CT Scanners and Pacemakers

Well, the phone lines were jumping today. It seems the FDA has issued a "Preliminary Public Health Notification" that CT scanners might cause some medical devices, including pacemakers and defibrillators, to "malfunction:"

Most patients with electronic medical devices undergo CT scans without any adverse consequences. However, FDA has received a small number of reports of adverse events in which CT scans may have interfered with electronic medical devices, including pacemakers, defibrillators, neurostimulators, and implanted or externally worn drug infusion pumps. There have been similar reports in the literature.

It is possible that this interference is being reported more frequently now because of the increased utilization of CT, the higher dose-rate capability of newer CT machines, an increase in the number of patients with implanted and externally worn electronic medical devices, and better reporting systems.

We are continuing to investigate this issue while working with device manufacturers and raising awareness in the healthcare community. To date, no patient deaths have been reported from CT scanning of implanted or externally worn electronic medical devices.

Specifically, for pacemakers, the effect has been described only as "transient changes in pacemaker output pulse rate."

Recall that pacemakers must sense existing heartbeats and respond with pacing when no signals are detected. If the pacemaker or defibrillator senses outside signals, it might interpret that "noise" as a biologic signal and respond accordingly. So, if a pacemaker senses outside "noise" and interprets it as a biologic signal, it might briefly inhibit pacing. If a defibrillator senses such "noise" as a biologic signal, it might either inhibit pacing or, if the noise detected is of a sufficiently high frequency for long enough, it might respond with an attempt to correct the rhythm by rapid pacing or a shock (depending on how the defibrillator was programmed).

From the FDA's announcement, it appears the problem primarily occurs when a high radiation dose is emitted from the scanner directly over the device - and this is usually only a brief phenomenon. Whether is is a new finding, or just better reported, remains to be seen (I suspect the latter).

The biggest impact of this announcement will be for device companies and EP nurses, doctors, and technicians - since the implication from this disastrous "early notification" is that we might have to check every pacemaker or defibrillator after every CT scan performed (you've got to be kidding me!).

The lack of guidance for heart rhythm specialists by the FDA and the Heart Rhythm Society in this regard is stunning and warrants review. It seems the Heart Rhythm Society just parrots the FDA's announcement. Perhaps it was because maybe it's not such a big deal after all:

MedSun is the FDA's Medical Product Safety Network of 350 hospitals spread throughout the United States. Information from 132 of these facilities indicated that they have not experienced any CT medical device interference, while 3 have had from 1 to 3 events that may have been CT scan induced. Fifteen MedSun facilities indicated they take some precautionary steps when CT scanning patients who have electronic medical devices.

In short, this seems like a "cover your ass" move by the FDA that threatens to potentially scaremonger our patients.

I guess thanks to the Congressional oversight these days, when it comes to such notifications, the FDA is damned if they do and damned if they don't.

-Wes

Grand Rounds Is Up

Unprotected Text does the honors, tabloid-style.

-Wes

It's Official: University of Chicago Joins With ENH

Evanston Northwestern Healthcare (ENH) and University of Chicago will join hands to train U of Chicago medical students.

For the Northwestern University medical students we currently train, the feelings are mixed. Perhaps this is fear of the unknown. Perhaps the feelings are justified. I spoke with a third-year medical student who felt that the ripple effect has already taken hold and worries that their training will be viewed differently when they apply for jobs. What is clear, is how vulnerable they feel during the upcoming transition period and the uncertainty of their continued training.

For faculty members here at ENH, too, many questions remain: what will be the new name of ENH? (Expect an announcement soon, now that ENH can move on.) What benefits for faculty members will convey from the former Northwestern affilitation agreement to the new affiliation agreement with U of Chicago? Who will keep their academic appointments and who will lose them?

One thing's for sure: there'll be lots of changes. Let's hope they're for the better.

-Wes

Messin' With People

Should news stories about new unproven innovations in medicine be reported in the mainstream media as though they were already safe and effective?

It's an age-old problem, but one that warrants revisiting.

Certainly for the companies developing the technology, there is a desire to find patients who might be good candidates for a clinical trial that tests the new device. Companies have limited budgets to negotiate the complicated regulatory environment of the Food and Drug Administration (FDA) in their quest to acquire approval for the sale of their device. So if a little "press release" escapes to the media about the new technology, well, all the better.

For the researchers, there are often powerful financial and academic incentives to being the most experienced individual in medicine with a new technology is launched: patients learn of one's expertise and the researcher gains first access to the data from the clinical trial permitting an opportunity for the researcher to be "first author" on the sentinel paper describing the technology in a major medical journal. Reputations are made in our profession by such notoriety.

Hospitals and research institutes, too, are constantly looking for more funds to grow their "foundations." Donors are urged to contribute to their next endeavors, holding their best and brightest researchers forward at their rubber-chicken fund-raisers.

For news agencies, too, the push to acquire new and interesting content for their readers and viewers improves readership and advertising revenues. Nearly always, the news outlets are interested in the "human interest" aspect of the technology: how does it affect the Average Joe? So they seek out a patient who has benefited from the technology to tell the story. "Doctor, do you have a patient who could describe their experience using this new gizmo?"

And there begins the problem.

Well-meaning doctors gush forth with the name of their favorite patient experience. The patient is called, tells the "Best Story Ever" and is affable and approachable. The media bring their lights, cameras, and sound equipment to the hospital. Patients and doctors feel important, valued. The marketing opportunity, the public relations benefit, the cache' of being the most cutting edge - it's all so sexy. Everybody's happy. Ahhhh, the glory! What's not to like?

Unfortunately, plenty.

There is much to lose by such PR. This practice of early reporting of technologies before they are proven safe or effective introduces unprecedented bias in to any trial: bias for the research subjects, bias of the researcher's perceptions of the technology, and bias for the public at large. The patient who didn't fare so well is never brought forward - this would too unseemly for the institution, the doctor-researcher, and the company's aspiration to sell their device. Unless trials are prospective, randomized, multi-center trials, it is rare to have negative results reported in the literature, since it is much harder to right about what went wrong than what went right. Who wants that scarlet letter on their resume'?

Clinical researchers have an obligation to tell our patients the good, the bad and the ugly about any new innovation. Certainly no one wants to short-change the opportunity for patients to know about new innovations that might help their condition. But a 90-second feel-good sound bite in the media is just not the place to do that.

Ever.

-Wes

Time Critical Healthcare

Gosh, a while ago I published this tongue-in-cheek piece about feeding the beast of healthcare and this piece about the complexities of the 90-minute door-to-balloon (D2B) time for a heart attack treatment. I had no idea that others would actually take me seriously:

House Bill 1790, sponsored by Rep. Robert Wayne Cooper, creates a "Time Critical Diagnosis System" for stroke and ST-elevation myocardial infarction (STEMI), a particularly fatal type of heart attack. Missouri is the first state in the nation to enact legislation governing a STEMI and stroke statewide system of care.

Well, since this is D2B time is now a tracked "Pay-for-Performance" measure, I guess it's not surprising that we're circling our wagons and spending countless hours to fufill the government's expectations. But the data upon all of this wild excitement rests is based on "hospital door" to "balloon" time, not "patient's door" to "balloon" time. Doctors still need time to assess the complexities of social situations and confounding medical issues. Should a patient with widely disseminated cancer who also has an acute heart attack recieve similar "life-saving" resources? Further, one wonders how much more administrative and bureaucratic overhead our healthcare system can handle for this one initiative. What about the patients already in the ER waiting to be seen? It goes without saying that the administrative complexities of this system are sure to be stunning. Just look at all of the bureaucratic planning:

The health department has already been preparing the state to implement a system of stroke and STEMI centers. A Time Critical Diagnosis Task Force that was formed by the department in November has been meeting to discuss how to build the new system. The task force included more than 100 members of the emergency medicine community.

The first question to be answered by the Task Force should be this: when have 100 people in a committee ever fully agreed on anything?

-Wes

Medical Instruction: Dying on the Vine

It's happening more and more:

The program to train cardiologists at Los Angeles County-USC Medical Center has been stripped of its national accreditation by the Accreditation Council for Graduate Medical Education. The decision marks the first time a residency or fellowship program at the facility has lost accreditation. The council faulted the program for "insufficient teaching time by the faculty."

It's really not unexpected, though. Clinical faculty at medical schools are increasingly pressured to maintain "productivity" standards based on Medicare's RVU system, while rarely being compensated for the time spent teaching students. As a result, training programs suffer.

