Surgeon Caseload Largely Explains Hospital Volume Link to Mortality

Numerous reports have shown that operative mortality is lower at hospitals with high procedural volumes. Now, new research suggests that this association is largely mediated by the caseload of the operative surgeon.

Therefore, a patient undergoing surgery at a low-volume hospital by a high-volume surgeon could have a better outcome than one undergoing surgery at a high-volume hospital by a low-volume surgeon. The relative importance of surgeon volume depends on the particular procedure, according to the report published in the November 27th issue of The New England Journal of Medicine.

For example, mortality with aortic-valve surgery is almost entirely related to surgeon volume. So, in this case, selecting an experienced surgeon may be more important than choosing a high-volume hospital. In contrast, mortality with lung resection did not appear to be closely related to surgeon volume, so selecting a high-volume hospital may be more critical.

"Our findings are really surprising to me and to many who've followed this area carefully," lead author Dr. John D. Birkmeyer told Reuters Health. " For years, the assumption was that hospital volume mattered a lot more than the volume of the operating surgeon. Our study really didn't find that to be true."

This article argues for referring patients to surgeons who have great experience with a specific type of surgery. The data make sense, as the task is difficult, fraught with many hazards, and experience should give one a better "check list" to use during surgery. I suspect that the same is true (to a less dramatic effect) for many medical conditions. As a general internist, I would never try to give chemotherapy - I just do not have the volume to keep up with changes in the field.

Studies have shown that among generalists, specialoids (those who focus on a disease or system without advanced training) have better outcomes. We suspect those better outcomes occur because volume leads to experience which leads to a better understanding of the nuances of care.

These findings do not argue against the importance of generalists. Generalists can (and do) care very well for most common diseases. For example, type II diabetes mellitus is so common that we should have a large enough volume to have excellence. Similarly experience occurs with coronary artery disease, congestive heart failure, dyspepsia, chronic obstructive lung disease, hypertension as several examples.

The truly excellent generalist will become an expert at caring for the most common diseases and retain expertise in diagnosing the great majority of complaints. Part of our excellence comes from knowing when we do need to refer. We must all beware the error of not referring when indicated.

I find the findings of this article sobering. Perhaps we should evolve our health system in ways which take these findings into consideration. Interestingly, the durrent issue of JAMA considers this problem - Regionalization of High-Risk Surgery and Implications for Patient Travel Times (paid subscription required). The essence of the article:

With low-volume standards (1/year for pancreatectomy; 2/year for esophagectomy), approximately 15% of patients would change to higher-volume centers, with negligible effect on their travel times. Most patients would need to travel less than 30 additional minutes (74% pancreatectomy; 76% esophagectomy). Many patients already lived closer to a higher-volume hospital (25% pancreatectomy; 26% esophagectomy). Conversely, with very high-volume standards (>16/year for pancreatectomy; >19/year for esophagectomy), approximately 80% of patients would change to higher-volume centers. More than 50% of these patients would increase their travel time by more than 60 minutes. Travel times would increase most for patients living in rural areas.

These findings challenge us to consider the trade off between inconvenience and outcomes. I do not think it a difficult decision.

Anecdotally, most physicians who have complex disease (especially cancers) travel almost any distance to find the specialist for that disease. What do physicians know?

Surgeon Caseload Largely Explains Hospital Volume Link to Mortality

Numerous reports have shown that operative mortality is lower at hospitals with high procedural volumes. Now, new research suggests that this association is largely mediated by the caseload of the operative surgeon.

Therefore, a patient undergoing surgery at a low-volume hospital by a high-volume surgeon could have a better outcome than one undergoing surgery at a high-volume hospital by a low-volume surgeon. The relative importance of surgeon volume depends on the particular procedure, according to the report published in the November 27th issue of The New England Journal of Medicine.

For example, mortality with aortic-valve surgery is almost entirely related to surgeon volume. So, in this case, selecting an experienced surgeon may be more important than choosing a high-volume hospital. In contrast, mortality with lung resection did not appear to be closely related to surgeon volume, so selecting a high-volume hospital may be more critical.

"Our findings are really surprising to me and to many who've followed this area carefully," lead author Dr. John D. Birkmeyer told Reuters Health. " For years, the assumption was that hospital volume mattered a lot more than the volume of the operating surgeon. Our study really didn't find that to be true."

This article argues for referring patients to surgeons who have great experience with a specific type of surgery. The data make sense, as the task is difficult, fraught with many hazards, and experience should give one a better "check list" to use during surgery. I suspect that the same is true (to a less dramatic effect) for many medical conditions. As a general internist, I would never try to give chemotherapy - I just do not have the volume to keep up with changes in the field.

Studies have shown that among generalists, specialoids (those who focus on a disease or system without advanced training) have better outcomes. We suspect those better outcomes occur because volume leads to experience which leads to a better understanding of the nuances of care.

These findings do not argue against the importance of generalists. Generalists can (and do) care very well for most common diseases. For example, type II diabetes mellitus is so common that we should have a large enough volume to have excellence. Similarly experience occurs with coronary artery disease, congestive heart failure, dyspepsia, chronic obstructive lung disease, hypertension as several examples.

The truly excellent generalist will become an expert at caring for the most common diseases and retain expertise in diagnosing the great majority of complaints. Part of our excellence comes from knowing when we do need to refer. We must all beware the error of not referring when indicated.

I find the findings of this article sobering. Perhaps we should evolve our health system in ways which take these findings into consideration.

For those who want to read a wide variety of opinions, here goes:

• Am I sad or am I glad? - from Assymetrical Information
• POLICY: Medicare bill passes from the Health Care Blog
• Will Medicare now cover my depression about domestic politics? from Daniel Drezner
• Almost everything over at The Business Word, Inc.
• Medicare: 54-44-2. from the Bloviator (who does not like this bill at all)
• Parties Without Ideology from Insults Unpunished

If you run into more reasonable links, please let me know.

This is the second post on the Medicare bill. Many critics dislike the provision which allows participants to choose another insurance plan. In trying to understand this opposition, I am assuming that critics worry about a dilution of Medicare as we know it.

Thus, we must ask if we would rather have a monolithic insurance, run by legislation, or free market competition. I dislike much of Medicare, and believe that a little competition could improve it. I like that there is a provision for demonstration projects.

I find nothing objectionable here. Hopefully, the competition will have a desired effect. It might even eventually positively impact drug pricing.

This is the first in a short series of commentaries on the Medicare bill. The essence of the bill is captured in the first post today (since I post in reverse chronological order, scroll down).

The drug benefit has 2 parts. For '04 and '05, seniors can buy (for $30) a discount card. This card will give an estimated 15% savings on drugs. Thus, if you spend more than $200 a year on drugs you will save some money. Low income seniors also would get a $600 subsidy.

Starting in '06 the big plan takes effect. This plan has modest benefits for those with minor drug expenses (I define minor as < $2000 per year). There is then the doughnut (There would be no coverage for drug costs between $2,250 and $3,600 out of pocket -- the so-called coverage gap). Then coverage is excellent above that amount. Those with less income would get co-pays and premiums waived.

The drug benefit could be called catastrophic drug insurance. The big benefit accrues to those who need multiple expensive drugs.

