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.


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