Grand Rounds is Up

... over at Moneduloides:

Welcome to Grand Rounds 5.15: At the interface of evolution and medicine, a celebration of blogging on the myriad ways evolutionary biology influences medicine. Why evolution and medicine, you may ask? Why now? Well, in anticipation of the new year, of course; 2009 marks the bicentenary of Darwin’s birth, and the 150th anniversary of the publication of On The Origin of Species, and the one thing that just doesn’t get as much recognition as it should is the role of evolutionary biology in both research and clinical medicine.

Heady stuff and relatively short since the editor was brave to include only pertinent posts.

-Wes

A New Year's Gift

* ding dong *

"Who could that be at the front door? It's dinnertime," I asked.

"I'll get it!" my son said, rushing to the door. ("Strange, he's never moved this fast before, " I thought.)

A few momemnts later...

"Awesome! It came!" He entered the room with a package.

"Dad, do you know where there's some batteries?"

"Uh, I think there's some in the top drawer over there... why?"

A few moments later. He appeared with a new t-shirt on. Not just any t-shirt, mind you, but one upon which he could play the drums. I kid you not. Here, check it out.

File this under "what will they think of next."
(Be sure to play the video on their site to get the whole effect)

Heh.

-Wes

More Alphabet Soup

"ACC/AHA/ACR/ASE/ASNC/HRS/NASCI/RSNA/SAIP/SCAI/SCCT/SCMR/SIR 2008 Key Data Elements and Definitions for Cardiac Imaging"

I could not make those initials up. This was the title of the recently published paper in the Journal of the American College of Cardiology from the writing committee organized to develop clinical data standards for cardiac imaging.

Translation:
ACC = American College of Cardiology
AHA = American Heart Association
ACR = American College of Radiology
ASE = American Society of Echocardiography
ASNC = American Society of Nuclear Cardiology
HRS = Heart Rhythm Society
NASCI = North American Society for Cardiovascular Imaging
RSNA = Radiological Society of North America
SAIP = Society for Atherosclerosis Imaging and Prevention
SCAI = Society for Cardiovascular Angiography and Interventions
SCCT = Society of Cardiovascular Computed Tomography
SCMR = Society for Cardiovascular Magnetic Resonance
SIR = Society of Intervential Radiology

Wow, that's a tour-de-force of cardiac imaging specialists.* These are smart men and women who understand how the Medicare payment game is paid played. They understand that data, lots and lots of data, in fact, so much data that your head will spin, is the way to assure Medicare payment. In short: gather lots and lots of data, any way you can, to assure the folks on the Hill that you are really serious about showing the cost effectiveness of all of this testing:

The ACC and AHA recognize the importance of the use of clinical data standards for patient management, to assess outcomes, and conduct research, and the importance of defining the processes and outcomes of clinical care, whether in randomized trials, observational studies, registries, or quality improvement initiatives. Hence, clinical data standards strive to define and standardize data relevant to clinical topics in cardiology, with the primary goal of assisting data collection by providing a platform of data elements and definitions applicable to various conditions. Broad agreement on a common vocabulary with reliable definitions used by all is vital to pool and/or compare data across studies and assess the applicability of research to clinical practice. The growing adoption of electronic medical records renders an even more imperative and urgent need for such definitions and standards. Therefore, the ACC and AHA have undertaken the task of defining and disseminating clinical data standards—sets of standardized data elements and corresponding definitions to collect data relevant to cardiovascular conditions. The ultimate purpose of clinical data standards is to contribute to the infrastructure necessary for accomplishing the ACC/AHA’s mission of fostering optimal cardiovascular care and disease prevention.

On the surface, these efforts seem like the best way to begin to get a handle on the cost-effectiveness of cardiac testing. No doubt the shear volume of data generated will be heretofore unmatched and a rich source of research grants for academe for years to come.

But tied to each of these data element sets created for every cardiac imaging test, is the requirement to include as an "administrative" data element the patient's insurance information. The writing group explains this data-element necessity as a means to "foster optimal cardiovascular care and disease prevention" because:

The insurance payer element was included to be certain that patients of all payer status were included in studies equitably, especially those funded federally (ed: emphasis mine). The inclusion of this data was not to in any way suggest that cardiac imaging patients should be screened on the basis of ability to pay.

