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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 ...

Monday, September 30, 2019

Why have price controls on hospitals not caused a shortage

Arnold Kling has said that economists do not save the useful economic thoughts and insights for graduate level courses but teach the good stuff in econ 101.

One of the pearls in econ 101 is that wage and price controls typically have some very predictable consequences.These are shortages,decrease in quality of the good or service, mis-allocation of resources and black markets.

The Center for Medicare and Medicaid services,CMS, has placed price controls on hospital care in the form of something called DRGs.

A patient admitted to the hospital with pneumonia is classified under the DRG system. A given DRG determines the maximal amount that CMS will pay for hospital care for a patient with that diagnosis.If the patient remains in hospital too long then the hospital costs will be greater than the allowed charges. This seems to be one important reason for the rise of the hospitalist movement in which physicians hired by the hospital can strive to get the patient home soon.

However, the governmental control over hospital care is not that simple.

Anyone who has been in a hospital or examined a relative's hospital bill will be struck with the fact that the amount charged is greater ( often markedly greater ) that the "allowed charge" ( the amount medicare or a private carrier will pay). So why is the bill configured that way?

See here for some information about the complicated details of the DRG system.

The difference between the allowed charge and the amount charged is considered to be "uncompensated care". The federal government gives a rebate to the hospital for some fraction of this uncompensated care for Medicare patients.

This rebate is not a secret but my guess is very few people know about this.In the strange world of government control ,this perhaps makes some sense in a non traditional sense of the word "sense",but to the non policy work it seems odd to impose price controls with one hand and the with the other institute a program to mitigate the effect of the control.

Friday, September 27, 2019

Will hospital adverse internists loose their critical care skills

In the waning years of my professional medical life I witnessed a trifurcation of internists into  three groups, the hospitalists and those who only saw patients in their office ( officists) with a third small group who soldiered on trying to do both, swimming against the strong economic tides.

It occurred to me that perhaps if a physician who trained to be able to care for complex, very sick patients in the hospital no longer did that type care that his critical care skills would atrophy. Further, since he now longer needed to know about the advances in the care of various types of very ill patient his incentive to keep up in those areas would decrease and the periodic testing for recertification would become even more of a contrived, farcical   exercise benefitting the ABIM.

Thursday, September 26, 2019

The endless demand for excelence - a burden too great?

Go to this post by Dr. Jeffrey Parks who blogs under the name "Buckeye Surgeon".

He write about the endless demand for excellence and quotes Cicero who said:
"For the better he is at his job, the more frightened he feels about the difficulty... about its uncertain fate... about what the audience expects of him."

Back though the years perhaps  there was a time of the "complete internist", before the economic hegemony of the third party medical payers divided internists into officists and hospitalists,when the general internist shared similar frightening challenges that the surgeon from Ohio writes about so well. This was time when the internist was not a competitor of the NP , PA and family doctor. (no, I do not equate the family physician with the two categories of "physician extender"). The challenge of the complex, critically ill patient was parallel to the challenge that the general surgeon faced with a "tough case". So today far fewer general internists do that sort of thing as they are relegated to the office and juggle guidelines for routine management of standardized problems and inquire about seat belt use,and flossing and offer wellness to the worried well in the form of various preventive measures .

I began to sense the endless demand for excellence in medical school in the clinical years.You could never know too much.Something you did not learn or did not do could result in a catastrophic for someone entrusted to your care. There seemed to be endless demands. It seeemed like too much was expected.

Monday, September 23, 2019

Is it valid to compare numbers needed to treat (NNT)

Scattered throughout medical literature is the metric known as number needed to treat or NNT.

It has been claimed that in trials in which there are varying follow up times the simple NNT measure can be misleading - see here for a statistical discussion of that point from the NEJM commentary that suggests Kaplan Meier approach be used to account for varying followup time.

NNT is typically presented without a confidence interval or an error term.but apparently there are at least two methods for determining the CI of a NNT ( see here ) but according to this critique the two methods can yield markedly different results which I believe leads to the conclusion that one cannot compare NNT from one trial with a NNT from another trial.

It seems that one of the factors taken into account in the PHSTFP recommendations was the difference in the NNT from women 40-49 versus women over 50 in regard to mammograms.

Sunday, September 22, 2019

Can high school football players develop Traumatic brain injury without a concussion

note:This a reposting of a commentary posted five years ago. So few people saw the post I am offering it again as High School Football season is underway and subconcussive head blows occur every Friday night. 

Traumatic brain injury (TBI) is classified as mild,moderate and severe based on mental status change and duration of loss of consciousness (LOC). Mild TBI  involves LOC less than 30 minutes and corresponds to  a Glascow Coma Scale rating of 13-15. For example, a football player who appears stunned and confused with only brief of no loss of consciousness would have a Glascow score of 14.