The benefit is tied to income, those who make more, pay more.

While this solution to prescription drug coverage is not ideal, it does have some pluses. The coverage helps those in the greatest need for help - those with low income/assets and those with huge drug costs. Those with more resources would pay more.

Certainly this plan is better than no plan. I worry more about paying for the plan, than the true benefit to recipients. They will get some benefit (which clearly is better than they currently have).

Starting in April, Medicare beneficiaries could get a prescription drug discount card that would yield savings estimated at 15 percent to 25 percent. Low-income beneficiaries would also get a $600 subsidy applied to the card but would still be required to make a co-payment of between 5 percent and 10 percent for each prescription drug.

Beginning in 2006, beneficiaries could sign up for a stand-alone drug plan or join a private health plan that offers drug coverage. They would be charged an estimated premium of $35 per month, or $420 per year. After meeting a $250 deductible, insurance would pay 75 percent of drug costs up to $2,250. There would be no coverage for drug costs between $2,250 and $3,600 out of pocket -- the so-called coverage gap. When out-of-pocket spending reaches $3,600, insurance covers 95 percent of drug costs or requires a modest co-payment. The premium, deductible and coverage gap would be waived for people earning up to $12,123 a year. To qualify for the subsidy, seniors could have no more than $6,000 in fluid assets. The subsidies would be phased out between $12,123 and roughly $13,500 in yearly income.

Beginning in 2006, the legislation would give beneficiaries the option of enrolling in private health maintenance organizations or preferred provider organizations. Beginning in 2010, the legislation provides a "demonstration," with direct competition between traditional Medicare and private plans in as many as six metropolitan areas.

The bill would increase Medicare funding for doctors, hospitals and other health care providers, particularly in rural areas, where reimbursement levels are far below what is paid in other regions of the country.

The bill would allow people with high-deductible health insurance policies - at least $1,000 a year for individuals, $2,000 for couples - to shelter income from taxes. Individuals younger than 65, employers or family members would make pretax contributions equal to the deductible, up to a maximum of $2,600 a year for individuals and $5,150 for families. After 65 years of age, earnings and distribution also would be tax-free, provided the money is used for health expenses, including insurance premiums, prescription drugs and long-term care. Otherwise, a 10 percent penalty would apply.

For the first time, higher-income seniors - those with incomes of more than $80,000 as an individual or $100,000 as a couple -- would be required to pay more for their Medicare Part B (doctor, out-of-hospital coverage) premiums than other beneficiaries. Now, beneficiaries pay 25 percent of the Part B premium and the government pays the rest. Individuals with incomes greater than $80,000 would pay a larger premium. The size of their premium would increase on a sliding scale, topping out at 80 percent for people with incomes over $200,000. The deductible would rise from $100 to $110 in 2005 and thereafter be indexed to the growth in Part B spending. Individuals with incomes below $13,055 and couples with incomes below $17,619 and with assets no greater than $6,000 per individual and $9,000 per couple would pay no deductible and no monthly premium for the new drug benefit.

The legislation would provide subsidies to insurance companies to encourage them to offer private coverage to seniors. Tax-free subsidies, perhaps worth as much as $70 billion, would be provided to employers who maintain drug coverage for retirees once the Medicare drug benefit begins in 2006.

The legislation would limit drug makers' ability to halt competition by generic alternatives, specifically providing one 30-month stay for patent infringement suits involving a generic drug application.

The bill would maintain the ban on importing prescription drugs. It would allow such drugs from Canada, but only if the Health and Human Services Department certifies safety, something it has declined to do. The legislation would authorize a study of safety issues.

from Analysts: Seniors' drug costs to rise My commentary will start later this morning and probably continue through the holiday weekend. At a first glance I see both ponies and manure. On balance, the bill has many major pluses. The overall cost does bother me, but I will try to put even that into perspective. Posted by at 04:57 AM | Comments (1) | TrackBack (0)

This has nothing to do with medicine. I love the article anyway - thanks to Occam's Toothbrush for the link. Golf and the Thin Veneer of Civilization

Derek Lowe is always good. This rant exceeds even his high standards. Things Only a Friend Can Tell You. Please go read it.

I found this study interesting. In-Hospital Initiation of Lipid-Lowering Therapy Predicts Long-Term Use

Heart disease patients who begin lipid-lowering therapy while hospitalized are nearly three times more likely to report long-term use than patients who do not start such drugs during hospitalization, new research indicates.

Most blogs have recurrent themes. Excellent blogs stray occasionally, but generally have major themes that the author revisits frequently. Pain control represents one of my major themes.

Physicians feel squeezed when we discuss pain. We all understand that we have a responsibility to relieve pain. However, we also feel obligated to avoid creating narcotic addiction. We also fear (as I state repeatedly) being duped into providing narcotics for addicts (and even worse for resale to addicts).

This article adds to the discussion, pointing out that patients with real pain rarely develop addiction. The Delicate Balance of Pain and Addiction I highly recommend this article as giving a balanced view of the conflict that we perceive. I still do not know the answer.

Go clickity, clickity and laugh your socks off - Lawyers on medicine in the court room

Comments greatly improve this blog. I will continue to encourage and support them. However, some old posts get too many unnecessary comments. Therefore, I have installed a plug-in which restricts comments to posts within the past 14 days. If you have an important comment on an issue older than that, please email instead.

Thanks

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For those interested, this links to today's Letters to the Editor about the pharmaceutical industry and medical education. They are solid, but our commentary surpasses. The Doctors and the Drug Makers (6 Letters)

The AMA has this one right! Evidence doesn't support push for clinical skills exam During a time when we urge students, residents and all physicians to base their practice on evidence, the NBME has added a new expensive examination without first collecting any evidence of its importance.

The timing of the examination is a paramount consideration for students. Taking the test earlier allows the opportunity for a re-exam, since retesting is not allowed within 60 days of a failed exam. However, the earlier a student takes the test, the fewer opportunities he or she has to get the clinical experience necessary to pass. Does the medical school have any responsibility to remediate this student? Whose responsibility is it?

There are downsides to taking the exam later, too. The paucity of testing sites, combined with the 60-day retest rule, means there will be no possibility of a retest prior to graduation, should a student fail. For those students, this will delay graduation and cancel their residency match.

Why force this dilemma by making an arbitrary decision about timing? We can make a strong argument for making this test a requirement for residency, not for medical school.

In addition to these concerns about when to take the examination, the high cost of the exam and the expense of reaching one of the test sites must be borne by each student. This just adds to the crushing debt that already burdens our medical students.

Finally, and most importantly, there is no evidence that this exam will produce the results that are desired, i.e., fewer state license actions for misconduct, negligence and incompetence. These are legitimate interests of the state, but overwhelmingly take place after many years of practice. Ironically, in this day of evidence-based medicine, those who would tell us how to practice the profession, for which we have trained extensively and exhaustively, have yet to consider any evidence for the requirements they so pompously heap upon us.

The AMA continues to voice our firm opposition and has requested NBME to increase the number of test sites immediately; consider rotating actors throughout the sites while centralizing the scoring of videos; provide a list of recommended texts to prepare students, including NBME products and others; and address and carefully plan for the remediation and retesting issues that may arise.

