A Letter to Congress: Let Us Help You

Dear Congress:

I wanted to write you to tell you how proud I am of you. You’ve worked so hard on health care reform and focusing on what matters to Americans. Your beautifully conducted Health Care Summit, live before the C-SPAN cameras (finally) was a welcomed site. I have such a better grasp of the issues now. Thank you. You folks are awesome.

I did notice that both sides seem to be entrenched over what to do going forward – at least on camera. Everyone wants everyone to have insurance, but that thorny issue of costs keeps raising its head. Dog gone it. There always seems to be something to serve as a spoiler when real discussions take place in this health care reform debate.

But take heart. There is a way to fix all of the problems encountered with health care reform and I think you know what that the answer is: cut the doctor’s Medicare payments, already only 80% of costs, by another 21%.

We, your ever-ready and willing sycophants think that’s a great idea.

Knowing that we can be “team players” that are willing to take a leading role in health care reform will finally cement our image as omni-beneficent. People will finally be able to see through the media stories (transcript) that aired the day before the Health Care Summit about doctors as sexual predators. (video here). As Rahm Emmanuel said, “"You never want a serious crisis to go to waste. And what I mean by that is an opportunity to do things you think you could not do before." We as physicians are happy to do our part to counter these "systemic" problems with doctors. Thank you.

Now just so you know, we might have to make some eentsy–teensy–weentsy adjustments to how we do things, but it’s all be good. Really. Don’t worry. We’re innovators and entrepreneurs after all. We’ll figure out a way to curb inflation. We’ll lower the costs of staffing and equipment. And we’ll even single-handedly take ourselves off your payroll to lighten your load.

And it will all be good.

I mean, what could go wrong?

-Wes

Don't Abandon Manual Blood Pressure Cuffs

... they might help preserve myocardium:

333 consecutive adult patients with a suspected first acute myocardial infarction were randomly assigned in a 1:1 ratio by computerised block randomisation to receive primary percutaneous coronary intervention with (n=166 patients) versus without (n=167) remote conditioning (intermittent arm ischaemia through four cycles of 5-min inflation and 5-min deflation of a blood-pressure cuff). Allocation was concealed with opaque sealed envelopes. Patients received remote conditioning during transport to hospital, and primary percutaneous coronary intervention in hospital. The primary endpoint was myocardial salvage index at 30 days after primary percutaneous coronary intervention, measured by myocardial perfusion imaging as the proportion of the area at risk salvaged by treatment; analysis was per protocol.

...

Median salvage index was 0·75 (IQR 0·50—0·93, n=73) in the remote conditioning group versus 0·55 (0·35—0·88, n=69) in the control group, with median difference of 0·10 (95% CI 0·01—0·22; p=0·0333); mean salvage index was 0·69 (SD 0·27) versus 0·57 (0·26), with mean difference of 0·12 (95% CI 0·01—0·21; p=0·0333).

Interpretation
Remote ischaemic conditioning before hospital admission increases myocardial salvage, and has a favourable safety profile. Our findings merit a larger trial to establish the effect of remote conditioning on clinical outcomes.

Hey, lose blood flow to an arm to save a heart. Works for me.

-Wes

Reference:
Bøtker HE at al. "Remote ischaemic conditioning before hospital admission, as a complement to angioplasty, and effect on myocardial salvage in patients with acute myocardial infarction: a randomised trial" Lancet 27 February 2010 375: 727-734.

Live Blogging the ACC.10 Meeting

It's official.

I've been asked by the ACC to help live blog portions of the ACC.10, i2 Summit in Atlanta March 14-16, 2010 that includes a Health Information Technology spotlight session.

There will also be a lively session entitled “U.S. Health System Reform: Where are we headed?” on Sunday, March 14 from 12:15 to 1:45 p.m. with both sides of the political aisle represented by Chris Jennings, Deputy Assistant to the President for Health Care Policy and Congressman Paul D. Ryan Jr. (R-Wis.). No doubt it will be as productive as yesterday's White House Health Care Summit.

There will also be a session on insights into the tort reform controversy from Richard Anderson, M.D., CEO of The Doctors Company. Trial lawyers are particularly invited to this session (I need news, after all!)

Needless to say, while electrophysiology remains my passion, I'll see if there's some new gadget, gizmo, controversy or cardiovascular policy issue that stretches beyond the typical fray.

You can follow the posts on this blog or via Twitter (@doctorwes).

For full disclosure, the ACC is paying my registration fee, but transportation and housing are on me. I am NOT industry sponsored for this event and the ACC only asks that I refrain from using four-letter words.

I'll try.

-Wes

Could a Boob Job Save Your Life?

Don't count on it, but it sure makes for one heck of a story:

When a gunman stormed a Simi Valley dental office last summer and shot Lydia Carranza in the chest, salvation may have come in the shape of her size-D breast implant.

That's the theory at least of a Beverly Hills cosmetic surgeon who hopes to drum up support to defray the costs of Carranza's reconstructive surgery.

"She's just one lucky woman," said Dr. Ashkan Ghavami, who says he will perform the surgery for next to nothing but has urged Carranza to tell her story in hopes of getting implant companies to donate the supplies.

Ghavami contends that the implant absorbed much of the bullet's impact, limiting most of the damage to the breast itself.

"I saw the CT scan," he said. "The bullet fragments were millimeters from her heart and her vital organs. Had she not had the implant, she might not be alive today."

The hospital where Carranza was treated is not prepared to make that call.

"This is not a medical issue; it's a ballistic issue," said Kris Carraway, a spokeswoman for Los Robles Hospital & Medical Center in Thousand Oaks. "The emergency physician who treated the patient was not aware of the breast implant having any impact or whether or not it saved her life."

But Scott Reitz, a firearms instructor and deadly-force expert witness with 30 years' experience in the LAPD, said that, although he was not involved in the case, the scenario Ghavami describes is entirely plausible.