A major element of TBI is diffuse axonal injury thought to be caused by rotational and linear acceleration of the brain. Conventional MR imaging and CT images do not detect that type of changes. However, diffusion tensor imaging (DTI) can detect changes in fiber tracts reflecting changes in diffusion of water into nerve tissues.A DTI based measurement ,fractional anisotropy (FA) ,reflects water movement along the axons.In normal tissue FA is high ( approaches 1)

DTI abnormalities have been demonstrated in concussive cases of  mild TBI and the degree of abnormality correlates with the severity of post trauma symptoms.(see here). Typically FA increases acutely in TBI and later on values are decreased (see here ), although there is some inconsistency about the direction of change in this measurement  in the literature and there are case reports in which acutely FA decreases.

Football players  college,high school and professional, who have sustained concussions,have been shown to have abnormal DTIs.

There are  several publications  (1. Davenport et al,2.Talavage,3.Barzarian  4.McAllister )describing research involving college and high school football players that have shown similar DTI changes in athletes who did not have clinical concussions,These imaging changes seem related to multiple sub-concussive head blows.Some studies-but not all- have also shown that these DTI findings correlate with decrements in memory test results over the course of one season.Generally these DTI abnormalities correlate with measurements of acceleration forces of the skull detected by in- helmet accelerometers.

 1)EM Davenport and her colleagues from Wake Forest studied the cumulative effects of head impacts in a single high school football season in players without a recognized concussion.(Abnormal white matter integrity related to head impact exposure in a season of high school varsity football" J of Neurotrauma 2014 Jul 14, published ahead of print).

The authors' summary:

"We show that a single season of football can produce MRI measurable brain changes that have been previously associated with mTBI (mild TBI) .Finally, we demonstrate that these impact related changes in the brain have a strong association with postseason change in cognitive function." The cognitive function was noted in a verbal memory composite score which correlated with the magnitude of the MR findings.

 2) TM Talavage and coworkers studied 11 high school players with functional MRs (fMR),measures of head impact events and neurocognitive function testing. "Functionally detected cognitive impairments in high school football players without clinically diagnosed concussion." J of Neurotrauma. 31:327-338,Feb 2014)

 Unlike most of imaging studies of TBI this group found abnormalities in the frontal lobe with functional MR.DTI was not done.

 Quoting from the authors summary:

"Additionally, we observed players in a previously undiscovered third category, who exhibited no clinically-observed symptoms associated with concussion, but who demonstrated measurable neurocognitive (primarily visual working memory) and neurophysiological (altered activation in the dorsolateral prefrontal cortex [DLPFC])."

3 JJ Bazarian  studied 10 college football players over the course of one season. ( "Persistent Long Term cerebral White Matter Changes after Sports related Repetitive Head Impacts. Plos one 9(4),e94737)

 Head impacts were recorded and measured by helmet accelerometers and DTI was done preseason, immediately post season and six months after the end of the season.

 DTI abnormalities in white matter were noted in these players none of whom sustained a clinically evident concussion. The changes in most players,but not all, were also seen in the six month followup images. .. There was a positive  correlation between number of head impacts and DTI findings. The DTI changes were not correlated with changes in cognitive testing or tests of balance.

4)  TW McAllister's study involved 80 college football and hockey players ( "Effect of head impact of diffusivity measures in a cohort of collegiate contact sports athletes", Neurol. 10:1212/01Dec 11 2013.)
Quoting the authors:
"The magnitude of  [TDI] change in corpus callosum MD (mean diffusivity) was associated with poorer performance on a measure of verbal learning and memory."  Again these findings occurred in players with no recognized concussions.

The risk of concussion is greater in certain positions such as quarterback and wide receivers. Lineman , on the other hand have fewer concussions but most experience multiple head impacts during each game and each full contact practice session.See here for a detailed study on impact forces on various player positions.

Maugans and coworkers studied athletes younger than typical varsity high school players.These players were 12 to 15 years of age and DTI scans done fairly soon after the concussion did not show abnormalities in diffusion indicators including fractional anisotropy.

Dementia Pugilistica as a clinical condition in professional boxers was described as a clinical entity in a JAMA article in 1928.In 1973 the pathological findings were published. In 2005,Omalu et al published the results of an autopsy on an National Football League  player, Pittsburgh Steeler center,Mike Webster, on whom Dr. Omalu had performed an autopsy 3 yearns earlier.This was the first report of Chronic Traumatic Encephalopathy in a football player.

Zhang et al provided some data regarding brain changes in boxers who were symptoms free and who had a normal neurological exam. 47 professional boxers ( age 30 +/-4.5 years ) underwent conventional MRIs and DTIs.In 42 the conventional MRI was normal while 7 demonstrated some focal non specific white matter changes. The 42 demonstrated abnormal DTIs, with decreased fractional anisotropy in regions of the corpus callosum and internal capsule.Boxers have been the canaries in a coal mine.Their experience has made it clear that repeated blows to head can cause permanent progressive brain damage that is not immediately apparent but develops over a  variably long period of time.The question is to what extent does this apply to football in which the players wear helmets.For years it was believed that helmets were adequately protective but now that view is increasingly less plausible.

