ACP Internist

Tuesday, March 9, 2010

Coffee and the Heart - Researchers are Getting Paid Way Too Much to Rehash Old Data

This post by Westby Fisher, MD, originally appeared at Better Health.

This week, coffee seems to be good for the heart: "People who are moderate coffee drinkers can be reassured that they are not doing harm because of their coffee drinking," said Arthur Klatsky, the study's lead investigator and a cardiologist at Kaiser's Division of Research.

These "surprising" data were presented at the American Heart Association meeting on March 5th.

But a quick Google search on Dr. Klatsky's earlier studies using the same questionnaire database shows the problems with using questionnaire data to make such sweeping conclusions. Take, for instance, these findings from 1973: Coffee drinking is not an established risk factor for myocardial infarction.

And yet a bit later, in 1990, there's a flip flop: Because of conflicting evidence about the relation of coffee use to coronary artery disease, the authors conducted a new cohort study of hospitalizations among 101,774 white persons and black persons admitted to Kaiser Permanente hospitals in northern California in 1978-1986. In analyses controlled for eight covariates, use of coffee was associated with higher risk of myocardial infarction (P=0.0002). (By the way, British researchers failed to find a similar correlation in instant coffee drinkers.)

So what, really, do these data from the Kaiser questionnaire data regarding heavy coffee consumption and the heart say?

What they say is:
1) Questionnaire data crunched to suggest correlations are insufficient to mean causation, irrespective of how the media parses it.
2) Questionnaire data are subject to significant sampling and reporting biases.
3) Rehashing the same old questionnaires using the same samples with newer data can dramatically alter prior findings.
4) Researchers are getting paid way too much to keep rehashing the same data for large health systems.
5) On the lighter side, college undergrads and medical students should note that they could use these types of questionnaire data to justify significant caffeine consumption along with alcohol to protect themselves from developing cirrhosis.

Sigh.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

Labels: alcohol abuse, cardiology, coffee, evidence-based medicine, heart, heart disease

Once Upon A Time

AUTHOR'S NOTE: I am very frustrated with a system that increases cost dramatically and yet reduces what I get paid. The rest of the money is going somewhere, and since it is not improving the overall quality of care, it is mostly waste. We are enamored with MRI scans, stents, and expensive cancer treatments, with little to show for them except increased expenses and a lot of third parties getting rich off of this waste: drug and device manufacturers, medical imaging companies and other para-healthcare industries. This story, which originally appeared at Musings of Distractible Mind, is prompted by my frustration with waste and how it spurs unneeded health care delivery.

Once upon a time there was a land on the ocean. The people lived off of the food from the ocean and were very happy. But as they grew bigger, they had a problem: They made a lot of waste! Yuk! Nobody likes waste. What could they do about all of this that stuff that nobody needed?

Some said that they should find a way to make less waste. They said that the people of the land were not smart and should be making less waste. But most of the people in the land didn't like to change what they were doing. It's hard to change. So they built a large pipe that pumped the waste into the ocean.

The land was clean again and the people were happy!

As time went on, they had to build more and more pipes to handle their waste. Nobody ever tried to make less waste because they could just make more pipes and pump it into the ocean. This even built a very successful industry of pipe-workers. This helped the economy.

But then one day something terrible happened. The pipes pumping waste killed off several species of sea life. This made the environmentalists in the land cry out in protest. But as it stood, the number of species in the ocean were so vast that the killing off of a few of them was felt to be no harm. So the pipes kept pumping. The people still could be happy with a few less species.

And then came a day when something magical happened. New species of sea creatures formed around the pipes. These creatures fed off of the waste and thrived around these pipes. These new creatures became very big and very fancy, and this made the people of the land very happy. What were the environmentalists all worried about? So what if a few species had died off; there were new exciting species being formed! The people were so excited that they made even more waste and more pipes so they could make more new species of sea creatures.

What fun!

Now, these fancy new creatures were hungry. They ate all of the waste and wanted more. They ate most of the other sea animals and wanted still more. They couldn't get enough food. So they sent lobbyists to the government of the land to get them to build more pipes and send more waste. The creature lobby was very rich, and so poured lots of money at the government of the land. This made the politicians very happy. So the happy politicians told the companies of the land to make more pipes and send more waste out to the sea. And the sea creatures were happy.

And so it went for many years: more pipes sending more waste making more fancy sea creatures eating more waste sending more lobbyists to make politicians get more companies in the land to build more pipes. Everyone seemed to benefit from this nice arrangement! Maybe they'd be happy forever!