"Common sense would dictate that any time you have something that interrupts the velocity of the projectile, it would benefit the object it was trying to strike," he said. And because a saline implant is like a high-pressure bag full of salt water, it probably would provide more resistance than plain flesh, he said.

"I don't want to say a boob job is the equivalent of a bulletproof vest," he added. "So don't go getting breast enhancements as a means to deflect a possible incoming bullet."

Sounds like wise advice and I knew you needed to know this.

-Wes

Blogging from Haiti

Dr. Mike Howard - one of our plastic surgeons, is live-blogging from Haiti. Here's a sample:

Looking at the historical course of cases here has been quite interesting. The quake occured on 12 January. Most amputees relate their first operation was not until 19, 20 or 21 January. Most ex-fixes went on between 22 Jan and 3 Feb. There will be a huge need here in 3-4 weeks just taking off exfixes. The scene is bad now 6 weeks out; I cant imagine the traumatic, mangled extremity scene the first week post quake. Thousands of crushes untreated for days.

Many of our current surgical cases are dealing with complications of prior surgeries. It is at first tempting to say "what were they thinking, doing that?" But, stepping back, imagining the scene and realizing that there was no way of knowing if they or the patient would ever get another chance. It was essentially 4 weeks of damage control surgery. It is amazing that the first groups in, did so much, so well. For the most part.

Case in point: one of my wound patients was admitted, seizing, 4 weeks ago (about 14 days post quake). In the ER, Dr. Ken was about to give him some ativan when a nurse injected the contents of another syringe into the patient. Penicillin. The guy survived his full blown tetnus (Ed's note: types like me) episode and looks great.

And from Wednesday's post:

Got an email last pm from a friend saying, "wow, it must be depressing."

Quite the opposite.

Yes, there is an amazing amt of destruction. The death toll is staggering. The poverty is everywhere. People living in the streets with nowhere to go or tents in front of their houses, afraid to go back inside. Corruption rivaling that of Chicago - maybe worse. The trauma fresh on the peoples faces and bodies. A generation of amputees in a country with zero handicap accessibility.

But, in the midst of all that, the sun is shining beautifully, the orphans at our hospital are truely smiling. The Haitian people are so friendly and appreciative. The volunteers are coming from everywhere, some alone, some by the bus load.

Health care doesn't get better than this. Nice work, Mike.

-Wes

Occupational Sciatica

Ever note lower back pain that radiates down your leg after standing at a cath lab or operating room table?

Timothy Sanborn, MD, director of cardiology at our institution shared his experience with this occupational hazard in a recent editorial (pdf) from Catheterization and Cardiovascular Interventions and offers an interesting non-invasive remedy short of laminectomy: hyperextension of the lower back using McKenzie exercises (video).

It's helped him.

-Wes

Putting the Cart Before the Horse

As Congress and their sycophants bicker over their current industry-sponsored 2,700-page health care bill and promise to save costs by continually bitch-slapping their physician workforce, perhaps they should consider these data:

Our findings are consistent with the possibility that economic factors such as lower fees and increased market pressure on physicians may have contributed, at least in part, to the recent decrease in physician hours. Further reductions in fees and increased market pressure on physicians may, therefore, contribute to continued decreases in physician work hours in the future.

Whatever the underlying cause, the decrease in mean hours worked among US physicians during the last decade raises implications for physician workforce supply and overall health care policy. A 5.7% decrease in hours worked by nonresident physicians in patient care, out of a workforce of approximately 630 000 in 2007, is equivalent to a loss of approximately 36 000 physicians from the workforce, had hours worked per physician not changed. Although the number of physicians has nearly doubled during the last 30 years, many workforce analysts and professional organizations are concerned about the adequacy of the size of the future physician workforce. This trend toward lower hours, if it continues, will make expanding or maintaining current levels of physician supply more difficult, although increases in the number of practicing physicians either through increases in the size of domestic medical school classes (ed's note: expensive option) or further immigration of international medical graduates (ed's note: cheap option) would mitigate those concerns. Moreover, if this trend toward lower physician hours continues, it could frustrate stated goals of health reform, which may require an expanded physician workforce to take on new roles and enhanced functions (ed's note: as nurse managers and transcriptionists) in a reformed delivery system.

Yep, I'm seeing nothing but good things ahead if the current health bill before Congress is passed.

-Wes

Staiger DO, Auerbach DI, Buerhaus PI. "Trends in the Work Hours of Physicians in the United States" JAMA. 2010;303(8):747-753.

Medicine's Infinite Variety

He was a pleasant, elderly man with an automatic defibrillator installed many years ago who unfortunately developed atrial fibrillation with rapid ventricular response that coincided with the same rates as his slow ventricular tachycardia, resulting in shocks from his ICD that he really preferred not to have. But he also was plagued by a more concerning problem (as far as the family was concerned) that had grown worse over the years: dementia.

I had explained the pros and cons of AV junctional ablation in great detail to him and is faily members in great detail the night before and all agreed this was the best course of action. His wife co-signed the consent. Everything was set. He was brought down to the holding area before his procedure with the family members beside him. As is customary, I greeted them before the procedure and turned to him to ask if he was ready and if he had any further questions.

Smiling, he said: "Nope, but that stuff you pour on those stumps sure works great - gets rid of the roots and all."

And that, in a nutshell, is why I love my job.

-Wes

Another Medicare Billing Blunder

Yes folks, doctors' Medicare payments are in the best of hands:

If your heart skipped a beat when you saw that January’s Correct Coding Initiative (CCI) edits bundled catheter ablations with electrophysiology (EP) studies, you weren’t alone.

Good news: CMS has decided to delete the edits retroactively because their addition was a mistake, according to the Heart Rhythm Society (HRS).

Snag: The deletion won’t happen until April 1.

Interesting that Uncle Sam can charge interest to you if you don't pay your taxes on time, but we can't charge Uncle Sam interest when we don't receive our payments on time.

