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The Great Coronary Angioplasty Debate: Giving Patients the Right to Speak

Earlier this month, the editors of THCB saw fit to post my essay, “The End of the Era of Coronary Angioplasty.”

The comments posted on THCB in response to the essay, and those the editors and I have directly received, have been most gratifying. The essay is an exercise in informing medical decisions, which is my creed as a clinician and perspective as a clinical investigator.

I use the recent British federal guideline document as my object lesson. This Guideline examines the science that speaks to the efficacy of the last consensus indication for angioplasty, the setting of an acute ST-elevation myocardial infarction (STEMI). Clinical science has rendered all other indications, by consensus, relative at best. But in the case of STEMI, the British guideline panel supports the consensus and concludes that angioplasty should be “offered” in a timely fashion.

I will not repeat my original essay here since it is only a click away. The exercise I display is how I would take this last consensus statement into a trusting, empathic patient-physician discourse. This is a hypothetical exercise to the extent that little in the way of clear thinking can be expected of a patient in the throes of a STEMI, and not much more of the patient’s caring community.

So all of us, we the people regardless of our credentials, need to consider and value the putative efficacy of angioplasty (with or without stenting) a priori. For me, personally, there is no value to be had rushing me from the “door to the balloon” regardless of the speed. You may not share this value for yourself, but my essay speaks to the upper limits of benefit you are seeking in the race to the putative cure by dissecting and displaying the data upon which the British guideline is based.

There is an informative science, most of which cannot deduce any benefit and that which deduces benefit finds the likelihood too remote for me to consider it worth my attempt. A hundred or more patients with STEMI would have to be rushed to the catheterization lab to perhaps benefit one (and to harm more than one).

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The End of the Era of Coronary Angioplasty

In a single generation, the evidentiary basis for the practice of medicine has grown from a dream to a massif. No longer need physicians rely solely on experience and opinion in formulating diagnostic and therapeutic approaches to the care of the patient.

However, for any given clinical challenge, the available science is never flawless, monolithic or comprehensive, nor is it likely to be durable in the face of newer studies.

The international medical community has mounted two approaches to sorting the wheat from the chaff: One targets the doctor in convening committees to formulate guidelines for patient care. The other targets the patient for evaluating options, so-called informed medical decision making. Both approaches are now sizable undertakings clothed in organizational imprimaturs and girded by self-promotion.

But they are largely parallel undertakings with work products that can cause considerable cognitive dissonance on the part of the patient and the physician. In a recent article in the British Medical Journal [1] the Guideline Development Group convened by the National Institute for Health and Clinical Excellence (NICE) summarized the thinking behind the guidance it was offering regarding the management of STEMI. This is an object lesson in such cognitive dissonance.

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Hearts on Fire: a Tale of Two Californias

The concept of practice variation raised its ugly head again this weekend in the northern California news media. And buried in the stories are several themes for our ages. But the conclusion is, the power of individual health systems and very small numbers of physicians to change patterns–and the cost–of care are enormous.

First the stories. Both about health care but also both revealing the future of investigative reporting. The BayCitizen is a non-profit blog about the San Francisco metro, created as response to the local papers cutting their reporting. It also provides stories to the NY Times–I’m unaware about how much of its revenue comes from the Times, but it’s part of  the Times’ entry into non-NY competition with retreating local papers.

For this story on heart program readmission picked up on an older UCSF press release and showed how UCSF used a $500K+ donation from the Gordon & Betty Moore Foundation (that’s the Moore of Intel & Moore’s law fame) to create a very sensible program that gave in-home support to newly discharged elderly cardiac patients. It cut readmission rates by 30%. The BayCitizen though will upset Gary Schwitzer as it did not include the actual numbers but the UCSF press release does, and yes this is a relative not an absolute cut. Here’s the key graf

Over the past 11 months, only 16 percent, on average, of the hospital’s heart failure patients were readmitted within a month of discharge, down from 23 percent in 2006. That’s well below the national 30-day readmission rate of 25 percent. The average readmission rate was 11.6 percent during the first four months of 2011.

So UCSF was about average and got much better and seems to be getting better still–but there’s quite a way to go. But it is an indication that at least one AMC is capable of moving the ball in the right direction. Of course UCSF is a leader in the pro-Dartmouth “use resources sensibly” camp, and we may or may not see the “keep em alive at all costs” folks at UCLA follow suit.

Meanwhile up in rural northern California it looks like the same Dartmouth data set is about to bring a series of visits from the FBI. Continue reading…

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