Then, after being slapped by residency-review committees about their deficiencies and threatened with a sudden drop in federally-mandated funds for teaching, hospitals jump to action:

County-USC hopes to fix the problems and have the 21-year-old cardiology program recertified before June 30, 2009, when the accreditation is to be withdrawn.

Teaching subsidies must flow more consistently to the people doing the teaching and not to support the training program "overhead:"

A main argument for reducing IME payments is supported by data demonstrating that teaching hospitals have substantially higher margins on their Medicare business than other hospitals. In 1999, inpatient Medicare margins for all hospitals were, on average, 11.9 percent. For major teaching hospitals this figure was 22.3 percent versus 11.6 percent for other teaching hospitals, and 6.5 percent for non-teaching hospitals.

Finally, some point out that the logic of providing support for the social mission of teaching hospitals under Medicare IME is not rational, and that it is a "disguised" payment that should be more transparent. This argument suggests that these types of payment mechanisms provide little accountability for the funds provided for the social missions of teaching hospitals.

Only when such transparency is evident to the instructors will there be a long-term incentive to maintain most clinical training programs.

-Wes

Atrial Fibrillation: Let's Chat

As part of our Web 2.0 initiative to discuss health issues with patients, I have agreed to perform an online "live" chat about atrial fibrillation and its diagnosis and treatment options on Wednesday, 6 August 2008 at 7PM, central standard time. Oh, there will be some pre-screening of questions so the usual flame-throwing inherent to the blog-o-sphere can be avoided, but hopefully, it will be informative.

You can request an e-mail reminder so we can torment you, if you'd like. Also, if you want to front-load some questions you'd like addressed on this post, feel free to post them here so I can come prepared.

Lookin' forward to the opportunity...

-Wes

Fragmentation

If you haven’t seen the remarkable management of a medical “never” error that was displayed by Paul Levy, President and CEO of Beth Israel Deaconess Hospital over at Running A Hospital, I’d encourage you to read it. This post should be a “must read” for any hospital risk management personnel or hospital administrator.

In short, this is what happened:

It was a hectic day, as many are. Just beforehand, the physician was distracted by thoughts of how best to approach the case, and the team was busily addressing last-minute details. In the midst of all this, two things happened: First, no one noticed that the wrong side was being prepared for the procedure. Second, the procedure began without performing a "time out," that last-minute check when the whole team confirms "right patient, right procedure, right side." The procedure went ahead. The error was not detected until after the procedure was completed.

Mr. Levy described the doctor’s, hospital’s and hospital board’s response to the error, which, considering the proverbial cat-was-out-of-the-bag, was commendable. Readers were awestruck by the “openness” and “humanness” of the moment. I confess, I too, was impressed at the handling of a disaster that no one should have to endure. Of course the natural question that arises in such a circumstance is “How could that happen?”

So off went the “physician safety division” to interview all involved while the details regarding the incident were fresh in everyone’s mind. The doctor (appropriately) notified the patient’s family and made a full apology. And the board member chimed in:

"Protocols are meant to make procedures insensitive to distraction and busy days. These are inadequate and embarrassing excuses. The 'culture of safety' has not permeated the front lines. Culture of safety training, and application of advances in safety science, I believe, are critical to preventing the type of complex harm that occurs in hospitals. Not just for new staff. For everyone who wears a BIDMC badge, or is affiliated as a physician to the hospital. I know that this is a new science, and a new way of doing business, but this event might just give that leverage needed for change."

There it was. Corporate speak: “culture of safety,” “culture of safety training,” that “hasn’t permeated the front lines”, the era of “new science, and a way of doing business.”

I read through the more than 45 responses to Mr. Levy’s remarkable post, and there, at the very bottom, was the one response that stopped the entire thread in it’s tracks, as one brave Noah Zark stepped forward and said:

”I have an idea. Perhaps the surgeon (as opposed to a PA, NP, intern, or Family Doc) should perform and record the complete pre-op history and physical exam requisite for surgery. This ancient protocol ensures that the surgeon knows the patient for the sake of both...; but it is not followed any more.

Don't waste your time with high tech digital video that can be played from your state of the art computers...just be sure the surgeon examines the patient before he/she is in the OR...the old fashioned way.”

We all know Mr. Zark is right. We also know that it is unlikely, in today’s day and age of the “business” of medicine, that real change in how care is delivered by physician’s stretched to do more in less time than ever before, will occur. We have become fragmented as a profession – too specialized – too procedurally based - too frenetic to stop and really speak and examine patients like we all learned in medical school. Those values lose their cache in the business world of medicine and is exactly the reason that wrong site surgery exists today. That’s why this error was so sad...

... we realize what we’ve lost.

-Wes

Change of Shift - Year Three

Be sure to check out the best of nursing's blogs with Kim over at Emergiblog as the nursing blog carnival "Change of Shift" begins its third year:

In celebration, I asked nurse bloggers to send in their first posts and tell us a bit about why they started blogging.

Enjoy!

-Wes

Back up and Runnin'

Thanks to our Information Technology department for making this blog and that of my administrative colleague, Tony Chen, available to all at our institution. The firewall issues appear to be resolved.

-Wes

Never Mind the Trolling

It was just another concerned patient: another victim of a screening test… a patient caught by our trolling net of screening tests for the worried well.

This time is was a “screening” for atrial fibrillation: charged to the patient and their employer under the guise of a corporate “wellness” initiative:

(Click image to enlarge)

Never mind that the “EKG” wasn’t really an EKG, but rather a “screening” that contained only six of the usual 12 EKG leads, so if an “abnormality” was found, another real EKG would have to be performed.

Never mind that no one would explain the results to her, but rather sent this letter describing a “suspected abnormality” whose findings are “described on the enclosed rhythm strip:”

(Click image to enlarge)

Never mind that the patient could not read the findings “described on the rhythm strip.”

Never mind that the patient’s short PR interval was not identified.

Never mind the patient already had an EKG in the past and had already had an electrophysiology study (which was normal).

Never mind that the screening company, in their effort to “spread good health practices” fails to mention how to perform “lifestyle modification” or “risk factor management” in their cover letter.

Never mind that all of the other tests performed by the screening company for carotid/stroke, abdominal aortic aneurism, peripheral vascular disease aren’t real tests either, but different “screening tests” that will require more tests if an abnormality is found.

Never mind a cardiac electrophysiologist charges the patient several hundred dollars for “clarification” of the scribbled interpretation of the rhythm strip: “Bradycardia.”

Worse still: never mind that taking a pulse would have served as a much more cost-effective “screening” test for atrial fibrillation in most patients.

Regarding ways to save money to our healthcare system and patients…

… oh, never mind.

-Wes

I Need Your Support

Heh. Very clever viral marketing, eh?

-Wes

Grand Rounds - The Seinfeld Way

Some of the best moments in Seinfeld (and med-blogging) history are shown ... thanks to TBTAM over at The Blog That Ate Manhattan.

-Wes

Why Doctor's Don't Use Electronic Communication

Benjamin Brewer, MD over at the Wall Street Journal gives his take:

When it comes to e-visits my patients don't seem to want another password to remember. And they really don't want to pay the $30 I charge for an online consultation and that their insurance doesn't usually cover.

Maybe patients don't use our email system because we provide good access by phone and in the office.

In retrospect, I should have surveyed my patients before I spent money on a secure email platform and state-of-the-art software for electronic consults. I guess I was a little too far ahead of the curve.

In some parts of the country doctors are using e-visits and electronic communication to good effect. Some are even getting paid for it. We aren't. Our local insurers, Medicare and Medicaid haven't embraced the idea.

Right now it costs my practice $1,800 a year to maintain our cool Web site. The company that provides it wants a $6 transaction fee for each e-visit, and 50 cents for every appointment and prescription refill I process with their software. We haven't come anywhere near covering our costs.

I checked with another popular company and they wanted a $3.50 cut from each visit. Giving 14% or more of e-visit fees to a transaction processor still seems too much.

The cost is too high for small practices for this to really catch on. The right combination of ease of use, price, security and connectivity to physicians' electronic records systems hasn't been found yet.

For the small, independent practice, Dr. Brewer articulates the barriers to entry for many doctors. Larger health systems, like ours, have heavily-integrated secure communication systems that can transmit test results and facilitate communication without the need for "transaction fees." Until such systems become available (and affordable) to rural docs like Dr. Brewer, widespread adoption of electronic medical record systems will be limited.

-Wes

Pharmaceutical Overreaching?

I stand in awe.