We have also requested medical schools not to require passage of the clinical skills examination for graduation and we have encouraged residency program directors not to require passage of the exam for entering into the residency.

The AMA member medical students, residents, medical school faculty members and physicians have spent hundreds, if not thousands, of hours examining this problem -- and communicating it to the powers that be.

Despite repeated accountings of our concerns, the NBME and FSMB have paid little if any attention and have recently affirmed their recalcitrant position. I urge you to contact the NBME (www.nbme.org), your state licensing board and your medical school.

Points well made!!!!

I found another pony! Deal sets path for vote on Medicare physician pay fix

An agreement between House and Senate negotiators has set the stage for a final vote in Congress on a Medicare bill that would reform the program, add an outpatient prescription drug benefit and eliminate cuts in physician payment.

At press time, a vote was expected before Congress adjourned for the Thanksgiving holiday. Medicare officials said that should allow enough time for a Jan. 1, 2004, implementation of payment rates that reflect the 1.5% increase in physician reimbursement contained in the bill, as opposed to the previously scheduled 4.5% cut.

So we have an admittedly flawed bill, with several gems. The adjustment in physician payment is very important to maintain access for Medicare patients.

Long time readers know that I argue often that patients need an excellent physician who has the time to provide complex care. However, complex care takes time. This article suggests that I am right. Spend the money up front, and patient care benefits. Managing multiple conditions: A challenge for Medicare: A Medicaid project in North Carolina has cut costs and improved care for patients with chronic diseases. Can Medicare do the same?

Good business ideas come from spotting unmet needs. Sometimes one must convince consumers of that need (marketting), sometimes it is just so obvious that the business succeeds immediately. A middleman steps into the physician-patient relationship

The idea of a patient advocate certainly is not new, but most services focus on helping patients in their struggles with insurance companies and employers.

Proponents, however, say that when a complicated health care system combines with a sudden serious illness, advocacy services on the care side can be vital. Internet research alone cannot replace a person who can interpret doctors' orders and help explain options, said Marsha Hurst, PhD, director of the health advocacy graduate program at Sarah Lawrence College in Bronxville, N.Y.

A physician starting a side business as an advocate "almost confirms the fact that it can't be a normal part of a physician's practice anymore," she said.

Physicians aren't the only ones getting involved. For example, Susan Del Signore of Boston started her patient advocacy business in 2001 after caring for her parents through overlapping terminal illnesses. She charges $125 per hour and bills in 15-minute intervals. Del Signore said she has worked with clients with a wide range of medical problems.

Dr. Kranitz charges clients a $500 registration fee plus $150 per hour to act as their liaison and advocate, which he said is less than half of what a physician would bill insurers per hour for a normal office visit. He is looking into the possibility of converting his business into a nonprofit organization, so he could lower his fees and become more accessible to lower-income clients.

Dr. Kranitz said he offers advocacy services from a physician's perspective, but he does not take clients on as patients, nor does he take the place of a primary care physician. There probably are only a few patients in an average practice who would be suitable candidates for his services, he said.

And it has come to this. Physicians do not have the time to advocate for their patients. Our billing and payment systems do not handle this need. I hate this. Advocacy should be a part of regular medical care. We should have a financial system that allows this.

Nonwithstanding Bernie's comments the other day

Sounds like another victim of what I call "double blind myopia" -- the idea that it hasn't been shown to work in a double blind clinical trial it can't be true. My favorite example of this is an editorial several years ago in NEJM. An article was published in NEJM showing that injections of testosterone increased strength in athletes. The NEJM editorialized, "now we know steroids work." Of course, every high school football player knew exactly the same thing without the benefit of the clinical trial. But somehow their experience was only anecdotal evidence until it had been sanctified by this clinical trial.

It's good to remember that blinded clinical trials are a relatively recent phenomenon. The paper that first proposed the protocol was published after World War II. And most of the important medical discoveries: sterile surgery, anesthetics, x-rays, antibiotics, to name a few predated the blinded clinical trial.

Well Bernie, loyal reader, you happen to be missing the boat here. We need double blind trials. They are not myopic. Let me give you the classic example.

In the 70s and 80s when patients had a myocardial infarction and then had premature ventricular contractions, we would prescribe an anti-arrhythmic drug. After all, when the patient has an arrhythmia, an anti-arrhythmic should decrease fatal arrythmias. However, when they finally did the study, the patients who received the anti-arrhythmic more likely died.

Just another quick example. We assumed from epidemiologic studies that post-menopausal hormones would decrease heart disease in women. When they did the study, they found that the opposite was true.

We need carefully collected data to help patients make difficult decisions. Apparently Bernie and those of his ilk disagree. The Ongoing Problem with the National Center for Complementary and Alternative Medicine This article is long and comprehensive. The National Center is laughable. We must study things carefully and appropriately. To not do careful studies puts patients at great risk. Just like taking herbals that have not had careful study.

Our legislative process has great flaws. The bills they construct make a camel look normal. Almost any observer can find flaws with any bill. Each bill contains something which makes great sense.

Most of you know the expression - there must be a pony in here. Perhaps this is the pony. Rural Doctors Welcome Medicare Overhaul

The Medicare bill before Congress contains help for rural health care providers that would significantly strengthen service in those areas, hospital administrators and doctors say.

The centerpiece of the huge Medicare bill is a prescription drug benefit for older Americans, but the measure also would boost payments to doctors and hospitals in rural areas by $25 billion and rework a reimbursement system they say is outdated.

"The bottom line is that there have been some very damaging provisions in Medicare for many years for the way rurals are paid, and this erases most of them," said Dr. Wayne Myers, president of the National Rural Health Association.

The government has used different rates in rural and urban areas to determine the size of checks sent to hospitals that treat Medicare patients. The formulas date to the 1980s and were based on the belief that medical treatment is less expensive in small cities and towns.

Many lawmakers and hospital administrators say that no longer is the case as hospitals everywhere compete to recruit doctors and pay the same for high-tech equipment.

"The costs (in rural areas), believe it or not, are also very high, and in many cases higher than in cities," Sen. Max Baucus, D-Mont., said on the Senate floor Friday.

The bill reduces the extent local wages factor in the formula that determines what a hospital gets paid from Medicare, which would raise the reimbursement rate in rural areas, said Myers, a former official with the Health and Human Services Department's office of rural health policy.

It also would eliminate a provision that set the hourly rate of a rural doctor lower than an urban doctor's for cost-reimbursement purposes; raise payments in regions that are short on physicians; and increase how much rural hospitals can be reimbursed for treating uninsured patients.

These provisions have great importance. They are long needed and very welcome. Keep searching, there may be more ponies.

Surgeons tell this to patients. So do generalists. Oftentime the risk is worthwhile. However, we should never downplay the risk. Hospital stops gastric bypass surgery

ROBERT MESSA JR., 27, who worked at the hospital, died Tuesday about a half-hour into the laparoscopic gastric bypass operation, Davey said.

It was the third death among the 340 gastric bypass procedures performed at the hospital over the past three years, chairman of surgery Paul Liu said.

I still advocate for bariatric surgery in some morbidly obese patients. We bemoan the error of commission, but must understand clearly the error of omission. The majority of patients who need this surgery have such poor projected health and survival as to make the risk worthwhile. I have written previously about the successes.