By 2013 the NFL agreed to settle a class action law suit brought about by former NFL players and their families  but the judge did not agree to the amount offered..Now the NFL has seemingly admitted that as many as one third of players will develop some sort of cognitive impairment and that they will have funds available to cover the agreement.

The distinction between a concussive and a sub-concussive head blow is on the margin indeterminate.  A player may experience a blow to the head and feel slightly dizzy or dazed and not report those symptoms to the coach or trainer. There may be social or peer pressures on players to not report symptoms as they would be benched and not allowed to play until they complete whatever concussion protocol is in place.So the distinction between a group of players with a concussion and a group with no history of reported concussion is  not one based on clear cut objective criteria,often relying on the voluntary reporting of subjective symptoms.So it should not be surprising that cognitive tests and brain imaging studies show similar findings in football players with and without a concussion history.

So in reply to the title question, yes I believe there is convincing evidence, But there has not yet been established a clear linage between the changes in cognitive tests and brain imaging studies  seen after a season of high school or college football  and the development of  chronic traumatic encephalopathy .


Saturday, September 21, 2019

How does the elite endurance athlete's heart differ from normal people and the non-elite

The cardiovascular system of the trained endurance athlete differs in a number of ways from the untrained person.These include:
1.increased red blood cell mass and blood volume
2.increased numbers of mitochondria and capillaries in leg muscles.
3.lower peripheral arterial resistance
4.lower systolic and diastolic blood pressure during exercise.

Those and likely other factors I have neglected to mention will be found in both the elite and the non endurance athletes. What distinguishes the elite endurance  athlete is the capacity of left ventricle to fill with blood quickly without significant increase in the ventricular pressure. The elite have much better diastolic function.While endurance training and high intensity training may somewhat improve diastolic function , they do not seem capable of developing the super compliant left ventricles of the world class endurance athletes.Genetics provide the substrate for the marathon winner,training finishes the process.

Friday, September 20, 2019

High Intensity interval training and atrial fibrillation

Does high intensity interval training increase the risk of atrial fibrillation (AF) or does it mitigate the AF burden in patients with non permanent AF or both?

An article from Brazil with a 3 year followup suggest that HIIT increases the risk of AF and increases atrial size when compared with moderate exercise in hypertensive patients with chronic renal failure (1). But what about normotensive folks with no renal disease?

A short term trial (2) from Norway comparing HIIT with no exercise in patients with non permanent AF demonstrated less AF burden in the HIIT group.

1)Kiuchi,MG The effects of different activities on atrial fibrillation in patients with hypertension and renal failure. Kidney Research and Clnical Practice. 2017, spet 36 (3) 264

2)Malmo,  Aerobic interval training reduces the burden of atrial fibrillation in the short term  Circ 2016,133 466-473

Physicians as Guardians of Society's Resources-

In the early part of the second half of the 20th century when I received by medical education,physicians were taught they had a fiduciary duty to their patients. There was for the most part no third party obligations. There were  no  major presence of HMOs at that time.Richard Nixon changed that.

As medical care costs and expenditures increased, third party payers including the growing HMOs and  large corporations who provided health insurance  (some were self-insured) took measures to control costs. There were larger deductibles and co-payments and more scrutiny by insurance companies on what exactly they would pay for. There were guidelines and pre approval rules for testing. These counter measures probably helped somewhat but costs continued to rise and continue they would as basically this was folks spending someone else's money and the fingers on the cost gun were in the hands of hundred of thousands of physicians.

The problem was how to control the activities on these physicians who had been schooled  for many decades with the ethical imperative of do what is right for the patient. For physicians trained in that ethical environment, cost to the " system", be it United Health Care,Exon, or Medicare,was not a major priority in their value  system or decision making calculus.

So various variations of carrots and sticks were employed by the third party payers.Pay for performance grew up as a type of bribe to docs to follow the cost cutting guidelines which went by the wink,wink,nudge, nudge name of quality guidelines.

Although carrot and stick techniques have a proven history of changing behaviors to some degree,what is even better is to have as the triggers of medical cost initiation i.e physicians (or some alternative "health care provider, eg NP, PA)) folks  who  really believe their duty lies at least to a significant operational degree in cost saving.Clearly to the third party payers physicians had their priorities all mixed up.

Enter the concept of physicians as stewards of society's resources.

I have not devolped a detailed chronology of that part of the literature which deals with medical policy matters to be able to date with any precision when and how this concept arose. I have written before on some of the earlier papers in the mainstream medical literature.

In 1988 Hall and Berenson writing in the Annals of Internal Medicine said that "the traditional ideal" [the prime duty to the patient ] was "not compatible with the role that existing insurance contracts and manged care arrangements define for physicians." Their comments were not subtle when they said :

We propose that devotion to the best interests of each individual be replaced with an ethic of devotion to the best interests of the group for which the physician is personally responsible.

