Personalized medicine is ready for prime time now!

H. Robert Superko, M.D., presented data on genetic polymorphisms (SNPs) and cardiovascular disease. The boosters of comparative effectiveness research are pushing government policy away from personalized medicine. After listening to Superko’s presentation I am convinced that this is the wrong direction to go.

Two examples:

The KIF6 variant predicts statin responsiveness. In the PROVE IT trial, NNT for intensive statin benefit was 10 in carriers, 125 in non-carriers!

A variant of the LPA gene is a powerful predictor of aspirin responsiveness (NNT 37 vs. 400!).

More on this soon.

What’s new and exciting in atrial fib?

Dr. Timothy Fleming gave a nice overview in yesterday’s sessions. Here’s what was of particular interest to me:

The CHADS2 score is useful in clinical decisions.

Warfarin should be withheld from elderly patients with increased fall risk. Fact or myth? Myth, if their CHADS2 score is 2 or greater.

What about the percutaneous left atrial appendage occlusion device as an alternative to long term warfarin therapy? Although the PROTECT AF trial showed non-inferiority to standard warfarin treatment the procedure associated complications were very problematic, and the procedure, while worth consideration in very select patients, is not ready for general use.

Dronedarone---a non toxic amio? Maybe. No iodine moiety, no thyroid or pulmonary problems. Can be used for rate control or to maintain sinus rhythm. Associated with decreased mortality (first a fib drug to do so!) when used for rate control excluding class 4 heart failure but increased mortality seen when used in severe HF to maintain NSR. (Now who knows what hidden toxicities lurk in the post marketing experience).

Do “non-a fib drugs” prevent a fib? ACEIs yes; ARBs yes; statins maybe (didn’t quite reach statistical significance in a meta-analysis). A fib was a secondary endpoint in trials of these drugs for their approved indications.

Health care in New Zealand

I’ve gotten a unique glimpse of health care in New Zealand by attending this conference. One of the faculty members, Timothy Fleming, M.D., spends half of each year practicing and teaching in Seattle and the other half practicing and teaching in New Zealand. By some accounts New Zealand might be considered a model single payer system---comparable “hard clinical outcomes” but at markedly reduced cost compared to the U.S. Fleming, who eschews simplistic statements about which system is “better”, offered some examples from his perspective as a cardiologist of how costs are cut:

Brand name drugs require administrative approval and may take weeks to obtain.

There’s no one to read your images for you. You do it yourself and there are no extra fees.

In the U.S. if you have atrial fibrillation of uncertain duration and want cardioversion you can get a TEE to be sure there are no atrial appendage thrombi and get shocked that same day. A TEE (or a TOE as they call it) to enable prompt cardioversion is unheard of in New Zealand. You take your coumadin and wait 3-4 weeks.

In the U.S., influenced by the legacy of CAST, doctors generally avoid prescribing flecainide to help patients maintain sinus rhythm after conversion from atrial fibrillation without first performing imaging studies to rule out structural heart disease. In New Zealand flecainide tends to be a drug of first choice without regard to structural heart disease. That saves a lot of imaging studies. Fleming tends to think the outcomes are just as good, and the difference in practice is driven largely by differences in malpractice concerns.

This week we ran into a nice older couple from New Zealand taking a bus tour of the National Parks. They seemed satisfied with their healthcare system. He didn’t seem to mind the long wait for his CABG, knowing all the while that had he suddenly clutched his chest and collapsed on the street he would be moved to the front of the line. Tongue in cheek he suspected that some patients game the system by feigning cardiac emergencies.

But people in New Zealand are generally community minded. They appreciate the benefits of community support and are willing to put the medical commons above the individual. Their single payer system would never be accepted in the U.S., a society based on individualism. We are a society of different values, but to say we are inherently more selfish would be preposterous.

CME in Wyoming

The first day’s sessions have ended. Two more half days to go. I’ve been pouring over my syllabus, driving my wife crazy. Every year I leave this conference wondering how they could possibly make it better, but it seems they always succeed.

I’m not actually blogging in real time during the sessions; over the next few days as time permits I’ll try and post impressions on those topics that interest me most.

The organizers of the conference told me that funding is an increasing challenge. This year the registration fees were offset by one drug company, several device companies, a couple of genomics firms and a couple of non-profits. Efforts at funding are, of necessity, becoming increasingly creative. Although there is as yet no official ban on industry support for CME, public pressure from the pharmascolds is making an impact. One of these days they will get their way and shut this conference down, but I am hoping it will keep going for a few more years, and that is the intent of the organizers.