Yep, it's all to justify to the Medicare National Bank that, yes sir, we really DID need this test. While the test might be ordered irrespective of the ability of the patient to pay as the writing committee suggests, for the first time we will be granting insurers direct automated line-item access to clinical information and the test results. The implications of this are concerning.

Imagine, line item data on your renal function, ejection fraction, stress test results, cardiac risk factor analysis - all instantly available to an insurance company's computer database and conveniently entered unwittingly by the echocardiography clerical staff in the hospital of your choice. Imagine the next time you then go to purchase insurance. Best of luck to you.

Or imagine you are a doctor without an electronic medical record and ordering system - best of luck to you as you complete the test-request form that will soon look more formidable than the MCAT bubble answer sheet used to qualify for medical school. Remember to use a number 2 pencil.

Or consider if a clerical error is made during data entry: what recourse will you have? Will you have the option of editing the data entered to assure insurer payment for the test they claim was not appropriate because four data fields were left blank? "Sorry Mr. Jones, on the basis of a creatinine of 1.6, and four empty data fields on the ordering questionnaire, this test should not have been ordered, so * b-o-o-i-i-n-n-g-g *, we're not going to pay for that test after all."

But in this era of "evidenced-based medicine," these convoluted, complicated, and thoughtfully-produced-but-arbitrary data forms (Note: 20 pages were devoted in the article just for the medical history fields alone. And what is an "equivocal" test anyway?) are being feverishly developed by these cardiac imaging societies. They must justify continued testing and Medicare payments on the basis of a promise of future as-yet-undeveloped studies based on retrospective utilization data completed by the non-medical clerks at the time of test ordering. And thanks to hoards of well-meaning academics that are eager to secure more grant funding, this same dubious retrospective data will soon serve as paradigms upon which our treatment and further testing "guidelines" will be based.

But retrospective data collection like this is far easier and less expensive to gather rather than a prospective, randomized trial. Who needs those?

Heck, I guess I should stop complaining.

After all, I am a cardiologist.

-Wes

* The conflicts of interest of the authors of this document warrant notice. They are not insignificant - so much so that the article reviewers conflicts were also disclosed as an appendix to reassure a more "non-biased" critical review of paper occurred.

Reference:

"ACC/AHA/ACR/ASE/ASNC/HRS/NASCI/RSNA/SAIP/SCAI/SCCT/SCMR/SIR 2008 Key Data Elements and Definitions for Cardiac Imaging." J Am Coll Cardiol, 2009; 53:91-124, doi:10.1016/j.jacc.2008.09.006 (Published online 8 December 2008).

Heard Over Dinner

"My Dad loves Medicare! Heck, there isn't a test he doesn't like! It seems as he gets older that's he and his wife can think about. Once he had a pain in his butt and his doctor ordered an MRI just to tell him what he already suspected: that he pulled a muscle. And to think he didn't have to pay a thing..."

Yep. No wonder everyone wants government-run health care - it's the bomb!

-Wes

All-Star JailHouse Rock

Brilliant and courtesy of Parady and Son.

-Wes

90 is the New 80

A new milestone was recently reached: a man living 112 years.

It used to be eighty-year-olds were the most common people in the hospital. Maybe it's me, but the the ninety-year-olds seem to be supplanting the eighty-year-olds these days in hospitals.

That's because their 70-something-year-old kids can no longer take care of them.

-Wes

On Young Women, Heart Attacks and Denial

I read this article that appears in the Chicago Tribune today about a 27 year-old woman who reportedly had a "heart attack." I'm not sure what the point of the story really was - perhaps to wake up young women that heart attacks can occur in their demographic - and if so, well, fine.

But there is another, more sinister tone in the article: one that doctors should not be trusted and are mostly interpersonal buffoons. Nowhere is there a thoughtful discussion about the potential causes of why a young woman might have a heart attack, like spontaneous coronary dissection, paradoxical embolis, congenital coronary anomalies or familial hyperlipidemias. Nowhere do we hear from the doctors who interacted with this patient. No, that would require some thought and journalistic background analysis.

Instead we are greeted, once again, to only the patient's perspective: "If your doctor won't listen, fire him and find one who will."