This article reminds us that the decision to undergo bariatric surgery should never be taken lightly. In fact, the surgeons involved here understood those issues.

Davey said Messa underwent about three months of preparation for the surgery, including consulting with a cardiologist, psychiatrist and dietitian and attending a three-hour seminar on the risks and benefits of the procedure.

Just to reiterate, I have linked here to remind readers that the procedure carries danger. It also conveys benefits.

I agree with this editorial. O Canada, O cannabis

Cartoons like this keep my blogging in perspective!

My father sent me this article. I liked it, and found it online. What's the Harm?

The choice is not between scientific medicine that doesn't work and alternative medicine that might work. Instead there is only scientific medicine that has been tested and everything else ("alternative" or "complementary" medicine) that has not been tested. A few reliable authorities test and review the evidence for some of the claims-- notably Stephen Barrett's Quackwatch (www.quackwatch.org), William Jarvis's National Council against Health Fraud (www.ncahf.org), and Wallace Sampson's journal The Scientific Review of Alternative Medicine.

Several weeks ago I upgraded my version of Movable Type. I was slowly able to get everything to work - even changing my database to a mysql database. However, searching did not work.

I use the searching function myself to find old rants. I suspect that many of you use it also. So today I have finally fixed the problem. You (and I) can search again.

I have not expended sufficient energy on this question. However, I do believe that Chris Rangel has. The most vociferous portion of this debate has occurred on RangelMD and Medpundit. Rangel latest rant - Terri Schiavo and patient autonomy Read his interpretation of the issues, and please click on his link to Medpundit's interpretation. These heated debates, while carried out on weblogs rather than in person, represent the strength of medical weblogs. Try to understand the arguments that each excellent blogger makes. Then you can decide your position. I side with Rangel here, but I do understand the issues and feelings that this case creates.

This is a bill that everyone can (and will) criticize. If you are interested here are some links with selected quotes. 6 Democratic Candidates Attack Medicare Measure

"This is a Trojan horse bill," General Clark said. "It's got provisions in it to undercut Medicare. I think the American people want their representatives and their association to stand up and be counted for senior citizens, and that means rejecting this bill."

The debate offered a hint of the fault lines likely to emerge as Democrats struggle to position themselves on an emotionally charged issue that carries great weight with their constituents. The bill includes provisions intended to inject market forces and more competition into Medicare, which Republicans say will lead to better, more cost-effective care. Many Democrats condemn such efforts as tantamount to privatizing the program.

But the bill, which would create the largest transformation of Medicare in its 38-year-history, would also significantly increase spending on the program and offer a prescription drug benefit that many Democrats had sought for years.

Incremental medical repair

Conservative lawmakers who were balking over the bill said it did not go far enough in the direction of true privatization reform to yield the kind of savings that would make it more affordable. Liberals, such as Sen. Ted Kennedy of Massachusetts and several Democratic presidential hopefuls, think it goes too far, sticking the nose of privatization under Medicare's tent that they warned would eventually destroy the fee-for-service nature of this virtual government monopoly.

In a stunning political split among the Democrats this week, the powerful 35 million-member AARP (which lobbies for America's retirees) embraced the GOP's compromise. AARP policy director John Rother said he was won over by the added subsidies the bill would give low-income Medicare patients, plus incentives aimed at keeping employers from abandoning existing drug coverage for their retired workers.

Endorse Medicare

On the liberal side of the ledger, USA Today notes that "Sen. Edward Kennedy, D-Mass., and other critics are denouncing parts of the new plan as a $12 billion slush fund for private insurance companies to lure seniors out of traditional Medicare. But they offer few alternatives other than open-ended spending."

But conservatives are no better when they claim that an experiment falls far short of real reform, since the time limit dooms the proposal to failure. They forget that in 1996, welfare reform legislation,whichMr. Kennedy also strongly opposed, was offered as a five year experiment requiring re-authorization. What conservatives did was to insure that welfare reform worked and when re-authorization time came, to improve and refine the policy.

Medicare Monstrosity

Instead, Republican negotiators, joined by Democratic Sens. John Breaux and Max Baucus, went behind closed doors and decided to use the public's demand for drug coverage as an opening wedge to change Medicare. The shame of it is that Republicans and Democrats in the Senate had already reached a real compromise. The bipartisan proposal, crafted in cooperation with Sen. Ted Kennedy, was inadequate. Yet it was better than this bill. It passed the Senate overwhelmingly because it left the larger Medicare issues open for real debate later.

But House conservatives weren't willing to go that far. They want medical savings accounts, a tax cut for the wealthy in disguise, and they insisted on experiments with privatization.

But if privatization is such a good idea, why do the private insurance companies need such big subsidies to enter the Medicare market? The bill includes $12 billion for what Kennedy calls a "slush fund" to subsidize the private insurers. That's not capitalism or competition. It's corporate welfare.

The debate is interesting. The Democratic candidates have sided with Ted Kennedy in attacking the bill. The NY Times (not known as a conservative bastion) has endorsed the bill. AARP (which many consider pro Democrat generally) has endorsed the bill. Everyone dislikes something about this bill. This bill is clearly a compromise. So I leave you with two quotes about compromise:

A COMPROMISE is the art of dividing a cake in such a way that everyone believes that he has got the biggest piece. (Ludwig Erhard - a German politician)

The COMPROMISE will always be more expensive than either of the suggestions it is compromising. (Arthur Bloch)

Shoulder pain represents an extremely common joint complaint. I have had rotator cuff tendonitis, and can attest to the discomfort. This study demonstrates that for the subset of calcific tendonitis, we have a worthwhile therapy - Extracorporeal Shock Wave Therapy Benefits Patients With Calcific Tendonitis of the Shoulder

Both high- and low-energy extracorporeal shock wave therapy (ESWT) are beneficial for treating rotator cuff calcifying tendonitis, although high-energy ESWT appears to be more effective than low-energy ESWT, a randomized trial suggests.

Previous trials of ESWT for the treatment of calcific tendonitis of the shoulder have been deficient in their methodology; therefore, whether this treatment is beneficial for this condition is unclear.

Ludger Gerdesmeyer, MD, from the Technical University Munich in Germany, and colleagues sought to determine whether fluoroscopy-guided ESWT improved function, reduced pain, and diminished the size of calcific deposits in patients with chronic calcific tendonitis of the shoulder.

The Medicare Choice

Despite its shortcomings, the Medicare prescription drug bill heading for a vote in Congress is worthy of passage. Fears that the legislation contains seeds that will ultimately destroy the traditional Medicare program strike us as overblown. Our own chief qualm is that the country, with deficits looming as far as prognosticators can see, cannot afford a program that will cost, at a minimum, $400 billion over 10 years.

Millions of middle-income Americans will get only modest help from the program, and they will have to cope with a crazy-quilt pattern of benefits. But fortunately, the bill is strongest when it comes to the most important target groups: elderly people with low incomes or very high drug bills.

The provisions that alarm some liberals mostly involve issues beyond the drug benefit. They particularly worry about demonstration projects in up to six metropolitan areas that would stage a competition between Medicare and private plans. The competitions would not go into effect until 2010, assuming that political opposition did not block them. There is clearly a danger that the deck would be stacked in favor of the private plans. But our guess is that the elderly, a potent political force, will be able to head off the worst nightmares imagined by proponents of traditional Medicare.

