Honest Pay for Honest Work.
Times have changed. And it’s time they change again.
In the past, medical care was more episodic than it is now. People went to see the doctor when they felt unwell. Diabetes affected mostly older patients, who didn’t live long enough with the disease to develop complications.
There were no blockbuster drugs for high cholesterol, Hepatitis C, fibromyalgia or chronic heartburn; we didn’t manage nearly as many patients on multiple medications as we do now.
In those times, a payment scale based on the length and complexity of the visit made sense, and there wasn’t much doctor-patient interaction between visits.
Today, we manage more chronic conditions, use more medications, do more laboratory monitoring, more patient education, and more administrative work on behalf of our patients than before.
Payment scales based only on what we do in the face-to-face visit have become hopelessly antiquated and stand in the way of the new demands of society – physicians providing longitudinal care for chronic conditions in patient-centered medical homes.
Continue reading “Who Should Pay Doctors?”
Filed Under: Physicians, THCB
Tagged: Chronic conditions, Hans Duvefelt, Insurance claims, Physicians, practice management, Reimbursement
May 1, 2014
The landmark 2001 document from the Institute of Medicine’s (IOM), Crossing the Quality Chasm, should have guided us out of the healthcare cost-quality crisis. It argued that the root cause of our difficulties has been a failure to meet the needs of patients with chronic disease. We have not solved this crisis because we have almost entirely ignored the recommendations for reform found in that document.
The claim that we have the best healthcare in the world is correct only if you have an acute condition. If you are having an event, such as a heart attack, our system can provide an emergency stent — for as much as $50,000 — that will open the blocked artery, immediately relieving the pain and saving your life. We are really good at rescue medicine-crisis medicine.
But acute conditions generate enormous costs only because we have not addressed the chronic condition earlier, interrupting the disease progression that produces the acute events. Since most healthcare cost growth over the past 2 decades has been related to patients with 4 or more chronic conditions, this should be recognized as the foremost issue in healthcare reform.
In fact, the IOM charged that, despite the central role of chronic disease in most pain, disability, death, and cost, care continues to be designed around the needs of providers and institutions, and most patients with chronic conditions do not receive the care they need. A 17-year lag in implementing new scientific findings results in highly variable care.
That cardiologists favor coronary stenting over optimal medical therapy — that is, managing vascular disease using $4 drugs and recommended lifestyle changes — provides a powerful case in point.
Continue reading “The Only Way Out of the Health Care Wilderness”
Filed Under: Uncategorized
Tagged: acute conditions, Cancer, Chronic conditions, chronic disease, crisis medicine, Crossing the Quality Chasm, Health Care Costs, Obesity, prevention, primary care, Richard Bohmer, smoking, William Bestermann
Dec 17, 2012
Walmart — the nation’s largest retailer and biggest private employer – now wants to dominate a growing part of the health care market, offering a range of medical services from basic prevention to management of chronic conditions like diabetes and heart disease, according to a confidential company document.
In the same week in late October that Walmart announced it would stop offering health insurance benefits to new part-time employees, the retailer sent out a request for information seeking partners to help it “dramatically … lower the cost of healthcare … by becoming the largest provider of primary healthcare services in the nation.”
On Tuesday, Walmart spokeswoman Tara Raddohl confirmed the proposal but declined to elaborate on specifics, calling it simply an effort to determine “strategic next steps.”
The 14-page request asks firms to spell out their expertise in a wide variety of areas, including managing and monitoring patients with chronic, costly health conditions. Partners are to be selected in January.
Analysts said Walmart is likely positioning itself to boost store traffic – possibly by expanding the number of, and services offered by, its in-store medical clinics. The move would also capitalize on growing demand for primary care in 2014, when the federal health law fully kicks in and millions more Americans are expected to have government or private health insurance.
“We have a massive primary care problem that will be made worse by health reform,” says Ian Morrison, a Menlo Park, Calif-based health-care consultant. “Anyone who has a plausible idea on how to solve this should be allowed to play.”
Continue reading “Walmart Wants To Be Nation’s Biggest Primary Care Provider”
Filed Under: THCB, The Business of Health Care
Tagged: Chronic conditions, Health Care Reform, in-store medical clinics, primary care, Walmart
Nov 9, 2011
Unless you spend a lot of time around health policy wonks, you’ve probably never heard of the term “value-based health insurance benefits.” In fact, you may not even know that it’s the hottest new fad in the field.