Note-now we are talking about a benefit to a specific HMO or PPO and  not in the benefit of some abstract "society" yet often the arguments for the new ethics is framed in terms of benefits to society.

Note:Berenson glibly justifies that sea change because the role that insurance contract define for the physicians. Here we might pause and remember that one of the defining characteristics of a profession is that members are bound by a ethical code that is largely self defined.Now it seems that medical ethics should be defined by insurance company interests.

Over the next 20 years far from that proposal being dismissed out of hand as medical ethical heresy which is how many of us at the time would have characterized it, it has become part of the generally accepted medical ethical package nestled in professionalism statements by most medical organizations and has become or is becoming part of medical education .

The fiduciary duty to the patients seem to have been demolished ( or at least made secondary) without much more that the occasional outcry by physicians of the old school. Various attempts to resist this over turning of traditional medical ethics have not prevailed. The dogs bark and the caravan moves on.

We have traveled a long way since the Berenson article.Now we read of a suggestion that "cost-consiousness and stewardship of resources be elevated by the ACGME and the ABMS to the level of a a new seventh general competency." In other words, residents should be schooled and graded on their mastery of the skill set necessary to be good stewards of [society's] resources. ( reference, The Idea and Opinions Section, Annals of Internal Medicine,20 Sept 2011,Vol.155 no.6, by Dr. Steven E. Weinberger,of the American College of Physicians.

Wednesday, September 18, 2019

Cardiac pacemaker interrogation reports-who does it and how well?

This is a revision  of an earlier posting on this subject, redone and reposted because I believe this is an important topic about which very little seems to be said. 

In the first 4 years of living with a cardiac  pacemaker (PM) implanted, the following instances of misinformation,lack of proper oversight,delayed reports and/or  misdiagnosis occurred.I did not need that stress after having a titanium foreign body containing a 3 V battery  crammed under my left chest wall muscle attached to wires going to various parts of my heart  which was quite enough to ramp up my anxiety level to at least sub-panic attack levels.

1)In October 2015 I had a pacemaker implanted- one  which is designed for bi-ventricular pacing  the most common form of CRT (cardiac resynchronization therapy).This has 3 leads, right atrium,right ventricle (actually mine is in the His Bundle position) and a Left ventricular lead (in a vein along the wall of the left ventricle)

 2)The technician who assisted and provided technical advice to the EP cardiologist at the time of the implantation told me on the following day that my home -bedside PM communication device  would send a recording every night to the manufacturer's web site  and then to the hospital PM center.

Only 6 months later was I informed by him , in reply to a question from me, that no -that was not true and that arrangement was only for devices with a defibrillator  which I did not have.  So for six months I made a effort  to be near  near by communication device device each night that in fact did nothing at all.Someone apparently had not read the manual.

2.In October of 2016 my device recorded several episodes designed as AF/AT  (atrial fibrillation/atrial tachycardia) Episodes of AF are thought to be common  ( at least 30% by three years in patients with a PM- according to one data base).This lead to to my fairly extensive literature review of the issue of AHRE ( atria high rate episode). I learned that the topic is controversial and opinion varies as to what if any threshold there is for "signficiant volume of AF" to justify anticoagulation. (There are 2 randomized clinical tarials underway that are designed to try and answer that question).So it was an opportunity to research a medical topic-fear being a great motivator.

Also, all AHREs so designated by the PM's algorithms are  not in fact AF. The phenomenon of far field r wave sensing (FFS) and  and a less common and more obscure PM rhythm disturbance known as  recurrent, non reentrant ventricular atrial synchrony (RNRVAS)  are capable of mimicking AF.The technician at the hospital PM center  who is tasked with screening the remote interrogation report had not recognized that the rhythm was FFS and apparently did not feel that the issue required calling the matter to the attention of the EP cardiologist.

I send an email to my EP cardiologist  and I was  told  the issue of short episodes of possible AF are very controversial and I  did not need to come any sooner or consider taking anticoagulants. He apparently did not address the possible issue of FFS or RNRVAS or actually review my interrogation report until months later even though I has asked in my email if the data really indicated AF.

 However three months later, at routine office followup a  Medtronic technician said  that the earlier interrogation did not actually show AF but rather FFS  the reoccurrence of which he intended to prevent  by increasing the sensitivity threshold(i.e making detection less sensitive) on the atrial lead. The EP cardiologist  agreed, and I later leaned that FFS is not an uncommon cause of AHREs particularly so in the type of lead placement that I have. (Placement in the Bundle of His which in my case is higher up in the ventricle than the standard apical placement of the RV lead-sometimes the His Bundle Lead is in the atrium)

3)At an August 2018 in office PM interrogation, the technician and I entered into a conversation about battery life estimation  and she wondered if the estimate of battery life was disproportionately shorter than what may have  been expected on the basis of the settings .She forwarded the data to the home office and the engineers found nothing to do to improve the settings.Her concern and interest was appreciated but ..