I have not studied the plan carefully. I understand that this plan exists for political reasons. I suspect that you and I could develop a better plan. But we live in a political world, and as the NY Times states, this plan is likely better than no plan.

Think Troy Aikman. Study looks at football-field concussions

College football players who suffer concussions are left prone to another one, especially if they return to action too soon, and they also become slower to recover from such blows to the head, researchers say.

The research -- designed to help schools decide when and if to play injured athletes -- support guidelines that say athletes who have had a concussion should wait seven days after symptoms disappear to get back in the game.

The results add to previous research suggesting that concussions might make athletes prone to more lasting head injury from another blow.

Some smaller studies have also suggested one concussion might make an athlete more likely to suffer a second one. But this study found that the reason may have nothing to do with the athlete's position or playing style.

Instead, the findings suggest that one concussion might cause tissue injury that leaves players more vulnerable to additional concussions, said Kevin Guskiewicz, director of the sports medicine research laboratory at the University of North Carolina at Chapel Hill.

Multiple concussions are known to increase the risk of permanent brain injury, and Guskiewicz said after three or more concussions it "might be time to think about taking up tennis or golf."

The Universal Cure - clearly a very interesting proposal and relevant to our previous discussions. What do you think?

Your Doctor's Drug Problem written by Arnold Relman - former editor of the New England Journal of Medicine.

Relman identifies the problem of drug company controlled CME, but overextrapolates the evil.

To renew their licenses, doctors in almost all states are required to enroll in continuing medical education programs, and these are now largely subsidized, directly or indirectly, by the pharmaceutical industry. There are official guidelines for keeping these programs free of commercial bias, but they are voluntary. Most of these educational programs are presented by industry-friendly experts who are selected and paid by the companies selling the drugs being discussed, and most of their talks emphasize the medical benefits of those drugs. Some of this information is useful, but much of it is simply marketing disguised as education.

Let us clearly understsand the problem. Often drug companies will sponsor a speaker on a topic. The speaker will talk about an issue relevant to the company's drug. Some talks almost blatantly cheerlead for a particular drug. Other talks just increase awareness of the entity that the drug treats.

There are multiple levels of hell. We can modify our current system to disallow the most egregious talks, while preserving the true contributions.

I agree that we have a problem. I disagree with the extent of that problem. I disagree with Relman's assertion

So it is not merely that the pharmaceutical industry is using doctors to sell its products. Medical schools and other educational institutions are not teaching doctors how to use drugs wisely and conservatively. Until they insist that the pharmaceutical industry stick to its own business (which can include advertising but not education), we are unlikely to get the help we need from our doctors in controlling runaway drug expenditures.

I hear many talks at medical schools which do teach physicians how to use drugs wisely and conservatively (and I even give some of those talks myself). We have a problem, but many educators are addressing the issue.

So read his op-ed, but try to keep his thoughts into perspective, avoiding the hyperbole.

If you have not read Thomas Sowell's 3 part essay and the many outstanding comments that this post engendered, go there, read the post, Thomas Sowell and the comments. Then come back to here and I will rant. Thomas Sowell - no free lunch medicine

Welcome back! We clearly have a health care crisis in this country. Let me enumerate my concerns:

• We have great advances in pharmaceuticals, which many patients cannot afford.
• Many patients cannot afford basic care
• Many physicians have significant overhead problems, while having either a fixed or decreasing income per patient visit
• Physicians often act in fear - fear of malpractice.
• Excellent medical care is becoming increasingly complex. This complexity requires physicians to spend more time reading and more time with patients. Yet, our system discourages spending time with patients and time reading.
• Our system does not fit a free market system as patients are divorced from financial medical decision making (the insurance companies have abrogated that responsibility). Moreover, the physician generally has little control over revenue per patient (again the insurance companies and in particular the government have that responsibility).

That admittedly short list provides a foundation for my frustrations. Let me first state that I love medicine and being a physician. I would highly recommend this profession to any one who asks. That does not mean that we cannot improve our current crisis.

Thomas Sowell argues for a free market approach to medical care. I agree. However, I probably disagree with him on this fundamental assumption - we are far from living in a free market system today. We are beset by bureaucracy and poor laws. Let me try to explicate.

I favor medical savings accounts for most medical care (rather than insurance). Medical savings accounts would encourage patients to ask questions about prices. With insurance and a drug benefit, the patient might want Nexium (the evil purple pill). If that same patient were paying from a medical savings account he/she might choose Prilosec OTC (for approximately 20% of the cost).

We should combine this with a new method of billing for outpatient care. We should be billing for time spent with the patient (with everyone understanding that physicians spend significant time on that patient's care while not physically in the room). Patients would know what a 10 minute appointment costs, what a 20 minute appointment costs, etc. While this billing method has some problems, having the patient actually pay the moneys would minimize abuse of the system. Patients would have an explicit expectation of service from us, and would make reasonable demands on our time (knowing the cost involved).

We need to modify the pharmaceutical laws. We do not need loopholes for drug companies to block generics as their patents expire. They deserve a fair run at profits on an individual drug, then let the marketplace work.

We need to fund more studies comparing 2 or more drugs of a class, and drugs of different classes. These studies (with appropriate publicity of results) would inform patients and physicians - choosing the right drug for the patient.

We need even better post approval studies of side effects. We need to better know the rates of side effects for each drug.

We need free market pricing. Currently we have price controls on physicians and hospitals. We a different system of paying physicians and hospitals, free market forces would control prices. We would have winners and losers. Physicians, who patients perceive provide more value, would be able to charge more. Similarly, hospitals perceived to provide better care might charge more. This system would encourage better care (and therefore more profits).

We need better tax incentives for providing charity care. Many physicians willingly provide a percent of charity care (I would suggest 10 percent as a good start). They would be able to "write off" that care as a charitable donation. I believe this could become a good policy. The same process should work for hospitals. I might even go so far as to demand that all health care providers (physicians, hospitals, clinics) provide a reasonable percentage of charity care. We would also expect a usable system of providing pharmaceuticals and diagnostic testing.

I do understand that I am dreaming. Developing a new system would have too many enemies - insurance companies, perhaps the pharmaceutical industry, perhaps big business. However, our current system is broken.

Some might ask why not universal care? I despise bureaucracy, and bureaucratic decision making. Universal care would bring us bureaucracy. As practiced in most other countries that I have studied, it would lead to rationing. The choices that we would have to make are choices that I would rather not make. They are choices that most of our patients would not want us to make.

I have thought about this issue for the past few days, reading the comments on the previous past carefully, and examining my own philosophy. This rant is not a polished proposal, however, I do stand by the concepts that I have proposed. So bring on the commentary. Attack my ideas. But always refrain from ad hominem attacks on any commentary.

From 'morbid obesity' to 'Wow!'

Bravo!

My defining moment came in 1978 during my residency. I was caring for a patient who had aplastic anemia. Because of almost non-existent neutrophils, he was in the medical ICU on strict reverse isolation.