-Wes

A Stethoscope App for the iPhone

It's out there. It makes a cool picture, but I wonder how many medical students realize how unimportant apps like this have become to today's cardiovascular care. Don't get me wrong, it's good to hear the difference between a systolic and diastolic murmur, or for the really talented, a diastolic rumble on physical exam. Recognizing the difference between mild and severe aortic stenosis is also very helpful. After all, the physical exam remains the most cost-effective instrument in medicine.

But graphics to show the murmur that requires an electronic stethoscope and preamplifier to connect them to your iPhone? How much money do you want to waste on these toys?

The best way I know how to learn is get off the computer and get to the bedside. Look, listen, and feel the precordium a thousand times over. Only by doing will you learn. You really don't need an expensive stethoscope (but it does helps the auditorially challenged). I admit that I've stopped using super-expensive stethoscopes because I always lose them when I change into scrubs or round on too many different wards (or they're often stolen).

Honestly, by the time I'm asked to see a patient, the echocardiogram is already done, so for me, listening to the lung sounds and measuring blood pressures (especially orthostatics for patients with syncope) remains the most important reason I still carry (or borrow) an the old, cheesy, analog version of the stethoscope.

-Wes

h/t: Dr. Joseph Kim via Twitter.

Antiviral "Boosting" Boosts Arrhythmia Risk

The FDA issued this press release today regarding several antivirals used in combination to treat HIV that can cause pro-arrhythmia by prolonging the QT interval on the EKG:

Invirase (saquinavir) and Norvir (ritonavir) are antiviral medications given together to treat HIV infection. Norvir is given at a low dose with Invirase in order to increase the level of Invirase in the body. This is a process known as "boosting."

FDA's analysis of these data is ongoing. However, healthcare professionals should be aware of this potential risk for changes to the electrical activity of the heart. Invirase and Norvir should not be used in patients already taking medications known to cause QT interval prolongation such as Class IA (such as quinidine,) or Class III (such as amiodarone) antiarrhythmic drugs; or in patients with a history of QT interval prolongation.

Patients should not stop taking their prescribed antiviral medications. Patients who are concerned about possible risks associated with using Invirase and Norvir should talk to their healthcare professional.

I like the last line: "...talk to their healthcare professional."

What that really means is that if you're on these two medications, you should get an EKG right away to see if your QT interval is prolonged. If it is, your doctor will have to decide which (if any) drug might need to have its dose adjusted or be stopped.

This problem is a common one in patients on many different medications that can interact and cause QT interval prolongation on the EKG and these antivirals need to be added to a long list of other medications. QTDrugs.org has a fairly comprehensive listing of them.

Be careful out there...

-Wes

JACC to Appear on the Kindle

This Christmas, I bought my wife, an unmitigated book-lover, a new Kindle 2 from Amazon. While she's a bit of a Luddite when it comes to technology, she has quickly become a believer - uploading three books at a time to bring with her on weekend trips. (She's even one of my three subscribers to this blog on the Kindle!) My only regret is hearing the soft "*click* ... (pause) ... *click*" in bed as she turns electronic pages at bedtime.

While hard copy books will still be great permanent reference sources, the plethora of fast-moving printed journals seem ripe for electronic disruption. I wouldn't be surprised to find that most journals as we know them eventually go the way of the dinosaur. As proof comes this from the ACC:

The Journal of the American College of Cardiology (JACC) will be available on the Amazon Kindle e-book reading device starting this March. JACC is the first cardiovascular journal on the Kindle platform and the second medical journal after the New England Journal of Medicine. Visit the Kindle store on amazon.com beginning on March 12 to order and learn more. Also, bring Kindle to ACC.10 in Atlanta to download the meeting abstracts and final program.

Welcome to the 21st Century!

-Wes

Dick vs. Bill

Bill Clinton gets chest pain, hits the hospital, gets a few stents and, voilà, is back at work. A veritable poster child for stents. No doubt JNJ stock climbed on the news.

On the flip side today: Dick Cheney gets chest pain, hits the hospital, and (I'll bet) he stays a while.

What do you mean, Dr. Wes? Can't cardiologist magically fix everything? Do a cath! Give him a stent! Cardiology is so slam bam thank you ma'am, isn't it? Heck, he's got an ICD! He's the bionic man!

Cardiology is easy until it isn't.

No doubt Mr. Cheney has had impecable cardiovacular care. But despite that care, after three bypasses, a history of atrial fibrillation, deep venous thrombosis, a cardiomyopathy that requires a defibrillator or two, and scores of medications to stabilize the angina - you've suddenly got a tough case. One thing's for sure, a re-do bypass is pretty much out of the question (he probably has limited vascular conduits left to borrow).

For the treating cardiologists hoping for an obvious target to angioplasty, I wouldn't be surprised the "target" vessel will not be so obvious to determine after his angiogram today. Look for a nuclear scan tomorrow to figure which wall of his heart is affected (yes, Congress, he'll get one of those all-too-often ordered i-m-a-g-i-n-g studies!). Then look for either a risky angioplasty atempt to improve his symptoms or a (more appropriate) "tuning" of his medication regimen that will take time.

Bill vs. Dick: it's not about Democrats vs. Republicans. Rather, it's about the multifasceted care required of the same disease in two different patients that demonstrates nicely how health care for the individual will never be adequately managed through cookbook means.

-Wes

Name Alert! Treating PE

My entire medical career "PE" used to be about a pulmonary affliction where a blood clot goes to the lungs: pulmonary embolus. Now, thanks to the power of marketing gurus who have little regard for medical nomenclature, there's a new "PE" in town involving the same organ as the heavily marketed malady, "ED."

Sheesh.

Talk about the yin and yang of urology...

