Go Red?

Tomorrow, I'll be wearing a red sweater to support the Go Red for Women campaign, sponsored by the American Heart Association and the National Institutes of Health, but I do so with mixed emotion. While I support the concept of raising awareness of women's heart health, I get nauseated at the grotesque sums of money this campaign earns from corporate interests, especially when significant potential conflicts of interest arise in sponsorship. It's not to say that the movement's "near-term goal is nothing less than a 25% reduction in coronary heart disease and stroke risk by the year 2010" isn't noble. Certainly the new broader definition of myocardial infarction revealed this year will go a long way toward achieving that goal. In fact, given that new expanded definition, they can probably already proclaim victory in achieving their goal since heart attacks will be diagnosed more frequently next year compared to last year.

Also, zillions of nice "events" are planned for this day - each with tons of sponsors' paraphernalia - all sprinkled about the audience to raise awareness of heart disease, tune-ups, floor tile, and cutlery while corporations add to their marketing budgets. The conflicts that this bling brings to the event reminds me of the conflicts inherent to "free lunches" provided at Grand Rounds sponsored by drug companies.

Take for instance, Merck. They're one of the "Proud National Sponsors" of the Go Red for Women campaign.

But they're also interested in the controvertial promotion of Gardasil for women to prevent cervical cancer. Merck also sells Vioxx, Vytorin, and Zetia - several drugs without such great press lately in their quest to prevent heart disease.

Other corporate sponsors' motivations are less clear - like Jiffy Lube, Diet Coke, Campbell's Soup, Cutco, Brighton, Clairol Professional, Hamilton Beach, Flooring America, Starkist, Del Monte, Swanson's and RiteAid pharmacies. I mean, its so touchy feely and the women's purchasing power so important that corporations have jumped on this feel-good campaign like a tick on a bloodhound. Where exactly are their heart health motivations? In assuring sodium loading, cutlery, or toxic chemical exposures to women?

Or is this campaign really about funding research for the prevention of women's heart disease?

If so, can anyone point me to studies funded by this endeavor? Or does it just go to the general operating budget of the American Heart Association or NIMH for their big comfy corporate furniture, officer salaries, or office appointments? It's just not clear where all the money goes.

Maybe it goes for all those nice red dress pins or the Heart Checkup website? Seems like a heck of a lot of dough for that.

Yes, I'm jaded. I admit it. But I remember grocery store Green Stamps - that cute marketing invention of grocery store chains of the 1950's and 1960's that proported to help people save money if they just saved more stamps, yet actually made money for the sponsors because people never redeemed them. So I am skeptical of corporate marketing bonanzas like the Go Red Campaign that have yet to demonstrate tangible benefits to reducing women's heart disease while exacting considerable costs to our society.

So if you see me in red tomorrow, remember that I hope my red sweater raises awareness of the need for women to have a better appreciation of their heart health. I just hope it doesn't also advocate for the red budgets of families unable to afford healthcare and medications in America.


-Wes

Is the Superbowl Hazardous to Your Health?

Once again, the New England Journal of Medicine has sunk to new lows in the interest of increasing its impact factor.

The very notion that an article that used retrospecive ER chart reviews to evaluate the incidence of heart disease and claims to have identified "risk factors" that increase the incidence of heart attacks in people at the time of world cup soccer while conveniently excluding years when the World Cup was not in Germany is ludicrous. And if not enough, the authors go on to conclude that "in view of this excess risk, particularly in men with known coronary heart disease, preventive measures are urgently needed."

Give me a break.

What should we do, turn off the TV? Or maybe we should ban all hot dogs and salted pretzels at the soccer games?

But the media, oh baby, the media takes this well-timed drivel and extrapolates that men with coronary disease are more likely to have a heart attack watching the Superbowl! (See here, here, and here, for instance).

Well OF COURSE they will! It's really a conspiracy to lower the world's population of men with coronary disease! Why else would they have the halftime band be Tom Petty and the Heartbreakers?

Maybe Barry Manilow would be more calming and preserve a few more lives. (Heck, that would kill me, but I digress).

It is a shame that journalistic marketing of medical journals has sunk to this new low - but hey, it's all about the advertising revenues...

... and the egos.

Here's what I say: Watch. Cheer. Socialize. Be Happy.

After all, it's good for your heart.