We consulted hematology and they told us that we had no options for treating his neutropenia. (This story precedes bone marrow transplantation.) Hospital epidemiology insisted that he have strict reverse isolation (gowns, masks, gloves) to prevent overwhelming infection. The gentleman (in his 60s if my memory is correct) asked very politely but with great emotion if we could remove the isolation requirement. He told me that he knew that he might die a few days sooner, but he want to see faces, he wanted to hug loved ones, he wanted his last few days to have meaningful interaction with family. He said (and he was right) that the accouterments of reverse isolation decreased his quality of life.

He convinced me and turned on a light bulb. Fortunately I had a wonderful attending who agreed and we overturned the hospital epidemiology decision (to their howling protests). The patient died in a few days, but he died happier and his family was greatly appreciative.

The palliative care movement is (in my opinion) having a major positive impact on many patients and families. They have a new trust in our system of medical care. This piece is just one in a series that I have spotlighted. I will continue to spotlight this issue because it stimulates a positive passion about our ability (as physicians) to make a difference. Providing Care, When the Cure Is Out of Reach

Kind Practice, Bad Policy

Turns out that perhaps two-thirds of internists provide some charity care, usually to their patients who have become uninsured, according to a report last week in the journal Health Affairs. In a survey of internists, 68 percent said they charge no fee or a reduced fee to patients who are labeled "self-pay/uninsured."

What a nice, warm, fuzzy finding about doctors. Right in line with the concept of a Compassionate Society, promoted by advocates of laissez-faire medicine who say: Let the marketplace shape the health care system. The kindly doc -- he still makes a pretty good living -- he can be counted on to pick up the slack in health coverage and care for those in need.

Poof: no more health crisis with the uninsured.

And now for the truth: Charity medicine is a Band-Aid. It is being used to cover up deep flaws in the disintegrating system of health care. No one knows this better than the internists who don't charge their patients. "On a human level, it's important and noteworthy that they do this -- but [charity care] is not a substitute for health insurance," says Gerry Fairbrother, a senior scientist at the New York Academy of Medicine and an author of the report.

Charity care is great rhetoric, but not always good medicine. In the survey, internists expressed doubts that they could provide quality care to uninsured patients. While they were generally able to spend the same amount of time with insured and uninsured patients, they couldn't provide needed care beyond the office. They couldn't ensure that their charity patients get the drugs they prescribed. They couldn't set up diagnostic or laboratory tests for the uninsured. Less than a quarter said they could refer the uninsured to specialists. What kind of care is that?

Doctors who lose gain credibility

At nearly 6 feet and 286 pounds, Dr. Michael Fleming recently began thinking about what it meant to be handing out advice about diet and exercise when he wasn't practicing what he preached.

Fleming, whose family history is rife with heart attacks and obesity, was about to become president of the American Academy of Family Physicians — a group that was launching a 10-year national fitness initiative. He'd long chafed at the jokes made by friends who said they'd become his patients because he wasn't one to talk about slimming down. But then something his rail-thin wife said about their four grandchildren made him think it was time to get off his duff.

She asked, "Do you want to be around to watch them grow up?"

At that point, Fleming, 53, of Shreveport, La., realized that he had to take charge of his health. At the same time, as the academy's incoming president, he could set an example for fellow physicians and patients.

In August, Fleming resolved to give up his carbohydrate-loving ways and get back to exercise, something he hadn't done since high school athletics, where the thinking was "big guys are good."

On Sept. 30, at the academy's annual meeting, a few days before he assumed its presidency, he challenged his colleagues to follow his lead. He encouraged them to buy pedometers to help attain a federal goal of 10,000 steps a day, to monitor their weight and to live a healthier life.

Dr. Robert Pallay, a family physician in Hillsborough, N.J., and chairman of the academy's new Americans in Motion program, said the first step toward improving the nation's health is to get family doctors "to walk the talk." That gives them credibility.

"The thought was, if we can work on getting members of our specialty fit, we'll have a better shot at convincing the patients," he said. Doctors still command respect, so if patients see physicians committing to fitness, "they're more prone to believe there's something to it" and more open to making healthful behavioral changes..

Since late August, Fleming has peeled off 17 pounds. He fights to keep his pants up, and his suits need altering.

Bravo!

Whether you agree or disagree with Thomas Sowell, one must respect his ability to explain his perspective. He is doing a series on price controls related to medical care. Here are the second installment. Free-lunch medicine, Part II You can get to the first instsallment by choosing to look at his archives (bottom of the page). If you are reading this after this weekend, you will need to explore the archives to find his writing. Here is a sample of his thinking.

The only reason such rhetoric has even the appearance of plausibility is that price controls work in the short run — and that is good enough for politicians, since elections are held in the short run. After all, when the government drives down prices paid to doctors, hospitals or pharmaceutical companies, there is not much that they can do about it immediately.

Doctors are not going to give up practicing medicine and become truck drivers. Medical schools are not going to be turned into bowling alleys or hospitals into skating rinks. Pharmaceutical companies cannot suddenly shift to manufacturing cars. So price controls seem to work in the short run — but only in the short run.

When you confront doctors with more hassles with bureaucrats and lower payments for their services, do not expect the medical profession to remain as attractive to bright young people deciding what careers to follow. In the long run, every single doctor is going to have to be replaced by someone from the younger generation, or else we are going to have a shortage of doctors.

Britain, for example, has had government-run medical care for decades and nearly half their doctors are imported, often from Third World countries with lower standards of medical training. Canadian hospitals have less modern equipment available than American hospitals do. They depend on American medicines after destroying incentives to develop their own with price controls.

Is this what we are supposed to imitate?

His arguments make one think. I have argued often that the percentage of GNP spent on health care is rising because we can do more. Our advances do require resources. We can return to lower cost medical care, and we can have the outcomes of old. We would rather have the better outcomes (both quality of life and quantity of life) that technology and pharmaceuticals have given us. To achieve these successes we must spend money. No rhetoric, no political speech, no wishing can make that economic fact disappear. We need a real debate on health care costs. Understand the long term impact of economic decision making on health care must underlie those debates.

Why do we consistently ignore the consequences of our actions? This commentary argues that the ban on DDT allows the West Nile virus to infect an increasing number. Mosquitoes kill us; DDT doesn't

Written perhaps with tongue in cheek - Hang in there, tubby America, your day in the sun will come

Surprise, surprise, some baseball players (in fact at least 5%) use steroids to enhance muscle mass. So now they will have to undergo mandatory testing. Results of Steroid Testing Spur Baseball to Set Tougher Rules

Beginning next season, the first time a player tests positive he will receive treatment and education about the substance that was abused and be subject to further testing. A second positive will result in the player's being identified publicly and include a 15-day suspension or up to a $10,000 fine. The penalties escalate to a one-year suspension or up to a $100,000 fine for the fifth positive test. Suspensions will be without pay.

"If it's something that will ultimately make the problem go away or speculation of a problem go away, then what's wrong with that?" said Mets pitcher Tom Glavine, the National Leaguers' representative during the negotiations last year.

Players had no specific knowledge of when they would be tested, but they knew since the collective bargaining agreement was reached on Sept. 30, 2002, that tests would be administered at some point this season. Billy Beane, the general manager of the Oakland Athletics, said it probably surprised him that players tested positive despite having at least four months' advance knowledge that testing was imminent.