-Wes

Using Videos to Help Consent Patients

Consenting patients for complicated procedures like atrial fibrillation ablation takes considerable time to do well and our facility might do things very differently than other institutions. To assure patients heard a consistent message and to help facilitate our visits with them, we decided to create a 9-minute video to supplement our discussions during our procedural consenting process. While our video was professionally produced (and the circles around my eyes disclose the time of day this was shot), no doubt a simpler video using a hand-held HD video camera and iMovie software on a MAC could provide similar results at lower cost.

In general, I think our patients have appreciated that they can view the video online at home or here in our office as often as desired. We also have burned copies to a DVD so the video can be viewed on a DVD player at home. While the work cannot be completely comprehensive, doesn't have subtitles, and includes only a single patient testimonial, it assures that we convey salient points consistently about what the patient can expect before, during, and immediately after their ablation procedure. Needless to say, they still must sign our standard surgical consent form before undergoing their procedure.

Writing the script for this video forced all three electrophysiologists in our group to agree on the video's content - no easy task as each of us came to this procedure with minor biases as to what were the most important aspects to convey - but this exercise helped us focus our message. Our ongoing challenge will be to update the video as new innovations or information become available in this fast-moving field.

We are not the first ones to use video consenting. Similar efforts have been a common theme in research, such as HIV, neurologic stimulation or chemotherapeutic studies. One trial in performed before arthroscopic procedures showed improved comprehension of information with video compared to standard consent forms. It is also interesting to note that there is an NIMH trial underway to study video consenting in patients with mental illness compared to standard methods.

Important disclaimer: For those contemplating catheter ablation of atrial fibrillation, this video might prove helpful to improve general understanding of the procedure but should not be construed as representative of how other centers perform the procedure nor as a comprehensive list of all of the risks, benefits, or alternative therapies involved in treating atrial fibrillation.

-Wes

Image reference: Jason Wolfe.

True Confession

I came across this picture of my desk just before we went "all in" with our electronic medical record six years ago:



It was a huge amount of work for our staff to organize and box all those old medical records that were sent off to a site unknown. I remember early on when we tried to get some old records after that happened. People just shrugged - no one had a clue how to retrieve them.

But you know what?

Now that we're farther away from that time, I can't say that I miss them.

Still, my current desk looks just as disorganized.

-Wes

Swiss Call Girls Offer Full Cardiovascular Services

... all in the name of satisfied customers who will hopefully live long enough to assure payment:

Prostitutes in the picturesque Swiss lakeside town of Lugano are adding defibrillation to their list of services following the death of several elderly punters whose hearts just couldn't take the pace.

According to the Corriere della Sera, there are currently 38 brothels and sex clubs in the Lugano area, and more are planned to accommodate the rising tide of customers who pop over the border from Italy.

For some, though, this proves to be a day trip too far. The most recent case was a pensioner who suffered a heart attack while enjoying Lugano's delights with the aid of "pharmaceutical assistance".

Looks like we've done a good job getting the message out on the benefits of automatic external defibrillators...

-Wes

h/t: @rlbates via Twitter.

How to Bring Health Care to Its Knees

... just infect hospital electronic medical record (EMR) systems with a worm:

Computer systems at the West Middlesex University Hospital NHS Trust were infected by the worm last Friday, leaving hospital staff unable to book appointments via computer. The outbreak has been contained but some hospital IT systems remain unavailable, resulting in ongoing delays to patients and affecting the smooth running of the medical facility.

A hospital spokeswoman told El Reg that the malware infection, identified as the Conficker-A, struck on Friday afternoon. "Most of the computers had to be cleaned, so we've had to rely on a pen and paper system to book appointments. Technicians worked over the weekend to clean up systems. Priority systems are running but the clean-up is likely to last until the end of the week."

The really scary thing is, today's medical personnel (newer doctors, nurses, residents, medical students, secretaries, lab technicians - the whole works) have no clue how to work a paper-based medical record any longer. Worse, there's no regular contingency plan in place should an EMR crash for over an hour.

But no worries, it'll never happen.

-Wes

Using Cow Manure to Say I Love You

Nothing says I love you like a pile of... well, cow manure (video).

If nothing else, you have to admire this farmer's creativity...

-Wes

Pacemakers and Defibrillators in the Dental Chair

Powerful magnets that can interfere with pacemakers and defibrillators can pop up in the strangest places, like dental chair headrests:

A few months ago, Boston Scientific, one of the major manufacturers of pacemakers/ICDs, added a new caution to their contraindications for dental patients. They warn that if a patient has a pacemaker/ICD, and the dental chair has a magnetic headrest with strength over 10 gauss, the patient should NOT sit in the chair.

The company states: “Some dental chairs contain magnets located in the headrest. If the pacemaker or defibrillator is programmed not to respond to a magnet, patients may sit in these chairs. If the implanted device is programmed to respond to a magnet and the magnet power is less than 10 gauss, patients may sit in these chairs. If the magnet power is greater than or equal to 10 gauss, patients should not sit in these chairs as the device function/programming may be affected.”

Allow me to explain. Magnet strength is measured in gauss units. The farther the distance from the magnet, the weaker the gauss reading, which means a weaker magnetic field. The magnets on dental chairs currently in use contain magnets with strength over 400 gauss. (Strengths vary slightly among manufacturers.) Therefore, sitting in the typical dental chair with a pacemaker/ICD, one would have to be five to six inches away from the magnet to be safe. Sometimes, however, dental professionals have trouble accessing certain parts of the mouth, and we ask patients to move up in the headrest, which is closer to the magnet. When we get too close to the magnet, the magnetic effect increases, and therefore, so does the potential for complications.

The linked article above does a good job giving a balanced review of this topic, so take a minute to read the whole thing.

-Wes

Reference: Boston Scientific's "Dental Equipment and Implantable Pacemakers and Defibrillators" white paper dated 2 Feb 2009.

