a radically new approach to the Medicare entitlement program. We do not have a choice. The political suicide of such an action is however glaring. Our Congress is bogged down in billions of dollars of free cash flow coming from the coffers of big business looking to keep their gravy train flowing. It will take enormous servitude by our government officials to declare an end to the automatic money train known as Medicare. A restructuring of the program towards a transparent means based qualification system is necessary. Having Uncle Sam pay for an elective cataract surgery so grandma can go on an African safari is inexcusable in a time of financial collapse. The war in Iraq is peanuts compared to the financial destruction extolled by our entitlement programs.

Read it. All of it. Including the comments.

We have to come up with solutions, not political placations. Or else.

-Wes