Despite admitting "not 'a whole lot' of data on pediatric use of cholesterol-lowering drugs, recent research showed that the drugs were generally safe for children" and that "average total cholesterol levels as well as LDL and HDL cholesterol have remained stable, while triglyceride levels have dropped, based on data collected from 1988 to 2000" it seems we have an "epidemic" of hypercholesterolemia that now requires drug therapy:

The nation’s pediatricians are recommending wider cholesterol screening for children and more aggressive use of cholesterol-lowering drugs starting as early as the age of 8 in hopes of preventing adult heart problems.

The new guidelines were to be issued by the American Academy of Pediatrics on Monday.

I can see it now: a young, overweight teenager with a family history of heart disease is placed on a statin drug. She later becomes pregnant.

Oops.

Given the unknown implications of statins in pregnancy, one wonders if we should know more before promulgating such far-reaching recommendations.

-Wes

For a more detailed review, please see Sandy Szwarc's recent excellent review following similar recommendations that emanated from the American Heart Association.

Addendum 8 Jul 2008: Statins for kids: the New York Times reconsiders.

The Patients Who Cry Wolf

If you want to find out how a hospital of emergency room works, do you send in "secret shoppers?"

"As a matter of ethics, you always have to justify why you would need to deceive someone," said Nancy Berlinger, deputy director and a research associate at The Hastings Center, a bioethics research institute in Garrison, N.Y.

Questions have also been raised about how far these undercover patients should go, because they could be exposed to procedures and medications that carry real risks.

Earlier this year, an Essex County, N.J., hospital had some of its own employees pose as secret shoppers to see whether nurses were reading back physician medication orders over the phone to ensure accuracy. Protocol also called for the nurses to record the encounter in the patient's chart

A spokesman for the hospital said employees from doctors to technicians were tapped to secretly observe the nurses, then record whether they complied with the rule.

"We discovered there was very high compliance, although it wasn't 100 percent. In those instances where the person was not complying, we just contacted them and informed them we really needed them to do this," spokesman Richard Wells said, adding that no punitive action was taken.

In a time where ER's are overcrowded, resources are in short supply, doctors and nurses are pushed to their limits, and patients' care is compromised by this fraudulent activity, this monitoring practice should be outlawed.

-Wes

Bummer

Some of our good friends lost their house today.

Sad. Fortunately, they're okay.

Here's pics from the area before the fire. The last one was from their balcony.

-Wes

Addendum: The AP video containing the remnants of their home: just the outline of the foundation and fireplace stonework remained.

Where Some Hospital Systems Get Their Money

From their friendly neighborhood Congressman and my tax dollar.

It seems hospital construction projects were in vogue last month in Montana: Billings area hospitals got $250,000, Roundup Memorial Hospital got $350,000, Missoula Area Hospitals got $650,000, and Benefis Health System in Great Falls got $700,000 and Sidney Health Center got $100,000.

$2,050,000 to hospitals all from one little bill.

Nothin' like a little pork rider, huh?

-Wes

Should Teens be Fined for Smoking?

Eric Zorn, syndicated columnist at the Chicago Tribune, likes the PUP laws (laws that ban the "purchase, use and possession" of tobacco by minors) that fine teens for smoking. And he has supporters:

That makes sense, said John Banzhaf, executive director of Washington-based Action on Smoking and Health. PUP laws "serve to draw parents into the situation" and give children an additional reason to resist peer pressure.

"Treating cigarettes like we do alcohol would go a long way" toward discouraging teen smoking, Banzhaf said. And if you stop a teen from smoking, he said, the odds are overwhelming that he'll never be a smoker.

While I admire his bravery, I beg to differ.

Why do the police and I have to be drawn "into the situation?" Isn't there enough of a power struggle regarding separation going on already in adolescence?

Not only do police have bigger fish to fry, the very people who like such a laws inforced on teens all-too-often will be the same people who pay their own teens' tobacco possesion fines for them.

-Wes

Grand Rounds for Independence Day

Dr. Rich over at the Covert Rationing Blog carries the flag:

This week, bloggers from across the Internet have submitted articles that will help us celebrate the 232nd birthday of the United States of America. Their patriotic postings, organized according to their relationship to the Founding, follow:

And it's worth the time just to read his astute interspersed commentary:

Taking into account the bizarre incentives, Byzantine inefficiencies, and systematized grievances that are provided in such luxurious abundance by Medicare, Happy (and DrRich) can only marvel in dazed wonderment that anyone thinks that turning the whole healthcare system over to these people is a good idea. Imagine our honored forebears clamoring to turn over the entire colonial economic system to the perpetrators of the Stamp Act!

It makes you want to go out and get yourself a muzzle-loader...

-Wes

Grabbin' Us By the Short-hairs

Hey folks! Let’s try a little quiz! I’m going to give you a list of drugs and let’s see if you can guess the diagnosis, okay?

Here are three lists:

1.)Lasix (furosemide), Coreg (Carvedilol), Vasotec (enalapril)
2) metformin, glyburide
3) zidovudine, AZT, azidothymidine, ZDV

Now take your time. Think hard about the answers…. Okay, did you guess:

1) Congestive heart failure
2) Type II diabetes
3) AIDS?

If so, you’re a winner! Way to go!

Now, imagine if every person has every drug they ever took on a single database. Imagine that every doctor in the United States could access that database to assure their patients are on the correct medication. A place where drug coverage information and a list of retail and mail-order pharmacies will be housed under one electronic roof. A place where old drugs, like prior use of psychotropics that might interact with other drugs, could be reviewed. That would be Utopia, right? I mean, fewer errors, more legible scripts generated from that database, an easy-to-update location to stay current on the latest drug information and all.

Now what would such a database be worth? Gosh, I have no idea. Certainly, it wouldn’t be worth much, right? I mean, there wouldn’t be any business potential to such a huge data warehouse, would there? After all, you don’t think an insurer might like to look at that database and you know, guess what illnesses a person has, would they?

Nah, that wouldn’t be worth much. It’d be chump change. It’s be worth so little that even IF the largest electronic prescription warehouses in the world came together to join hands it would be worth so little that the Federal Trade Commission would have to look into them for antitrust practices. Really they wouldn’t. After all it ain’t worth a dime, I mean, they say so:

The country's two largest electronic-prescription networks Tuesday announced a merger, creating a single, secure network for the exchange of digital health information.

In a cashless transaction, which closed late Monday, RxHub LLC, a joint-venture of pharmacy-benefit managers, CVS Caremark Corp., Express Scripts, Inc. and Medco Health Solutions, Inc., will combine its operations with SureScripts, a private company founded by the National Community Pharmacists Association and the National Association of Chain Drug Stores. The merger isn't subject to antitrust review because the fair market value of the combined entity isn't high enough, according to the companies.

The owners of RxHub and SureScripts will each retain a 50% stake in the new venture, which will initially go by the name SureScripts-RxHub, LLC, according to executives from the two companies.

Gosh, I feel so much better knowing that this merger won’t be worth much to the companies, insurers, pharmacists, and drug company marketers and that the FTC can ignore this transaction! I mean, who needs competition, right? It’s all one big lovey-dovey moment! Can't you see those executives from the SureScripts-RxHub, LLC holding hands?

And why not? Their company won’t be worth much at all (really it won't), Congress will love it, AND they'll effectively have our healthcare system and privacy by the balls.

"Kum-ba-ya, my Lord. Kum-ba-ya..."

-Wes

Paying for Health Care the Chicago Way

Just raise the sales tax to 10.75%, the highest in the country.

-Wes

Squelched

I'm not trying to be antisocial, but I've had trouble reaching my blog at this URL recently - seems a new firewall's been installed at work. I have an inquiry in now with our IS department... hopefully things can be reinstated. So while I can still post and respond at home, my ability to respond to comments made during the day has been curtailed, at least for the time being...

Thanks for your understanding.

-Wes

Revisiting Cardiac CT Angiograms

The New York Times published an extensive article on the CT angiogram (CTA) for the diagnosis of coronary disease and is a very worthwhile read. In the report, they describe the controversy between cardiologists surrounding these tests. But in their push to provide eye-catching content, they permitted a CT angiogram proponent, Dr. Harvey Hecht of The Lenox Hill Heart and Vascular Institute of New York, to show perfect 3D images of a normal CTA obtained in nice, slow, regular heart rhythm that peels away the rib structures and shows some of the coronary arteries, the inside surface of the heart, and heart valves as he narrates the video. It's like watching something from the "Undersea World of Jacque Cousteau." Yes, they are beautiful pictures and demonstrate the incredible capabilities of this technology. Gosh, who wouldn't want those beautiful pictures of their heart?

Thank you, NYT, for giving Dr. Hecht, and the entire CT proponents all they need to peddle their scans, after all, a picture is worth a thousand words, right?

