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Is the new professionalism and ACP's new ethics really just about following guidelines?

The Charter ( Medical Professionalism in the New Millennium.A Physician's Charter) did not deal with just the important relationship of ...

Thursday, March 29, 2012

More on medical guidelines being hazardous to your health

A subset of pneumonia patients -those considered at risk of having a multi-drug bacterial etiology-did worse if their physician complied with ATS-IDSA guidelines according to a recent study. See here for reference to the article that was published on Lancet online.

I have blogged before about the dangerous tendency of guidelines tendency to cause unintended consequences and talked about the idiotic four hour pneumonia rule, one unintended consequence of which was the treatment of non-pneumonia patients for pneumonia within the four hour deadline.Well at least the treatment was started within 4 hours.

My longest screed about guidelines can be found here.

Guidelines can be considered part of the mind that says " medicine is too important and too complicated to be left to the individual physician and individual patient." This dangerous mind set was made explicit and championed by the former header of CMS, Dr. Don Berwick who said :

"Today, this isolated relationship [ed. the individual doctor-patient ] is no longer tenable or possible… Traditional medical ethics, based on the doctor-patient dyad must be reformulated to fit the new mold of the delivery of health care...Regulation must evolve. Regulating for improved medical care involves designing appropriate rules with authority...Health care is being rationalized through critical pathways and guidelines. The primary function of regulation in health care, especially as it affects the quality of medical care, is to constrain decentralized individualized decision making.” (My bolding).

Yeah,that pesky decentralized decision making just gets in the wise of wise centralized decision making which history tells us worked out really well in the 20th century.

The best quality or guidelines rules are supported to varying degrees by randomized clinical trials but even here one should proceed slowly because the well known efficacy-effectiveness gap tolerates simplistic approaches poorly. RCTs are often small and have multiple exclusion rules and fail to capture the perplexing diversity of relevant pathophysiological variables (known and unknown) that coexist in complex, hospitalized patients. It is in the sickest patients that rules formulated by committees based on what-ever data or personal bias that the most harm can be done and in whom individual variation overwhelm premature generalizations and an eager rush to mandate treatment rules.No, all guideline writers do not always intend that their wisdom should be mandatory ( but some do) and write disclaimers at the end of the articles to that effect, but guidelines have a way of morphing from suggestions to dicta and rules the ignoring of which may have financial or other consequences for the rouge doctor.

The mandatory and quasi mandatory nature of guidelines or quality indicators as wielded by the CMS mandarins and other institutional elites become even more dangerous with the spreading use of the "disruptive physician" doctrine. Not only must you go by the rules you can't complain about them without incurring the wrath of the hospital's disruptive physician committee.This doctrine is a brilliant control mechanism.If you challenge the disruptive physician concept you are by definition disruptive.

Monday, March 26, 2012

Cardiac stress test before endurance exercise might just make sense

The party line (I mean the consensus of reasoned expert opinion by panels of highly educated people) has been there should not be stress tests before a person begins training for or entering a marathon because of some combination of the following reasons: low incidence of cardiac events in endurance races and shorter fun runs,large numbers of false positives noted on treadmill stress testings,and the dominant theory that the major cause of cardiac events precipitated by exercise is acute plaque rupture rather than fixed coronary artery stenosis.

An extensive assessment of cardiac events during long distance runs might change the thinking in that regard.

JH Kim et al reached that conclusion following their analysis of cardiac arrests associated with marathon and half marathon races in the US from 2000 to 2010.See here for ref.

The authors' data including races involving 10.9 millions runners and 51 men had cardiac arrests. Hypertrophic cardiomyopathy and atherosclerotic coronary disease were the two most common causes.

The authors said:

"The absence of coronary plaque rupture in these persons was surprising because prior data and expert consensus documents have suggested that exercise induced acute coronary syndrome result from atherosclerotic plaque disruption and coronary thrombosis.

Their findings suggested that rather than plaque rupture that there was an imbalance between oxygen supply limited by stenotic coronary arteries and oxygen demand greatly increased by the exercise.

So exercise testing would be useful to the extent that the exercise related events were due to fixed obstruction. Of course both mechanisms could be present alone or in combination in various people. A resting ekg should be helpful in alerting to the possibility of hypertrophic cardiomyopathy. But, of course, there is that new directive by the progressive medical elite for parsimonious care to take under consideration.

