Sunday, February 14, 2010

Clinton's stents, Obamacare and comparative effectiveness research

You know where this is going. First, a look at a disappointing piece of coverage from Fox News:

Here as in many news reports we see a conflation of issues concerning stent therapy. The reporters seem confused about the applicability of the results of COURAGE, which studied only patients with low risk stable angina. That would not apply to Clinton who, from what we can gather from news reports, had acute coronary syndrome. He was complaining of chest pains.

Under some all-powerful government CER panel would Clinton have received the stents? What does CER tell us about the best treatment for ACS? We have comparative effectiveness studies out the wazoo on this issue alone and they would be too numerous to mention here. For the most part these studies are compiled and evaluated in the latest ACC/AHA guidelines for unstable angina/NSTEMI, which is what Clinton most likely had. Under these guidelines either an initial conservative or invasive strategy is allowed, and if the patient stabilizes clinically a stress test is recommended before cardiac catheterization. Positive cardiac markers and ST segment or T wave changes suggest, but do not mandate, an initial invasive strategy under the guidelines. My summary is a gross oversimplification. Be assured the government will oversimplify even more. The Fox piece is distorted and non-informative but suffice it to say that in an era where government panels wrest EBM from the hands of physicians Clinton (or some ordinary person with a presentation like Clinton's) might have been denied his stents.

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