Friday, May 29, 2009

Does ultra sound help decisions regarding length of anticoagulation for DVT

The answer provided in a recent issue of the Annals of Internal Medicine suggests use of U/S to help determine how long to continue anticoagulation in cases of DVT is a qualified yes. See here for abstract,full article requires subscription.

Why qualified? As is often the case the exclusion criteria for entry into a clinical trial limits the applicability. In this instance, patients were excluded if they have prior DVTs,"continuing risk factors or thrombophilic factors ( except for factor V Leiden)."

Previously I wrote about some evidence that an elevated d-dimer may be worthwhile used as indicator of the need for continuing anticoagulation. There appears to be some plausible pathophysiological rationale for both tests.( I remember when internists like to talk about pathophysiology rather than guidelines,quality indicators and coding techniques.)

Thursday, May 28, 2009

Annals Internal Medicine commentary laments imminent death of internal medicine

Dr. David D. Nerenbert writing in the May 19,2009 issue of the Annals of Internal Medicine offers his analysis of why internal medicine is dying;"the progressive devaluation of individualized clinical judgment". See here for abstract.Subscription is required for full text.

In the past,he continues, "careful thought was thought to be our forte".He correctly observes that a physician cannot do justice to the complex,complicated patients with multiple medical problem in fifteen minutes. There is no time for careful thought and still stay in practice, at least not if you play the Medicare and third party player game. Can you do it all in fifteen minutes?Of course, you can't.Why are we even trying? How did the hour we used to spend for new patients and perhaps 30 minutes for return visits morph into the now prototypical 10 to 15 minute farce?" Because we can't afford to spend the time any more because the per visit charges are too low and we are trying to mitigate the economic loss by increasing volume.

Is it really all about money? Is the root cause simply the imposition of price controls by Medicare and the third party payers generally following suit. The practice pattern of internists in the 70s and early 80s of spending time with patients in the office AND caring for patients in the hospitals was made possible by the income level internists enjoyed in that era. Not only did the practice patterns depend on a reasonable level of income but the practice environment-bereft as it was of mandates and insurance company driven requirements-was one in which there was a strong sense of professional identity and satisfaction and prestige among other physicians,patients and others in the health care endeavor. And then the price controls from Medicare came on the scene around 1991 and gradually everything changed.See here for my earlier attempt at summarizing the events that marked the beginning of the end of the internist as we once knew him.

Is the rise of NPs and PAs and the birth and development of hospitalists based on the same economic causes? The consequences of price controls are well known and include: shortages, poor quality and black markets or rationing by favoritism. We have all of that except black markets (unless retainer practices are ultimately outlawed and then we will see the full spectrum of the effects of wage controls)

A small single digit increase in Medicare payments, federal funds to increase the number of internists trained, or a plan to help with medical student loans will not fix the internist's plight. More residency slots are not the answer when the current slots do not fill now.Those who choice a retainer practice may be able to sidestep the problem on an individual basis.Hospitalists can salvage one aspect of the practice on the internists of the 80's but some worry they can do so only at the pleasure of the hospitals and there is no guarantee of that in the future.

The origin of the internists dilemma is government imposed price controls and tweaking the prices a bit and increasing the role of government in medical care will not fix the systemic problem. Mandating health insurance for everyone will not fix the problem of too few primary care doctors; it will make it worse. Again, I point to Massachusetts as the canary in the mine shaft. See here for recent update in waiting times. Dr.Nerenberts's suggestion of a pilot program with internists being on government salary to take care of Medicare patients is again to purpose a governmental solution to a government caused problem, and I think few internists, as upset as they are with the way things are now,would sign up for a salaried government job.

Tuesday, May 26, 2009

Cogent commentary about the Dartmouth Atlas conclusions by a senior medical educator and troublesome observations by Atul Gawande

The Obama administration is promoting the idea that we can finance a wide and expensive variety of government programs-including better quality health care for everyone- by getting the waste out of medical care. The factual (alleged) basis for this claim to some degree comes from a widely quoted ecological study, the Dartmouth Atlas. The publications from this project apparently has had significant influence on policy recommendations.

This study divided the nation into five Medicare quintiles and then compared money spent with several outcomes.When the region's selected outcomes did not improve as expenses increased they concluded that the difference in expenditures was "wasted" money. Other conclusions are possible and from what I read may make more sense although no one speculation based on aggregate data should stand unchallenged. One such conclusion is that differences in poverty level and in total medical expenditure offer a better explanation ( see below) that the notion that for some basically unexplained reason physicians in some regions just are prone to waste money by doing too much in terms of health care services.