-Wes

Dilberts or Doctors?

What do we define as quality care or excellence in a physician? Is it someone who is responsive to your needs, compassionate, caring, communicative, patient, scholarly, or some mix of these?

Or is it someone who checks your blood pressure and lipid panels again and again and tells you to stop smoking?

If you see patients these days, corporate America has decided it’s the latter example.

The Bridges to Excellence coalition of businesses and health plans including General Electric, Verizon, and IBM is now rewarding doctors to provide “quality care” by following cookbook measures. Hell, if you do a good job, they’ll even throw in a $125 gift card for you for each patient you check this way - money they want primary care doctors to throw towards an electronic medical record (before they feed their families, I guess.)

Never mind that the doctors who now collect this small token of corporate beneficence already have an electronic medical record.

You see the Bridges to Excellence has a few little “loopholes” to qualify for that $125 gift card and a gold star. In order to qualify, doctors have to submit their paperwork and documentation of who was “carefully followed.” And only patients over 18 qualify for the program (sorry pediatricians, you’re out of luck). Doctors must prove that at least four of five pre-specified measures of the care have to be met, not just one.

Yep, you need a computer to track this stuff because it’s bureaucratic mindlessness gone wild.

What’s funny (and sad at the same time) is that if we examine the cardiovascular measures for instance, a physician needn’t take part in the “quality care” delivered. Skilled nurses or nurse practitioners could fill the bill. I mean, as long as the “provider” can take a blood pressure, draw a little blood and type in the record that they told the patient to stop smoking, well, – voilá – a “quality physician” is born! A $125 dollar gift card will be delivered to your door and a notation made in the Healthgrades physician database that you’re the highest of high quality physicians. What a deal!

But perhaps a better word for this incentive program is not a reward, but a bribe to do more testing and mindless documentation. Worse, maybe this money is really a kickback scheme to reward the large hospital-owned primary care physician groups (with whom they have contracts); the same groups who already have electronic medical records and teams of gnomes who can sift through these electronically-identifiable “quality” measures. Maybe these refunds will offset the salaries of the gnomes who assure the documentation takes place and constantly remind their doctors to spend a few more minutes clicking checkboxes so the gerbil wheel can continue to spin even faster and faster.

Such incentives do nothing to reward a doctor for taking the time with a patient, explaining their care, walking them through treatment options and reconciling their medicines.

Before handing healthcare over to the Dilberts, caveat emptor.

-Wes

A Pacemaker for Weight Loss?

It's always cool to hear about new ways pacemaker-like therapies can be used to improve patients' lives.

And now there might be some hope of using pacing therapy to help with weight loss by stimulating the vagus nerve. The company generating the most excitement right now is EnteroMedics. Using vagal nerve stimulation, they hope to decrease people's weight by 25%. Seems plausible, especially since stimulating the vagus nerve might cause early satiety. But the vagus nerve is also responsible for the SLUD syndrome: Salivation, Lacrimation, Urination and Defacation as well as heart rate slowing and the development of atrial fibrillation.

Their trial of this device could get interesting, eh?

Unfortunately, the device still has to be surgically implanted - often under general anesthesia - and the risks of depressing respirations in morbidly obese individuals can be considerable. But, like bariatric surgery, if found to be effective and with few side effects, they might be on to something here.

-Wes

Yep, Medicare Can Ration Too

Only took a year to get this ECG reimbursement paid.

For unknown reasons, the paperwork proving Medicare became the couple's primary insurer on Feb. 1 was not submitted until Oct. 3. Every claim submitted by the doctor for the ECG was before Oct. 3, so all the claims were denied, McLeod said.

Funny how the payment went through after the government's new fiscal year starts after 1 October.

-Wes

America's 10 Most Wanted

Cardiovascular services are number one.

-Wes

Neat and Tidy

... and dumb.

A surgical gown has been developed to help medical students get a closer understanding of what it is like to go under the knife.

. . .

The idea is that it should be worn by students in the classroom, and supplement traditional teaching aids in helping to explain surgical procedures.

Plastic models can be used to show areas of the body where incisions will roughly be made, say the creators, but give no sense of empathy for the patient.

Potentially, the gown could also help explain procedures to patients.

How about going to see a patient with the scar instead? Must everything in medical education be depersonalized and sterilized?