Thursday, March 22, 2012

More spending leading to better care seems true in Canada also

Recently I blogged about data indicating that sometimes more (money spent ) is better (better outcomes in health care) as well as in most everything else even though you sometimes hear just the opposite from devotees who misinterpret and over interpret the Dartmouth Atlas data.

Now we have this JAMA article from Canada that suggests that outcomes for heart failure,hip fracture and some other conditions are better when more money in spent.

Monday, March 19, 2012

Guess what - Obamacare will cost more than one trillion over ten years

The hype leading up to the passage of Obama care included claims that the bill would protect the country from bankruptcy,bend the health care cost curve and boost health care quality. Now the projection for 10 years of Obamacare is for 1.76 trillion and by the time we can get a even finer tuned projection it will likely be twice what it was claimed to be. See here for the projection of OBM.

I guess the social justice will cost a little more as we watch 34 million new health care card carrying folks scramble for the shrinking number of primary care doctors who will see Medicaid and Medicare patients.

The one trillion dollar number seemed to play an important role in the push and pull going on before the health care bill was passed.The cost of the plan had to be less than one trillion and getting the projected cost to be less than one trillion apparently played a significant role in the bill finally being passed.However, the cost estimates were rigged and only three years later are we getting more realistic projections showing how much flim- flam was involved.

Friday, March 16, 2012

Sometimes spending more on health care brings better outcomes -duh

The widely quoted data from the Dartmouth Atlas has been almost as widely misunderstood to mean "more is less". How something so counter-intuitive and contrary to much everyday experience could get so much argumentative traction is a testament to a cognitive weakness that even Dr. Kahneman failed to document and explain in his book Thinking Fast and Slow. Maybe he does, it is simply gullibility or buying into data that confirm your priors.

Dr. Ashish K Jha sets the record straighter .See here.

Here is part of what he had to say.

“The Dartmouth Atlas shows that among communities, there are large variations in health care costs and large variations in quality, and some with high costs also have low quality. This convinces a lot of people that there can be a free lunch—that if we can get spending down in high-costs communities like McAllen, Texas, to levels seen in Minnesota, where spending is low and quality is high, we can save money and improve outcomes. But how you implement this in policy is hard, and often policy makers misunderstand what to do."

Dr, Jha's study is certainty not the first to counter some of the over-blown nonsense about the relationship to spending and outcomes in health issue. Here is an earlier on post dealing in part with some of the enlightening work of Dr. Richard Cooper in that regard. Also here is a thoughtful discussion of Cooper's work by one of my favorite economists, Arnold Kling.

The Atlas used coarse grained data, regional variations in cost and outcome, but was used to make much more fine grained conclusions by those who hyped the study .Individual hospital or (God forbid) individual patient data were not analyzed yet policy recommendations were applied to the more fine grained entities.

Monday, March 12, 2012

Colon cancer screening - not for 75 years olds?

The headline references one of the latest recommendations from the American College of Physicians (ACP).Seven members of the Clinical Guidelines Committee of the American College of Physicians have "determined" that consistent with the principle of cost conscious,high value care that "clinicians should not screen adults aged greater than equal to 75 years or those with substantial co-morbid conditions ..with a life expectancy of less than 10 years ."

The reference is "Screening for Colorectal cancer: A Guidance statement from the American College of Physicians. Annals of Internal Medicine 2012:156;378-386.

This is in contrast to the less rigid recommendation of the USPSTF which said:

USPSTF recommends against routine screening for colorectal cancer in adults 76 to 85 years of age. There may be considerations that support cancer screening in an individual patients.

Kudos to the USPSTF for allowing something that might at least pass for " patient centered care" to actually be centered on the patient and her concerns and her particular set of facts and to have those considered by her and her physician rather than having the option of colonoscopy categorically excluded by a general rule based on age. Further, the opposite of kudos to the ACP committee for their recommendation for not doing so.

ACP quotes a study in the Archives of Internal Medicine that "suggests that colonoscopy is overused in elderly patients including repeated screening at less than 10-years intervals and routine screening of patients older than 80 years."

The referenced article( see here for abstract) was an analysis of a large sample of Medicare patients who received colonoscopy exams for screening and around 45% received an second exam in less than 10 years. This is evidence than a number of patients received exams sooner than the 10 years recommendation for repeat exam so in that limited sense there was "overuse". The logical leap from that article to the recommendations of no screening past age 75 is unsupported by evidence or articulated reasoning expressed in the Annals article.