Here is my layman’s summary: If you are like most people, you are not a very good consumer of health care. Odds are, you will fall for the latest fad advertised on TV or follow the advice you get at the bridge club instead of buying the care that has been scientifically shown to be better for you.
So as a corrective, a lot of employers are finding ways to “nudge” you into better decisions through financial incentives. Say you have a chronic condition and need to take certain medications. Your employer might drop your deductible down to zero (or may even pay your to take them) to encourage your compliance. But for services where there appears to be wasteful overuse (such as MRI scans), the employer might impose a hefty $500 deductible.
This idea intrigued me, so I turned to a rather lengthy article in the Washington Post, which informed that value-based insurance benefits are incorporated into the new health reform law, “including the requirement that new insurance provide free recommended preventive services such as mammograms and colon cancer screenings.”
In the world of big business, this idea is all the rage. One in every five employers employing at least 500 people is already doing it. Four in five employers who employ at least 10,000 workers say they are interested.
So if big business is for it; the government is mandating it; and health policy wonks like it; how could anyone possibly obj-…….. Continue reading “Employers as Doctors”
Filed Under: THCB
Tagged: Chronic conditions, Value-based health insurance, Wellness
Feb 18, 2011
They are coming in fast under the radar, out of peripheral vision, in the magician’s other hand—and they will change everything. New ideas, surprising networks, stealth business models that may change health care profoundly, are bubbling up in pilot programs, experiments and full-on corporate transformations. There is something here that does not yet have a name, that no one is yet calling a movement, that no one is yet seeing as revolutionary.
While we have been mesmerized by federal health care reform, government intervention on behalf of the uninsured and government attempts to “bend the cost curve” to shave a few percentage points off medical inflation, things have been happening in the private sector for people who are already insured that result in outright medical deflation, drops in costs of 20 percent or more, all while giving people more care, not less.
Help me out here. This picture is just forming, the Ouija board is still in motion, but I think what we may have here is some truly big news about the future.
The Difference Is Integration
First, consider the huge regional differences in health care costs. Think about what it means that it costs twice as much for patients in the last six months of life to be involved with Cedars-Sinai in Los Angeles, UCLA Medical Center or New York University Medical Center than it does for them to be involved with Mayo Clinic in Minnesota or the Cleveland Clinic; or that Medicare spends half as much per patient per year in Temple, Texas, as in McAllen or Harlingen or Brownsville, Texas; or why Medicare spending per patient per year in the top and bottom quintiles of hospital catchment areas differ by 60 percent.
These are vast differences—and the more expensive areas show no better outcomes than the less expensive ones; in fact, for some conditions they show worse outcomes. Continue reading “How the Future of Healthcare Will Actually Work: Nuts and Bolts”
Filed Under: Uncategorized
Tagged: Chronic conditions, geographic differences, Integration
Sep 26, 2010
As we work to change health care in America, we must recognize the need to dramatically change diabetes. Twenty-four million Americans have diabetes at a cost to our nation of an estimated $218 billion for diabetes and pre-diabetes, according to a series of studies recently published in Population Health Management. Imagine the effects diabetes will have on our health and economy in the future if we don’t take action now. The prevalence and economic burden of undiagnosed and pre-diabetes make the case for the importance of policies that promote early diagnosis and prevention. About 25 percent of Americans with diabetes aren’t even aware they have the disease. And, those with undiagnosed diabetes result in $18 billion in health expenses, or $2,864 per person each year, according to one of the studies mentioned above.
Continue reading “To Change Health Care, Change Diabetes.”
Filed Under: OP-ED
Tagged: Chronic conditions, Diabetes, prevention, Quality
Sep 29, 2009
Reader Murry Ferris writes in:
I am a 65 year old retired ad exec and also an insulin-dependent
diabetic. I have other medical complications, but taking care of the
diabetes is the big one.
Every day I test my blood glucose
levels as many as ten times. A box of test strips retails for between
$40-$60 and lasts less than a week…. you do the math. In case you
were not aware, your glucose levels are in a state of constant flux
depending on your intake of food and exercise. Bottom line, keep your
levels, "level" and you'll lead a more normal life.
Now with all the
talk about raising taxes to pay for the rising cost of health care I
hear absolutely no discussion about reining in the unjustified
increases of medical supplies and equipment. Just ten years ago I
could buy test strips for $10. Now they come in slick PVC canisters,
wrapped in four-color labels and packed in plush slick cardboard boxes
stuffed with layers of "instructions" and phony code strips. Remember
all you need do is stick your finger an put a drop of blood on the end
of the strip. How hard is that?