-Wes

Grand Rounds - Beatles Style - Vol 4, No. 18

...is up over at Emergiblog.

Hey Jude, don't be afraid...

-Wes

What'dya Expect?

Mandates don't work if you can't enforce them:

The Food and Drug Administration can't keep up with requirements to inspect domestic makers of medical devices to assure manufacturing quality, and the agency rarely examines foreign facilities, according to congressional investigators.

In testimony scheduled to be delivered today before a House Energy and Commerce subcommittee, the Government Accountability Office will tell lawmakers that it found "weaknesses" in the agency's oversight of an industry that makes products ranging from contact lenses to defibrillators. According to FDA officials' own estimates, overseas makers of the riskiest products, such as pacemakers, were examined only every six years, and moderate-risk device manufacturers on average went an estimated 27 years between FDA inspections.

Pacemakers have historically been far safer than their more complicated cousins, defibrillators. Yet it is important to remember that nearly every recall or device advisory in recent times has been generated by either doctors evaluating the outcomes of their patients or by the development of concerning trends in device manufacturers' product performance, not FDA intervention. So why do we insist that the FDA inspect manufacturers biannually?

Probably because knee-jerk scare tactics work best at generating revenues for bureaucracy on Capitol Hill.

-Wes

How Insurers Fail to Serve Their Customers

In 2001, a patient at age 22 crashes their car and is found to be in ventricular fibrillation by police who arrive on the scene. Amazingly, patient is successfully defibrillated before being removed from the car. This patient was later found to have Long QT syndrome. A single ICD was placed. The patient did well, but later had recalled ICD battery in 2005, which was also replaced. No problems since.

This patient has been carefully followed every three months in our clinic since. Seen once in 2006 for another appropriate ICD shock.

Lots of visits. Lots of records taken - all recorded on an electronic medical record. Patient is covered by insurance.

Today, a letter arrives from this patient's insurance company:

"Dear Doctor or Provider:

Thank you for your recent claim. We appreciate the opporunity to be of service to you.

Unfortunately, we are unable to process the claim due to the reason(s) listed below:

Date of placement for defibrillator, the MD evaluation of patients cardiac status prior to the date and medical necessity for the device.

Please submit the information requested above. Once we receive the requested information, we will be happy to complete our review.

...

Sincerely,

Customer Advocate - UR0482
Blue Cross Blue Shield
Rockford Service Center"

My response:

"Dear Customer Advocate - UR0482:

You call yourself a "Customer Advocate?" How, exactly, does this advocate for your customer? It seems to me that this is another effort to ration care and deny your "customer," my patient, from payment as you promised this individual. Please shove your little computer-generated form letter up where the sun never shines.

You have access to the electronic medical record, as you know, as the patient has granted you access to their record for reimbursement purposes. Please take a few minutes of your precious time to review the record and all of the previous reimbursements you have paid for the indication for this individual's device. The patient's past medical events are clearly documented, as we are required to do each time we see the patient so we can get paid. Further, your attempts to ration care like this and delay reimbursement have resulted in significant legal actions against insurers in other states who have generated similar delays to physician payment.

Sorry I had to notify the world about your lack of "customer service" to my patient.

I hope you understand.

Sincerely,

Dr. Wes"

In-ies or Out-ies

Are you an in-network doctor or out-of-network doctor? You know, an "In"-ie or "Out"-ie?

Depends on the insurer, doesn't it?

Honestly, I have no idea which insurer I'm "in" with and whom I'm "out" with for an individual patient. My job is to see patients, irrespective of whose insurance they hold.

But insurers, well, it matters hugely to them who patients see. After all, they have pre-negotiated amounts they are willing to pay for services with those physicians. And for the most part, this is OK - consumers sign up for these cheaper plans knowing they might be inconvenienced from time to time.

Until doctors don't agree to insurers' rates and refuse to accept terms negotiated by insurers. Doctors sometimes decide not to be "in-network" with a particular insurer.

Fair enough.

But sometimes, those doctors are emergency physicians or radiologists - all of 'em - for a particular hospital. So patients in a HMO plan sometimes have to go to the closest hospital for emergent care. They then receive bills from these "out-of-network" physicians. They become enraged because the ER doctor and/or radiologists bill them when the insurer has "promised" to pay for their healthcare! "How dare you!" they scream. Doctors become the bad guy.