Mount Moran from across Willow Flats

From below the terrace just behind the conference center at Jackson Lake Lodge, Grand Teton National Park. The picture window in the main lobby affords a similar view.

Images from Grand Teton National Park

Pilgrim Creek from under the Colter Bay Road Bridge

Bald Eagle, viewed from our Snake River raft

Pair of Bald Eagles, viewed from Snake River

The Blue Heron Lounge, Jackson Lake Lodge's popular watering hole

Relaxing in the wifi zone at Jackson Lake Lodge

Welcome reception tonight. Conference starts tomorrow. More soon.

Cocaine cardiotoxicity

Reviewed in the American Journal of Cardiovascular Drugs.

Arrived in Wyoming

We meet the most interesting people here every year. Tuesday we met Amy Cohen. Today we ran into a couple from New Zealand and had an interesting conversation about how their health care system compares with ours. More about that later, maybe.

Yesterday we hiked the Colter Bay Road. Out of shape, didn’t take enough water, dehydrated and tired when we got in. But it was a good tired.

Snake River float tonight.

The conference starts in a couple of days, and I’ll live blog as time and access allow.

Abdominal compartment syndrome update

There’s been another review published in Clinics in Chest Medicine.

The term ACS was first used by Fietsam and colleagues^[2] in the late 1980s to describe the pathophysiologic alterations resulting from IAH secondary to aortic aneurysm surgery: “In four patients that received more than 25 L of fluid resuscitation increased IAP developed after aneurysm repair. It was manifested by increased ventilatory pressure, increased central venous pressure, and decreased urinary output. This set of findings constitutes an abdominal compartment syndrome caused by massive interstitial and retroperitoneal swelling… Opening the abdominal incision was associated with dramatic improvements….”

But this is not just a surgical entity. Though increasingly described in critically ill medical patients the syndrome remains underappreciated.

Background here.

Best of History Web Sites

Lots of good stuff here.

Via Clinical Cases and Images blog.

Sepsis

Here is another of many sepsis reviews, this one published in Clinics in Chest Medicine. It is a comprehensive evidence based review although it does not take into account NICE-SUGAR and the recent systematic review regarding steroids. Although the paper resembles many other recent sepsis reviews these statements on acidosis and nutrition are interesting in that they challenge popular practice:

Even though experimental data do not support the practice, as a practical matter, many physicians feel compelled to intervene when pH declines below 7.10.

And---

As with other critically ill patients, there are two basic “truths” about nutrition. First, prolonged starvation (weeks to months) is fatal, and second, any patient can tolerate a few days without feeding. Almost every other aspect of nutritional support is argued.

This was new to me:

At this time, there is no compelling evidence to suggest that any particular enteral feeding formula or particular balance of components is superior to another for the patient with severe sepsis, but there are compelling phase II data from patients with acute lung injury. Three trials now suggest that an enteral formula enriched with omega-3 fatty acids, antioxidants, and other specialized ingredients may improve outcomes. ^{[120] , [121] , [122]}

August recess

My own, that is. I'm doing some traveling the next three weeks. Although a few autoposts will keep the blog going, it may be slower than usual.

If I get a chance I'll do some live blogging from my CME meeting.

“Show me where it says end of life counseling is mandatory!”

---said John Stewart to Betsy McCaughey.

Bob Wachter provided a link in the comment thread of Thursday’s post.

The unedited footage, including the off-air segment, is linked here.

Stewart skillfully leveraged jokes, mockery, and audience reactions to out-maneuver McCaughey. How did she do against those odds?

Well, no smoking gun. She did try to establish that the counseling it would be a performance measure and associated with penalties for underperformance. All I could glean for sure was that the counseling provisions would be pay for reporting measures as an extension of Medicare’s PRQI program. If that’s all she’s basing it on she’s making a bit of a leap.

But, again, I wish she’d been given more of a chance to make her points. She didn’t have the home field advantage, and Stewart’s smack down was a little cheap.

Much of the concern about this bill, which I share, is that in its vagueness it leaves a great deal to unelected policy czars whose agenda the public doesn’t trust.