"It's good that there's been some attention to it," he said. "Both sides have agreed there should be attention paid. This is the result of it."

Many in the US either buy, or would like to buy prescription drugs from Canada. We would like to save money, and most prescription drugs have lower prices in Canada. However, our desire for a bargain may negatively impact Canada! Canada to U.S.: Don't buy drugs here

Gov. Rod Blagojevich is lobbying the federal government to let the state buy drugs at lower prices in Canada for its 230,000 state employees and retirees. He says the state could shave $91 million a year off the rapidly increasing cost of drugs.

But pharmacists from the province of Manitoba, invited to Springfield by the Illinois Pharmacists Association, urged Blagojevich on Wednesday to drop the plan, saying it could make drugs scarcer and jeopardize Canadians' health care.

"We're going to be denying them treatment, care, drugs -- it just blows the whole thing up as far as Canadian health care. We're exporting our health care," said Michelle Fontaine, vice president of the Coalition for Manitoba Pharmacy, an organization that promotes ethical behavior in the field.

Never forget that actions generally have unintended consequences.

On vacation. Have web access. May blog. May not. Back to regular blogging on Monday. But may blog later today. Just depends.

Having periodic allergic rhinitis, I have used nasal steroids with good effect. However, I am one of the 15-20% who develop nose bleeds from nasal steroids (in fact the only 2 nose bleeds of my life came from nasal steroids). This study tells me that I can try them again, just change my technique!! Nasal Steroids: Contralateral Hand-Nostril Technique Curbs Epistaxis

With the aim of pinpointing the source of the bleeding and whether it could be prevented, Dr. Nsouli's team studied 19 patients with perennial and seasonal allergic rhinitis who were using various nasal steroid sprays and experienced recurrent episodes of mild epistaxis.

"Nasal flexible fiberoptic rhinoscopy showed that the bleeding was coming from the septum--the middle cartilage of the nose that contains a lot of blood vessels," Dr. Nsouli explained.

This made sense, he said, because the conventional technique for delivering nasal spray--using the right hand to spray in the right nostril and vice versa--deposits much of the drug the septum. "This causes irritation and erosion of the lining of the nose reaching to the blood vessel complex and leading to bleeding," Dr. Nsouli said.

Using an alternate hand technique--the right hand to spray in the left nostril and the left hand to spray in the right nostril--aims the medicine to the outer part of the nose, avoiding the septum and dramatically reducing epistaxis, according to the results of a 2-week test in 13 of the study subjects.

"No patient had epistaxis when they used this contralateral hand-nostril spray technique," Dr. Nsouli, who is with Georgetown University Medical Center in Washington, D.C., said. "Now we advise all of our patients to use this contralateral technique in order to prevent bleeding and improve compliance and symptoms of allergic rhinitis."

Now I must see if I have sufficient coordination to use the technique!!

Universal care has a big price: patients wait.

Now I must throw in a brief rant before the commenters go crazy! The article points out that Canadians have a higher life expectancy than those in the US. This statistic may or may not have relevance. We would really like to understand the difference in demographics. We would need to know the causes of death. Unadjusted life expectancy is like unadjusted surgical mortality. Extrapolating from these data are hazardous.

We know that some statins lower LDL more than others. Some raise HDL more than others. What we do not know is whether those differences matter. This study suggests that the differences may be important. Study of Two Cholesterol Drugs Finds One Halts Heart Disease

In patients taking pravastatin, or Pravachol, made by Bristol-Myers Squibb, atherosclerosis worsened slowly over 18 months. But the disease was halted in those who took the highest dose of atorvastatin, or Lipitor, the drug made by Pfizer.

"We saw something extraordinary," said Dr. Steven Nissen, the cardiologist at the Cleveland Clinic who directed the study of 502 patients.

"All statins are not alike," Dr. Nissen said, adding that with pravastatin, heart atherosclerosis will worsen, but with the highest dose of atorvastatin, that is unlikely.

At the study's start, the middle-aged, mostly male heart disease patients in the study had levels of low density lipoproteins, or L.D.L., of 150, on average. L.D.L. carries cholesterol to arteries. Atorvastatin lowered participants' L.D.L. levels to 79, while those taking pravastatin had an average level of 110.

After 18 months, the atorvastatin patients had no change in the plaque in their arteries. But plaque increased by 2.7 percent in pravastatin patients. The study did not assess patient outcomes like heart attacks and deaths, which would have required 8,000 patients and taken five or more years.

One can also read more details on this study at theheart.org (no direct linking of articles, but it appears in the November 12th entries). This important study deserves several caveats.

• The study compares high dose 80 mg atorvastatin (Lipitor) with moderate dose 40 mg pravastatin (Pravachol). Why do they do this? Why not compare equivalent dosing?
• The maker of Lipitor funded the study. This does not bother me as much as the dosing selection.
• The study measured an intermediate endpoint - atherosclerotic plaque - not clinical outcomes. We must always urge caution from such studies, as the intermediate outcomes will not necessarily result in clinical improvements.
• I cannot find data on HDL in the descriptions of this study (from either the NY Times or theheart.org). Perhaps atorvastatin raises HDL more, thus explaining the effect. I would like to know those data.
• The data show that atorvastatin 80 mg lowers CRP levels greater than pravastatin 40 mg. Since accumulating data have convinced me of the importance of CRP, this information is fascinating.

As most good research does, this study raises as many questions as it attempts to answer. We must always remember that we rarely have definitive answers based on a single study. Rather, we must view clinical knowledge growing in fits and starts, with data accumulating over time.

If I had coronary artery disease, I would probably take atorvastatin 80 mg a day. I can afford it, and it just might help.

I will finish this rant with these quotes from theheart.org.

More information on whether the REVERSAL data do have an effect on clinical outcome will become available soon, with the results of the PROVE-IT study. This trial, in which Cannon and Braunwald are both involved, is comparing the exact same two regimens in REVERSAL but in 4000 ACS patients and has a clinical outcome as the primary end point. Results are expected at the American College of Cardiology meeting next March.

Several other clinical-end-point trials comparing high-dose vs moderate- or low-dose statin treatment are also under way. These include TNT (atorvastatin 80 mg vs atorvastatin 10 mg), IDEAL (atorvastatin 80 mg vs simvastatin 20 mg), and SEARCH (low-dose vs high-dose simvastatin).

I know, I have beat this horse to death. However, I just might help one person but redundantly blogging about this issue. If so, I will have done something important - Too much H20 may be a no-no

Read Overlawyered's take on how physicians are responding to HIPAA. Medical privacy madness, cont'd

... Silly doctors, to be so spooked by the prospect of $10,000 fines for overstepping hundreds of pages of guidelines.

Last week I referenced a NY Times editorial on IV HDL. Derek Lowe has nailed this one - you must read it - To The Editors of the New York Times

Chris Rangel is on a roll! First read this link he gives on the "obesity is a disease" question - Is Obesity A Disease? (Rosemary), then read his analysis - Does Obesity=Disease and what are the causes?

Finally, read Matthew Holt on Canadian physicians moving to the US. While I do not entirely agree, you should read his arguments - POLICY: Oh Canada.