Tapping Corporate Clients' Cadillac Plans

It's the new trend in mega health care center back-room deals:

Retailer Lowe's will offer its employees heart surgery at the Cleveland Clinic, under an alliance between the hospital in Ohio and the No. 2 home improvement chain.

Mooresville, N.C.-based Lowe's Cos. says the new benefit will provide full-time workers and their covered dependents with the "best of the best" in cardiac care, with lower out-of-pocket expenses than at other facilities.

Lowe's said Tuesday that it will cover all medical deductibles and co-payments for elective, prescheduled heart surgery at the Clinic, and will pay travel and lodging costs for the patient and a companion to go to Cleveland. Concierge services will be provided to make the trip arrangements.

Neither Lowe's nor the Cleveland Clinic released financial terms of their deal.

I'm sure that paying the insurance co-pays, deductible, airfare and accommodations as well as the cost of surgery will make the transfer of care to Cleveland Clinic more than cost effective to these lucky patients. Heck, they won't see a thing!

Remember the age old saying as we work to cut health care costs in America: "Hey, if it's free, it's for me!"

-Wes

Using the iPhone for Cardiology

It's being done:

An EKG is one tool used to diagnose various cardiovascular conditions, including a heart attack or heart failure.

Within two minutes the EKG technologist will have loaded the test results onto a secure Web site at the hospital, the Picture Archiving Communication System.

The cardiologist is able to log in to the system from anywhere there is Internet access, including mobile connections such as iPhone. In the past, if the cardiologist was not at the hospital the alternative was to await a fax showing the graph of the electrical waves.

Quintana said he predicts more physicians will begin using the iPhone to aid in diagnoses, but cautioned against abandoning traditional technologies; he recommended a combination of all available tools.

“The interpretation of an EKG is based on patterns,“ he said.

“The field of view on an iPhone is smaller, so there’s a limitation there. It’s good for a quick diagnosis, but it’s not the final answer.”

The use of mobile technology such as the iPhone in medicine is not limited to cardiology.

Hospital officials said obstetricians and gynecologists can purchase an application to view wave forms; radiologists may read X-ray images or magnetic-resonance images; and the iPhone can even be used at bedside to help patients identify which medications they take.

Despite it's obvious advantages, some centers have been slow to adapt this approach because of the iPhone's security concerns. Still, doctors can't get such practical uses for mobile devices fast enough. One only has to look at the advantages of being able to snap a picture of a rhythm strip or pathological lesion and paste it into a medical record or send the image to a specialist to see the power of applying this technology to improve patient care.

-Wes

Cardiology Cuts Taking Their Toll

From San Antonio, Texas:

More than 10 employees for this group have lost their jobs. More layoffs loom. More than half of cardiology patients are on Medicare, but some specialists may stop accepting new Medicare patients.

“At some point, doctors are going to tell their Medicare patients ‘you know, I really can’t afford to keep taking care of you,’” Rabinowitz predicted.

His practice is handing out a letter about its concerns to patients, using them to contact their Washington representatives, calling for action to sop what they consider devastating cuts.

Rabinowitz predicts patient waits for visits will be longer and the visits themselves much shorter as doctors try to fit in more patients to make up for lost income. At the heart of the matter is an uncertain future for private cardiologists.

“It’s not really my choice,” Rabinowitz said. “It’s not my preference to start practicing like that. But I’m being forced to practice like that because otherwise, I’ll be out of business and I won’t be practicing at all.”

To think that cuts of this magnitude won't impact the quality of seniors' cardiovascular care in communities across the country is magical thinking.

-Wes

The Risks of Hospitals Live-Tweeting Surgeries

Should hospitals send twitter "updates" on patients undergoing complicated catheter ablation procedures using "pre-approved" scripted story lines?

In a far corner of the operating room Thursday, a Web producer and a cardiac expert with St. Vincent’s huddled over a laptop. They chronicled the procedure largely from a script that Oza had signed off on a day earlier.

The procedure uses radio frequencies to scar parts of the heart. The scars block signals sent from a quartet of veins in the left atrium, signals that cause the heart to go haywire. The entire procedure is done using a catheter inserted into a patient’s groin while the patient is anesthetized.

Given several hours of time to fill and only a page and a half of script, Candy Bowen, the Web producer, sprinkled in descriptions about atrial fibrillation and gave health tips. Meanwhile, in the waiting room, Peacock’s family watched the updates on a wide-screen television.

“It’s some reassurance that everything’s going well,” Melissa Peacock said.

A few minutes before 6 p.m., this message popped up on Twitter: “Mr. P says Hi, and is responsive.” And then a minute later: “Mr. P has been informed that his family has been updated. And he’s smiling.”

I'm all for education using social networking, but when doctors and technicians tweet live (even if it's scripted), they risk appearing more concerned about their marketing efforts than the patient's well-being. If a complication ever arose in such a situation, what would happen? Would the world be updated? What about the family watching the tweets on television as a doctor returns to explain what really happened during the procedure?

One only has to look back at the problems a formerly anonymous doctor blogger encountered when his identity was revealed in court during a malpractice trial and the contents of his blog than might have been used against him in court. He settled.

As trendy as tweeting "live" surgical procedures might seem, I fail to see how this benefits the patient undergoing surgery at all. Education of a surgical procedure can always occur before or after a procedure. If a complication were to arise during a live-tweeted or scripted-tweet surgery, the responsible doctor and hospital might ultimately find themselves in the very uncomfortable position of having to explain their actions to a jury.

-Wes

The Carrot and the Stick

It's an age-old problem, made more complicated by our new era of electronic medical records: optimizing collections in a time of unprecedented price pressures on our health care complex. With the economic downturn and declining government payments for services, everyone in health care is feeling the pinch.

It is no secret that work not billed will ultimately be work not paid. Hospitals and practice managers, adept at business principles, know this. Deep down inside, doctors know this, too. Historically, doctors dictated when they billed their patients, even if it meant waiting over a week to do so. If a doctor was to take a vacation, some of those billings could wait until his return.