So, for $2,600 a year I get to
stick my finger ten times daily, throw a pile of unread and expensive
packaging in the trash, and pay increasingly higher health care
Filed Under: Uncategorized
Tagged: Chronic conditions, Commentology, Costs
Aug 6, 2009
While Congress is debating health reform and struggling to accomplish the apparently competing goals of reducing costs while improving quality, I am part of a program that does both. As co-director of the Washington Hospital Center’s Medical House Call Program, I visit the sickest, frailest Medicare patients who consume a wildly disproportionate amount of Medicare dollars. Not only am I providing better care for my patients, I’m doing it where they want it — at home. House calls allow me to better manage their chronic conditions by seeing their medications, diet and home life and enabling me to better support their caregivers and coordinate their medical care. The math is simple: the better I do, the happier they are and the fewer times they need to visit an expensive hospital or nursing home. Shockingly, this proven approach that reduces unnecessary spending is being overlooked in the current reform debate.
Take one of our patients, Mrs. C, who has heart failure and pulmonary disease. She is chair- and bed-bound. She relies on her daughter for all her basic needs and cannot easily get to the office. Through our program, a team of doctors, nurse practitioners and social workers can visit Mrs. C at home and provide care on-site. We can manage her heart and lung problems on the spot, rather than having to wait until her symptoms are so severe that she has to go to an emergency department by ambulance. Additionally, avoiding the hospital means Mrs. C is less likely to face medical complications from a hospital visit. The accrued savings pay for a year’s worth of house calls for eight patients. Our program has shortened the hospital stays of 600 patients by a quarter, and reduced hospitalizations at end of life by 75 percent. Continue reading “The Case for Home Health Care”
Filed Under: Physicians
Tagged: Chronic conditions, Costs, Health Care Reform, Home Health Care, Medicare
Jul 25, 2009
The challenge of constraining costs while maintaining or enhancing the quality of medical care is vividly brought to life by Atul Gawande in his recent widely-read New Yorker essay. The anecdotal evidence presented in the article is compelling as a description of how physician practices can relate to excessive costs. The assertion that the observations in McAllen also explain McAllen’s costliness is an inductive exercise that may go too far. Physician ownership of imaging facilities, ownership interest in hospitals and more subtle forms of self-referral are all substantially present in large healthcare market areas across the country. Is McAllen an extreme example of a bad physician culture or is there another explanation? Our analysis of Medicare data from McAllen Texas demonstrates that exceptionally high rates of chronic disease and poverty explain much of the variation in cost.
According to Gawande, McAllen Texas has a physician culture that promotes high cost, low quality care. By comparison El Paso is portrayed as having a similar patient population to McAllen with lower costs of care. Grand Junction, Colorado, however, the antithesis of McAllen according to the article, is credited with having a physician culture that promotes low costs and high quality. Ultimately Gawande warns that by failing to change the physician culture nationally, “McAllen won’t be an outlier. It will be our future.” But is McAllen really an outlier, a harbinger of physician income-enhancing practices run amok?
A fair comparison between McAllen and Grand Junction would include a more precise analytic methodology than could be offered in Dr. Gawande’s article. Such an analysis is important: the correct diagnosis of the health care cost crisis is an essential step in selecting an effective prescription. If McAllen is not an outlier and Grand Junction is not a paragon, then the solution is not to simply tamp down variation by exporting Grand Junction values to McAllen. If the physician practices reported by Dr. Gawande in McAllen lead to explainable patterns of costs according to current norms, then those practices are part of a national phenomenon right now, not in a nightmare future.
An analysis of the Medicare population in the three counties can place Dr. Gawande’s observations in a more complete context. Medicare beneficiaries enjoy a standardized benefit package, and detailed data are available on the services they receive. We can use cost data for Medicare enrollees in the three counties to test Dr. Gawande’s assertions regarding McAllen’s and Grand Junction’s comparative health care costs. Medicare fee-for-service claims provide us with service level payment and patient health status information; Medicare monthly enrollment data details HMO affiliation, Part B premium assistance and beneficiary demographics. The Centers for Medicare and Medicaid Service supplies researchers (including the Dartmouth Health Atlas team) with data of this type for Medicare policy analysis.