But if you read the article carefully, those beautiful pictures come at a price: both for the patient and our economically-burdened healthcare system. Not only are they fairly expensive, but the risks of radiation to the patient are real. To the authors' credit, they made this point. But they also failed to explain that for women with generally smaller frames and greater levels of breast tissue, those risks of radiation are amplified. They also didn't show a flawed CTA in their online article sidebar: like one taken in atrial fibrillation (an irregular heart rhythm) or with lots of skipped heart beats - you see, those images aren't quite so clear. Because the heart is a moving organ, collection of the images must be precisely gated to the heart beat. In people with irregular heart rhythms, motion artifact is introduced, degrading the quality of the images obtained.

The authors also failed to show the images of a patient with a heavy coronary calcium score. Those CTA images sometimes don't turn out so well, either. All CT angiograms use iodinated contrast material injected rapidly through an intravenous line placed in the arm. Scanning begins a few seconds later, after the operators think the dye has reached the patient's coronary arteries (the circulation time is estimated). Once the contrast agent reaches the arteries, it causes the blood vessels and chambers of the heart to "stand out" from the surrounding walls of the heart and blood vessels. In the case of someone with too much calcium in the arteries, the native calcium also "stands out" and might shadow the actual ability of the contrast to define the lumen of the blood vessel. Also, things like stents, which are metallic, interfere the same way. Additionally, the contrast agents used might be harmful to a patient if they have compromised kidney function, so most people have a blood test to evaluate their kidney function before the test (yes, more money).

Certainly in complex congenital heart disease, here are few tests better than CTA to define to course of anomalous blood vessels. CTA has also been invaluable to electrophysiologists to image the left atrium and the pulmonary arteries to define the size, number, and orientation of vessels before left atrial catheter ablation procedures. Likewise, there might be a role to perform CTA to exclude coronary artery disease in the chest pain patient who presents to the Emergency Room. But as a screening test for the general population or even our "walking well" in the cardiology clinic, these scans have no role today, despite what others may suggest.

Despite this, the patient testimonial was telling:

Nonetheless, in February, Mr. Franks took a test called a calcium score, which measures the amount of calcified plaque in the arteries. The test, a less extensive form of scanning, revealed a moderate buildup of calcium in his arteries, a potential sign of heart disease.

So he decided to have a nuclear stress test. When that test showed no problem, the cardiologist who conducted it said he did not need more testing.

But Mr. Franks was still not satisfied. “I’m someone who wants to know,” he said.

After doing research on the Internet, he found Dr. Hecht, who recommended a CT angiogram. Dr. Hecht acknowledged that Mr. Franks probably did not have severe heart disease. But he said the scan would be valuable anyway because it might reassure him. And his insurance would cover the cost.

"If it's free, it's for me," right?

Boo rah.

But adding up this patient's cumulative radiation dose (10 mSV for the "Calcium Score" + 27.3 mSv for the thallium study + another 21.4 mSv for the CTA) gives him the equivalent of almost 3000 chest x-rays worth of radiation.

And then his cardiologist (Dr. Hecht) wanted to repeat the test every year "so he could see how quickly the plaque in Mr. Franks’s arteries was thickening" claiming "how do we know that our therapy is effective?"

Boo rah.

For the record, I know of no study demonstrating the safety, cost effectiveness, or the ability of CTA to document CAD progression year to year. Further, Hecht's own paper demonstrated that even with extensive cholesterol lowering, no change to plaque burden was documented. I also have never seen such documentation be able to predict a cardiac event of any type. But Dr. Hecht seems to feel insults to those questioning the utility of CTA are appropriate:

Cardiologists like Dr. Brindis (and Dr. Wes, it seems) hurt their patients by being overly conservative and setting unrealistic standards for the use of new technology, Dr. Hecht said.

“It’s incumbent on the community to dispense with the need for evidence-based medicine,” he said. “Thousands of people are dying unnecessarily.”

Hmmm. Dispense with need for evidenced-based medicine? I wonder what Dr. Hecht will say to his patient when the CTA scan shows a tumor mass one year.

-Wes

References: Nico R. Mollet, Filippo Cademartiri, Carlos A.G. van Mieghem, Giuseppe Runza, Eugène P. McFadden, Timo Baks, Patrick W. Serruys, Gabriel P. Krestin and Pim J. de Feyter. "High-Resolution Spiral Computed Tomography Coronary Arteriography in Patients Referred for Diagnostic Conventional Coronary Angiography." Circulation 2005; 112: 2318-2323.

Abelson R, "Heart Scans Still Covered my Medicare." New York Times 13 March 2008.

Addendum 29Jun2008 @ 1523: - the opposing view over at "The Voice in the Ear".

The Ultimate in Woo: The Heart-Bean

You're not going to believe this: presenting... (drum roll, please)... the Heart-Bean:

Emerging from the wildly innovative art school Bezalel in Jerusalem is Heart-Beans, a coffee grinder which when you hold it close to your body, like a baby, grinds coffee based on the rhythm of your heart.

. . .

It’s pretty cool. It’s pretty smart. Everyone loves coffee - ‘cept for those snooty tea drinkers. And it’s technology with heart as you can see in the video below... It’s the robot that fulfills your innermost desire. In this case, coffee. Deep, rich and dark, from the bottom of your heart (beat). Ground with love - or whatever else you’ve got brewing inside."

Oh, baby! Spin for me!

-Wes

PS: Be sure to see the videos: for guys here and gals here. Have a great weekend!

Money Talks

Soliciting patient testimonials with cash or rebate incentives?

No thank you.

-Wes

More Fear-Based Medical Marketing

I'm not sure it gets better than this:

Scanning the heart's arteries for calcium deposits accurately predicts the overall death risk for American adults, a new study suggests.

"So far, this is the best predictor we have of who will have a problem and who will not," said study co-researcher Dr. Matthew Budoff, associate professor of medicine at the Harbor-UCLA Medical Center.

He and his colleagues reported the finding in the July 1 issue of the Journal of the American College of Cardiology.

A calcium scan looks for calcification, a hardening of the arteries caused by high blood fats and calcium deposits that can eventually block blood vessels, causing heart attacks, strokes and other major problems.

I can hear it now:

"Hey Marge, hey lookie here in the Washington Post! I wanna get one of dem der fancy schmancy CT scanner gizmos to find out if I'm gonna DIE sooner than you are! Let's take $600 bucks for that fancy schmancy thing-a-ma-bob out of our retirement fund. It'd be WORTH IT!"

Sometime later, in the doctor's office...

Doctor: "Well, Mr. Jones, I see my this fancy schmancy CT scan that you'd got some calcium in your coronaries. Hmmmm. And you calcium score is 210, just like Tim Russert! So, guess what?"

Mr. Jones: "What?"

Doctor: "Well Mr. Jones, you're at increased risk of DYING!"

Mr. Jones: "Uh, what do you mean, Doctor?"

Doctor: "You heard me: you're at increased risk of DYING with all that calcium in those coronaries - you know - BAM! Just like Tim Russert."

Mr. Jones: "Any idea when, Doctor?"

(Silence)

Mr Jones: "Doctor, did you hear me? When will I die? I mean, won't we all die sometime?"

Doctor: "Heck, Mr. Jones, I don't know! But I can assure you that based on this fine article here in the prestigious Journal of the American College of Cardiology (you know, the same one that's also promoting their new Cardiovascular Imaging journal) that you're gonna die of SOMETHING sooner than some of the other people who don't have that evil calcium in their arteries."

Mr. Jones: "Gosh. So what should I DO about it, Doctor?"

Doctor: "Well, you know, since we're proposing that it's a RISK FACTOR for DYING, you should do the usual stuff: eat right, take tons of statin drugs, don't smoke, take your aspirin, lose weight, eat a low trans fat, high antioxidant, super-radical-consuming diet, do yoga, take mega vitamins, face East, say a few 'Hail Mary's..."

Mr. Jones: "Uh, but I was already doing that stuff..."

Doctor: "Have you had your CRP level and genes tested yet?"

Mr. Jones: "How would that help?"

Doctor: "Well, Mr. Jones, it might mean your risk of DEATH is EVEN GREATER!"

Mr. Jones: "But what can I do about it if it's positive also?"

Doctor: "Well, you know, the usual stuff... like I said... eat right, take tons of..."

Mr. Jones: "That's okay, Doctor. I've had enough. Thanks for all of your help. Hope that $300 bucks comes in handy. Don't mind me: I'll keep doing what I've been doing and get started preparing my Bucket List. Oh, but one more thing..."

Doctor: "What's that Mr. Jones?"