But who's the "bad guy?" The doctor or the insurer? Doesn't the insurer have a responsibility to their patient members to at least provide adequate physician panels for coverage of their members? Do people really think doctors should work for free?

Inadequate healthcare networks is becoming an increasingly important issue and the efforts of the Texas Medical Association is a must-read as they fight to place the onus of providing adequate physician networks to the insurer and restore the doctor-patient relationship:

HMOs promise their enrollees that they will provide prepaid health care for a premium. However, they often fail to provide an adequate network of primary care physicians in their plans, leaving enrollees with unexpected medical expenses. A number of legislators and their staff have been victims of an unexpected charge and are blaming the one they receive their bill from – the physician.

At the heart of the inadequate networks issue is deciphering who is ultimately responsible for medical expenses incurred out of network. Insurance companies don’t want to be held accountable for creating adequate networks or informing their enrollees about adequacy of their plans. In essence, they want to keep breaking their promise to enrollees and surprise them with unexpected expenses, while continuing to post record profits and pay their senior executives millions in salaries and bonuses.

The Texas Medical Association clearly has their eye on the ball here and other states' medical societies should take note.

-Wes

h/t: M.D.O.D.

Hospital Wars

"With hospital costs already the biggest driver in overall health-care inflation, employers and insurers have serious concerns.

'Research clearly shows that the more hospital beds there are, the more costs are generated,' said Larry Boress, executive director of the Chicago Business Group on Health, a coalition of some of the area's largest employers, including Harris Bank, Abbott Laboratories and Sears, Roebuck and Co."

- Bruce Japsen, January 25, 2004, Chicago Tribune

"Nationwide, hospitals spent $24.5 billion on construction projects last year, U.S. Census figures show, up from $23.7 billion in 2005.

The five-year period from 2000-2005 saw a 47 percent increase in spending from the previous five-year period."
-Janet Kidd Stewart, March 19, 2007, Chicago Tribune

Here's Chicago's recent hospital construction costs:

Children's Memorial Hospital, Chicago, IL - $1 billion

University of Chicago Children's Hospital - $145 million

Loyola University Medical Center - $123 million

Northwestern's Prentice Women's Hospital - $500 million +.

Rush University Medical Center - $810 million

University of Illinois, Chicago - $326 million

Central Dupage Hospital $257 million

Condell Medical Center - $109 million

And yes, there's still many, many more.

These numbers make a travesty of the entire concept of a "Certificate of Need" states, of which Illinois is one. It is telling that the Illinois Department of Public Health has not updated their Hospital Capital Expenditures and Financial Information Report since 1999. Could it be the report would make a mockery of CON process as a means of controlling health care costs?

So what are the real "needs" for such construction?

Primarily, it is the "need" to attract the well-insured, affluent patient clientele from a high socioeconomic status.

Next, it is the "need" to attract the physicians and surgical groups with large well-insured, affluent patients in their practices.

Finally, it is the "need" to out-distance the competition - a sort of brick-and-mortar war between hospitals eager to compete for the almighty health care dollar: whether it be with other community hospitals or with physician-owned specialty hospitals.

Certainly, to their surrounding communities, large hospital projects are a billed as a source of civic pride, a monument to the great and wondrous miracles that occur in medicine every day. The development of incredible technlogies that permit unparallelled views inside the body or minimally-invasive robotic and nuclear techniques are a wonder to behold. But to the average Joe with common, chronic ailments like heart failure, diabetes, hypertension, renal disease or pulmonary disease - these centralized monoliths offer little additional for their exorbitant price tag. Except spas, flatscreen TV's, and an increased emphasis on running hospital foodservice departments as profit centers. And although hospitals offer some amount of uncompensated care to their communities, it usually comes at the expense of up-charging for services, which affects each of us.

Perhaps, too, the construction at non-profit hospitals serves as a convenient tax shelter should they become suddenly profitable.

Chicago is the third-largest city in the US behind New York and Los Angeles. But there are other large cities out there as well: Houston, Dallas, Atlanta, Birmingham (AL), San Francisco, St. Louis, Boston, Denver, Salt Lake City, Indianapolis, Minneapolis come to mind. What have the hospital construction costs been in these cities recently?

