Wednesday, October 25, 2006

USA TODAY Raises Healthcare Costs

USA Today, after a week of articles promoting health care reform, published an article about missed heart attacks that will lead to more defensive medicine:
Over the past six years, studies in the New England Journal of Medicine and other journals have found a heart attack diagnosis is missed in 2% of heart attack patients seeking help in the USA's emergency rooms, 3% in Canada and 6% in the United Kingdom.
"It is the horns of the dilemma. On one hand, there are limitations to the diagnostic tools, and they are very real limitations," Ornato says. "The electrocardiogram is the first screening tool, and it's only going to pick up, on a good day, 70% to 75% of heart attacks."
He says new devices, including an experimental ECG that maps the heart and CT scanners that can look inside of clogged heart arteries, offer new hope for the future.
But he says patients and their advocates must sometimes push doctors who are not listening.
"If something doesn't feel right to them, they have the responsibility to express that," Ornato says. "It's the responsibility of the nurses and physicians to listen."

The rate of missed heart attack diagnoses is better in the US than in several countries with single-payer systems. The only way to improve the rate is admit practically everyone who comes to an ER with chest pain, thus raising costs dramatically. Some ER docs do this already, and I think more are going to do this as a result of the article. The article also promotes cardiac catheterization:
After Gustafson had the same battery of tests Pettry had taken and doctors found no evidence of a heart attack, they went a step further. They admitted him to the hospital and performed more tests, including a stress test, putting Gustafson on a treadmill and monitoring his heart as the 59-year-old social worker was pushed to his physical limits.
"They could find nothing obvious," Connie says. "The cardiologist on call was dismissive. She said there was nothing to support the diagnosis that he had any kind of heart event."
But Connie says her husband "could feel that something was not right."

As the staff prepared to discharge Gustafson, he saw Barry Crevey, a cardiologist he had met through his social work, in the hallway. Crevey listened to Gustafson's story and explained that 25% of heart attacks may be "silent."
Considering Gustafson's history and the fact that both his parents had cardiovascular disease, the doctor suggested his arteries should be checked by threading a heart catheter into them, injecting dye and measuring the openings.
"When he told me his story, I'm thinking, 'This person needs a heart catheterization,' " Crevey says. "This is Cardiology 101. I would not have even bothered to do a non-invasive stress test."

The arteries were cleared with stents and a drilling procedure, and Gustafson is now back at work with "a clean bill of health," Connie says.
Gradus-Pizlo (the patient's initial cardiologist during the hospitalization) says, "In a patient with known disease, there is no question there are blockages there," but none of the blockages were putting Gustafson's life at immediate risk.
His heart was working fine with the reduced blood flow, which was confirmed by the fact that he passed the stress test, she says. "Even with those blockages, he had adequate blood supply. I'm not saying he doesn't have disease. He has severe disease. I didn't recommend therapy. I recommended aggressive medical management based on guidelines."
Though she agrees the blockages should have been opened once they were seen, she does not believe she misdiagnosed Gustafson. "I believe it is a difference of approach," Gradus-Pizlo says. "This is a matter of clinical judgment."

For patients not having and acute coronary event, there is no evidence that angioplasty/stenting improves survival more than aggressive medical management (lowering cholesterol, aspirin, beta-blockers, etc). Cardiac catheterizations and angioplasty have serious risks. I think USA TODAY did a disservice to the cardiologist (Gradus-Pizlo) who was conservatively treating the patient.

1st vs 2nd Generation Antipsychotics

1st vs 2nd Generation Antipsychotics
Retired Doc recently compared 1st to 2nd Generation Antipsychotics.Here are my thoughts:My opinion on atypicals vs 1st generation antipsychotics is:
1. Clozaril has clearly superior efficacy, Zyprexa is moderately more effective, and the rest of the atypicals are marginally more effective than the 1st generation.
2. Although ALL antipsychotics(old and new) can cause weight gain and diabetes and hypercholesterolemia, the risk is clearly greater with zyprexa and clozaril.
3. Risperidone frequently causes hyperprolactinemia. This commonly causes sexual side effects, including breast enlargement in men. Whether this hyperprolactinemia causes osteoporosis in the long term is unknown.
4. Seroquel, Geodon, and Abilify are reasonable initial choices when an antipsychotic is indicated. Like all of the atypicals, the risk of tardive dyskinesia is lower than the 1st generation drugs. In my opinion, their side effect profile is better than zyprexa/risperidone.
5. Clozaril remains the drug of choice in treatment resistant patients, but because of the risk of agranulocytosis, should not be used initially.
(republished from several weeks ago with copyrighted cartoon deleted. Sorry, I didn't save the comments).