But one day, some of the people of the land got tired of putting all of their money into building pipes to send waste. They thought their land should stop making so much waste and start putting those resources into schools, food and fighting crime. The government was raising taxes more and more so that they could afford to make more pipes. This made these people mad because some people couldn't afford any more taxes. Paying for all of this waste was too much.

But the lobbyists from the sea creatures put commercials on television saying how good the waste was. In fact, having so much waste made the land one of the best lands anywhere. They pointed out how many new sea creatures came to be because of this waste and how other lands couldn't do this. The pipe manufacturers also made commercials telling about all of the jobs these pipes were creating. They all made so much sense!

They also sent more money to the politicians so they would ignore the people who couldn't afford paying for the waste.

But then some of the people of the land ran out of money and stopped paying taxes. This made the government mad, and so it left these bad people to live in their own waste. Many of these people became sick in their waste, and some of them died. Finally, the cry of the people was loud enough that the politicians in the land took notice. They decided that all of this waste was a real problem. No other land had so many pipes sending so much waste. True, there were lots of fancy new sea creatures, but the people in the land were getting angry, and some were dying.

But the politicians started fighting. One group of the politicians decided that the pipe-making companies were the problem. They thought that the government should take over the pipe-making job and guarantee waste pipes for every home. Others thought that the government could never do as good of a job as the companies did. They said that those people who couldn't afford pipes were dead-beats and probably deserved to die.

They held town hall meetings to talk about who should be making pipes, and people got very angry.

Finally, someone who wrote a waste-pipe blog suggested that perhaps the problem wasn't the pipes, but instead it was the waste. He said that the people should find a way to cut back on the waste, and so need fewer pipes. The blogger was criticized sternly, because his suggestion would have very bad consequences. The new fancy sea creatures that made everyone so proud would die off if they cut back on waste, and the pipe-workers would lose their jobs and be very sad. Plus, people didn't want the government telling them how much waste they could make. It's a free country, and people should be able to make waste without the government rationing it.

But as the people of the land thought about what this blogger said, they saw the sense in it. Yes, the sea creatures and the pipe manufacturing companies put very moving commercials on TV about dying sea creatures and unemployed pipe workers. They were very sad commercials and they made a lot of people weep. But the people of the land realized that this land was for people to live in, not for pipe companies or fancy sea creatures. Yes, it would be sad to not have those fancy creatures, and they'd have to get new jobs for the pipe company workers, but it was the only way.

Oh, it was hard to cut back on waste and kill off the fancy sea creatures. People got very mad and lobbyist groups tried to change laws or pay off politicians. But this was a good and smart kingdom, and they didn't listen to the creatures any more. And finally the day came when the sea was clean again.

And everyone was happy.

Rob Lamberts, ACP Member, writes the blog Musings of a Distractible Mind and is on Twitter. His podcast, House Call Doctor, is available online and on iTunes). He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.

Labels: cardiology, climate change, drug companies, environment, health care delivery, humor, Rob Lamberts

Why Physicians Are Going To Stop Accepting Medicare

This post by Stanley Feld, MD, originally appeared at Better Health.

President Obama's health care reform bill will not work. It is based on decreases in physician reimbursement while forcing physicians to increase overhead with unaffordable electronic medical records. More and more physician groups and practices are starting to realize that they cannot make a living from the reimbursement from Medicare. They are quitting taking new Medicare patients and trying to get rid of the old ones by not taking assignment.

President Obama's idea is to force physicians to be more efficient producers. It is very difficult to force anyone to do anything they cannot afford.

Click on the "More" link to continue reading this post.

President Obama also believes that physicians over-test patients in order to make money. Wrong! Much of the over testing comes from the practice of defensive medicine. Many physicians have been sued for under testing. No one is sued for doing a test. Yet there is not a word about malpractice reform in either version of the healthcare reform bill to decrease testing by eliminating defensive medicine.

President Obama's solution is to prohibit physicians from testing in their office even though it is more convenient and efficient for patients. Ancillary services can help with overhead and does increase physicians' efficiency of care.

In fact, the fees for the ancillary services in a physicians' office are generally much less expensive than the fees for ancillary services in hospitals. President Obama ignores this fact. He believes physicians over test for profit. This might be true in some cases. However, this abuse can be discovered with the information technology system we have at present. He believes he can force physicians to tests less if it is outsourced to the hospital.

Physicians on average earn 20% to 30% less from Medicare than they do from private patients, and many are dropping out of the program.

The administration is beginning to feel the kick-back from the physician community. I think this kick-back will escalate in the coming months. It will worsen the delivery of medical care.

"President Obama last year praised the Mayo Clinic as a "classic example" of how a health-care provider can offer "better outcomes" at lower cost."