Accurate Medicare Cost Comparisons
The city of McAllen lies at the center of Hidalgo County, one of the costliest areas for Medicare. The population is racially diverse, low income and exhibits high levels of chronic disease. El Paso is similar to McAllen but with less poverty. Grand Junction is the county seat of Mesa County, a largely white and relatively wealthy region. In Exhibit 1 annualized Medicare fee-for-service payments for the counties of McAllen, El Paso and Grand Junction show wide divergence in the total Medicare spends per beneficiary.2
Exhibit 1: Annualized Payments per Medicare Beneficiary by County of Residence, 2006
|El Paso, Texas
|Grand Junction, Colorado
The payments in McAllen’s county are twice as high as in El Paso’s and nearly three times as high as in Grand Junction’s but adjustments are required to the statistics to make the comparison fair. These adjustments should include normalization for Medicare coverage type and population health. Relatively few McAllen area Medicare beneficiaries are enrolled in HMOs (2%) in comparison to Grand Junction (42%) and El Paso (16%). Medicare publishes costs only for services paid on a fee-for-service basis; some services supplied by cost-based HMOs (more common in Grand Junction than in either McAllen or El Paso) are included and some are not. As a result the cost of care for counties with high numbers of Medicare HMO enrollees is under reported. In addition, while all eligible individuals receive hospital insurance under Part A of Medicare, beneficiaries must pay a monthly premium to receive outpatient coverage under Medicare Part B, or are enrolled by Medicaid if they are poor enough to meet the state’s income requirement. The percent of the population in the different counties without full Part A and Part B benefits varies. In Grand Junction almost twice as many beneficiaries do not have Parts A & B coverage compared to McAllen (4% versus 8%). The outpatient expenses of this population are not included in Medicare expenditure reports. In Exhibit 2 HMO enrollees and Medicare beneficiaries without full Medicare benefits are removed from the comparison.
Exhibit 2: Comparative Annualized Payments per Medicare Beneficiary by County after Managed Care and Medicare Part A&B Adjustments, 2006
|El Paso, Texas
|Grand Junction, Colorado
When the analysis is restricted to cost and enrollment data only for Medicare fee-for-service beneficiaries covered by both Part A and Part B, Grand Junction’s beneficiary annual costs rise by almost 25%. The difference between McAllen and Grand Junction beneficiary costs falls, but McAllen Medicare costs, now for populations with the same coverage, are still well over twice those for Grand Junction.
County Socio-Demographic Characteristics
The dissimilarities between the McAllen and Grand Junction county populations are extensive. The socio-demographic characteristics of a population affect its access to care, ability to pay out of pocket for uncovered care and rates of disease associated with diet and life history. The costs of Medicare co-pays and deductibles can be substantial barriers to access, and history of health care coverage and access to preventive care vary substantially based on socio-demographic variables. Low-income individuals often reach Medicare enrollment age with a lifetime history of access and cost barriers, a potent mixture. Barriers to access to care can lead to expensive hospital care for conditions normally treated on an outpatient basis.
Grand Junction Medicare enrollees are 98% white and only 11% require assistance in paying for their Medicare Part B premium (a proxy for low income status). In contrast McAllen and El Paso are both 26% Hispanic, and a higher proportion of Medicare beneficiaries rely on Medicaid to pay for Part B — 36% in El Paso and 48% in McAllen. To assess how socio-demographic factors affect Medicare costs, Exhibit 3 compares costs for beneficiaries with and without Part B premium assistance.
Exhibit 3: Comparative Annualized Payments by County and Need for Premium Assistance, 2006
||Premium Assistance-No(not low income)
||Premium Assistance-Yes(low income)
|El Paso, Texas
|Grand Junction, Colorado
Expenditures are consistently higher for low income beneficiaries, but McAllen is still more expensive than Grand Junction for both income groups — more than 45% more expensive for low-income beneficiaries and more than twice as expensive for those not receiving premium assistance. However, the Grand Junction advantage is not as great for the low-income population as for higher income beneficiaries. Could it be that a good part of the McAllen “excess” is simply due to its larger proportion of low-income Medicare beneficiaries compared to Grand Junction?
But socio-economic differences in themselves cannot explain cost differences. What makes the low income population so much more expensive to care for? And why is El Paso, which also has a large low-income Medicare population, so much less costly to Medicare than McAllen?