In talking to her I quoted the section of  the device manual that discussedto the device powering down a bit with several settings once three months has passed after the recommended replacement time ( RRT date). She said no that was not the case with my particular model However, I contacted the pacemaker company  technical support and they confirmed the manual's description was correct. 

4)Issue of high left ventricular (LV)  threshold occurring on multiple of the every three month reports.It was not until October 2017 (2 years after implantation ) that the left ventricular management system was switched to "monitor". I can only speculate as to the degree to which battery life was shortened by  what seems to be the less than prompt attention to that issue. 

The interrogation report is fairly long and reviewing it requires considerable technical knowledge about  cardiology,PMs in general as well as certain details regarding the specific brand,various programmable settings and particular model and various lead placement configurations and at least a little knowledge about electricity  and cardiac physiology.

 The device clinic technicians review reports from  various pace maker brands and also the more involved and complicated reports from ICDs (cardiac defibrillators) .Being a retired physician I have had the time and interest to spend a fairly large amount of time and effort into learning about PM lore and in particular the interrogation reports. My  shaken confidence in the folks monitoring  how well the wires  in my heart are performing has certainly provided incentive to learn how  to read the basics of device interrogation reports. 

5)By the summer of 4th year following implantation the   device clinic  services  had deteriorated to the point that I wrote the head of the EP section.They no longer directly  answered the phone and the messages left were only replied to days later and my complaints to them was met by curt replies that they were too busy. Reports that were typically available the same day took a week or more and required multiple phone calls . The section head  said  those issues were being addressed and apparently they hired a company that does device monitoring and were now also available 24/7 while their own in-house clinic also did some or all of their review work.How well that arrangement works remains to be seen. and I have not ben able to learn how the hosptial device clinic and the contract device monitoring company divide or duplicate the work.

Monday, September 16, 2019

coronary calcifications and the paradoxes of statins and endurance exercise

Coronary artery calcification is by definition coronary artery disease

Calcification can occur in the intima and in the media with possible different pathological implications.

All coronary artery calcifications (CAC) are not created equally. Dense calcification can occur in fibrous,stable plaques which carry little risk of rupture but can narrow the coronary arteries causing angina and ischemia on exercise. Spotty calcification can occur on unstable plaques which can rupture causing an acute coronary events and yet not be detectable on stress testing.

The is more than adequate epidemiologic evidence that statins can decrease the risk of coronary artery events- certainty when used in secondary prevention.So it seems paradoxical that more intense statin therapy as with the more potent statins  and for longer periods of time is associated with more CAC.The standard answer to this apparent paradox is that statins are able to stabilize plaques making them less at risk of rupture and that in part the putative stabilization involves dense calcification.

There is also more than adequate epidemiologic evidence that endurance exercise decreases the risk of coronary artery disease and cardiac vascular mortality.so it seems paradoxical that studies (at least some) have shown increase coronary artery calcifications with increasing levels of exercise. Might a reasonable answer to this paradox be that endurance exercise helps stabilize plaques by calcifying them. In fact some of the authors who have reported increased CAC with increased exercise have suggest that mechanism.

Merghani et al (1)reported on a study of  152 men who had logged an average of 31 years of endurance exercise type activities. All had echocardiograms,24 hour Holter, stress ECG,CT coronary angiograms (CAC) and cardiac MRs with gadolinium as did 92 age matched controls with similar Framingham Risk scores.

15  athletes and none of the controls had late gadolinium enhancement (LGE) on the MRs, 7 of which had a coronary artery pattern.(The LGE issue will need to be written about at a later date.,for now  the focus is on the  calcification.)

60% of the athletes and 63% of controls had a normal CAC score but only athletes (11.3%) has a CAC score of 300 or greater. So the incidence of any calcification was about the same in athletes and controls but the athletes had more calcium and more demonstrable luminal stenosis ( greater than 50%) in 7.5% of the athletes and in none of the controls.

So does this mean that long time endurance exercise increased the risk of coronary artery disease?
Maybe an answer to that is related to another question-does the increase in calcium scores noted in patients taking statins mean that statins increase the risk of coronary artery disease which is , of course, a conclusion contrary to realms of clinical trial results demonstrating the value of statins, at least in secondary prevention.

In regard to the second question there is a great deal of data regarding what could be called the statin plaque paradox-statins increase coronary artery calcium even as they shrike the plaques.A person's calcium score could increase even as the plaques regress because of the increased density of calcification bought about by the statins.

For long term endurance athletes who might be worrying that their ill spent youth and/or middle age and /or early old age was in fact ill spent might get some sense of relief from these comments from Dr  Benjamin Levine.

1)Merghani,A Prevalence of subclinical Coronary artery Disease in Masters endurance theleres with a low atherosclerotic risk profile. Circ. 2017, 136, p 137

Just a reminder from Maimonides

Recently I came across comments from a retiring Critical care doc who said that the 1978 novel by Samual Shem entitled "The House of God" no longer seemed so hilarious to him. The attitudes and behind the scene comments of the young house staff reflected a view of patients and medical care far different from what Maimonides had in mine. 