To that, I say, remember the case of Hank Gathers - a young basketball star with exercise-induced ventricular tachycardia and hypertrophic cardiomyopathy who was presribed beta blockers and advised not to play competetive sports. But he didn't like what the first doctors had to say to him. Instead, he "fired" his doctors and shopped around for another doctor who "listened" to him.

The rest, as they say, is history: Hank Gathers ultimately died of sudden cardiac arrest playing the game he loved.

Sometimes, doctors don't listen, that is true. Overburdened by higher patient volumes, more documentation requirements, and reduced compensation models in health care today, doctors are pressed like never before to do more with less time. Listening to patients sometimes takes a back seat to these demands. But patients, too, increasingly expect that they know what's best for them - after all they read it on the internet - and don't hear what their doctor says, or they ignore their advice completely.

Believe it or not, sometimes patients need to realize they have a role in their health care, too.

Even when the advice isn't what they want to hear.

-Wes

Health Care Information Giants Like the Auto Industry?

Rick Peters, MD over at The Health Care Blog thinks so, describing them as "a few large players who build big, expensive systems on outdated technology platforms."

Ouch.

-Wes

h/t: Dr. Bobbs via Health Care BS.

The Fat Tax

Beware, it's coming to economically strapped city councils near you: the fat tax.

-Wes

h/t: Instapundit

Silos

Driving in the Midwest, one cannot help but be impressed at the vast expanses of seemingly endless terrain on the prairie where heaven and earth meet without a tree or a structure separating them. You can drive for miles and look with wonder at the emptiness of it all - a strange beauty all its own. Only occasionally, the scene is interrupted by silos - tall, monolithic structures that stretch perpendicular to the horizon as they punch through the sight line to touch the clouds. Beautiful in their own right, they help interrupt the monotony of the drive but are only seen rarely, making their presence all the more appreciated.

The silos house grain that has been carefully gathered by the farmers and stored to later sell at market or to feed the livestock, especially in leaner times. Not only do they house the grain, they also permit it time to dry properly for later sale on the commodities market. Silos serve as an invaluable resource to farmers and cost them a hefty investment to install.

Eventually, though, the grain must leave the silo on its way to the commodities markets or to the cattle to ready them for the next batch of grain. The strategically-placed silos efficiently fill the train cars or trucks parked before them. In good times, the farmer can make a hefty profit from his grain and reinvest it into more fields and building another silo, usually near the last. If the farmer works hard and remains profitable, a cluster of silos eventually appears. Through such acquisitions the farmer's profits grow. Eventually, however, the farmer's land expands to touch a neighboring farm with its own shining silos.

To continue to grow, competition for land becomes paramount to survival for grain is the commodity that generates the capital required for growth. Either one farmer must buy the land of his competitor or a large fence must be erected between properties as each farmer weighs his options.

But what if a cow on one side of the fence closest to the competing farm wanted some of the grain from the silo of a neighboring farm? Could he get it?

Not easily. The silos have come too valuable to each farmer as they raise their separate herd of cows. Sprinkling grain across the fence would place one farmer at a distinct disadvantage over the other. But the reason the competing cows are told they cannot get the grain? Because the grain's privacy might be compromised and if it touched the ground it might not be safe to eat.

And so, the competing cows are left to create their own new grain to be grown on their own side of the fence.

And so it is with our current iteration of developing electronic medical records: huge information silos of vital information hoarded by the farmers and never simply shared with neighboring cows.

-Wes

Photo by Cindy47452.

Merry Christmas!

I made saw a few patients, read some Holters, and then came home his afternoon to two kids working feverishly in the front yard. Excited, they exclaimed, "Look, it's Santa and his reindeer!"

Careful inspection disclosed a moderately obese male, looking younger than his stated age without a palpable pulse, axillary temperature of 32 degrees and no discernable blood pressure nor respirations. Nonetheless, it was clear the instruments most have been malfunctioning, because the patient and his companion looked very real indeed, one with a carrot nose and the other with a cherry-tomato nose. Clearly, the spirit of Christmas is very luch alive!

Click image to enlarge

Merry Christmas to all the patients, friends, colleagues and loyal readers of this blog. May you have the healthiest and happiest of holidays.

-Wes

Angels

It was a day like any other, time spent in front of the television, relaxing. He sat on the sofa after she had put the kids to sleep. She returned to the large recliner and put her feet up on the ataman as she browsed their movie selections. With the dishes done, they settled back, chose a film, and each breathed a large sigh.