Exhibit 4 uses estimates of population rates of disease derived from Medicare hospital and physician claims to reveal that the prevalence of chronic disease is substantially higher in the McAllen Medicare beneficiary population than in Grand Junction or El Paso; and that the proportion of the McAllen Medicare population with more than two of these conditions is a whopping 52%, in comparison to 23% in the Grand Junction area and 34% in El Paso.
Exhibit 4: Disease Prevalence by County, 2006
|Single Selected Condition Rates per 1,000
|Ischemic Heart Disease
|Chronic Respiratory Disease
|Multiple Conditions Population Percentage
|None of the Selected Conditions
|One Condition Only
Many of the disease rates for the McAllen population are more than double those for Grand Junction. If the Medicare population in McAllen is truly that much sicker wouldn’t we expect the payments to be greater? A comparison of expenditures for Medicare enrollees without a diagnosis of diabetes or heart disease in the last year shows that costs for these standard populations are statistically very close (Exhibit 5).
Exhibit 5: Medicare Monthly Payments per Patient without a Diagnosis in the Year for Diabetes or Heart Disease, 2006
||Monthly Per Person Payments
|El Paso, Texas
|Grand Junction, Colorado
By eliminating diabetes, ischemic heart disease or heart failure from the population payment measures the Grand Junction advantage is completely removed. Grand Junction is just as costly as McAllen for populations without one of these conditions.
Even though diabetes and heart disease are both costly and highly prevalent in McAllen, beneficiaries experience a wide range of costly illnesses, and patients with multiple conditions are difficult to treat. We used a more sophisticated risk adjustment method to take into account an array of concurrent conditions.3 Beneficiaries in the top risk scores, the sickest patients, make up 27% of the McAllen, 16% of the El Paso and only 12% of the Grand Junction populations. Average Medicare payments were then computed for each risk group in each county (Exhibit 6). The effect on costs of accounting for this measure of illness burden is dramatic.
Exhibit 6: Annual Medicare Payments by Risk Level
Taking into account the disease combinations eliminates the apparent low cost difference across the full range of disease risk scores. If the disease levels in the McAllen population were magically made to match the Grand Junction disease distribution, but experienced McAllen-level costs, annualized Medicare payments would fall from $13,150 to $6,145. The morbidity-adjusted per beneficiary payment rate for McAllen is 10% higher than the $5,579 Medicare per beneficiary annualized payments observed in Grand Junction, substantially less than the observed 300% payment differential seen in the unadjusted data.
Discussion and Implications
McAllen is different from many areas of the United States: it is sicker and poorer. The observed differences in the rates of chronic disease are highest for those conditions rampant in low income American populations: diabetes and heart disease. Further, Medicare beneficiaries in McAllen have significantly higher rates of co-occurring chronic conditions. As a result the costs of caring for McAllen Medicare population appears high in comparison to other areas but not abnormally so. McAllen suffers from a tremendous burden, but it not caused by its physicians: the care they provide leads to costs that are substantially comparable to the other counties in the article once adjustments are made for the magnitude of the health problems they face. The disturbing pattern of physician practices uncovered by Dr. Gawande sounds a warning not because it foretells a McAllen-like future but because it portrays the on-going crisis that affects both McAllen and Grand Junction and it is national in scope. Physician culture is only part of the McAllen story.
Patients with chronic disease, especially those with multiple conditions, are extremely costly to treat. Cost savings will not be realized by denouncing and penalizing medical systems because they treat patient populations with high rates of disease. Instead health care reform must develop policies that support streamlining and coordinating care for beneficiaries with multiple chronic conditions, wherever they reside. Policies that support lifetime continuity of coverage, disease prevention and early treatment, could reduce healthcare costs for populations who now reach Medicare eligibility with a history of under-service. Physician culture has a role to play: Accountable Care Entities are intended to reduce barriers to access by facilitating care coordination. The high costs of care in places like McAllen will not be dramatically reduced by transforming physician ethics and organization if the roots of the crisis are in the interaction between class, demographics and chronic disease.
1) The payment amounts and beneficiary counts are from CMS claims and enrollment data that includes a 5% sample of the Medicare population. The data is hosted by JEN Associates Incorporated of Cambridge Massachusetts, a CMS MRAD contractor.
2) A risk score ranging from 1 to 13 was computed for each beneficiary using diagnoses found on Medicare physician and hospital claims. Beneficiaries with scores greater than 9 are not observed in the Grand Junction 5% data in numbers sufficient for analysis. The grouping and scoring system was developed by JEN Associates Inc. of Cambridge Massachusetts for Medicare and Medicaid program planning and evaluation applications. Diagnoses are selected based on correlation with future hospitalization, nursing home entry and death and grouped according to a disease’s functional impact.