Not so any longer.

As doctors surrender their autonomy to hospital systems with electronic medical records (EMR), more and more pressure is placed on them to complete electronic transactions in a timely fashion. Bills submitted to insurers simply must have all of the necessary data up front when submitted electronically, lest the have a high coefficient of elasticity and bounce back for revision before being paid. The EMR is incredibly savvy at tracking how many patient encounters are left open, for how long, and by whom. Daily reports are generated and performance tracked by administrators. Some doctors blend into the this computer-driven workflow naturally and are timely at completing records. Others are less so, accumulating open encounters for a period of time before sitting down to complete their documentation at a later date.

But delays in closing records has plenty of implications for patient care. For one, other providers can't see what the managing doctor's thought processes were during the patient's visit since their note does not appear "publicly" until the encounter is "closed" electronically. Tests that return before the note was completed might also be difficult to interpret based on the discussions held with the patient. Finally, there is a limit of how long Medicare or other insurers will permit claims to be submitted to assure payment for services rendered. In short, the clinical and financial log jam is significant when such delays to electronic documentation occur.

Physician and administrative leadership must assure timely documentation of patient visits and test results. To do so, a number of methods are tried, the most common being gentle reminders in person or by e-mail: a "carrot" of sorts. But when these fail, a more stern warning might be issued and if not completed, a stick can be levied not previously known to doctors: fines that must be paid on a per-open chart basis. Suddenly, documentation on a computer takes on new importance that supersedes future patient care until charts are completed. Invariably, this gets peoples' attention. In effect, the stick works.

Now if a reasonable time frame is allowed before the stick descends, even the most reticent of doctors can live with this approach. They understand the need for timely documentation. But how long should the grace period for chart completions or verifying test results be? One, three, five, seven, ten or fourteen days? Too long and finances and patient care lags. Too short, then doctors who do not reside at a computer terminal 24/7/365 will be unduly penalized for doing what they should be doing: talking to and examining patients, placing hands in and on patients, traveling between care facilities, rounding on wards or teaching students and the like. Further, if penalties are imposed after periods that are too short, the implicit (but never stated) expectation is that notes will be completed on-line after hours when the doctor is home or even on vacation.

Increasingly with financial and health care cycles shortening, it is clear that with improved "efficiencies" in health care delivery and billing practices inherent to EMR systems, increased pressure is being placed on doctors to stay connected to the EMR system - even with fines - that has little respect for physicians' personal lives or geographic location.

-Wes

For Love or Insurance

For this 45 year-old decently divorced woman with C4 complement deficiency, marriage is for insurance.

-Wes

TV spot: NBC5 Chicago Web Sights, 9 Feb 2009

How Technology Is Straining the Doctor-Patient Relationship

Technology is an incredible thing.
Technology is expensive.

Technology saves lives.
Technology can bankrupt.

When there's no technology, are you a "bad" doctor for not following guidelines?
When technology's used, are you a "bad" doctor because the patient has multiple comorbidities and the benefit for the implanted technology is questionable?

It's become the yin and yang of medicine. An inconvenient truth.

Medicine's technology is incredibly expensive, but incredibly valuable.

But if the struggle isn't enough, along comes the press to skew the debate by "raising awareness" with our patients.

Doctor, you need to "Get with the Guidelines." The subtitle with such an industry-sponsored trial and press report should be, "Oh, and business is off."

The journal article at the heart of the Chicago Tribune piece (referenced below) suggests the underpenetrated market of defibrillators (ICDs) was partially caused by three factors:

Adjusted analyses revealed lack of adherence for ICD use most notably with advancing age (odds ratio: 0.87; 95% confidence interval: 0.82 to 0.93 per 10 years), black race (odds ratio: 0.75; 95% confidence interval: 0.60 to 0.94), and lack of insurance (odds ratio: 0.45; 95% confidence interval: 0.26 to 0.78).

But other factors exist, they claim, like geography and available expertise:

Practices in the Northeast U.S. were more likely to adhere to guidelines (P <.001), as were those with a dedicated HF clinic (P = .004) and electrophysiologists on staff (P <.001).

These data are indeed valuable, even for an industry-sponsored trial. But patients should be aware that six of these devices must be implanted to save one life in properly selected populations of patients. Not to say that the cost-effectiveness of this approach hasn't been extensively reviewed, it has. But referring doctors and patients have also been barraged with the problems with these technologies. No doubt the chart reviews in the study cited probably didn't account for the rash of recalls whose influence continues today.

We must also place a jaded eye at the manufacturer's earlier press release about this trial that 35,000 charts had been reviewed, rather than less than half of that (15,381). Small error? Not so much.

Medicine is a complicated, non-linear profession. But as patients continue to shoulder more of their health care bills, doctors are finding themselves in the increasingly difficult position of recommending very expensive life-saving technology that might bankrupt their patients. Unless industry acknowledges that very real price pressures are straining this doctor-patient relationship, there will remain a reluctance to completely "Get With the Guidelines" and implant the technology, even when doing so stands to benefit the doctor.

-Wes

Ref: Evidence of clinical practice heterogeneity in the use of implantable cardioverter-defibrillators in heart failure and post–myocardial infarction left ventricular dysfunction: Findings from IMPROVE HF. HeartRhythm Dec 2009, 6(12), Pp 1727-1734.

Anatomically Correct Gifts for Everyone on Valentine's Day

For your ex-, consider this giant bleeding gummy heart candy or maybe some of these chocolate hearts from "Pushin' Daisies."

For your sweetheart, though, it's probably better to stick with this heart locket that opens to reveal the heart's four chambers.

Me? Well, the abstract has appeal and for that, I'm leaning toward getting one of these t-shirts. The only problem is, the shirt's probably better for those interventional cardiology "plumber" types.