They’d been soul-mates since high school: married for 15 years. They had grown comfortable with each others’ idiosyncrasies and limitations, but they always worked things out for the better. Now, in a moment of peace, they were content as one more day was coming to a close. And yet, as is the case with life’s great unknowns, they had no idea it was the calm before the storm.

As a commercial aired she heard something. She had never heard that sound before. Was it gurgling? She looked over at him. He stared blankly. “John, knock it off. That’s so inappropriate,” she said. The sound grew louder. He did not respond. “John, come on, that’s not funny.” Then he collapsed to the floor.

Instinctively, she rolled him on his back, panicked. “John? John? Dammit, John, wake the hell up!” He was turning blue. She ran to the phone and dialed 911.

“911, how may I help you?”

“My husband just fell to the floor – he’s not breathing! He’s blue! I think he’s had a cardiac arrest! Please, send an ambulance to 123 Main Street NOW! PLEASE!”

“I’ll send an ambulance right away. Do you need help with how to do CPR?” She dropped the phone and dashed back to him.

She started pressing. “Dammit, John, come on!” She kept pressing. Then she realized: the front door was locked. She jumped up and unlocked it, then returned to him, pressing. She wondered, “Should I wake the kids? Oh my God, please, not now! Keep pressing.” Moments later she heard the sirens. “Thank God! Come on, John! Hang in there!” she thought. She kept pressing. She could see the lights now as their iridescent flashes brightened, then darkened, the room. She could hear the squawk of the radio as they came in. They saw her sweating, pale with adrenaline. “Thank God!” she said.

One of the men opened their bag. Someone tore open his shirt. Stickers. Tubing. Patches with wires. The machine said something. They stopped. Why? She saw her husband’s body jerk slightly. They waited. A faint green line moved. Slowly at first. Then accelerated. They checked his leg. It was faint, but present.

“I think there’s a pulse!” Another man stood at his head with a silver instrument. Another man moved her away. “He’s putting a tube in to help him breath,” he explained. Things were a blur now. Tape, fluids, radios for assistance. Calls to others, more people arriving. “Seventy-eight over forty,” she heard them say. A cart entered the living room. They lifted him together. He wasn’t moving.

All too soon, he was gone.

She stood, shocked. People asking questions, she answered, but didn’t know what she said. “Will be be okay?” she thought. “Did I do enough? Where’s he going? My God, the kids! What will I do?” She called her best friend for help, for someone to help with the kids. “I think they’re taking him to General,” she told her.

“I'll be right over.”

* * *

He had woken the third day after 24 hours of medically-induced hypothermic coma. At first, he moved his leg, then his head and arms, then moved quickly to try to pull the tube from his throat as he opened his eyes. The next day the tube was out, he spoke to her, smiled, and asked what had happened. He soon knew how lucky he was. He squeezed her hand.

She held back tears and smiled.

Two weeks later, he received his defibrillator and returned home to the kids. It was snowing soft flakes. The house glowed with Christmas lights placed there by the neighbors. A nativity had been placed above the fire place. They stopped and took it all in as they hugged and gave thanks nervously. Uncertainty remained but they knew they were still together for a reason.

Angel after incredible angel.

All smiling.

-Wes

Bit

Look for this clever detective work on next season's "CSI-Finland:"

Sakari Palomaeki, the police inspector in charge of the case, said it was the first time Finnish police had used an insect to solve a crime.

"It is not usual to use mosquitoes. In training we were not told to keep an eye on mosquitoes at crime scenes," he said.

-Wes

"Care Integration"

Is this just another name for buying physician practices - even those across state lines?

I really don't think so.

Why?

Look how this is marketed:

...could allow Prairie to expand its cardiology services to Wisconsin, as well as parts of central and southern Illinois where Prairie doctors don’t currently visit or maintain offices...

...better able to thrive financially amid major changes in how the federal government and private insurers pay for health care...

“We are enhancing the future of health care for our patients and their families by working collaboratively with physicians to make the delivery of medicine more efficient and more structured around them, with their best interests being the highest priority.”

...to become more efficient...

...work more closely to improve care.

...Multiyear efforts to reduce waste as part of the care-integration plan will include “operational efficiencies in hospitals and clinics” and “better use of best practices in medicine,” according to HSHS. The plan doesn’t call for any job cuts, said Dave Urbanek, a heath system spokesman.