 Maimonides: "May I never see in the patients anything but a fellow creature in pain."

Not as someone who deserves his dyspnea because of cigarette use defying years of advice to quit, not as someone whose ascites is his just due from profligate use of alcohol, not as someone who should not be in this country at all, not as someone who would not be having the myocardial infarction at all if he had done what his doctors told him to do and not as someone who is taking "scarce medical resources" from someone who deserves them more or for whom the treatment could be more cost effective but as a fellow human whose is in need of what physicians spent so many years of their lives preparing themselves to be able to offer.(Not as the "gomers" Shem depicted)

The oath ( Maimonides) should remind us that being face to face with a fellow human in need

..makes judgment beyond the biomedical not only unnecessary but inappropriate.

Friday, September 13, 2019

More very important insights regarding how hospitals make money-by not getting paid

Dr. G. Keith Smith's website is a great source of important insightful information about how not for profit hospitals operate and how insurance companies make money by having higher billed amounts from hospitals. The name non-profit hospital is analogous to dry cleaning.Dry cleaning uses liquids soit is not really dry and if non-profit hospitals did not generate receipts greater than costs they would not be a hospital at all for very long.

See here for details from Dr. Smith regarding some of the ways hospital make money.

A few years ago  years ago a not for profit hospital sent me the following bill for a colonoscopy I had . This does not include physician's fee.

Total charge was $2527 and CMS and my Medicare supplemental carrier paid $ 589 leaving $1938 as "uncompensated" So why send me a bill for any amount that they knew would not be paid in its entirety? Thanks to Dr. Smith we have an explanation.

Smith calls it the "uncompensated care scam" which seems like an accurate characterization. To make up for the money that hospital "looses" in uncompensated care ( the difference between what they bill and what they receive) the federal government ( and I believe state governments may have a similar program for Medicaid) has a program known as DSH (Disproportionate Share Hospitals ). Using some arcade formula CMS computes a value that the hospitals will receive for this bookkeeping loss.

The medical insurance companies have their own scam,known as "repricing" in which they receive a percent of the "saving" they obtain for their employer clients by contracting fees for various procedures and hospital charges. The trick seems to be a mark up on the price the insurance company and hospital agree on so that the alleged savings and the reward for the insurance company is higher,

So the more the hospital losses the more they get paid by CMS and the higher the bills the hospitals charge the more the insurance companies make.


Thursday, September 12, 2019

Is it time to stop primary prophylaxis with low dose aspirin

Well, it might be if one construes broadly-perhaps too broadly- the results of a  systematic review published in the Lancet. See here for summary- registration needed for full text) Also see here for a good discussion and some details of the study.

The authors meta-analyzed some six studies with mega numbers of patient years on the table and basically concluded that in secondary prophylaxis the beneficial reduction in heart attack trumps the risk of bleeding while in those individuals without established diagnosis of coronary disease the bleeding risk appeared greater than the heart attack risk reduction.This study is said to be more informative than an earlier meta-analysis of the same six studies because of access to some individual patient data.

The NCEP formula for heart attack risk estimate is based on data from The Framingham study.The current version of that formula cranks out a ten year risk of 24% for a 70 year old,non-smoking male, with a BP of 140 on blood pressure meds,a total cholesterol of 230 and an HDL of 40. Widely quoted guidelines would all agree that one should recommend low dose aspirin for such a patient. Does the new meta-analysis have sufficiently fine grained subgroup data to alter that recommendation?

An important insight to the data is the following.(quote is from the second link mentioned above)My bolding

This proportional reduction in serious vascular events did not depend significantly on age, sex, smoking history, blood pressure, total cholesterol, body-mass index, history of diabetes, or predicted risk of coronary heart disease. The authors point out that there was not even a significant trend in the proportional effects of aspirin in people at very low, low, moderate, and high estimated risk of coronary heart disease. "If the proportional risk reductions in these different subgroups really are similar, then the absolute risk reductions will depend chiefly on an individual's absolute risk without treatment," the authors comment.

I don't think this is anything new or surprising but the following could be:
They also say that their analysis suggests that the same factors that determine risk of heart disease also determine the risk of bleeding with aspirin, so that, even for people at moderately increased risk of coronary heart disease, the major absolute benefits and hazards of adding aspirin to a statin-based primary-prevention regimen could still be approximately evenly balanced.
So apparently not only heart attack risk increases with increased risk factors but so does the risk of bleeding.

There is an argument that since we now have statins as an arrow in the preventive medicine quiver and they seem so effective and also seem to do; God- only- knows how many other beneficial things maybe aspirin with its precarious and ambiguous balancing of thrombosis prevention and bleeding may not be for everybody in regards to primary prophylaxis.