Bob Wachter throws down the gauntlet in the health care debate

The normally affable Bob Wachter adopted an uncharacteristic tone in Thursday’s post:

It’s time to fight back. The “death panel” nonsense is not a harmless and amusing political canard – it is modern McCarthyism: the shameless, heinous use of lies and distortions to scare and confuse people…

Then came Sarah Palin and the other hypocritical asses who have managed to take a serious, even profound, issue and turn it into a mockery…

There can, and should, be reasonable disagreements about health reform, but the Fox News/Town Hall crowd is not interested in negotiation, or progress, or bettering the lives of our citizens – they are ideologues hell bent on destruction, gamesmanship, and Neilsen ratings. It is time to use all the tools at the Administration’s disposal to out the truth and fix what’s wrong with American healthcare...

It can be done, but it’ll take a fight. So let’s have one.

Though my disappointment about this debate is more tempered (I’m a little to the right of Bob, you see) I understand his outrage. I remember how I felt in 1994, 1996 and 2000 when the Democrats had a few Nazi references of their own and tried to scare elders into thinking the Republicans would force them to choose between food and medicine. This is politics as usual. Among those of us who disapprove of hype the intensity of reactions, like the pain scale, can range from 1-10. Personally, I think a 2 or a 3 from participants on both sides of this debate would get the job done more effectively (the job being thorough, reasoned debate).

In support of such a cause I hope to come up with a more lengthy post on rationing and end of life issues soon, to address some of Bob’s points as well as Orac’s challenge to come up with a more nuanced analysis of Zeek Emanuel’s Lancet paper.

That may be slow in coming, as I am about to head out to this meeting followed shortly by a trip to St. Louis to help with an EMR go-live (yes, I’m turning to the dark side for a few days).

Who should get genetic testing for cardiac channelopathies?

The yield is low, the tests are expensive and reimbursement policies are inconsistent. A recent paper looked at the yield and costs in different patient populations:

Conclusions— Genotyping can be performed at reasonable cost in individuals with conclusive diagnosis of long-QT syndrome and catecholaminergic polymorphic ventricular tachycardia, and in patients with type I Brugada syndrome ECG with atrioventricular block. These patients should be given priority to access genetic testing.

Sarah Palin, death panels and Obama’s pain pills

Right you are again, Dr. Rich.

Universal coverage likely to fail because it will exacerbate the physician shortage: Kevin MD

Go read Kevin’s commentary over at CNN. He practices in New Hampshire and has been an observer of the unintended consequences of nearly universal coverage in neighboring Massachusetts:

Today, 97 percent of Massachusetts residents have health insurance, the highest in the country. But less publicized are the unintended consequences that the influx of half a million newly insured patients has had on an unprepared primary care system.

The Massachusetts Medical Society reported that the average wait time for a new patient looking for a primary care doctor ranged from 36 to 50 days, with almost half of internal medicine physicians closing their doors entirely to new patients. And when you consider that Massachusetts already has the highest concentration of doctors nationwide, wait times will likely be worse in other, less physician-abundant parts of the country, should universal coverage be enacted federally.

….since health reform was passed, according to state data provided to the Boston Globe, Massachusetts emergency rooms have reported a 7 percent increase in volume, which markedly inflates costs when you consider that emergency room treatment can be up to 10 times more expensive than an office visit for the same ailment.

That, of course, is one of the problems that health care reform is supposed to “fix.”

…the Association of American Medical Colleges is forecasting a shortage of 46,000 primary care physicians by 2025, a deficit that not only will balloon under any universal coverage measure…

God’s partners in matters of life and death?

Via the First Thoughts blog:

President Obama gave humankind a huge promotion the other day, claiming a partnership with God. Hubristic? Yes, and clueless about matters theological. More over at Secondhand Smoke.

As Wesley Smith points out, Obama may have unintentionally added a small log to fuel the fire over end of life issues.

Literature, arts and medicine database

Interesting reviews and commentary:

The Literature, Arts, & Medicine Database is an annotated multimedia listing of prose, poetry, film, video and art that was developed to be a dynamic, accessible, comprehensive resource for teaching and research in MEDICAL HUMANITIES, and for use in health/pre-health, graduate and undergraduate liberal arts and social science settings. It is a multi-institutional project (see Editorial Board) that was initiated by faculty of the New York University School of Medicine…

End of life counseling provision off the table?