So what, really, is "care integration" that promises such efficiencies?

It's nothing more than the electronic medical record.

Or more specifically, an electronic medical record tied to accounts receivable software and credit checking.

Thanks to exhorbitant costs of implementing EMRs in physician practices, the Medicare requirements for billing and prescribing electronically, and the prohibitive documentation requirements mandated by CMS in the name of "quality," independent physician practices of all types will have no choice but capitulate to larger entities that have a fully integrated electronic medical record paired with collection software.

-Wes

What History Can Teach Us

As we look toward more government policy directing our course in health care, perhaps it would be wise to take 25 minutes to reflect upon the roots of our current financial crisis and ask ourselves if we could be setting ourselves up for a similar crisis later with health care as Americans subsume an increasing amount of their health care costs.

As Blogojevich has taught us, it might be wise to take pause:

The scandal washing around Rod Blagojevich, the Illinois Governor, has sent ripples of unease through an American political establishment that has long traded favours or appointments for campaign donations.

Some suspect that the only difference between the traditional deal-making that lubricates Washington and the effort to sell Barack Obama's vacant Senate seat was that the Governor got caught.

-Wes

h/t: Instapundit

Why Shouldn't Patients Pay 14% More for Their Healthcare?

Especially when it's all in the name of quality?

In early 2007 Partners kicked the Beverly doctors out of its network. It said that because the local hospital was referring some patients needing advanced care to non-Partners hospitals, it could no longer ensure quality. The administrators said they weren't being disloyal and only turned to other hospitals for help on tough cases when Partners' teaching hospitals wouldn't.

Some members of the Beverly medical staff saw a different motivation for Partners' action. They believe Beverly Hospital was getting in the way of Partners' expansion.

Read it. All of it. This battle is coming to a metropolitan area near you.

Never mind that Massachusetts can't pay its healthcare bill.

-Wes

Lambs Being Led to Slaughter

I have decided that men should never shop.

Ever.

Especially during the few remaining days before Christmas.

That’s because we go to a mall, and the very first questions we ask ourselves is:
What the heck am I doing here?

No plan. No strategy. No tactics upon which to rely.

In short: lambs being lead led to slaughter.

Instead, we wander.

Aimlessly.

In search of the perfect gift that we haven’t thought about.

We walk by foreign lands with names like “Ann Taylor” or “J. Crew.”

Who?

Oh, we’ve heard of Tiffany’s, but guys know better than to get sucked in there, lest we lose our shirts: Tiffany’s is only approachable the day before Christmas if you’re really desperate.

We try to look like we have a clue, browsing and all. A helpful sales person comes up and asks, "May I help you?" and we politely state: "No thanks, just looking."

That's because guys never ask for directions: it's a sign of weakness.

So we continue, roaming. Lost. Looking at all the people who seem to have a much better plan than we do, carrying those big bags and all.

But there, like an oasis amongst the desert of untouchables, is the Apple Store. Simple. White. Comprehensible to men. Teaming with people, all looking at little expensive electronic gizmo’s like Romans amongst aphrodisiacs. Transfixed. Mesmerized. Stupefied. Like moths to a flame, they come. Drawn. And next to them stand a bunch of black-shirted skinny twenty-somethings with black-rimmed glasses wearing electronic money-suckers on their belts demonstrating the gadgets. The lowly gents mouths hand open. Small amounts of drool appear. Dripping.

Then the phone rings and terror strikes:

“Hello?”

“Honey, are you just about done shopping? We’ve got a party in 30 minutes.”

“Uh, just about, honey. Be there soon.”

And to their terror, they realize they have to come back…

… to shop again.

-Wes

Does Anyone Know Who This Heart Belongs To?

A heart: found on a car wash floor.

But who or what's heart?

Ah, the mystery... (I'm bettin' a deer's heart... I hope...)

-Wes

1400 CST: Update here.

Listening Sessions

Sounds like not much is "changing" on the Hill, eh?

But boy, they sure are "listening."

-Wes

Christmas Came Early

... to Chicago area kids this AM: it was a snow day!

Now there's at least one more young adolescent nestled snug in her bed with one happy smile on her face as Christmas break began one day early.

I not sure I could have planned a better early Christmas present.

-Wes