Why not age 73 or 76 or 80 or 65?

The age choice appears arbitrary and the absence of an articulated waiver based on individual circumstances is surprising and you have to wonder what evidence was used to reach their conclusion.You have to wonder because the article seemed bereft of any supporting evidence.

The print boiler plate disclaimer at the end of the article says:

"Clinical guidance statements are "guides" only and may not apply to all patients and all clinical situations.Thus,they are not intended to override clinicians' judgment."

But what will be remembered and quoted will be the 75 years cut point.

Page 385 of the Annals article has a table with the left hand column having a heading of "high-value,cost conscious care" across from the age related cutoff and their general screening recommendations.The implication is that the age recommendation is consistent with this "principle" of high-value,cost conscious care.

However,invoking the new magic words "High-value,cost-conscious care" (HVCCC) does not substitute for offering an analysis of the data regarding the outcomes of colonoscopy in older patients,e.g. complications, positive findings and ( here is something radical) how did the patients value the procedure.

I cannot help but worry that whatever righteous and rational reasoning and good intentions lead to the notion of HVCCC , it will become like the term "patient centered care" meaning whatever the authors of articles chose to have it mean. There are certain tactical advantages to have an elastic, ambiguous concept . I am preparing some comments on the notion of "value" as it is being applied to medical issues,particularly in regard to the difference between the use of the term by certain business consultant gurus and its questionable transfer to medical care and the standard
definition of value as explained in introductory economics texts.

Sunday, March 04, 2012

Department of HHS makes economic breakthrough: declares there IS a free lunch after all

Nobel prize winning economist,Milton Friedman, is quoted as saying that economics could be summed up with two principles. 1) There is no such thing as a free lunch and 2)demand curves slope downward or ( in non econo-speak) people buy more when the price is lower and less when prices are higher.

Dr Friedman did not live long enough to see that his first principle overturned.

When the dictum of the HHS Department ordering employers to provide medical insurance that included paying for birth control pills hit a snag when the Catholic Church hierarchy raised a loud and righteous ruckus as it impacted Catholic hospitals and schools, necessity once again became the mother of invention.

The Secretary of HHS , in a move alleged to be compromise, declared that: no, the employer would not have to pay but rather the insurance company would. (see here).When challenged with the argument that the insurance company would simply increase the premiums,the Secretary replied;no, the insurance company would not be allowed to do so. Further, that order would actually save the insurance company money because the savings from medical costs not incurred because of the decrease in the number of pregnancies pregnancies would be greater than the cost of the pills. So, not only are the birth control pill free but provide a saving to the insurance company.So it is even better than a free lunch. The insurance companies should be happy to be forced to save money.

But this previously unrecognized saving ( which for some strange reason insurers never recognized on their own) is only the beginning. If taking statins and blood pressure pills decrease the risk of heart attack, should not insurance companies be giving those medications to policy holders as well. After all, generic pills are cheap enough and treating a heart attack is a big ticket item. The opportunities along these lines seem endless.Once insurance companies grasp this principle their profits will soar and they will begin to "give away" a lot of stuff even without government coercion.

Some would argue that these dicta from the Department of HHS make any contract that existed between the insurer and the insured a farce since for hundreds of years a contract based on force or coercion rather than mutual agreement of the parties was considered not valid.(See here for the comments from the Institute for Justice arguing that is exactly what the individual mandate does.) Those naysayers just cannot see the big picture which is that a new economic principle has been discovered- namely there can be a free lunch if the government says so.

Now HHS needs to get to work on the abrogation of Friedman's second principle; the demand curve thing.Recently an MIT economist re-discovered that principle in regard to medical costs and Medicare.She found that there was an increase in the quantity of care demanded once older folks had the Medicare card which made their health care cheaper. See here for my earlier post explaining the data and analysis employed by the economist to "discover" that people like to spend other people's money.

Might not the huge increase in the number of folks who will be given an insurance card ( or forced to buy one) pose a real problem as there is no concomitant increase in the number of physicians to provide that care.One solution would be for HHS to determine that people do not demand more services and goods when they are cheaper which would solve the problem of a physician shortage.

Getting those silly economic misconceptions out the way should really make Obamacare work more smoothly and all of the social justice embedded in the 2000 pages of the statute can emerge.