I suppose the suggestion is that greedy and/or misinformed physicians tend to congregate in certain parts of the country.There is at least some anecdotal evidence that that certain cities may in fact have significantly higher medical expenditures due to variations in medical practices at least some of which may be profit driven.

A recent article in the New Yorker by the prolific Dr.Atul Gawande seems to argue the case that McAllen Texas is such a city. The article is worth reading and I found it very troublesome as Gawande relates stories (mostly heresay) of physicians requesting kickbacks for hospital admission and thinly disguised kickbacks from nursing homes. How widespread are the practices narrated by Gawande and to what extent overall health care expenditures are impacted are questions that remain unanswered as does the question why would that be regional.

Go here to read analysis from a former medical school dean, and longtime physician,Dr. Richard (Buz) Cooper, who obviously has spent much time and effort in studying this problem. He argues that Medicare spending is not an accurate proxy for total medical care expenditure and that in states with more total medical spending medical care is better, a conclusion 180 degrees from the Dartmouth conjectures.

I continue to be impressed by how often aggregate data can be used to reach conclusions and policy advice that is conjectural and at times agenda driven. The Dartmouth project may be one .Another is the recent NEJM article on hospital readmission rates of Medicare patients, a topic for a future blog.In both instances the numbers are real but the underlying factors are difficult to tease out and may be refractory to statistical techniques designed to eliminate confounding.Data gathering and statistical analysis have become cheap and widely available ,what to do with the data requires reasoning and that is as scarce as ever.

Dr. RW (see here) has recently commented on the illogical and overreaching conclusions of the Dartmouth folks.

The Dartmouth Atlas project is funded by three large insurance companies or their foundations ( Aetna,United Health care and Well Point) with the other two contributors being The Robert Wood Johnson Foundation and The California Health Group Foundation.

To claim that results may be influenced by their source of funding risks accusations of indulging in a version of an ad hominem argument. Still you have to wonder if large insurance companies would continue funding for a long standing project that published results that did not further their business interests or if they would spend much money in supporting research such as that discussed by Dr.Cooper.If you run a medical insurance company you have to like a study that claims to demonstrate widespread wasted medical spending. It is of interest that here waste is defined by a third party observer not by either the providers nor the recipients of the services. Having said that, the results are either valid or not (or we just can't tell) independent of who financed the project.

I remember learning that ecological studies might at best serve as hypothesis generating activities not as generating answers so definite and certain that they could form the basis for sweeping health care changes.

I continue to be very suspicious about conclusions from studies based on aggregate data.Serious and thoughtful and non-biased commentators are able to offer opposite stories to "explain" the data. However, Dr. Gawande's observations about practices and hospitals in several cities with significantly different practice patterns and levels of medical cost (and profits) and perhaps quality of care make me wonder if the Dartmouth conclusions might be not quite as unjustified than I want to believe as that conclusion painfully bumps up against my philosophical priors and epistemological biases. At least I am less inclined to dismiss them out of hand even though there must be more to the story than marked regional variations in greed.

Thursday, May 21, 2009

The IOM speaks: mandatory nap time for house staff

The very name Institute of Medicine for reasons that have eluded me seems to mean to many a venerable assortment of very wise people who unlike the rest of the human race are able to act without personal bias or agenda and do what it right or as the myth goes act in the public interest. Their latest unfunded quasi-mandate is to mandate nap time for residents and for the ACGME to monitor the program,which I guess means make sure everyone gets their naps.

Thanks goodness, for a change, some one has the gumption, to at least, question the consequences of this IOM's pronouncement. This article in the NEJM dared to ask the questions:what would the cost be and what is the evidence that the suggestions would achieve their stated goals. The answers: It would cost a lot and the evidence of beneficial outcome is lacking.

The IOM which has been around since 1970 is a non-governmental organization that was chartered as part of the US National Academies of Science.

More and More data is ganging up on Proton pump inhibitors

The story of PPIs apparently interfering with the beneficial effect of Plavix is widely distributed and read. Now we see data (see here for abstract) that links spontaneous bacterial peritonitis (SBP) in advanced cirrhosis with PPI use. This was a case control study with an OR of 4.3,so I cannot make my typical whinny remark about the appropriate level of concern with relative risks of less than 2.