Daniel Gilden is a health services researcher with 20 years of hard core quant experience.He’s the President of JEN Associates which provides highly specialized analysis of Medicare and Medicaid data. He contacted THCB regarding the fuss about the McAllen, TX “overuse” story. In his calculations the data suggests something very different from the “practice variation” theory–the patients really are sicker. As this goes counter to decades worth of work by Wennberg et al, we invited Daniel to share his data and methodology with THCB. And we invite those of you who like this kind of research but may disagree with Daniel’s analysis to respond. Finally it’s worth noting that if his conclusions are true this has huge implications for overall health care policy…Matthew Holt
Filed Under: Uncategorized
Tagged: Chronic conditions, Daniel Gilden, Dartmouth Atlas, health care cost, Medicare, Policy/Politics
Jun 25, 2009
The puzzle of improving care and reducing costs in American medicine and in vascular conditions (that is, diseases associated with blood vessel metabolism) in particular – these are responsible for 60 percent of all cost – has been in part due to the nature of medicine itself. Physicians are at their core scientists. Our undergraduate degrees are in the scientific disciplines of biology, chemistry, physics. We have been educated in the culture of science and that is the environment in which we practice.
Thomas Kuhn’s The Structure of Scientific Revolutions perfectly describes a central problem in cardiovascular diseases. A scientific community cannot practice without a set of core beliefs. These central constructs are, in Kuhn’s terms, the foundation of the “educational initiation that prepares and licenses the student for professional practice.” The student’s instruction is “rigorous and rigid,” with the purpose of ensuring that these beliefs are firmly fixed in the student’s mind.
Scientists go to great lengths to defend the idea that they know what the world is like. It should come as no surprise then that “normal science,” – that is, the framework to explain the world used by the scientists who lead the current paradigm – will often suppress novelties that undermine its foundations.
So research often is not about discovering the unknown, but rather “a strenuous and devoted attempt to force nature into the conceptual boxes supplied by professional education.” A generally-accepted paradigm, essential to effective scientific investigation, requires “some implicit body of intertwined theoretical and methodological belief that permits selection, evaluation and criticism.” That paradigm, in turn, forms the basis of a new profession or specialty, like Interventional Cardiology, and from this follows the establishment of journals, societies, and a special place in the medical academic structure. The articles in those journals are intended for professional colleagues who share the the field’s knowledge and who are the only ones capable of fully understanding them.
A shift in the accepted scientific construct occurs when research aimed at further developing that formulation of the evidence runs into an anomaly — a fact that does not fit the paradigm and cannot be explained away. When anomalies pop up, they typically are not welcome and may be ignored. The current paradigm’s scientists may make little or no effort to formulate a new theory to explain the phenomenon. They are also likely to be intolerant of practitioners who try to do so.
All the same, the discovery of anomaly is the stimulus that leads to a new paradigm. The failure of existing beliefs and rules is the necessary but insufficient platform for the development of new scientific and practice structure.
The leaders of an entrenched paradigm strongly resist alternate systems of science and practice. Only in crisis can that resistance be overcome. No better example of this can be found than the current situation in the treatment of cardiovascular and arterial disease.
The fixed blockage is the dominant paradigm today for both the science and practice of cardiovascular and arterial disease management. In other words, it is viewed as a plumbing problem. This paradigm has persisted because it made so much sense.
Angina is a historical diagnosis – particularly in a man. Just talk to the patient and you can make the diagnosis. If a man walks and gets chest pain that is relieved by rest, he has angina. Almost all of those men have a blockage of 70% or greater.
If the cardiologist does a catheterization he will demonstrate the blockage. If he opens the blockage with a stent the pain will go away. But many men with angina go on to have heart attacks – it is high risk. So it is no surprise that blockage became the dominant scientific paradigm. To this day, virtually the entirety of the science, practice, and financing are organized around this idea: Heart attacks are caused by a progressive blockage. If we open that blockage before it becomes complete, we will save the patient.
Now the anomaly. In 1988, WC Little and his colleagues at Wake Forest performed a study “to help determine if coronary angiography can predict the site of a future coronary occlusion.” If the plumbing model were correct and a progressive blockage of the artery caused myocardial infarction, the findings on coronary angiography should predict the site of heart attack. It did not.