Maybe when we can no longer afford our insurance or gasp when we see exorbitant hospital bills we should ask ourselves: how much of these construction costs am I paying for?

I would dare say, plenty.

-Wes

Pulling Back the Curtain on Statins

Business Week does a fine job.

Liao has charted some of these biochemical pathways. His recent work shows that one of the trucks, as it were—a molecule called Rho-kinase—is key. By reducing the amount of this enzyme, statins dial back damaging inflammation in arteries. When Liao knocks down the level of Rho-kinase in rats, they don't get heart disease. "Cholesterol lowering is not the reason for the benefit of statins," he concludes.

The work also offers a possible explanation of why that benefit is mainly seen in people with existing heart disease and not in those who only have elevated cholesterol. Being relatively healthy, their Rho-kinase levels are normal, so there is little inflammation. But when people smoke or get high blood pressure, their Rho-kinase levels rise. Statins would return those levels closer to normal, counteracting the bad stuff.

Add it all together, and "current evidence supports ignoring LDL cholesterol altogether," says the University of Michigan's Hayward. In a country where cholesterol lowering is usually seen as a matter of life and death, these are fighting words. A prominent heart disease physician and statin booster fumed at a recent meeting that "Hayward should be held accountable in a court of law for doing things to kill people," Hayward recounts. NECP's Cleeman adds that, in his view, the evidence against Hayward is overwhelming.

The field of preventitive cardiology and industry-sponsored drug trials is about to change - for the better.

-Wes

Check Your Heparin

Two different recalls of heparin contamination were just released:

One from Baxter Pharmaceuticals:

(WSJ) The Deerfield, Ill., company began recalling the lots on Jan. 17. Baxter said it normally receives 60 to 70 reports during a given year of possible reactions to heparin, but in this instance it received about 150 such reports just so far in January, the company said Friday. The reactions include a range of symptoms, such as nausea, vomiting, dizziness, fainting, throat swelling and low blood pressure.

The company said that so far one death has occurred that "may be associated" with the heparin in question.

The units in question are called "1,000 units/mL 10mL and 30mL multi-dose vials." Baxter said it hasn't seen an increase in adverse reactions to any of its other forms of heparin.

The other recall comes pre-filled syringes from AM2 PAT, Inc., of Angier, N.C.:

(via the FDA) Two lots have been found to be contaminated with Serratia marcescens, a bacterium that can cause serious injury or death.

These syringes are manufactured by AM2 PAT under the brand names Sierra Pre-filled, Inc. and B. Braun. They are sold in fill sizes of 3mL, 5mL and 10mL and syringe sizes of 6mL and 12mL.

Consumers and health care facilities with any of the recalled, pre-filled Heparin Lock or Normal Saline IV Flush syringes should stop using the product immediately. Health care facilities should immediately quarantine the products in their inventory and return them to their distributor. Individual consumers should return them to the location from which they were received, such as a pharmacy or hospital. They should also let their health care providers know that they have been exposed to syringes recalled by FDA.

The recall affects all lots of these products. The FDA received information that Heparin Lock Flush syringes from Lot 070926H and Normal Saline IV syringes from Lot 070917A have been found to be contaminated with Serratia marcescens, and have resulted in patient infections. The U.S. Centers for Disease Control and Prevention has confirmed growth of Serratia marcescens from unopened heparin syringes.

Traditionally, Serratia marcescens, a bacterium found in water and soil has been linked to pneumonia, blood infections, and urinary tract and wound infections. Some patients exposed to the recalled syringes have developed blood infections.

Weird how these came a day apart. But don't worry, the lawyers are already on it.

-Wes

References: Baxter's recall notice.

AM2 PAT's press release.

Automaticity

Elderly patient comes to ER for "feeling my heart pounding."

Patient seen my emergency room doctor, who does "physical" from EKG and recommends admission (it was thought to caused by his heart, after all).

Patient admitted.

Nurse notes slow heart rate. Recognizes intermittent complete heart block on telemetry. Asks electrophysiologist if he has been consulted.

Electrophysiologist has not been consulted. It is Friday.

Electrophysiologist notes patient is to receive the blood-thinner Lovenox and was presribed warfarin (Coumadin). Reviews EKG - Intermittent complete heart block and Mobitz II AV block on EKG from evening prior.