Mr. Jones: "You wouldn't happen to work with General Electric like those two guys who wrote that article you quoted, would you?"

-Wes

Looking for a Job?

If you're a new doctor in the hunt for a job after training, a new family physician blogger, Jonathan Dee from Clinton, TN, has some suggestions on how to get started.

(I wonder if Dr. Dee knows that he works about 15 miles from Dr. Helen and Instapundit?)

-Wes

Your Beatin' Heart

Check out this interactive heart animation from Hydrid Medical Illustration. You can use the slider on the video loop to create a "glass heart" through which you can see the heart valves and other structures inside the heart as the heart beats.

Pretty cool.

Hmmmm. I wonder if they could animate atrial fibrillation?

-Wes

PS: You can also check out their blood flow animation, too.

AED's - The Barriers to Entry

Melinda Beck of the Wall Street Jounal, did a nice piece on the need for automatic external defibrillators (AEDs) in public spaces today and started to address some of the issues of why these amazing gizmo's aren't available more widely:

Some states now require AEDs in schools; some require them in health clubs, shopping malls and golf courses. There's little uniformity; despite their foolproof nature, some businesses oppose them out of fear of being sued if something goes awry with an on-site AED. "I predict that 10 years from now, people will say, 'I'm not going to work in a building or stay in a hotel or eat in a restaurant that doesn't have an AED," says San Diego city-council member Jim Madaffer, who helped place nearly 5,000 AEDs in public facilities since 2001. They've saved 49 lives.

Schools have been a tough sell, too, largely because of cost. Some parents are raising money for AEDs themselves, often after a tragedy. Evelyn and Larry Pontbriant have donated 32 AEDs to Norwich, Conn., schools since last summer, when their 15-year-old son, an athlete with no known heart problems, suffered a fatal cardiac arrest during a running event in the local park. An AED arrived on the scene too late. "It's a good investment to have on hand in your school," says Mrs. Pontbriant. "It benefits not just the athletes, but also the teachers, coaches, referees, grandparents and siblings."

As electrophysiologists, we often get to see the "saves" made by these devices: the young boy playing baseball, struck in the chest by a fast ball ("commodio cordis") that fibrillates his heart and the police officer who responds with the AED in the trunk of his squad car to save the boy's life; or the father who collapses just outside the fire department and is rescued by their defibrillator. These event happen every day, but unfortunately as experienced in the Tim Russert case, many more are not so fortunate.

So why aren't these devices more readily available?

First and foremost: is cost. These devices are still expensive: the cheapest quoted goes for about $1300. But there are other costs not commonly discussed: like the cost of new batteries every 2-7 years (depending on the cost of the model) that can set folks back at least a $100 for each device. And what about those defibrillator patches placed on the chest? They contain a gel that improves the conductivity of the patches on the chest, making the devices more reliable at correcting the normal heart rhythm. That gel degrades and the patches must be replaced every two to seven years, too - to the tune of about $100 a set, too. These are the unspoken issues with AEDs that are never written about and schools and institutions must understand these additional costs and maintenance requirements if they are to assure the proper functioning of these devices.

Next, is the location consideration: where will these devices be used? Will they be in the office setting, car trunk, or placed next to the baseball field? Humidity, motion, and other environmental issues might require a more expensive device to be deployed without the bargain-basement price. Certainly, in the NIH-sponsored trial "Home Automated External Defibrillator Trial (HAT)," home use has not been found to be more effective than a conventional call to 911: in part because of the low incidence of events that occur in the home when a responder is present (58 patients out of 7001 studied, and only 32 had AEDs used and only 4 survived to hospital discharge).

But the cost and efficacy considerations might be offset if more defibrillators were deployed in public spaces where more responders were present and events occurred - thereby driving down the costs. I suppose it would be utopia if these devices could be deployed and maintained within 3 minutes of whereever a person traveled. But the path to implementation, especially with staffing and budget shortfalls, is a lengthy one. As a case in point: many doctors' offices, dialysis centers, and rehab units still do not have these devices and instead rely on calling 911 for a response in emergencies.

Sad, but true.

-Wes

The Feeding Frenzy Has Begun

... and it's all about the research money:

"An e-mail sent Wednesday to top Feinberg faculty from Rex L. Chisholm, dean of research, included an attachment that lists 29 researchers employed by Evanston Northwestern who draw federal research dollars. Those people will lose their Northwestern faculty positions as the affiliation is unwound over the next year.

“The dean’s office is interested in hearing from you if you have interest in exploring the possibility of recruiting any of them to NU,” Dr. Chisholm’s message says. He requests “a guesstimate of the resources that might be required to successfully move them to NU.”

About 700 of Northwestern’s 3,000 full- and part-time faculty work at Evanston Northwestern. The three-hospital system has its own research enterprise — it received more than $100 million in external grant money in 2007 — and competes with Northwestern for federal funding."

-Wes

The Obfuscation of Benefits

"Dr. Wes, I couldn't believe the prices after my wife's surgery and three and a half-day hospital stay."

"Yeah, it's crazy, isn't it? But the prices aren't really the prices, you know - everything's marked up because hospitals know they won't get paid the full amount by the insurers."

"Really?"

"Yeah."

"So why did my remaining deductible that I had to pay go to the hospital so they'd make 100% of their billed amount when the guys doing the surgery only got 29% of what they billed?"

"What do you mean?"

"I got sent this form that said it was my 'Explanation of Benefits' from my insurer..."

"Yeah."

"... and the hospital's portion of the bill was $53,619.70 and they got paid 100% of what they billed from my insurer provided, of course, you include my co-pay. You want to see? Here's what they sent me for the hospital charges:"

Click image to enlarge.

"See? I had to pay my co-pay so the hospital made 100% of what they billed... and yet the surgeon who did the surgery only made 29% of what he billed. Here's two 'Explanation of Benefit' forms of what they paid my surgeon....:"

Click image to enlarge.

Click image to enlarge.

"... I mean, why two payments to my surgeon? And why didn't he get paid the full amount he billed? He was the one doing the surgery, right? I would have rather my co-payment go to the guy doing the surgery rather than the hospital..."

"I'm sorry, I can't answer your questions."

"I mean, even the anesthesiologist got paid only 51% of what he billed, but the hospital got 100%! Look:"

Click image to enlarge.

"...I mean, wasn't the anesthesia guy pretty important to my wife when her surgery was going on? Why should the hospital get 100% and he make only a portion of what he billed?"

"That's the way it works, I'm afraid."

"You know what doc?"

"What?"

"That sucks. And you know what else?"

"What?"

"How the hell am I supposed to figure this out with such crappy itemization on these so-called 'Explanation of Benefits' forms? They should really be called 'Obfuscation of Benefits' forms; at least that name would lend them a modicum of credibility."

-Wes

Taking a Break

Dr. Wes will be taking a blog break far from internet access with family 'til Monday. See you then.

-Wes

A Pacemaker for the Diaphragm

Getting patients off a ventillator with diaphragmatic pacing: a simple idea whose time has come. Manufactured by Synapse Biomedical, Inc., this pacing system allows people to get off the ventillator for as long as four hours a day.

Remarkable.

-Wes

The Tim Russert Fallout

It’s hard for me not to sit amazed at the job medicine has done convincing people we can control heart attacks. One only needs to review the many news stories regarding news journalist Tim Russert's untimely death to see the public fallout of our efforts to "educate" the populace about "screening tests" used to "prevent" the likelihood of having a heart attack. You see, with Mr. Russert's death, those tests have suffered a huge public relations nightmare.

Cholesterol screening and statins: dead in the water.

CT scanning for detection of plague to prevent heart attack: harpooned.

Stress testing to assure you're protected against the Big One: pulverized.

Not one damn thing predicted (or prevented) Mr. Russert's death.

Oh sure, there's plenty of others who want to jump right in to promote the next great lifestyle modification, rather than those damn cholesterol drugs as a way to save your life, provided of course, you buy their book. Or those who promise reduced mortality if everyone just got an ultrasound of their carotid arteries, even though this test still can't predict acute plaque rupture and the onset of a heart attack like Mr. Russert's.

You see, the entire industrial complex of healthcare technology and innovation was shaken, not because Mr. Russert was a nice guy and great journalist, but rather because they will have to explain why their technology isn't worth a damn at predicting heart attacks.

Welcome, my friends, to the world of real-life medicine rather than marketing.

-Wes

Ending an Era

It's official: ENH and Northwestern are parting. It's a sad day, really. The relationship, while strained, was a good one in many ways for both parties. But business is business, and the complexities of the ever-changing Chicago healthcare market have strained the marriage to its breaking point.