Little and his colleagues studied 42 consecutive patient records of patients who had had coronary angiography before and up to a month after having a heart attack. In 19 of 29 (66%) patients, the artery that occluded subsequently had less than a 50% occlusion on the first angiogram. In 28 of 29 (97%) the stenosis (or narrowing of the vessel) was less than 70%, even though it takes a stenosis of 70% or greater to justify angioplasty with stenting.
“Because it was difficult to predict the site of subsequent occlusion in our patients from the initial coronary angiogram, coronary bypass surgery or angioplasty appropriately directed only at the angiographically significant lesions initially present in almost all of our patients would not have been effective in preventing the majority of infarctions…instead effective therapy to prevent myocardial infarction may need to be directed at the entire coronary tree…”
And, in keeping with Kuhn’s description of the scientific revolution, the best arterial disease scientists quickly developed a new paradigm that provides a much better explanation of the mechanism of heart attack and other vascular events. Within 7 years of the first anomaly, Erling Falk, Prediman K Shah and Valentin Fuster, leading academic cardiologists, summarized four studies that came to the same conclusion as Little. Only 14% of heart attacks occur in an artery that was 70% blocked on the previous catheterization. Only 14% of heart attacks occurred in an artery with enough obstruction to cause angina and justify bypass surgery or stenting. Falk and his colleagues described the new paradigm very simply:
“plaque disruption with superimposed thrombosis (obstructive clot) is the main cause of the acute coronary syndromes of unstable angina, myocardial infarction, and sudden death.”
Peter Libby is Chief of Cardiology at Boston’s Brigham and Women’s Hospital, one of Harvard’s teaching hospitals. One of the world’s foremost authorities on the science of heart attack and plaque rupture, he quite literally “wrote the book” on the topic. In the volume of Harrison’s Principles of Internal Medicine, the standard reference text for the discipline, that sits on my desk, Peter Libby wrote the chapter entitled The Pathogenesis of Atherosclerosis.
In 1995, the same year as the Falk article, Libby wrote a piece called “The Molecular Basis of the Acute Coronary Syndromes.”
“Bypass surgery or transluminal angioplasty (dilation of the artery and then, propping it open with stents) provide rational and often effective therapies for these fixed, high-grade stenoses (blockages). However, these treatments do not address the non-stenotic but vulnerable plaque (which may rupture and suddenly block the artery with clot). It is of interest in this regard that despite the well-accepted benefit of coronary bypass surgery on anginal symptoms, this treatment aimed at severe stenoses does not prevent myocardial infarction. To reduce the risk of acute myocardial infarction, one must stabilize lesions to prevent this disruptions, particularly the less stenotic plaque.”
In other words, heart attack is not caused by a gradual narrowing of the artery, but rather is the result of sudden cholesterol plaque rupture with subsequent clot formation, which blocks off the artery and cuts off blood flow.
Today, 14 years later, we can dramatically stabilize plaque and reduce plaque progression by smoking cessation and reduction of cholesterol, triglycerides, blood pressure, and blood glucose. We can prevent clot formation with aspirin and other medications.
The scientific revolution in vascular disease is 20 years old and the new paradigm firmly in place and supported by the very best vascular scientists. Still, the practice paradigm persists as if the science never changed.
Just last year, I heard a brilliant talk by Valentin Fuster, one of the co-authors on the Falk article. Afterward I asked him what it would take to move the practice paradigm forward. He responded that it would take the time required to replace current practitioners wi
th the next generation.
Can we afford to wait for that? Several years ago, I heard Dr Libby speak at a national meeting of the American Society of Hypertension. I later asked him, “Dr Libby, I read your article from 1995, saying that bypass and stenting do not prevent heart attack, do you still hold that view.” He became very animated and enthusiastic and said he was convinced that the new science was valid and required action to move it forward.
The science has become irrefutable. Yet the defenders of the old science still carry the day. I fear that medical scientists will not move this forward and it will require changes in payment and support for research coming from outside the professional community to bring the latest science to patients.
We have to recognize the suppression of anomalies and new paradigms in medicine. Only then can we develop mechanisms that can bring the latest evidence-based science to patients.
Bill Bestermann is Medical Director, Integrated Health Services at Holston Medical Group in Kingsport, TN.
Filed Under: Uncategorized
Tagged: Chronic conditions, evidenced-based medicine, Medicine, Obesity, Policy, primary care, Quality, Science, William Bestermann
May 24, 2009