How were better outcomes determined? The question is unanswered.

"Mayo said last week it will no longer accept Medicare patients at one of its primary care clinics in Arizona. Mayo said the decision is part of a two-year pilot program to determine if it should also drop Medicare patients at other facilities in Arizona, Florida and Minnesota, which serve more than 500,000 seniors."

Mayo says it lost $840 million last year treating Medicare patients, the result of the program's low reimbursement rates.

In Arizona alone it lost $120 million dollars. The losses are usually made up by cost shifting to the private insurers and private patients. These losses are getting harder and harder to make up by cost shifting.

"Mayo Clinic loses a substantial amount of money every year due to the reimbursement schedule under Medicare," the institution said. "Decades of underfunding and paying for volume rather than value in Medicare have led us to this decision."

The media has reported that Mayo Clinic has only dropped accepting Medicare in a small clinic in Glendale, Ariz. It has been reported as an insignificant event by the traditional media. Mayo Clinic is being very civilized by not eliminating participation in Medicare in all the clinics at once. The Mayo Clinic is sending a message to President Obama and his future plans. It will also be a signal to physicians throughout the country.

Ninety-two percent of family physicians accept Medicare. Only about 73% of those are now accepting new patients. This reduction in participating physicians comes on top of a shortage of primary care physicians.

Patients struggle to find any specialist who will accept Medicare. This experience is greatest in the specialties of neurology, oncology and gynecology. Cardiology is next.

Last week cardiologists filed a lawsuit in U.S. District Court for the Southern District of Florida, charging that the government's planned cutbacks will deal a major blow to medical care in the USA.

"It will force thousands of cardiologists to shutter their offices, sell diagnostic equipment and work for hospitals, which charge more for the same procedures."

The lawsuit is an attempt by a group of medical specialists to stave off steep Medicare fee cuts for routine office-based procedures such as nuclear stress tests and echocardiograms.

"What they've done is basically killed the private practice of cardiology," says Jack Lewin, CEO of the American College of Cardiology (ACC), which represents 90% of the roughly 40,000 heart specialists in the USA."

The government's response was politeness. It will hide behind regulations made as a result of congressional mandates. The result is typical bureaucratic gobbledygook.

"Jonathan Blum, director of the government's Center for Medicare Management, says the agency is bound by law not to increase spending when making reimbursement decisions each year."

"Lewin and other heart specialists met with Sebelius on Dec. 8 and explained their concerns. "I thought she was very empathic," he says, but Sebelius has yet to take action."

Kathryn Sebelius will not take action. Neither she nor President Obama really understands the problem, much less the solutions. One cardiologist said it is an efficient way of getting rid of cardiologists and ration access to care.

"It's so absurd, it's kind of funny," he says. "I know ACC doesn't think it's funny, but I do."

It isn't funny. It is an unintended consequence of government control of healthcare. Healthcare should be consumer driven not government controlled. Government should make appropriate rules to level the playing field for all stakeholders and then get out of the way.

A cardiologist in Silver City, N.M., not far from the Mexican border, said,

"The closest cardiologist to me is 150 miles away. With all these cuts coming, it will make it impossible for me to break even seeing 40 patients a day."

Does anyone want the government and its 118 new bureaucracies to take over medical care?

What is the problem?
1. The government is broke.
2. They have to reduce expenditures.
3. Physicians are the weakest link, politically, in the healthcare system because they are ineffectively represented.
4. The government will not fight the healthcare insurance industry's lobbying.
5. The government will not fight the Plaintiff attorney's lobbying.
6. The government will continue to waste taxpayers dollars on stakeholders who add little value to the treatment of sick patients.

It is about time groups of physicians started to make some noise.

Congratulations goes to the Mayo Clinic and the American College of Cardiology.

This post originally appeared on Better Health , a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

Labels: cardiology, health care reform, health information technology, Medicaid, physician shortage

Smokers finding air becoming rare in which to indulge

Outdoor smoking faces bans in big cities as the largest review to date concludes that public smoking bans reduce heart attacks by 26% annually, and the effects can be measured in as few as six months.

New York City’s health commissioner said a week ago that he wanted to ban smoking at parks and beaches. Mayor Michael R. Bloomberg released a response that he wanted "to see if smoking in parks has a negative impact on people’s health."

Yeah, it does, according to research in the Sept. 29 issue of the Journal of the American College of Cardiology. A systematic review and meta-analysis of 10 reports from 11 geographic locations in the North America and Europe compared heart attack rates before and after public smoking bans. The studies involved 24 million people and observations of the effect of the bans ranged from two months to three years.

