June 24th, 2011 by DrRich in Health Policy, Opinion
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Podcast:
In an article appearing last week in the American Heart Journal, investigators concluded that if American doctors would prescribe for their patients with heart failure each of the six therapies which are most strongly recommended in current heart failure guidelines, 68,000 lives per year could be saved.
The following (for the interest of the reader, and for the convenience of any attorneys who may follow DrRich’s offerings), is an ordered list of these six proven, life-saving heart failure therapies, along with the number of American lives that could be saved each year if only American doctors would stop grossly under-utilizing them in violation of published guidelines:
- aldosterone antagonist therapy – 21,407 lives
- beta blockers – 12,922 lives
- implantable defibrillators (ICDs) – 12,179 lives
- cardiac resynchronization therapy (CRT) – 8317 lives
- hydralazine plus isosorbide – 6655 lives
- ACE inhibitors or angiotensin receptor blockers (ARBs) – 6516 lives
The authors, of course, are careful to point out that their analysis is based on statistical methods, and thus must be counted as merely estimates of the magnitude of the benefit that would actually occur should American doctors suddenly begin managing their heart failure patients appropriately. (Their presentation of these estimates to five significant figures implies a level of precision far in excess of what can be justified, and therefore must be an oversight not only by the authors, but also by the reviewers and the editors. But still, one gets the idea. A lot of preventable deaths are being left on the table.)
Several studies have reported, over and over again, that fewer than half of American patients with heart failure Read more »
*This blog post was originally published at The Covert Rationing Blog*
June 20th, 2011 by DrRich in Opinion, Research
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In 2007, when the results were published from the COURAGE trial, all the experts agreed that this study would fundamentally change the way cardiologists managed patients with stable coronary artery disease (CAD).*
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*”Stable” CAD simply means that a patient with CAD is not suffering from one of the acute coronary syndromes – ACS, an acute heart attack or unstable angina. At any given time, the large majority of patients with CAD are in a stable condition.
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But a new study tells us that hasn’t happened. The COURAGE trial has barely budged the way cardiologists treat patients with stable CAD.
Lots of people want to know why. As usual, DrRich is here to help.
The COURAGE trial compared the use of stents vs. drug therapy in patients with stable CAD. Over twenty-two hundred patients were randomized to receive either optimal drug therapy, or optimal drug therapy plus the insertion of stents. Patients were then followed for up to 7 years. Much to the surprise (and consternation) of the world’s cardiologists, there was no significant difference in the incidence of subsequent heart attack or death between the two groups. The addition of stents to optimal drug therapy made no difference in outcomes.
This, decidedly, was a result which was at variance with the Standard Operating Procedure of your average American cardiologist, whose scholarly analysis of the proper treatment of CAD has always distilled down to: “Blockage? Stent!”
But after spending some time trying unsuccessfully to explain away these results, even cardiologists finally had to admit that the COURAGE trial was legitimate, and that it was a game changer. (And to drive the point home, the results of COURAGE have since been reproduced in the BARI-2D trial.) Like it or not, drug therapy ought to be the default treatment for patients with stable CAD, and stents should be used only when drug therapy fails to adequately control symptoms.
When the COURAGE results were initially published they made a huge splash among not only cardiologists, but also the public in general. So cardiologists did not have the luxury of hiding behind (as doctors so often do when a study comes out the “wrong” way) the usual, relative obscurity of most clinical trials. Given the widespread publicity the study generated, it seemed inconceivable that the cardiology community could ignore these results and get away with it.
But a new study, published just last month in JAMA, reveals that ignore COURAGE they have. Read more »
*This blog post was originally published at The Covert Rationing Blog*
June 20th, 2011 by Davis Liu, M.D. in Opinion
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Doctors are professionals. But are doctors cowboys or pit crews? Recently, physician writer, Dr. Atul Gawande, spoke about the challenges for the next generation of doctors in his commencement speech titled, Cowboys and Pit Crews, at Harvard Medical School. Gawande notes that advancement of knowledge in American medicine has resulted in an amazing ability to provide care that was impossible a century ago. Yet, something else also occurred in the process.
“[Medicine’s complexity] has exceeded our individual capabilities as doctors…
The core structure of medicine—how health care is organized and practiced—emerged in an era when doctors could hold all the key information patients needed in their heads and manage everything required themselves. One needed only an ethic of hard work, a prescription pad, a secretary, and a hospital willing to serve as one’s workshop, loaning a bed and nurses for a patient’s convalescence, maybe an operating room with a few basic tools. We were craftsmen. We could set the fracture, spin the blood, plate the cultures, administer the antiserum. The nature of the knowledge lent itself to prizing autonomy, independence, and self-sufficiency among our highest values, and to designing medicine accordingly. But you can’t hold all the information in your head any longer, and you can’t master all the skills. No one person can work up a patient’s back pain, run the immunoassay, do the physical therapy, protocol the MRI, and direct the treatment of the unexpected cancer found growing in the spine. I don’t even know what it means to “protocol” the MRI.”
Despite all of the advancements in medicine, the outcomes and consistency in treatment and care are not as good as they could be. Doctors are not doing basic things. The fact that Gawande, author of The Checklist Manifesto, spoke at one of the finest medical schools in the country indicates how much more the profession needs to go.
“We don’t have to look far for evidence. Read more »
*This blog post was originally published at Saving Money and Surviving the Healthcare Crisis*
June 8th, 2011 by PJSkerrett in Health Tips
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The crumbling Food Pyramid and its hip successor (MyPyramid) fell into oblivion yesterday, eroded by the stinging winds of science. Their replacement? A quartered plate called—wait for it—MyPlate that was designed to visually convey the elements of healthy eating to Americans of all ages.
The new icon consists of a white plate divided into four segments: green for vegetables, red for fruits, orange for grains, and purple for protein. Dairy has a prominent place, sitting where a glass of water should be. The hope is that the plate will nudge Americans away from meals dominated by meat and starch and towards meals made up mostly of plant-based foods.
The original Food Guide Pyramid debuted in 1992. It was built on shaky scientific ground. Over the next few years, research from around the world chipped away at the healthy eating message in the pyramid’s base (refined carbohydrates), the middle (meat and milk), and the tip (fats).
The Pyramid got an extreme makeover in 2005. Read more »
*This blog post was originally published at Harvard Health Blog*
May 26th, 2011 by Shadowfax in Health Tips
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There’s been quite a kerfuffle over the “Unprofessional” post Dr V wrote. A lot of people have been very shrill in denouncing physicians who write about their experiences using social media — blogs, twitter, facebook, etc — with particular emphasis on those who do not use their real names.
So, while I won’t tell someone how they should blog/tweet, or try to impose my vision of professional standards on a community that clearly is still coming to consensus with public conversations by healthcare workers, I will offer you my personal guidelines and values that I use in determining what I am willing to put into the public domain. These are just my opinions; your mileage may vary.
As a general principle: patients give physicians and nurses access to intimate details of their lives and they have a reasonable and valid expectations that we will respect their privacy and dignity. When using social media, that does need to be maintained. How you do that requires careful attention and may be controversial regardless of your approach.
Don’t blog or tweet anything that you wouldn’t want you boss/hospital administration to read. Stress test yourself by informing your employer or CEO about your blog and invite them to read it. That will keep you honest! Read more »
*This blog post was originally published at Movin' Meat*