Now ENH must choose a new name, change its stationary, find a new academic partner, re-establish some 180 academic appointments, re-certify its training programs, and work toward re-branding itself.

It'll be interesting, to say the least. I'll be interested to see what the community thinks...

-Wes

Addendum: More from the Chicago Tribune.

Why People Can't Afford Insurance

Maybe this little tidbit will bring some clarity to the issue:

"Almost every CEO of a publicly traded health insurance company made more than the median salary for a top executive in the S&P 500 in 2007.

...

In its analysis of S&P 500 companies, Equilar found median total compensation for the CEOs was $8.8 million. The six publicly traded health plans that are a part of the S&P 500 index all paid their CEOs more than that median: from $9.1 million for WellPoint's Angela Braly to $25.8 million for Cigna's H. Edward Hanway."

When the heck will this trend cease?

-Wes

Predicting the Future

In 2005, the Physician Quality Reporting Initiative, an effort by the Center for Medicare and Medicaid Services (CMS) to assure quality healthcare was tied to physician reimbursement, began with a mere 36 measures. This initiative has grown steadily, such that now 138 measures (with 16 new ones just last week!) have been defined.

I wondered if there was a growth trend that could be predicted as to how many quality measures for physicians will exist by 2019, when the Medicare Trust Fund is predicted to be bankrupt.

What was striking, was the remarkably linear relationship of growth of these measures. If one applies a least squares method to determine the annual rate of growth of measures so far, the number of measures is defined by the equation:

y = mx + b, where:
y = number of measures
m = 25
b = 11

Here's how the graph looks:



So if this formula holds true, by 2019 physicians should expect 386 measures to track!

Wow. Let's look at that. If we have an 8 hour work day, and there are 60 minutes in an hour, then there are 480 minutes to the average work day. If each of these measures take, say, one minute to collect and record, then 94 minutes will be left over to see patients.

Now, if we leave 15 minutes for a potty break and maybe a very quick bite to eat, then we've whittled it down to 79 minutes left for patient care. If the average doctor expects to see 20 patients a day, then 3.95 minutes will be devoted to each patient.

All in the name of healthcare rationing.

Keep up the good work, CMS!

-Wes

I Envision a New Medical World Order

Well, I don't, but Happy does:

If anyone in Washington believes PQRI or any other of an assortment of quality systems will put the brakes on health care inflation, they are fools. If you believe they are doing it for quality over money, you are a fool. It's not a quality issue. It's a money issue. And the money train is delivered by volume. We do too much. Way too much. And we do it because we get paid to do it. We do it because we get sued if we don't do it. We do it because the gravy train has a spigot that has no off position. We do it because patients have become doctors. We do it because drug companies have brainwashed the public. We do it because the lobbyists in Washington pay hundreds of millions of dollars in bribe money to keep their piece of the gravy train flowing. I see it every day. I get 10 pieces of junk mail a day telling me what I need to prescribe, what I need to order, what procedures I need to learn.

Read it. It's worth it.

-Wes

Russert Dead of Apparent Heart Attack

Bummer.

Exchanges like these will be sorely missed:

Russert: The night you took the country to war, March 17th, you said this: "Intelligence gathered by this and other governments leaves no doubt that the Iraq regime continues to possess and conceal some of the most lethal weapons ever devised."

President Bush: Right.

Russert: That apparently is not the case.

President Bush: Correct.

Russert: How do you respond to critics who say that you brought the nation to war under false pretenses?

President Bush: Yes. First of all, I expected to find the weapons. Sitting behind this desk making a very difficult decision of war and peace, and I based my decision on the best intelligence possible, intelligence that had been gathered over the years, intelligence that not only our analysts thought was valid but analysts from other countries thought were valid.

And I made a decision based upon that intelligence in the context of the war against terror. In other words, we were attacked, and therefore every threat had to be reanalyzed. Every threat had to be looked at. Every potential harm to America had to be judged in the context of this war on terror.

And I made the decision, obviously, to take our case to the international community in the hopes that we could do this — achieve a disarmament of Saddam Hussein peacefully. In other words, we looked at the intelligence. And we remembered the fact that he had used weapons, which meant he had had weapons. We knew the fact that he was paying for suicide bombers. We knew the fact he was funding terrorist groups. In other words, he was a dangerous man. And that was the intelligence I was using prior to the run up to this war.

Now, let me — which is — this is a vital question —

Russert: Nothing more important.

President Bush: Vital question.

And so we — I expected there to be stockpiles of weapons. But David Kay has found the capacity to produce weapons. Now, when David Kay goes in and says we haven't found stockpiles yet, and there's theories as to where the weapons went. They could have been destroyed during the war. Saddam and his henchmen could have destroyed them as we entered into Iraq. They could be hidden. They could have been transported to another country, and we’ll find out. That's what the Iraqi Survey Group — let me — let me finish here.

But David Kay did report to the American people that Saddam had the capacity to make weapons. Saddam Hussein was dangerous with weapons. Saddam Hussein was dangerous with the ability to make weapons. He was a dangerous man in the dangerous part of the world.

And I made the decision to go to the United Nations.

By the way, quoting a lot of their data — in other words, this is unaccounted for stockpiles that you thought he had because I don't think America can stand by and hope for the best from a madman, and I believe it is essential — I believe it is essential — that when we see a threat, we deal with those threats before they become imminent. It's too late if they become imminent. It's too late in this new kind of war, and so that's why I made the decision I made.

Russert: Mr. President, the Director of the CIA said that his briefings had qualifiers and caveats, but when you spoke to the country, you said "there is no doubt." When Vice President Cheney spoke to the country, he said "there is no doubt." Secretary Powell, "no doubt." Secretary Rumsfeld, "no doubt, we know where the weapons are." You said, quote, "The Iraqi regime is a threat of unique urgency.” “Saddam Hussein is a threat that we must deal with as quickly as possible."

You gave the clear sense that this was an immediate threat that must be dealt with.

President Bush: I think, if I might remind you that in my language I called it a grave and gathering threat, but I don't want to get into word contests.

Tim, you'll be sorely missed.

-Wes

Guys' Health Issues Kick Off ENH Radio

Wow, we've entered Web 2.0 at our institution as we delve into weekly podcasts. Feel free to check it out: the first two shows are for guys.

I've been asked to do one for atrial fibrillation sometime in late July or early August...

-Wes

EKG Du Jour - #9

Another from the EKG Hall of Fame:

An elderly man presents to the ER for a laceration of his hand and was noted to be bradycardic. An rhythm strip was performed and documented a wide complex, bradycardic rhythm. You are asked to see him.

He was completely asymptomatic, but the ER doctors were concerned and thought he might need a pacemaker. You decide to perform carotid massage, with the results shown:

Click image to enlarge

How do you explain what is seen? Does he need a pacemaker?

-Wes

PS: (EP's: please refrain for about 12 hours or so to let others have some fun... thanks!)

One Heck of a Way to Go

Poor guy. Talk about going out in a blaze of glory...

-Wes

The Diabetic Concept Car

... it's only the beginning. With this functionality, there will be no more need to worry when you ate your last cracker. Instead, if the device detects your blood sugar's so low that you might lose conciousness, it'll deploy the airbag just in time to wake your ass up!

But that's not all. Just think of the other possibilities we'll soon have with the advent of medical devices interacting with everyday objects.

Now when you're in the throes of passion with your loved one, she'll soon be able to hear you revved up heart beat as your defibrillator reaches its tachycardia detect zone and puts on a full blown light show with our new Bluetooth-enabled Lightning Alarm Clock!

Or use your supraventricular tachycardia to power your blender as you make those early morning smoothies for the family with the 5-speed polycarbonate VitaMix Super 5200 blender!

And now that the really cool G3-enabled iPhone here, you can be the first to upload your favorite heart-rate stimulating selections with the new iPod accessories promised soon! (Just be sure not to upload "Stairway to Heaven.")

Dang. I gotta get working on those patent applications...

-Wes

What's Hot on the Web? Health and Politics

Even though Walt Disney Co.'s ABC News is close to scrapping the current format of its daily "World News" Webcast, there are two sections they won't chuck:

Inside ABC's Web division, the mantra is: "Hard news is a hard sell." Of last Monday's 7.8 million clicks, three million were to photo slideshows, including one of celebrities at the beach and another of the "pregnant man." Some hard-news categories have done well: Page views for the health and politics sections of the site have increased around threefold since last year, with 14.9 million page views for the health section in May and 19.4 million for politics. Mr. Westin says ABC plans to build these niche focuses.