-Wes

European Health Care Ingenuity

You gotta love those Brits:

An oil worker who was flown to Lerwick from an offshore platform after suffering a heart attack had to be taken the final mile to hospital in a rented van because no ambulances were available.

The man was flown by the Sumburgh-based coastguard helicopter from the Heather Alpha platform, 92 miles north-east of Sumburgh, at around 6am on Tuesday morning. However, the helicopter crew waited half an hour for an ambulance which failed to arrive at the scene.

The patient was eventually transferred to the Gilbert Bain Hospital in the back of a Star-Rent-A-Car van, which arrived with a doctor behind the wheel.

A paramedic, who had been flying in the helicopter, went with the patient to the hospital where his condition was said to be stable and comfortable.

No wonder their health care costs are so low.

-Wes

When Kids Have Skin in the Game

Somehow, I like the message for Jump Rope for Heart much more than Go Red for Women campaign:

“I’m very proud of everyone who has collected and helped save lives,” McLaughlin said.

 Forty-five students, the most ever, collected donations. Although there were prizes for raising money, many students told their teacher they wanted to help people.

 “I had students say, ‘I’m not doing this for the prizes. I’m doing it to help people,’” he said. “I told them, that is a great attitude.

 “I couldn’t be more proud of them in these tough economic times.”

To me,that's what it's all about.

Nice job, kids!

-Wes

When Doctors Play Sherlock Holmes

"Could you tell me which medications you're taking?"

"Um, I'm not sure doctor, but I brought all of them with me."

"Great! Can I see the bottles?"

"Um. Here they are:"



"Thanks," (said without blinking an eye), "Now, what do you take these for?...."

-Wes

Illinois Supreme Court Strikes Down Medical Malpractice Caps

From Crain's Chicago Business:

The Illinois Supreme Court on Thursday struck down limits on jury awards in medical malpractice cases passed by the Legislature four years ago amid spiking liability costs for medical providers.

The court ruled that the caps on pain and suffering and other non-economic damages — $500,000 per case for doctors and $1 million for hospitals — are unconstitutional.

The court’s opinion upholds a 2007 ruling by a Cook County Circuit Court judge determining that the law violated the Illinois Constitution’s “separation of powers” clause, essentially finding that lawmakers interfered with the right of juries to determine fair damages.

It’s the third time the state’s high court has quashed limits on medical malpractice awards, having tossed out similar laws in 1976 and 1997.

The ruling is a blow to physicians, hospitals and malpractice insurers, who successfully argued in 2005 that frivolous lawsuits and runaway jury verdicts were driving up insurance rates and forcing physicians to leave the state.

Another blow to health care tort reform...

-Wes

Why Credentials?

Today, the ongoing turf war between nurse anesthetists and anesthesiologists was reported in the Wall Street Journal:

Gov. Arnold Schwarzenegger decided last year to allow nurse anesthetists in California to work without a supervising physician. Now two doctors’ groups are challenging the move in court, according to HealthLeaders Media.

The fight centers over 2001 Medicare rules that usually require a doctor to supervise when nurses administer anesthesia, but allow states to op out of the requirement if a governor sends a letter to the feds. California did that in June.

Needless to say, the anesthesiology community was not too happy and filed suit to block the decree.

But we must ask ourselves, where are the credentialling bodies in this debate?

On an recurring basis, doctors must obtain continuing medical education credits and pay large sums to state regulators to remain licensed to practice medicine in a state. The process involves validation of license to practice, education/training, malpractice coverage and claims history, DEA/CDS certificates, hospital privileges and whether or not the physician or healthcare professional has been sanctioned.

So when states want to replace doctors with nurse anesthetists, where are the credentialling bodies in this discussion? Don't such moves by politicians in the name of cost savings make the whole physician credentialling immaterial?

We already know that very few states legally protect the term "board certified" as having relevance to creditialling physicians, and the current efforts by a state governor to permit others not subject to similar review and standards to provide medical care makes a mockery of the entire physician credentialling process.

Hey, but at least not having to have all pay those licensing fees and education course fees would save everyone money.

-Wes

The New Health Care Crisis: Dueling Burger Joints

Heart Stoppers Sports Bar versus Heart Attack Grill:

A bed pan full of Cheese Chest Pain Fries is just one of several medically themed items on the menu here at Heart Stoppers Sports Grill in Delray Beach.

Anyone 350 pounds or over gets a free meal. Owner and Paramedic Iggy Lena came up with the idea.

The challenge burger is three pounds. And those who fail ... well, there's a special place for them here...the morgue!

But not everyone is laughing.

The owners of Heart Attack Grill in Chandler, Arizona filed a federal lawsuit.

Their lawyer says Heartstoppers is using many of the medical theme elements that heart attack originated.

Lena's attorney says the two restaurants have separate concepts. The restaurant in Arizona uses high choloric food as a gimmick and here in Delray Beach, they focus on medical themed equipment with something on the menu for everyone, vegetarians, young and old.

The lawsuit was filed last week.

God bless America.

-Wes

The Media, Robotics and Atrial Fibrillation Ablation

The NBC Today Show aired a segment on the Stereotaxis robotic system for performing catheter ablation of atrial fibrillation using magnetically-steered ablation catheters yesterday (video here). It sure generated a lot of buzz around our hospital. While I share the reporters enthusiasm for all the gadgets and gizmos (what doctor-engineer wouldn't like such neat toys?) the enthusiasm should be tempered with a strong dose of reality regarding this technology and any atrial fibrillation procedure.

First is the claim that the patient will be cured with "85-90%" certainty. While these success rates have been reported using this technology for the much simpler atrial flutter ablation, this level of success has not been substantiated in meta analyses of atrial fibrillation ablation studies to date:

The efficacy of AF ablation is largely influenced by a number of factors that include the following: operator experience, volume of ablations, type of cases ablated, to name a few. Nonrandomized trials document a wide variance in the efficacy of AF ablation. In the setting of paroxysmal AF, the efficacy of a single procedure ranges from 38% to 78%, with most series reporting an efficacy of 60% or more. The efficacy reported in persistent AF ranges from 22% to 45%, with most centers reporting an efficacy of 30% or less.