Many of the alarmists about the end of life counseling provision in HR 3200 would be satisfied if that small section of the bill, starting on about page 425, were re-written to make the counseling explicitly voluntary. That's what many of them have been clamoring for. So what are they going to do? HHS secretary Sebelius is now saying they'll probably drop it from the bill altogether! As Wesley Smith said, that's strange.

This is exceedingly strange. If the counseling is as important as its supporters have been saying, why not just ensure voluntariness? Why, instead, would the administration rather kill the counseling provision altogether? Maybe they plan to put the provision in by regulation instead of legislation? Inquiring minds want to know.

None of this makes any sense if Section 1233 was truly benign.

TZDs and heart failure

Here’s another review:

Concern over whether new or worsening left ventricular (LV) dysfunction is a contributing factor to TZD-induced peripheral edema and heart failure has led to several studies. To date, however, none have demonstrated a detrimental effect of TZDs on myocardial structure or function. Several echocardiographic studies have failed to reveal any adverse effect on LV mass index, LV ejection fraction, or LV end diastolic volume.

…Acute decompensated heart failure is an indication to discontinue the TZD, while peripheral edema is not. As per the AHA/ADA consensus recommendations, other potential reasons for peripheral edema should be sought, such as venous insufficiency, other edema producing drugs, and hypoalbuminemia.22 Increased edema may require decreasing the dose of the TZD, slower dose accelerations, and the use of diuretics.

…Due to a paucity of TZD studies in patients with NYHA class III and IV heart failure, their use continues to be relatively contraindicated in this patient population, and has a Food and Drug Administration mandated “black box” warning in patients with NYHA class I and II heart failure.

Update on acute liver failure

Here’s another review:

Acute liver failure (ALF) is defined as the development of impaired hepatic synthetic function with coagulopathy and the development of hepatic encephalopathy in the absence of underlying liver disease in less than 2 to 3 months time.[1] In the setting of ALF, hepatic encephalopathy may be associated with life-threatening cerebral edema, whereas by contrast this association is absent in patients who have chronic liver failure with encephalopathy.

Related posts here and here.

Thrombophilia testing after an episode of VTE---the controversy continues

Previous studies have questioned the value of thrombophilia testing after VTE. Guidelines have been largely silent on this issue and most expert recommendations stress informed patient preference as a deciding factor.

This systematic review now suggests that the finding of heterozygousity and homozygousity for factor V Leiden in probands and relatives may be predictive. It is debatable whether this finding would lead to treatment change that would improve outcomes. At this time the best we can say is that the decision for testing of hereditary thrombophilia should be individualized.

Bob Wachter on physician payment reform

Go read Bob Wachter's post about physician payment reform and accountability in local health care systems. Some great insights there. Careful, though, that you don't confuse substance with tone. After asking readers to get over the August silliness and move the discussion beyond the third grade level he said this:

Americans are often characterized, and sometimes lampooned, as being a selfish breed. Our tolerance of 45 million uninsured is seen by many around the world as a reflection of this trait; other nations prize the commons over the individual (and are willing to make the tradeoffs required to generate the resources to provide universal coverage), while America is all about “me”. Yet most of us would give our lives for our kids, community service and charity are strong American traditions, and most Americans are highly devoted to their colleagues and their communities. What is true is that in our huge, chaotic, melting pot of a society, relatively few people (they’re called unabashed liberals, if you can find ‘em) will voluntarily make significant sacrifices for faceless “others”. We’re willing to give things up for our neighbor, but not somebody else’s neighbor.

Americans are inherently more selfish and liberals inherently more altruistic, eh? Maybe Bob didn't really mean to say that but he came pretty close. By the way, I thought that individual-over-the-commons thing was a Judeo-Christian value.

Atul Gawande, Don Berwick et al on more efficient health care---New York Times

In this piece several communities notable for efficient health care---anti-McAllens, if you will, are profiled:

To find models of success, we searched among our country’s 306 Hospital Referral Regions, as defined by the Dartmouth Atlas of Health Care, for “positive outliers.” Our criteria were simple: find regions with per capita Medicare costs that are low or markedly declining in rank and where federal measures of quality are above average. In the end, 74 regions passed our test.