The meta-analysis was published in May 2009 so the most recent guidelines from the U.S. Preventive Services Task Force could not have taken its findings into consideration. This version of their recommendations give different advice for men and women. For men they say:

Men aged 45 to 79 with heart risk factors should take aspirin if the preventive benefits outweigh the risk of bleeding. The trick is , of course, to somehow discern if the benefits outweigh the risk.

Even the practice of using low dose aspirin for primary prophylaxis in diabetes has come under attack. This article in the BMJ makes the argument that evidence supporting aspirin use is weak even though their analysis did show a 43% decrease in myocardial infarction men, but not women.

Doctor, were you wrong then or are you wrong now?

Wednesday, September 11, 2019

"Population Medicine" is not just intellectually empty it is dangerous

Over twenty years ago my partner, who was a very good physician, would occasionally say somethng that puzzled me. He would say  we probably should not  do such and so for a given patient because of the cost to the society or the system. Sometimes he used one word sometimes the other. I let it- go we had a great working relationship which I did not want to damage it  with philosophical discussion in which we would each probably talk past the other.

He was ahead of curve of the philosophy of population medicine- a philosophy that places importance of the health of a group or a collective as opposed to the individual's health which had been the emphasis and the polar star for the physician in the centuries old  physician-patient relationship.

But the health of a group had never been the role of the physician-it was the health or well being of the person acrosss from him in the examining room. The fundamental ethic of the medical profession stood in oppostiton to the notions of population medicine. For the notion of population medicne, which included reference to social justice,and a utilitarian calculus to prevail medical ethics had to be chosen.

Leading the charge for change were a group of leaders of the American College of Physicians  and some like thinking European  internists.

Tuesday, September 10, 2019

Population Medicine is much worse than just a very bad idea

Here are the comments of Apu,owner of the Kwik e Mart after Homer Simpson quite his job there:

"He slept,he stole,he was rude to the customers.Still, there goes the best damned employee a convenience store ever had. "

In a way a free market based society is something like that. With freedom and capitalism there are booms and busts, there are demonstrable inequalities  among various parameters,there is information asymmetry, externalties, and apparent market failures.Still it is the best damned economic, social system a country ever had.

Quoting Deirdre McCloskey speaking on why freedom and markets are better than central planning:.

"How do I know that my narrative is better than yours?  The experiments of the 20th century told me so.  It would have been hard to know the wisdom of Friedrich Hayek or Milton Friedman or Matt Ridley or Deirdre McCloskey in August of 1914, before the experiments in large government were well begun.  But anyone who after the 20th century still thinks that thoroughgoing socialism, nationalism, imperialism, mobilization, central planning, regulation, zoning, price controls, tax policy, labor unions, business cartels, government spending, intrusive policing, adventurism in foreign policy, faith in entangling religion and politics, or most of the other thoroughgoing 19th-century proposals for governmental action are still neat, harmless ideas for improving our lives is not paying attention."

 Those medical progressives who champion the medical collectivism euphemistically referred to  to as population medicine have not been paying attention.

The 20th century made it crystal clear that collectivism does not work.Marx et al promised prosperity and equality by doing away with private property and individual liberty and delivered mass murder and starvation. The greatest welfare program in the history of the world was when Communist China did away with collective farming.

And astonishingly there is a faction of the medical leadership in this country who would institute a system of collective planning in regard to everyone's health  replete with acceptance of sacrifice of the individual to some purported calculable greater health metric for the group.

The very old wine in new bottle is labelled population medicine.

Population medicine is wrong on so many levels.It is antithetical to not only traditlonal medical ethics but also to classical liberal thought as well as Rawlian ethical precepts. It is something that both Robert Nozik and John Rawls would oppose.

His Bundle pacing is no longer the lastest thing in EP,Left bundle branch pacing may be

His Bundle pacing (HBP) is no longer the latest thing in cardiac electrophysiology (EP).Now direct pacing of the left bundle branch seems to be.

HBP is increasing recognized as a safe and more physiological alternative to right ventricular apical pacing. HBP is now part of the latest AHA/ACC/HRA guidelines. (2018).

HBP has been shown to be capable of normalizing the QRS duration and  the ejection fraction in as many as  80% of cases of nonischemic cardiomyopathy with left bundle branch block (LBBB). However, in 20% of cases HBP cannot correct the abnormal conduction pattern at a capture threshold suitable for long term pacing or is not effective because of distal His Purkinje disease.

There have been several case reports of  successful pacing in the left bundle branch in such cases. More recently Dr. Pugazhendhi Vijayaraman from Geisinger Clinc discussed his experience with Left bundle branch area pacing(LBBAP) in 100 cases at the 2019 Heart Rhythm Society meeting. See here.

He reported early success but emphasized the many yet to be answered question and concerns with this new technique. The electrode screw is inserted much deeper ( a centimeter or more) into the heart than with typical HBP pacing and the long term consequences of that are yet to be determined. Early report are encouraging ( lower capture thresholds and good r wave sensing )and hopefully better implantation tools will be developed to improve the process and more long term followup will help define what role LBBAP will have.