PPIs seem to be the mirror image of statins which have an increasing number of studies indicating a new benefit.With regard to PPIs, we may have to worry more and more about bad effects including: pneumonia ( see here for a rather unconvincing study), fractures ( see here), heart attacks ( see here for a good review of the Plavix-PPIs issue by Dr. Richard Fogoros) and now SBP. I would not be surprised if H2 blocker sales may have an uptick.

Monday, May 18, 2009

Electronic Medical Records, tool to save health care costs or windfall for the tool makers

One of the package of health care "reforms" that will increase quality, provide care for all and save money is the widespread implementation of electronic medical records (EMR). The other major elements are comparative effectiveness research and preventive medicine.

Here is one economist's take on one aspect of the EMR issue.As much as
"change" was heralded as a major characteristic of the new administration it appears that some things change very little.Lobbyists still stalk the halls of government and sometimes score big.

Whether the massive savings alleged by the proponents of the health care reform will accrue from EMRs or not will have to be seen in time. We do not have to wait to see how certain purveyors of these systems will make out. See here for a Washington Post article on the efforts,some of which have been years in the making, to cash in on the federal outlay of

See a detailed discussion of this special interest issue as well as concerns about the safety of this rush to implementation of EMR by one expert on this subject at Health Care Renewal.

Friday, May 15, 2009

Is the latest medical world cahoots insurance companies and academia

The Last Psychiatrist (TLP). suggests that an unholy alliance between medical insurance companies and medical academia is well underway.See here.

He discusses an article from medical academia that apparently concludes that the much hated by physicians "prior authorization" for medication is really a good thing. Good for whom? TLP suggests that the drug promoted is as likely as not neither the cheapest nor the best but rather the one for which a deal has been struck between the drug manufacturer and the insurers and or the medication management company. They don't need any stinking comparative effectiveness research.

The poster child for the new insurance company-medical academia alliance is found at Harvard where is found the "only medical school department cosponsored by a health plan". The plan is the Harvard Pilgrim Health Care and the department's name is The department of Ambulatory and Preventive Care.

Here is one paragraph from TLP:

"If you want to see what the next ten years in medicine look like, stop looking at Astra Zeneca. The next unholy alliance is between academic medicine and insurers/providers. The placebo controlled trials on the treatment of bipolar will no longer be controlled by Abott (Depakote off patent 2008), but by United Healthcare."

Next we will have to not allow medical students to have pens and mugs with insurance company logos.

Tuesday, May 12, 2009

More on the three magic elements of reforming health care.

To reform" health care" (and to fix the nation's economy) we are told we must have electronic medical records, government funded and managed comparative effectiveness research and more prevention.

In regard to the first I strongly recommend that you go here and read about just how much trouble there has been so far with the security of computerized medical information and why does anyone really believe that problem will just go away. Go here to see a good summary of other non-security related serious issues with the EMR proposed panacea.

In regard to the second I strongly recommend that you go here to learn the real reason that Dr.Rich favors government funded and managed comparative effectiveness research which he designates as "CER" as opposed to the generic term of cer. Dr Fogoros makes the argument that all cer may be biased so it is not the case that he favors CER because it will be not biased.Read his entry to see where his argument goes. I suspect more that a few advocates of CER will not be pleased.

Of course, even if we have much more cer with the addition of the CER to the data base, it will be all for nothing unless the medical profession gets on board and acts according to the published comparative effectiveness research. The grand guru daddy of the hospitalists. Dr. Bob Wachter suggests for those who won't go along they should be". dragged" along. Wonder who will be doing the dragging. In the new world of CER,will there be the draggers and the dragees? You betcha.Dr. Wachter in his dragging proposal is less concerned than is the new AMA president regarding the risk of malpractice suits if adherence to the CER directed guidance leads to the withholding of certain procedures that arguably lead to bad patient outcomes.

All in all it may be a good time to be a retired doc but as for being a patient, not so much.

Monday, May 11, 2009

Will Protecting people from second hand smoke decrease heart attacks?

Well, the early relatively small studies gave the public health rule makers some empirical justification for claiming success, further study suggest the opposite.Here is a blog posting suggesting a couple of reasons why that could be.The blog's author is Milton Friedman's son David who was trained as a physicist but writes about economics and has gained some fame for Friedman 's Law.

I'll bet we will soon be seeing papers that conclude that the attack rate of heart attacks is significantly down since the implementation of various local laws outlawing trans fat.