So we invited physicians, hospital executives and local leaders from 10 of these regions to a meeting in Washington so they could explain how they do what they do. They came from towns big and small, urban and rural, North and South, East and West. Here’s the list: Asheville, N.C.; Cedar Rapids, Iowa; Everett, Wash.; La Crosse, Wis.; Portland, Me.; Richmond, Va.; Sacramento; Sayre, Pa.; Temple, Tex.; and Tallahassee, Fla., which, despite not ranking above the 50th percentile in terms of quality, has made such great recent strides in both costs and quality that we thought it had something to teach us.

It's all about efficient, evidence based care. But I'm still struggling to understand how Don Berwick reconciles such evidence based efficiency with his notion of patient centered care.

The problem with HR 3200

---is that it is so vague. It's nearly inscrutable although there are some suggestions, such as making end of life counseling a performance measure, that raise real red flags.

Tothesource describes the problem this way:

There is one more important concern rarely mentioned in the debate about this complicated and mind-numbingly arcane bill. The legislation is only the general outline, the skeleton if you will—of what the remade American health care system would ultimately look like if the bill becomes law. The flesh and blood would be created beneath the public radar by unelected bureaucrats in the federal departments and agencies through the promulgation of thousands of additional pages of rules and regulations. Thus, whatever bill is ultimately passed, it will still be a pig in a poke. The devil, as they say, will be in the regulatory details.

Wesley Smith, commenting on the piece, said:

That is why it is foolish to pass a 1000+-page bill that is long on indecipherability as well as dead trees. We don’t want decisions that will legally impact so centrally on life, death, health, and welfare, left to unelected bureaucratic regulators.

Why does the notion of death panels resonate with the American public?

Brilliant, Dr. Rich.

Limbaugh, Gingrich, Palin and MSNBC

Three gotchas?

Visit msnbc.com for Breaking News, World News, and News about the Economy

Don't think so!

Such cheap distortion hardly warrants the effort of a full post here so go over to Orac's blog and read my comments (9, 11, 14 and 18) to find out what's really wrong with this piece. And, yes, my take differs a bit from Orac's.

Why is Dr. Ezekiel Emanuel important in the health care debate?

Denise Hunnell, M.D. explains:

Those advocating for President Obama's health care reform label concerns about rationing of care and denial of care to the elderly and disabled as irrational and the product of fear mongering. However, if you read the work of Dr. Ezekiel Emanuel, who is the health-policy advisor at the White House Office of Management and Budget (OMB) and a member of the Federal Council on Comparative Effectiveness Research (FCCCER) and also the brother of the President's Chief of Staff Rahm Emanuel, these concerns seem very reasonable indeed. The current legislation does not specify medical treatments to be covered. Rather, it delegates these decisions to a Health Benefits Advisory Council. This panel is advised by the FCCCER. That is why the ideology of Dr. Emanuel is very relevant to concerns about rationing of health care.

This should be the guiding principle:

The value of treatment to any given patient can be ethically evaluated, but every patient's life is of inestimable worth.

But don't take someone's word for it. Read Emanuel's recent Lancet article.

For intoxicated patients it the ER

---forget the banana bag. Just give 'em thiamine:

Conclusions
In our ED, patients with acute ethanol intoxication do not have B12 or folate deficiencies. A significant minority (15%) of patients have thiamine deficiency; its clinical significance is unclear. Widespread administration of multivitamins is unwarranted by these findings, but thiamine may be considered.

Primary PCI remains superior to fibrinolytic therapy for STEMI

---according to the latest evidence synthesis.

Underutilization of TPA in ischemic stroke

From Emergency Medicine Clinics of North America:

This article reviews the history of tPA use in stroke as a case study of a breakdown of knowledge translation in emergency medicine.

Sarah Palin's latest Facebook post on end of life counseling

The post advanced a very nuanced view. So much so that a couple of her commenters as much as accused her of having it ghost-written. And here, for the first time we see detractors of the HR 3200 end of life counseling provision acknowledging that the counseling may not be mandatory. The real problem, they say, lies in the conflict of interest, the slippery slope and the unintended consequences:

As Charles Lane notes in the Washington Post, Section 1233 “addresses compassionate goals in disconcerting proximity to fiscal ones....”

Although a good palliative care service can save an institution money its focus is on what's best for the individual patient. Sometimes those goals are in conflict, sometimes not, but an excellent palliative care team will manage the conflict appropriately by putting the individual patient first, no matter the impact on the medical commons. When an end of life counseling provision is part of a bill with a clear agenda to control costs some degree of skepticism is appropriate.