I mean, with such authoritative stories like this, I learn a lot, don't you?

-Wes

Kids Say the Darndest Things

One of our staff cardiologists is due to deliver in August, and her 3-year old son was overheard speaking to friends about the pregnancy:

"My mommy is getting bigger and bigger. I think she's going to have a boy or a puppy."

Heh. I guess he's not sure which one he wants...

-Wes

The Bits and Bytes of Pathology

Imagine: digital image processing and informatics complementing pathology - well, it's here, and Dr. Keith Kaplan, a former pathologist from our institution who has relocated to Mayo Clinic to pursue this area has a cool blog over at Digital Pathology Blog. As he says:

The intent of this blog is to cover issues relevant to imaging and image analysis in pathology.

I particularly liked his post with the video on "Combating Cervical Cancer With Cameraphones" which highlights how cameraphones are being used to deliver routine gynecologic care to rural Africa.

There's a lot more over there - he's been at it for a year: check it out and say "hi."

-Wes

More Rain on the "Report Card" Parade

It seems hospital "report cards" documenting "quality measures" fail to predict "preventable" deaths after bypass surgery.

Maybe the idea of Medicare reimbursing for "pay-for-performance" measures really misses the point: they should pay for outcomes, not for the performance of mere documentation. It's like asking a student to grade their own class performance: funny how almost all of them get A's that way.

For instance, here's the "quality data" of three different hospitals in our area:

Percent of Surgery Patients Who Received Preventative Antibiotic(s) One Hour Before Incision	92% of 885 patients	95% of 435 patients	94% of 357 patients
Percent of Surgery Patients Who Received the Appropriate Preventative Antibiotic(s) for Their Surgery	98% of 909 patients	97% of 448 patients	97% of 362 patients
Percent of Surgery Patients Whose Preventative Antibiotic(s) are Stopped Within 24 hours After Surgery	90% of 856 patients	90% of 417 patients	87% of 339 patients
Percent of Surgery Patients Whose Doctors Ordered Treatments to Prevent Blood Clots (Venous Thromboembolism) For Certain Types of Surgeries	92% of 182 patients	92% of 150 patients	95% of 178 patients
Percent of Surgery Patients Who Received Treatment To Prevent Blood Clots Within 24 Hours Before or After Selected Surgeries to Prevent Blood Clots	92% of 182 patients	92% of 150 patients	88% of 178 patients

Now, which of these three hospitals will give you the lowest bypass mortality?

Stumped? Gosh, how can you be? I mean the data are so, well, CLEAR!

Just think: how many chart-reviewers were required to review these charts and gather these data? How many hours? How much money do we spend annually to assure these "quality" data are posted to make the governmental "grade?" Most importantly, with hospital reimbursements tied to such worthless performance measures, how are our patient "consumers" ever going to use this data when the variance between centers is so slight and skewed consistently toward perfection?

You get what you pay for, alright. Pay for "good" data and you'll get "good" data. After all, it's the "Skinner Box" effect: if hospitals push the right levers, they get their "conditional reward" of slightly higher Medicare reimbursements.

Even if these measures don't mean dog-doo-doo.

-Wes

Polypharmacy Gone Wild

If you've ever wondered why doctors gone insane managing patients, take a look at this inpatient drug treatment list on a single patient. It came to my attention on call this weekend that many of the drugs that seem repetitious are actually computer-generated by the electronic medical record "management:"

Furosemide SOLN 40 mg (LASIX)
Enoxaparin SOLN 135 mg
Carvedilol TABS 6.25 mg (COREG)
Furosemide TABS 20 mg
Valsartan TABS 80 mg (DIOVAN)
LevoFLOXacin SOLN 750 mg (Levaquin)
Polyethylene Glycol PACK 1 Each (MIRALAX)
Ferrous sulfate TABS 300 mg (FEOSOL)
Pantoprazole TBEC 40 mg (PROTONIX)
Docusate CAPS 200 mg (COLACE)
Hydrocodone-Acetaminophen 10-325 MG TABS 1-2 Tab (NORCO)
Ezetimibe TABS 10 mg (ZETIA)
FLAVOCOXID CAPS 250 mg
Ranolazine TB12 1,000 mg (RANEXA)
Clopidogrel TABS 75 mg (PLAVIX)
GlyBURIDE TABS 5 mg (MICRONASE)
Pioglitazone TABS 15 mg (ACTOS)
ROSUVASTATIN CALCIUM TABS 40 mg (CRESTOR)
Acetaminophen TABS 325-650 mg (TYLENOL)
Aspirin Enteric-Coated TBEC 325 mg (ASPIRIN)
ALBUTEROL-IPRATROPIUM 2.5-0.5 MG/3ML SOLN 3 mL (DUONEB)
Insulin (Aspart) Correction Table INJ (Novolog)
Bisacodyl SUPP 10 mg (DULCOLAX)
Milk of Magnesia SUSP 30 mL (MOM)
ProCHLORperazine SOLN 10 mg
Nitroglycerin SUBL 0.4 mg (NITROSTAT)
Glucose CHEW 16 g
Dextrose Gel GEL 15 g (GLUCOSE GEL)
Dextrose SOLN 12.5-25 g (DEXTROSE)
Glucagon SOLR 1 mg (GLUCAGEN)

Note the last several highlighted formulations of glucose and glucagon. If the patient has diabetes, a "hypoglycemic protocol" order set is automatically generated by the pharmacy. (No doctor order is required, but the treating physician's name is attached automatically to the orders, and these orders are typically reviewed by hospital physician "experts" endocrinologists before being deployed). It seems there are glucose blood sugar cut-offs that mandate a different form of glucose to be administered to the patient. Here's our example of cook-book medicine:

If Blood Glucose is <70mg/d (less than 60mg/d in the pregnant patient): 1. Give 15g of simple sugars: 4 Glucose Tablets (if unable to chew, give 4 oz of juice) 2 Recheck Blood Glucose in 15 minutes 3 Repeat 15g of Simple Sugars if glucose is not above 70mg/dl 4 Recheck Blood Glucose 5 Repeat 15g of Simple Sugars if glucose is not above 70mg/dl and notify physician

If patients' blood Glucose is <70mg/d (less than 60mg/d in the pregnant patient) and is conscious but NPO: - Dextrose 50% Half Amp IV - Recheck Blood Glucose in 15 minutes - Repeat Dextrose 50% if blood glucose is not >70mg/dl

If patient's Blood Glucose is <70mg/d (less than 60mg/d in the pregnant patient) and is unconscious: -1. Dextrose 50% 1 Amp IV and notify physician.- -2. If unable to administer D50 wihtin 5 minutes, give glucagon 1 mg IM and contact physicican. Monitor for nausea and vomiting.- - Recheck Blood Glucose in 15 minutes - Notify Physician, if blood glucose is not >70mg/dl

Imagine: these four orders for every patient admitted to the hospital with diabetes.

Does this save lives? Or does this cost patients for four different medications perhaps never needed? What is the cost of such automaticity when orders appear to manage patients without physician involvement? (That "little" order for glucagon, costs $104.82 retail at CostCo pharmacy. How much is it marked up for the hospital?)

Also, how many errors occur on the basis of misinterpretations of these automatic orders ("Oops, I forgot to ask if she was pregnant.")? Where are the evidence-based studies demonstrating the utility of this automated approach to patient care? Could this be why EMR's have not been found to save money to our health care system? Are we losing cost savings to our system by removing physician judgement?

In this era of cost overruns and exhorbitant Medicare expenditures, should we not be asking these tough questions?

No. That would be too difficult. Rather, it's far easier to cover your butt with automatically-generated orders that the patient has to pay for in the interest of assuring their own "safety."

-Wes

Gone Golfing

... with the UroClub!

(Actually, I'm on call, hence the worthless nature of this post...)

It's sure to extend the hours playing golf! Who needs a clubhouse? IU should issue this to all of his patients when they hit the links!

-Wes

h/t: A faithful reader. ;)

Where I Draw the Line

Okay, I'm alright with measuring blood pressures, and pulses, and counselling people to stop smoking and discussing family hisories of heart disease and a million other things....

... but toenail clippings?

Come on now! I have to draw the line somewhere...

-Wes

English As A Second Language

An interesting issue came up today as I sat before our Investigational Review Board (IRB) on behalf of a colleague who was trying to get a multi-center, prospective, randomized NIH-sponsored trial approved. The trial uses a medical device in one arm (the subject of randomization). The issue at hand involved the insistence (by trial design) that the patient participants should be fluent in English.