Friday, September 06, 2019

Medical scribes may help a bit but will not fix the EHR mare's nest


Some developments have appeared on freeing the physicians from a bit  hegemony of the computer mandates . Back in the old days physicians would often see a patient and  do an exam and then dictate a note, in other words they used a scribe. Enter the computers and the reason for scribes was somehow forgotten and it was thought to be appropriate for physicians to transcribe their own notes  using the computer keyboard.

 The reason for scribes to begin with is explained by the economics 101 notion of opportunity cost. Simply put, the physician's time was worth more seeing the next patient than typing. This would be true even in the unusual case in which  the doc was a better typist that the scribes he uses.The opportunity cost of a physician doing her own typing is too high. Now it looks like the scribes are coming back. My eye doctor has been doing that for years. See here for details on the new scribe resurgence. Of course, this fix  does not alleviate the problem of "meaningful use".Scribes may decrease the amount of time wasted by physicians but the issue of the  mandated or quasi-mandated use of computers not  designed to facilitate physicians' work  is not fixed by this.

Wednesday, September 04, 2019

Why would physicians advocate replacing Hippocratic medicine with Platonic Medicine?

The notion of a fiduciary duty of the physician to his patient is long standing . In the era in which I grew up medically  ( now over fifty years ago) the idea that a physician should be obligated to care for the group of which his patient is a member was not talked about.

I first read about the Platonic notion of the physician as one obligated to provide the best care for a group as opposed to an individual in a series of articles in the Journal of the American Medical Association (JAMA). I make no claim that this was the earliest advocacy but only the first of which I became aware.

A series of articles was published  in 1995 authored by Dr. David Eddy that championed the  merits of decision analysis which he hailed to be a mechanism to increase the quality of medical care while reducing costs. Eddy defined quality as the greatest medical good for the greatest number within some economic medical collective. Eddy discussed the merits of decision analysis but the purpose of his version of medical decision analysis was to bring about a utilitarian outcome, namely the greatest medical outcome for the greatest number. Eddy admitted that there would be winners and losers in such an approach and implied that the group benefits trumped any individual loss or losses.

Dr. Robert Berenson  carried forward the plea for Platonic medicine  in the Annals of Internal Medicine  in 1998  in which he proposes that physicians should be devoted to  the health of the collective rather than the individual patient.

"We propose that devotion to the best interests of each individual be replaced with an ethic of devotion to the best interests of the group for which the physician is personally responsible."

Berenson recommends a replacement of the fiduciary duty of the physician to the patient with a duty to a group .This represents a sea change in medical ethics.

Outside of the HMO setting (or now the ACO) to what group would a physician owe his allegiance ?(Would a retainer physician strive to maximize the health of the city or states in which he practices or the country or what? Berenson's ethical proposal seemed to be aimed  primarily at HMO physicians as in the late 1990s the role of physicians in HMO settings was of concern and the topic for much discussion.


Tuesday, September 03, 2019

I'll pretend to be your doctor,Medicare will pretend to pay me

Has it really gotten that bad? Are things devolving to the point where an application of a version of the following Russian joke is applicable to the changes in medical practice? Russians would say " we pretend to work and they pretend to pay us"?

This off-the-wall thought emerged from two of us perhaps catalyzed by dinner wine, as three retired internists gathered for a meal and pointless complaining session.

One of the three played several roles in my life; partner in an internal medicine practice,consultant when I left that practice, my personal physician until his group practice faced bankruptcy.It was he who remarked about his recent annual check up with a younger general internist who had been his former partner. He was irritarted how brief and perfunctory his physical exam had been. I was able to top that.

My recent annual exam with another former partner from that same clinic was interesting.He had me strip to shorts and put on a open-in-the-back paper gown. He then auscultated my posterior chest and that was it. I could have had an alien creature bulging from my anterior chest or abdomen and it would have gone unnoticed.

Monday, September 02, 2019

Contracting out post operative wound care-economic opportunity and what effect on patient care

I have been out of the game so long that I did not realize that apparently post operative op wound care,at least those with infected wounds,are often  contracted to wound care practices.

Wound care centers treat more than post operative wounds,including skin ulcers from venous or arterial disease,radiation burns,trauma etc.

What I found interesting was that  in regard to post op wounds t,hat this was something historically managed by the surgeon and post op followup was considered paid for by the surgical fee. ( if anyone can correct me on that please do)

So this was  a situation in which medical care that could be carved out and now compensated for.Someone found a new income stream. Is it sensible to think of this as a win-win situation as the surgeon is relieved of frequently being reminded of his complication and someone else can take care of problem and be compensated for it. Further, to the extent that a wound care facility is good at what they do ( maybe better than the surgeon) it is a win-win-win situation.

This is another example of the increasing fragmentation of medical care. Internists have morphed into outpatient doctors and hospitalists and many procedures traditionally done by various varieties of internists have been handed off to the  interventional radiologists,