She goes on to quote Lane further:

If it’s all about obviating suffering, emotional or physical, what’s it doing in a measure to “bend the curve” on health-care costs?” [6]

As Lane also points out:

Though not mandatory, as some on the right have claimed, the consultations envisioned in Section 1233 aren’t quite “purely voluntary,” as Rep. Sander M. Levin (D-Mich.) asserts. To me, “purely voluntary” means “not unless the patient requests one.” Section 1233, however, lets doctors initiate the chat and gives them an incentive -- money -- to do so. Indeed, that’s an incentive to insist.

Patients may refuse without penalty, but many will bow to white-coated authority.

End of life counseling issue needs clarity

Washington Post columnist Kathleen Parker weighs in on the substance and tone of the debate surrounding the end of life counseling previsions of HR 3200:

Unfortunately, Palin's more thoughtful comments followed a made-for-the-tabloids Facebook post suggesting that under President Obama's health care reform, a "death panel" would kill her elderly parents and her Down syndrome baby.

Once upon a time, radical reformers could only dream of such helpful enemies. Now that the world is chasing hyperbole, we indeed risk overlooking troublesome language in the end-of-life section of the House health bill, aka Section 1233 of HR 3200.

For purposes of civil discourse, let's assume that no one wants to kill off old people.

She seems to agree with me that it's impossible to be sure in reading the bill whether the counseling provision is mandatory or not:

In practice, however, the debate is over whether these consultations are conclusively voluntary -- and the bill, to the extent it is comprehensible at all, is vague enough to cause concern.

A lot of folks on both sides of this debate seem pretty cock sure about what the bill really says. I have called them out to explain the legalese to the rest of us. So far no one's stepped up to the plate.

If nothing else there's the concern for unintended consequences:

It would be nice to think that everything goes as intended by patients, but we can safely assume that when human error collides with bureaucratic efficiency, nightmarish enforcement scenarios could ensue.

The health benefits advisory committee, many of whose members, according to the bill, would be appointed by the President, will have a large role in determining health care benefits, and the vaguer the language of the bill the more power they'll have.

And this, from Parker's article, is chilling:

Not least, the bill is an enabling document that leaves great discretion to the secretary of health and human services to develop guidelines that ultimately could change the character of what seems to be offered.

In just one of dozens of examples, the bill leaves it to the secretary to develop "quality measures" on end-of- life care and advanced care planning.

What might such quality measures look like? Who knows? But other documents floating around hint at what the secretary might consider.

One is a 2008 Rand Corp. report, "Advance Directives and Advance Care Planning: Report to Congress," which suggests mechanisms by which poor "advance care planning" could be viewed as "medical error," otherwise known as malpractice.

Here's the section of the bill on “quality” measures, starting on page 431 line 16:

(b) EXPANSION PHYSICIAN QUALITY REPORTING

OF

17 INITIATIVE FOR END OF LIFE CARE.—

18 (1) PHYSICIAN’S QUALITY REPORTING INITIA-

19 TIVE.—Section 1848(k)(2) of the Social Security Act

20 (42 U.S.C. 1395w–4(k)(2)) is amended by adding at

21 the end the following new paragraphs:

22 ‘‘(3) PHYSICIAN’S QUALITY REPORTING INITIA-

23 TIVE.—

24 ‘‘(A) IN GENERAL.—For purposes of re-

25 porting data on quality measures for covered



432

1 professional services furnished during 2011 and

2 any subsequent year, to the extent that meas-

3 ures are available, the Secretary shall include

4 quality measures on end of life care and ad-

5 vanced care planning that have been adopted or

6 endorsed by a consensus-based organization, if

7 appropriate. Such measures shall measure both

8 the creation of and adherence to orders for life-

9 sustaining treatment.

10 ‘‘(B) PROPOSED SET OF MEASURES.—The

11 Secretary shall publish in the Federal Register

12 proposed quality measures on end of life care

13 and advanced care planning that the Secretary

14 determines are described in subparagraph (A)

15 and would be appropriate for eligible profes-

16 sionals to use to submit data to the Secretary.

So, even if the counseling is voluntary it will become a performance measure! Now, if doctors are to be reimbursed for end of life counseling who's to say there won't be penalties for failure to counsel according to the government's performance standards?