Electrophysiologist wonders "Why would anticoagulation be prescribed for person who might need pacemaker?"

So he signs on the Emergency Medical Record (EMR) system to write order to stop lovenox therapy until decision is made regarding pacemaker implant.

At which time he the orders algorithm of the EMR suggests that "patient's age and risk factors warrant use of DVT prophylaxis."

Electrophysiologist is enlightened.

-Wes

Dr. Wes Does Internet Talk Radio

Thanks to Dr. Anonymous for the opportunity to appear on The Doctor Anonymous Show last evening, a weekly web-based blog talk radio show about medicine and med-bloggers on the web. The intro theme song? Why "Sweet Home Chicago" of course! Last night we touched on my background, how I came to be an electrophysiologist and med-blogger (and how that related to the t-shirt website I co-founded with my wife, MedTees.com). I also discussed the difference between pacemakers and defibrillators, and a bit about the recent defibrillator recalls and the challenges they posed to doctors as well as patients, and finally, a bit about the future of electrophysiology.

If you missed the show, feel free to check out the archived copy.

-Wes

Cardiology Hospitalist: A New Career Path?

Cardiology Hospitalist?

Will provide direct clinical support, evaluating ED patients for admissions, follow-up care, expediting discharges, assisting with cardiac emergencies, completion of CORE measures, coordinating care teams of house staff and nursing staff. Plenty of opportunity to attend cardiology conferences, lectures, grand rounds.

Opportunty, certainly, but I've never seen any hospitalists attend our cath conferences or most medical conferences for that matter... they're just too busy "expediting discharges."

Sneaky marketing, though, but I'd suggest that the potential "cardiology hospitalist-to be" look at this position with some skepticism.

-Wes

Dr. Wes Live on the Doctor Anonymous Show at 8 PM CST Tonight

Tonight, I will be a guest on the Dr. Anonymous Show, a weekly internet talk radio show conceived, developed and hosted by the infamous Doctor Anonymous at 8 PM Central Standard Time, 9PM Eastern Standard time.

A chat room and call-ins are featured. Directions for participating can be found here.

I stand ready with my flak-jacket look forward to hearing from you.

-Wes

2007 Weblog Awards Announced

Congrats to Paul Levy and his blog Running a Hospital, winner of the Best Medical Blog, who also won the category I was nominated for as well: Best Ethics/Health Policy blog.

Other award-winners include Random Acts of Reality (Best Literary Blog), Dr. Val and the Voice of Reason (Best New Blog) , New York Emergency Medicine (Best Clinical Sciences), ChronicBabe (Best Patient Blog), and the Best Technologies Blog is still pending...

For all who voted for me, I am forever grateful, but as I mentioned, I was happy to have just been selected as a finalist.

Thanks to all of the Medgadget guys for their efforts.

-Wes

Cells: The New Antiarrhythmic?

Innovative work was reported in Circulation on-line (before print) that demonstrated that genetically-enginnered rat fibrous cells that expressed an important potassium channel found in heart tissue could alter the electrophysiologic properties of neighboring cardiac cells to beat slower in culture compared to control cells, and prolong the heart tissue's refractory period (the ability for a skipped beat to re-stimulate the heart).

Rat fibroblasts (fibrous cells) were genetically engineered to express the voltage-sensitive potassium channel Kv1.3 and placed within cell cardiocyte cultures. They altered the electrophysiologic properties of neighboring cardiocytes (heart cells) by reducing (68%) the spontaneous beating frequency of the cultures compared with baseline values compared to control fibroblasts. Following this finding, the same fibroblasts were injected into pig right ventricular tissue and showed some lengthening of the myocardial refractory periods in pigs as well. While very preliminary, the authors (many of whom are affiliated with the Iraeli start-up company GeneGrafts, a Technion University incubator company) observed changes in the local ventricular electrophysiological properties that indicated the "ability of the engrafted engineered fibroblasts to survive, to integrate with host tissue, and to modulate local excitability by generation of electrotonic currents with neighboring cardiomyocytes."

While there was good evidence that the authors' proof of concept study was successful, its application to man is a long way from certain. Fibroblasts, after all, create scar and scar is inherently arrhythmogenic in myocardium. Nonetheless, the concept is intriguing as a new avenue to pursue for possible antiarrhythic therapy.

-Wes