Immediately, the reviewers of the protocol were concerned that excluding patients based on their language of origin might suggest enrollees were discriminated upon based on their ability to speak English. This was, after all, an NIH-sponsored trial. It is true that, historically, women and minorities have been underrepresented in national trial designs – the desire to adequately represent these groups seems appropriate. But I found it difficult not to require enrollees to be fluent in English for such a complicated trial involving over 2 years of follow-up – it is, after all, our national language. More importantly, I argued, the very reason we were sitting before the IRB was because the investigation was felt to pose “less than minimal risk” for our patients. If a problem arose during the course of the trial, and a non-English-speaking patient calls our center, would they be able to communicate their concerns? More importantly, would we have the capabilities to communicate with them? Would this potentially increase the risk to the patient if communication were compromised? In to how many languages should our consents be translated? Spanish? Hindi? Urdu? Mandarin? Russian? Polish? The list seems endless.

Are we discriminating against a sect of the population that is non-English-speaking by not offering them these trials or just playing it safe by excluding those not fluent in our language?

The answer seems obvious to me, but then, I speak English. Any one else have thoughts on this? Suggestions?

When Airlines Affect Clinic Schedules

It can be tough on your Monday clinic patients:

A Perth cardiologist has lashed out at national airline Qantas, saying regular flight delays were potentially putting country patients at risk.

Western Cardiology consultant Johan Janssen has flown to Kalgoorlie every Monday for the past five years. This year, only about four of 20 flights have been on time, with some experiencing delays of up to four hours.

Dr Janssen said even one-hour delays on May 19 and 26, both due to mechanical problems, could have had a devastating effect on his patients.

“I’m so busy I’m booked three months in advance, so if I’m an hour late between five and 10 patients can’t see me,” Dr Janssen said.

“Some are really upset because they don’t feel well and if they’re elderly they can’t travel to Perth,” he said.

Talk about office overhead. I wonder how he covers the expense of airfare?

-Wes

One Step Closer

... to hosting the 2016 Olympics.

Congrats, Chicago.

-Wes

Chicago: A Case Study in Healthcare Market Consolidation

It was quite a morning for Evanston Northwestern Healthcare physicians as we heard from Mark Neaman, our President and CEO, about the rapidly-evolving healthcare market in Chicago. In his presentation, he chronicled the series of events that have lead to the changes seen so far in Chicago, and opened a glimpse of what’s to come.

Most of the news was old news:

1. He reviewed the financial struggles of Condell Medical Center in Libertyville from “contractual discounts” resulting in its suit with Blue Cross and subsequent countersuit of Blue Cross against Condell with the eventual withdrawal of Blue Cross patients from the Condell system. Condell bled so much red ink they were soon seeking a buyer as the economic impact of the situation became clear. (ENH looked at the opportunity, but Advocate was favored by Condell as their suitor),


2. The financial struggles and huge debt load of Rush North Shore, coupled with Rush Medical Center (downtown)’s desire to make a $1 billion dollar mega-expansion and ENH’s need for local geography, prompting ENH to bid for Rush North Shore, and


3. the newer alliance between Northwestern Memorial Hospital and its Northwestern Medical Faculty Foundation, making it a formidable competitor to the our financially separate ENH system as they also compete for market share in the desirable Northern and Western suburbs of Chicago – especially since they just bought 10 acres of prime real estate near I-294 and Willow roads, only 1 mile from ENH’s Glenbrook Hospital.

If the dust settles and the Federal Trade Commission approves, it is clear that the Advocate/Condell acquisition will compete with the ENH/Rush NS system, which will, in turn, compete against NMH/NMFF for the affluent patient population in Chicago.

Much of this healthcare system consolidation has been enabled by the emergence of the Electronic Medical Record that permits geographically disparate “virtual offices” to exist within a single healthcare system: it’s no longer which hospital or clinic you receive your healthcare from, but rather which “system.” The Mayo Clinic, with its satellite centers in Scottsdale, Arizona and Jacksonville, FL, has known this for years.

This has lead Evanston Northwestern Healthcare (ENH) to rethink their name and academic affiliation, since their tenuously amicable academic affiliation with Northwestern University has become seemingly irrevocably strained, limiting ENH’s ability to differentiate itself from its staunchest competitors (especially since its name contains "Northwestern"). For many reasons, it seems, the earlier 1994 academic affiliation agreement between Northwestern’s Feinberg School of Medicine is not likely to last much longer. While there were initial reports of an academic affiliation with Rosalind Franklin medical school, it was revealed today that ENH has recently entered into a 60-day agreement to evaluate a possible academic affiliation with the University of Chicago. This would be a represent a more formidable competitor to stem Northwestern's north suburban expansion.

Yes folks, our purple logo may soon change to maroon and the ENH 'brand' will likely cease to exist in the not-so-distant future.

All's fair in love and war when it comes to hospital systems, it seems.

It is important to note that these discussions are still ongoing, but public enough for them to have been announced to a significant portion of the ENH physicians today. Therefore, I suspect they are serious. Many questions remain unanswered. What this means to academic affiliations for ENH’s “affiliate” physicians, physician academic benefits, and the like, are uncertain. Clearly, ENH has a vested interest in maintaining its hard-earned physician affiliations and will be working to resolve these issues once the air clears a bit about our future.

While change is difficult, it seems necessary if ENH is going to continue its own growth strategy while the market forces evolve in Chicagoland. One thing is certain, though, the competitive climate between centers is more feverish than ever and change, it seems, is inevitable.

Perhaps on a broader note, other cities across America are likely to see the same forces toward consolidation, especially as the electronic medical record facilitates geographic spread of hospital system brand identity. It is clear that many doctors will increasingly become reliant on large healthcare systems to weather the economic impact of the threatened 10.1% Medicare physician pay cut in July, the ongoing unrealistic bureaucratic requirements for pay for performance measure documentation, the ongoing lack of tort reform, and increased work requirements by staff physicians to offset the upcoming resident work hour reductions from 80 to 56 hours per week.

-Wes

Grand Rounds: All Roads Lead to Happy

Happy Hospitalist hosts this week's best of the medical blog-o-sphere with all bloggers leading to Happy in six degrees of separation or less...

-Wes

Electrophysiologists Are Nerds

Nice to know we're hip right now.

-Wes

You'll Be Disabled No More

... with this flame-throwing wheelchair:

According to Lance Greathouse, "It was made for the disabled person looking for something a little different, why drive something that looks like a medical device when you can drive something lethal?"

-Wes

h/t: Instapundit.

More photos.

The Microeconomics of Medical Practice

“Microeconomics is a branch of economics that studies how individuals, households and firms make decisions to allocate limited resources, typically in markets where goods or services are being bought and sold. Microeconomics examines how these decisions and behaviors affect the supply and demand for goods and services, which determines prices; and how prices, in turn, determine the supply and demand of goods and services.”

- Wikipedia

It’s been a nice weekend: gorgeous weather, enjoying “connect time” with the family, and attending a mammoth high school graduation with all of the family activities that that entails. Needless to say, I failed to sit before a keyboard this weekend and reveled in the lack of computer-screen fluorescence.

But earlier this month, the Mrs (or should it be 'Drs?') has been working to shore up the coffers before the personal economic onslaught of two simultaneous college tuitions takes hold. As such, she has slowly been growing her clinical psychology practice: office space, rent, business cards, website, phone, etc. For months she has been working outside The System on a fee-for-service basis: she bills patients directly for services rendered. Accounting is simple and unencumbered: she pays her expenses from the revenues generated, and if at the end of the month she discovers her bank account is positive, she stays open for business. If not, she shudders the practice. Call it “Shoebox Economics:” put all your bills in a shoebox, then pay them off each month and see what’s left over.

Then she decided to “expand” her practice and become a Medicare provider in hopes of securing a larger patient pool.

First, she was unsure how to apply for a Medicare provider number, so being the ever-resourceful person that she is, she hired a billing professional friend who understood the system to help her with the paperwork. “Problem solved,” she thought, and continued seeing patients peacefully. At least until the Medicare provider number arrived, which it did, Friday. Suddenly and graphically, she met The Beast and reached an epiphany:

“Group number? Why do I need a ‘group number?’ Where’s my individual provider number?”

“What do you mean I must bill electronically?”

“What do you mean I can’t just complete a simple form and be reimbursed for my professional services?”

“What do you mean I have to hire a ‘billing specialist’ to do my billing?”

“There’ll be no money left over to apply to tuition!”

* blink * (Light turns on above her head.)

This morning, I saw the first flecks of dust beginning to accumulate on her Medicare provider number letter… It’ll be interesting to see where this goes.

-Wes