As Wesley Smith points out:

The bill might not create punishments, but the regulations that would be created in the shadows outside the direct democratic process could.

More on Obama and surgeons' fees

Some fact checking by Wesley Smith.

From the American College of Surgeons: Mr. President, get your facts straight

Press release here.

Via Dr. Wes.

Remember Google Knol?

One year after launch it's struggling.

Via Clinical Cases and Images blog.

Night call frustrations

---Anonymous Doc writes:

My second-year resident didn't let me sleep last night. This whole overnight thing depends so much on the resident in charge. This guy must be on drugs or something, because he just did not get tired. At 2AM, he pulls me out of bed to check the labs on a patient, said he felt like it would be a "teaching opportunity," and that he wanted to show me something about something I can't even remember. I finally get back into bed by 3 and at 3:30 he grabs me "to go over the patients for 7AM rounds, just so we're on the same page." At 3:30 in the morning?? Then the nurse with the EKG at 4, and a patient wandering out of bed and pulling out his tubes at 4:30, that the nurse felt compelled to wake me up to tell me. And I couldn't get to sleep after that, wrote my morning notes, then stumbled through rounds before finally getting to leave a couple of minutes ago.

My pet peeves? Waking me up at 3AM to “touch base.” And please, please, in the middle of the night, I don't need a “heads up.” I'll be more alert and engaged when you really need me if I get a little sleep.

Acute kidney injury in patients undergoing cardiothoracic surgery

---impacts long term survival even when renal recovery occurs:

Conclusions— The risk of death associated with AKI after cardiothoracic surgery remains high for 10 years regardless of other risk factors, even for those patients with complete renal recovery. Improved renal protection and closer postdischarge follow-up of renal function may be warranted.

Can a family history of heart disease be overcome?

---asks Kevin MD.

Well, yes, in most cases. Unfortunately it takes individualized medicine, something low on the agenda of today's medical policy makers. For a primer on individualized medicine and coronary heart disease read these papers.

BTW Dr. Superko, an expert on cardiovascular genetics and co-author of both papers, will be speaking at Tutorials in the Tetons, 35^th Annual Update in Cardiovascular Diseases.

Senator Arlen Specter's town hall on health care reform

Video of the entire meeting via C-SPAN. Amazing. Ordinary people are reading HR 3200 in the original. They've been given a glimpse of big government and they don't like it. As the commenter at 21:25 said, “You have awakened a sleeping giant.”

H/T to Instapundit.

Archives of Internal Medicine paper on hospitalists and “quality”

Do hospitalists improve the quality of inpatient care? I like to think so but you wouldn't convince me with this paper. The investigators found that hospitals with hospitalists had better adherence to selected measures for MI, pneumonia and CHF. One weakness of the paper the authors acknowledged is that adherence to these measures could not be directly attributed to hospitalists. Many patients in hospitals with hospitalists may have been cared for by non-hospitalist practitioners.

But the real weakness of the paper, one which the authors did not directly acknowledge, was revealed in the introduction. After a discussion about hospitalists and quality this statement was made (my italics):

The aim of this study was to examine the link between hospitalists and performance as measured by the HQA benchmark quality measures for acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia.

So the whole premise of the paper, that performance equates to real quality, is faulty! I have pointed that fact out in several posts including this one where I dissected the reasons why the performance movement has failed.

Before moving to the related editorial I should mention another unsupported claim in the paper, which was that the hospitalist model results in lower length of stay and costs per case. That notion is entrenched in medical literature and popular perception thanks to a huge dose of publication bias.

Robert Centor (DB) and Benjamin Taylor wrote a related editorial in the same issue. After commenting on the unfortunate confusion between performance and quality and mentioning some methodologic problems with the paper they suggested a change in the research agenda for hospital medicine:

As a young field, hospital medicine has strengths and weaknesses. Future investigations should focus on defining the strengths and minimizing the weaknesses. We believe that hospitalists can help decrease hospital errors and improve safety if they are totally integrated with hospital processes and supported as champions for these important efforts. Lumping hospitalists without a consideration of organizational differences could hide the promise of excellent hospitalist groups. The major contribution of hospital medicine should involve system improvement along with excellent bedside care. We must understand the contributors as well as the detractors to excellence for the hospitalist movement to achieve its full potential.

Sarah Palin’s comments on “death boards”---do they go too far?