Thirty-two states and cities have banned smoking in public places and workplaces. Recently entering into the fray is Rockville, Md., which voted the same night as New York's proposal to ban smoking within 40 feet of city parks and may push for a more comprehensive ban. A nationwide ban on public smoking could prevent as many as 154,000 heart attacks each year, the study concluded.

Steven Schroeder, MACP, director of the Smoking Cessation Leadership Center University of California, San Francisco, said, "Several years ago, the idea that secondhand smoke was harmful to the heart was a theory and one with some controversy attached, but this article moves us from the theoretical to fact and to practice. The reduction in heart attacks associated with public smoking bans is a big deal."

Labels: cardiology, smoking cessation

This post will not teach you about syncope

I assume that the packed house of internists learned a lot from this morning's session on syncope, but since medical-writer school doesn't include a course on reading electrocardiograms, what I picked up were some jokes about bears.

So here goes: The president wants to decide which law enforcement agency is the best so he releases a rabbit into the woods and sends the CIA, FBI and NYPD to get it. The CIA interviews all the animals, can't find it. The FBI kills everything in the woods, including the rabbit. After the NYPD goes in, a badly beaten bear comes out saying, "Yes, yes, I swear I'm a rabbit." The point was something about how electrophysiology is like the NYPD--you get an answer but it might not be the right one.

Then, presenter Fred Kusumoto, MD, told us about how premature ventricular contractions are like bear poop. If you're hiking in the woods and you see poop, you'd better watch out for a bear. Cleaning up the poop will not make you any less likely to run into a bear. Similarly, studies have found that using medication to get rid of patients' PVCs does not improve mortality.

Labels: cardiology, internal medicine 2009

A disparity you can do something about

Just about every week, a new study comes out reporting on health disparities between men and women, blacks and whites, etc. Here at ACP Internist, we've discovered that this kind of research tends to attract little interest from our readers--maybe because it seems like the same sad, but inexplicable, story over and over again. No one favors disparities in care and health, but what do you do about them?

But the latest disparity study from the NEJM comes with some solutions. Blacks are vastly more likely to develop heart failure at a young age than whites, the researchers found. They also highlighted three frequent causes: hypertension, obesity, and systolic dysfunction. Control those conditions in young blacks and the disparity in heart failure should decline. Of course, that's easier said than done (if Americans could find a way to control obesity, we'd be looking very different as a country), but it at least gives the health care community something to work on, instead of just more bad news to bemoan.

Labels: cardiology, disparities

Depression linked to cardiac death

Healthy women with severe depression have double the risk of sudden cardiac death, as well as higher risk for fatal coronary heart disease.

Depression and heart disease are linked by cardiovascular risk factors such as high blood pressure, diabetes, high cholesterol and smoking, which are more common among severely depressed women. Possible explanations could be autonomic dysfunction, higher resting heart rates and reduced heart rate variability.

Researchers prospectively studied 63,469 women from the Nurses Health Study with no evidence of prior heart disease or stroke between 1992 and 2004. They used self-reported symptoms of depression and antidepressant use, and then examined those with the most severe symptoms on a mental health index or those regularly using antidepressants. They reported their results in the Journal of the American College of Cardiology.

Low mental health index scores were associated with an increased risk of heart disease, with a hazard ratio of 1.5 after controlling for other risk factors. Sudden coronary death risk was 3.3 times greater in subjects who took antidepressants, more so than the mental health index scores, causing an editorial writer to raise the specter of needing further research into this drug class while emphasizing that the benefits outweigh the risk. As usual, one study raises more questions to answer. In the meantime, doctors should closely monitor patients with depression for risk factors for coronary heart disease.

Labels: cardiology, depression, heart, heart disease, heart failure

What's your poison?

While there has been evidence galore that alcohol in moderation may be good for your heart (see this, this and this for a few examples), a new study has raised a serious counterpoint. The study from the Feb. 24 online Journal of the National Cancer Institute found that women who drank even small amounts of alcohol were at higher risk of cancer than those who drank nothing.

To wit, for every extra drink per day, the increase in incidence per 1000 women was 11 for breast cancer, 1 for cancers of the oral cavity and pharynx, 1 for cancer of the rectum, and 0.7 each for cancers of the esophagus, larynx and liver. That adds up to 15 cancers per 1000 women, the journal said. Put another way, the authors estimated that about 13% of cancers of the breast, aerodigestive tract, liver, and rectum could be attributed to alcohol, an editorial noted.

The editorial goes on to say: "From a standpoint of cancer risk, the message of this report could not be clearer. There is no level of alcohol consumption that can be considered safe."