Wednesday, October 18, 2006

McCain Discusses Suicide

Arizona Sen. John McCain, a likely Republican presidential contender in 2008, joked on Wednesday he would "commit suicide" if Democrats win the Senate in November.
McCain, on a visit to Iowa to campaign for Republican congressional candidates, was asked his reaction to a potential Democratic takeover of the Senate in the November 7 elections.
"I think I'd just commit suicide," McCain told reporters, to accompanying laughter from Republicans standing with him. "I don't want to face that eventuality because I don't think it's going to happen."

boutique medicine

Marketwatch reports on Boutique Medicine:

Taylor was seeing as many as 35 patients a day but his business was struggling after a five-doctor practice he was part of disbanded. So he contracted with MDVIP, a company based in Boca Raton, Fla., that helps doctors transition to boutique practices.
"What convinced me to try it was I tried everything else," he said. Now he's winnowed his patient base to 425 from a high of nearly 4,000 and sees "anywhere from eight to 15 at the most on a very busy day."
Such a reduction often translates into longer and same-day appointments, extensive physicals, better coordination with specialists and more follow-up as well as a greater emphasis on preventive care. Taylor's staff of two, for example, is able to keep track of which patients taking cholesterol medications are due for blood work and call them.
"Patients are happier; I'm happier," he said. "I've got more time to devote to each problem a patient has. I feel much more comfortable and confident about what I do."

Physicians want to regain control of their schedules and are frustrated that they still have to spend so much time wrangling with insurance companies after years of pushing for systemic changes, he said.
Retainer practices also cater to some patients' desire to check out every health risk factor and has evolved as an alternative way to navigate the system, Caplan said.
"It's there because the current health-care system is broken and we actually have to pay people to talk to us," Caplan said. "You're buying back personalized medicine, a relationship with somebody, because the current business model has weeded that out."

"It's a tiny drop in a huge ocean," Plested said. "The economic reality and demographic reality is there aren't that many areas that will support this type of practice."
Still, retainer practices point to an uncomfortable truth, Caplan said. "It undermines one of our favorite myths, which is same quality of health care for all. That's never been true, but this rubs our nose in it as a society."

It's hard to practice high quality medicine in a primary setting. PCP's need to see too many patients in too short a time. Fortunately, in my specialty (sleep medicine), I am able to subsidize patient visits with income from sleep studies. The generous reimbursement for sleep studies allows me to spend more time with patients.

Friday, October 13, 2006

Pill Splitting

Should physicians encourage pill splitting as a way to help patients save money?

Splitting pills can help patients save money:
The first time that a patient asked me to write a prescription for a higher dosage of a medication was in the late 1990s. Viagra was a highly desired medication for some older male patients, but at $10 a pill, many couldn't afford that much of it. But these motivated patients soon learned that both the 50-mg and 100-mg tablets cost the same amount. Splitting the higher-dose pills effectively gave them a 50% discount.
Many of the world's best-selling drugs, including Lipitor, Zocor, and dozens of others, are priced similarly, with higher doses carrying the same price tag as lower doses. These medications are candidates for cost savings by splitting tablets.

However, pill splitting has its risks:
Splitting pills can be dangerous for certain types of patients and for certain medications. The difficulty is determining what medications can be safely split and for which patients.
Medications that have special enteric coatings, have extended-release formulations, or are capsules containing powder or gel are some examples of those that should never be split.
Another category of medicines that are dangerous for pill-splitting are those that have a narrow therapeutic index, where precise dosing is a critical element of the therapy. Even with pill- splitting devices, splitting the medicine can result in a plus or minus 20% variation in the effective dose.
Similarly, there are certain types of patients who are not good candidates for pill splitting, such as the elderly, patients suffering from dementia, and those with visual impairments or other conditions that would make it difficult for them to split a pill precisely.
So even if you had a medication that might appear to be safe to split, there are always going to be patients for whom the practice is going to be risky.

Another risk of pill splitting is confusion about the dose of medication. For example, a patient may have a bottle full of 40 mg blood pressure pills. If he goes to the ER with his bag of meds, the ER doc may think he is taking 40 mg daily of the medication rather than the 20 mg his primary care doc told him to take. I've seen this happen before in busy ER's and inpatient services.

Thursday, October 05, 2006

Foley is not a pedophile

Any suggestion that Mark Foley is a pedophile is false," the former congressman's lawyer, David Roth, said Tuesday at a news conference in West Palm Beach, Fla. He was right, but not for the reasons he probably had in mind. According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, pedophilia involves "intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child or children (generally age 13 years or younger)." The disorder is one of a number of conditions known as paraphilias, which the APA defines as sexual obsessions or fixations "that generally involve non-human subjects, children, or other non-consenting adults, or the suffering or humiliation of oneself or one's partner." Examples of other well-known paraphilias include bestiality, necrophilia, exhibitionism, sadomasochism, and voyeurism. Some therapies that focus on changing cognitive and behavioral patterns are believed to help sufferers of paraphilias control themselves, if they are motivated to do so. But fully overcoming their predilections is a more difficult challenge.
Based on what has been revealed so far, former Rep. Foley seems to suffer from a different condition: ephebophilia, which is defined as a sexual attraction to post-pubescent adolescents and older teenagers. The DSM IV doesn't include ephebophilia as a diagnostic category. Sexual contact with children is explicitly illegal in all jurisdictions in the United States. But such contact between older teenagers and adults presents a murkier legal picture. The laws on age of consent vary from state to state, and prosecutors have wide latitude to determine whether to charge an individual with a sexual offense.
From Slate