US slams Canada over Vancouver's new drug injection site

Dr. Andrea Barthwell, deputy director of demand reduction for the White House Drug Policy Office, says the Canadian initiative will only serve to prolong suffering and disease. "It is akin to using laetrile instead of chemotherapy to treat cancer," says Barthwell, who argues that supervised methadone maintenance, where appropriate, and long-term residential care are superior. She says injection rooms will help people continue the behaviour and will send a societal message that drug use is acceptable. "This is absolutely the wrong way to go," she says.

Her comments echo those of John Walters, director of the US National Drug Control Policy, who earlier called the new facility "state-sponsored personal suicide."

But the comments don't carry much weight in Vancouver. "I don't understand the argument that this facility encourages drug users," says Jill Chettiar, volunteer coordinator for the Vancouver Area Network of Drug Users. "If anything, it deglamorizes drug use by moving it out of the party scene and into a clinical atmosphere. I could argue the war on drugs encourages drug use."

Bravo Jill. She understands, the White House does not.

We need a fresh look at drug abuse. Prohibition does not work. Messages of fear do not work. Criminalization does not work. Much substance abuse causes health problems, but so do alcohol and tobacco. We are slowly winning battles against tobacco and alcohol. We are losing the "drug war". We are losing because the unintended consequences of that war are harmful.

From my vantage point, Canada is taking a more enlightened approach. I will bet that they will have more success.

These results are not surprising, but they are welcome. VALIANT Results Suggest ARBs as Effective as ACE Inhibitors Post-MI

Valsartan is as effective as captopril in reducing mortality and morbidity after myocardial infarction (MI), but combining the two drugs does not improve outcome and increases the risk of adverse events, according to results of the 14,808-patient Valsartan in Acute Myocardial Infarction Trial (VALIANT).

Results of the study were presented here today at a late-breaking clinical trials session at the American Heart Association Scientific Sessions and simultaneously published by the New England Journal of Medicine (NEJM).

The NEJM reference for those who want the details - Valsartan, Captopril, or Both in Myocardial Infarction Complicated by Heart Failure, Left Ventricular Dysfunction, or Both and editorial - Angiotensin-Receptor Blockade in Acute Myocardial Infarction -- A Matter of Dose

But while valsartan demonstrated clinical efficacy, it is nonetheless significantly more expensive than captopril, according to an editorial that accompanies the study in NEJM. "Given that ACE inhibitors have been shown to reduce the risk of death and nonfatal events after acute MI in 100,000 patients, whereas the clinical experience with angiotensin-receptor blockers has been more limited," write Douglas L. Mann, MD, and Anita Deswal, MD, MPH, "and given that, in the United States, the cost of using valsartan at the doses in the study by Pfeffer et al. is approximately four to six times as high as the cost of using generic captopril at the doses used in this study, ACE inhibitors remain the logical first-line therapy for high risk patients after acute myocardial infarction."

In an interview, Dr. Pfeffer countered by pointing out that ACE inhibitors are often not well tolerated by patients. "It is not only a question of which drug, but of which drug will the patient really use and continue to use for the rest of his or her life," he said. In practice, he suggested that valsartan is a good option "first for patients who don't achieve the desired response with an ACE inhibitor and second for those patients who stop taking their ACE inhibitor because they can no longer tolerate the drug." In addition, he noted that in the real world of clinical practice many physicians are not prescribing generic captopril, but rather newer — and more expensive — ACE inhibitors such as ramapril.

In my opinion this study makes more clear our options. We continue to use ACE inhibitors first, but know that when patients do not tolerate ACE inhibitors we can use ARBs with similar results. And that information is worthwhile.

and not that well! Best Diet? Take Your Pick

In the year-long study, 160 overweight and obese people were randomly assigned to one of these four regimens. Those in the Atkins, Zone and Ornish programs received a book describing their eating plans. The Weight Watchers group got a cookbook published by Weight Watchers International. (This difference has drawn criticism from Weight Watchers because the organization's full program is not outlined in any book.)

...

The good news: All the diets seemed safe and all produced weight loss, although there were no huge drops in poundage. All programs also reduced participants' risk of heart disease to a statistically significant degree.

"The study shows that no single approach has a monopoly on weight loss," says Thomas Wadden, director of the University of Pennsylvania's Weight and Eating Disorders Program.

So dieting works - but just a bit - but that bit is worthwhile.

Compare these two headlines for the same study - Doctors fail to give basic heart care and Study Documents Large Variation in Heart Failure Care .

Now read the description of the study and its results:

Nearly one third of patients hospitalized for acutely decompensated heart failure who are candidates for treatment with angiotensin-converting enzyme (ACE) inhibitors are discharged without a prescription for the potentially lifesaving drugs, according to the results of the Acute Decompensated Heart Failure National Registry (ADHERE), the largest study of its kind.

The study, presented here Sunday at the American Heart Association Scientific Sessions, "documented large variations in heart failure care at the nation's hospitals," said chief investigator Gregg C. Fonarow, MD, the Eliot Corday Chair in Cardiovascular Medicine and Science at the University of California at Los Angeles.

"There are some hospitals where 100% of eligible patients get individualized treatment and counseling [at discharge] and others where patients had a better chance of winning the lottery," he said.

The phase IV observational open-label study showed that 32.2% of candidates for ACE inhibitors were discharged without receiving a prescription for the drugs; 71.6% were discharged without receiving a complete set of discharge instructions.

Also, 65.6% of current or recent smokers were not counseled on smoking cessation, and left ventricular function was not measured in 18.2% of patients, Dr. Fonarow reported.

All four measures are core quality-of-care indicators for the treatment of heart failure patients, according to the Joint Commission on Accreditation of Health Care Organizations (JCAHO). "The variation among hospitals regarding discharge instructions was staggering," Dr. Fonarow told Medscape. "All patients received instruction at five hospitals. But at one in four U.S. hospitals, not a single patient got complete discharge instructions."

Dr. Fonarow also noted that ACE inhibitor use varied considerably: "There were about 30 hospitals where all patients got prescriptions but 16 to 20 hospitals where none did," he said.

So which headline makes the most sense? Perhaps we should have a headline contest. What do you think would make the most balanced headline for these data?

As a researcher in the area of quality improvement, I abhor the sensational headline. This study does not plow any new ground. These findings fit with many previously published studies (including our own research).

One can decry the performance of some physicians, or one can try to understand the why behind these findings. Medpundit blogged about this issue yesterday (no permalinks, just scroll down). She made some very cogent points, however the problem is more complex than any one commentary can explain.

Our current research focuses on the tools that physicians need to provide higher quality care. While we find "deficiencies" in quality, we focus rather on why, and how to improve care.

If one studies heart failure, one becomes an expert on the nuances of CHF management. We study the literature, and understand the texture of the problem.

Most physicians cannot focus on one problem alone. We must provide excellent care of CHF, COPD, diabetes,cirrhosis, headaches, sore throats, cellulities, venous thrombosis, pap smears, breast cancer screening, etc, etc. We must do this with inadequate reminder systems. We must do all these things in short time chunks.

So when I read these headlines, and read the study results, I ask how we can improve medical care. I do not and will not castigate physicians. We must understand the difficulties of practice and help them provide better care.

So what is your headline? I bet that the readers can develop much better headlines than the news services!