Let's not confuse the tone of her remarks with their substance. Once again, Wesley J. Smith finds the proper balance:

Palin is not being paranoid. Some of President Obama’s most influential health-care advisers have promoted rationing and quality-of-life judgmentalism. For example, Dr. Ezekiel Emanuel, White House chief of staff Rahm Emanuel’s brother, has suggested that we can no longer afford Hippocratic medicine, laid the intellectual groundwork for rationing based on age, and even stated that medical services “provided to individuals who are irreversibly prevented from being or becoming participating citizens are not basic and should not be guaranteed.”

and this---

True, Palin would be a more effective critic of Obamacare if she didn’t write like a college-student blogger. But her concerns are legitimate and substantive. And that shouldn’t be lost in the criticism of her lexicon.

Go to the primary source. Ezekiel Emanuel is a top health care policy maker in the Obama administration. Just pay attention to what he says if you don't like listening to Sarah Palin.

Conflicts of interest go beyond the drug and device companies

The World Association of Medical Editors has recently released its new policy statement for journal editors concerning conflicts on interest (COI) on the part of authors and reviewers. No longer focusing on financial conflicts due to proprietary interests, the statement takes a broader and more balanced view. It's long overdue. Some excerpts (italics mine):

Journals often have policies for managing financial COI, mostly based on the untested assumption that financial ties have an especially powerful influence over publication decisions and may not be apparent unless they are made explicit. However, other competing interests can be just as damaging, and just as hidden to most participants, and so must also be managed.

Examples cited as significant conflicts, in addition to the obvious financial conflicts, include:

Academic commitments. Participants in the publications process may have strong beliefs (“intellectual passion”) that commit them to a particular explanation, method, or idea. They may, as a result, be biased in conducting research that tests the commitment or in reviewing the work of others that is in favor or at odds with their beliefs.

Personal relationships. Personal relationships with family, friends, enemies, competitors, or colleagues can pose COIs.

Political or religious beliefs. Strong commitment to a particular political view (e.g., political position, agenda, or party) or having a strong religious conviction may pose a COI for a given publication if those political or religious issues are affirmed or challenged in the publication.

Institutional affiliations. A COI exists when a participant in the publication process is directly affiliated with an institution that on the face of it may have a position or an interest in a publication.

It'll take a while for journals to fall into compliance, but this is a welcome development.

We all know there are things in health care that need fixing

The real divide is about whether we trust government over the private sector to fix things.

Via Instapundit.

Serum proteins and SPEPs

A few pearls from the Clinical Correlations blog.

Pneumonia and acute coronary syndrome

The association of ACS with acute infection, including pneumonia has been known for years. Here’s another report on pneumonia and ACS.

Diabetes and liver disease

Diabetes (sometimes with unusual presentations) is a known extrahepatic manifestation of Hep C and hemochromatosis as reviewed here.

Nixonian enemies list in health care debate?

Check this out:

A new White House tactic to control the message on health care reform has critics accusing the Obama administration of playing "Big Brother" and threatening the privacy of average Americans.

"No one expects that when they exercise their First Amendment rights to ask questions or complain about a proposed government program that they're going to be listed on a database in the White House," Sen. John Cornyn, R-Texas, told FOX News Thursday, saying the White House effort raises serious privacy concerns.

Report thought crime to flag@whitehouse.gov

Town hall meetings, fishy emails and You Tube videos

The health care debate is turning rancorous according to a Reuters report (via Medscape):

Democrats will make their case to the public with stories of patients bankrupted by costs that insurers would not cover, hundreds lining up for charity, and people in need forced to delay life-saving treatments.

Republicans and others will try to stop Obama from achieving his No. 1 domestic goal with a counter-argument: Why should Americans think that any plan conceived in Washington will in any way improve the medical attention they get now?

Outspoken in their support of free enterprise, Republicans accuse the Democrats of trying to "socialize" medicine -- anathema to the many Americans who oppose government intervention in their lives.

This will be an interesting couple of months. Prepare to witness the power of alternative media like never before.

Disease and early death is a normal part of the human condition, and thank God we've medicalized it!

Megan McArdle on pharma-mockery and medicalization:

I can live with a headache, so should I retire to a dark room rather than "medicalizing" my condition and taking an aspirin?

Via Instapundit.

Public option or single payer?

This is video was apparently linked on Drudge and has been flying around other places, including, probably, some of those fishy emails.