Certainly, patients with intermittent atrial fibrillation typically do better than those with chronic atrial fibrillation, but we are not privy to the number of procedures a patient has to undergo to achieve the success rate suggested by the physician operator in this news segment.

It is also interesting that we learn little of the limitations of robotic navigation using magnets previously reported in the literature:

Using the coordinate approach, the target location was reached in only 60% of the sites, whereas by using the wand approach 100% of the sites could be reached. After step 2 ablation, only 1 PV in 4 patients (8%) could be electrically isolated. Charring on the ablation catheter tip was seen in 15 (33%) of the cases. In 23 patients, all PVs were isolated with the conventional thermocool catheter, and in 22 patients only the right PVs were isolated with the conventional catheter. After a mean follow-up period of 11 ± 2 months, recurrence was seen in 5 patients (22%) with complete PVAI and in 20 patients (90%) with incomplete PVAI.

Admittedly, the data regarding char formation on the ablation catheter were presented before the approval of irrigated-tip ablation catheters less prone to coagulum formation that are used more recently, but few data have been published. But we recall that the reporter makes a huge claim that moving the catheter with the magnets is more "precise," using the analogy that "it's like trying to write on a piece of paper with a pencil using the eraser..." The above data dispute these accuracy claims. Further, she conveniently ignores the errors in catheter placement inherent to the patient's respiration or from the movement of the heart itself. Also, we hear little of the additional time involved in moving a catheter with a magnet versus the hand.

While robotics might help the operator's back and help reduce radiation exposure during the procedure, I am aware of no data that supports the superiority of robotics to achieve success with better safety or accuracy with atrial fibrillation ablation over more conventional manual approaches. Further, long-term data regarding success rates of this technology for catheter ablation in atrial fibrillation have yet to appear to any large extent in peer-reviewed journals.

-Wes

Disclaimer: I have no industry ties with Stereotaxis or other robotic atrial fibrillation ablation systems.

Addendum 3 Feb 2009 11:30 am CST: An even more scathing review of the journalistic tactics used for this piece appear at Cardiobrief.org.

Grand Rounds is Up (Along With the Groundhogs)

... over at Dr. Rob's place at Musings of a Distractible Mind.

-Wes

Why Canadian Health Care Is So Great

... because the Canadian Premier can still come to the US for heart surgery.

-Wes

The New Commodity on E-bay: Used Cardiac Ultrasound Probes

At nearly a $500-$1000 a pop when auctioned on E-bay, used phased-array cardiac ultrasound probes have recently become a hot commodity for theft in our local hospitals. This poses big problems when they're needed urgently in the electrophysiology or cardiac catheterization laboratories.

Be warned.

-Wes

Happy Heart Month!

Yes, folks, February is heart month - you know, Valentine's Day and all. (I love it when a marketing plan comes together!)

No doubt you'll be hearing plenty about the American Heart Association's "Go Red for Women" campaign that kicks off Friday, February 5th, but don't forget, just like last year: Go Red's still for men, too.

So guys, make sure you wear your red boxer shorts every day this month and get out there and purchase stuff, okay?

-Wes

Hospital Monopolies Get Pushback

From the AMA Medical News:

A Peoria, Ill., ambulatory surgery center will get its chance to try to prove allegations that the dominant area hospital improperly manipulated an exclusive contract with an employer health plan to edge the surgicenter out of the market. Without addressing the case's merits, the U.S. District Court for the Central District of Illinois on Dec. 30, 2009, allowed Peoria Day Surgery Center's antitrust lawsuit to proceed to trial. The court said it heard enough evidence that OSF Saint Francis Medical Center's actions could harm local competition and, ultimately, health care access. The trial is expected to begin March 8.

It is no secret that monopolies can lead to higher health care costs, but how that occurs is interesting. From a report by the Attorney General of one of the highest health care cost states in the US, Massachusetts:

... our preliminary review has revealed serious system-wide failings in the commercial health care marketplace which, if unaddressed, imperil access to affordable, quality health care. In brief, our investigation has shown:

1. Prices paid by health insurance companies to hospitals and physician groups vary significantly within the same geographic area and amongst providers offering similar levels of service.



2. Price variations are not correlated to (1) quality of care, (2) the sickness or complexity of the population being served, (3) the extent to which a provider is responsible for caring for a large portion of patients on Medicare or Medicaid, or (4) whether a provider is an academic teaching or research facility. Moreover, (5) price variations are not adequately explained by differences in hospital costs of delivering similar services at similar facilities.



3. Price variations are correlated to market leverage as measured by the relative market position of the hospital or provider group compared with other hospitals or provider groups within a geographic region or within a group of academic medical centers.



4. Variation in total medical expenses on a per member per month basis is not correlated to the methodology used to pay for health care, with total medical expenses sometimes higher for globally paid providers than for providers paid on a fee-for-service basis.



5. Price increases, not increases in utilization, caused most of the increases in health care costs during the past few years in Massachusetts.



6. The commercial health care marketplace has been distorted by contracting practices that reinforce and perpetuate disparities in pricing.

Not to say that adding a single doctor-owned surgery center is going to change downstate health care pricing much since patients remain sheltered from what is actually being paid by insurers for their surgical procedures. But as patients bear a increasingly larger portion of their health care costs, demands for transparency of pricing for elective procedures will mount. Further, as long as competition between centers exists, the wanton nature of health care service price increases by hospitals who monopolize markets has at least a snowball's chance in hell of slowing.

But then again, I'm sure that the Massachusetts AG's finding doesn't pertain to other areas in the United States...

-Wes

h/t: WSJ Health Blog