Has it come to this: Hesitating at the wine or beer aisle, as you contemplate whether you'd rather have cancer or heart disease? That's being melodramatic, of course, but what should a PCP tell a patient who asks whether she should be drinking a glass of wine a day "for her heart"?

Labels: alcohol, cancer, cardiology

Temper, temper

The stereotypical image of the angry person suddenly clutching his or her chest might have found some physical evidence. Not just stress but strong emotions may lead to potentially lethal ventricular arrhythmias.

Researchers studied 62 patients with implantable cardioverter-defibrillators who underwent monitoring during a mental stress test that asked them to recall a recent situation in which they were angry.

Researchers measured the patients' T-wave alternans (TWA) and then followed them for a mean of 37 months to determine who had arrhythmias that triggered their pacemakers. Patients with higher levels of anger-induced TWA were more likely to trigger their pacemakers--a predictor of heightened risk of up to ten times that of other patients.

Combining exercise tests with mental stress test may help clinicians better select patients likely to have arrhythmia and benefit from a defibrillator, and it might provide insight for patients who can't exercise, researchers wrote in the Journal of the American College of Cardiology.

Naturally, therapies focused on helping patients deal with anger and other negative emotions may help reduce arrhythmias and, therefore, sudden cardiac death in certain patients. It's not the first time anger's been linked to heart disease, but researchers said we are beginning to understand how anger and other types of mental stress can trigger potentially lethal ventricular arrhythmias.

Labels: cardiology, heart, heart disease

How depression breaks the heart

It's been known for quite some time that depressed patients have a higher risk of heart problems than those who are mentally healthy. What's been unclear is why-- till now.

A new JAMA study finds that, in depressed patients with coronary heart disease, most of the higher risk of CV events can be chalked up to a lack of exercise.

The study followed more than 1,000 outpatients with CHD for nearly 5 years. Patients reporting symptoms of depression had a 50% greater risk of CV events. Adjusting for comorbid conditions and cardiac disease severity lowered the risk to 31%, but adjusting for lack of exercise pretty much wiped out the association completely (along with a few other "health behaviors," like diet). Put another way, not exercising was associated with a 44% higher rate of CV events-- almost the same as the depression association.

So now the real question is: how do you get those depressed patients to exercise? (Which, by the way, is likely to improve their mood.) That's a whole other study in and of itself. For now, the Mayo Clinic has these tips on motivating depressed patients.

Labels: cardiology, depression, heart, mental health

Don't forget your history

Twice today I've heard pleas for doctors to do a better job of collecting family histories. One came as an aside from an audience member at Dr. Oz's lecture, and another from Allen Taylor, MD, who spoke at a seminar about when to order various imaging tests. He was tasked with talking about patients with intermediate risk of heart disease.

Dr. Taylor noted that the classic definition of "intermediate risk" for CAD is 10%-20% on the Framingham, yet this misses some patients because the Framingham doesn't take family history into account. As such, his definition of "at risk" is a patient with a Framingham of 6% or greater and a family history of premature coronary artery disease.

When taking family history, you should go deep, he said. Ask about first and second degree relatives. Ask about the age that relatives developed CAD, and how many relatives had CAD. The more relatives, and the younger those relatives were when they developed CAD, the greater the risk. Especially if they are siblings.

Those deemed at risk by family history should undergo coronary artery calcium testing, he said, especially middle-aged and older patients, for whom it's been shown to be a stronger risk predictor than carotid IMT tests. IMT might make more sense for primary care offices, however, for practical/convenience reasons, he said.

It's really important to identify those at intermediate risk, he noted, because they are a big group-- and also the most likely to improve with therapeutic intervention. It's a message I've heard several times at this conference.

Labels: AHA Sessions, cardiology

ACP Internist hosted Grand Rounds on June 16, wrapping up the best of the medical blogosphere. Click here for the complete wrap-up.

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American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

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Robert M. Centor, FACP, contributes short essays contemplating medicine and the health care system.

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EverythingHealth is designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

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Getting Better is the continuation of Dr. Val Jones' previous blog at Revolution Health. It is devoted to helping people understand health issues from a balanced, scientifically sound perspective.

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A roundup of health policy news drawn from a database of hundreds of Web sites.

Interact MD
Michael Benjamin, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

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The alter ego of Kevin Pho, ACP Member, is the closest thing to royalty in the medical blog world.

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The Public Library of Science's open access materials include a blog.

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One of the most popular anonymous blogs written by a doctor.

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ACP Internist

Tuesday, March 9, 2010

Coffee and the Heart - Researchers are Getting Paid Way Too Much to Rehash Old Data

Monday, March 1, 2010

Once Upon A Time

Wednesday, January 27, 2010

Why Physicians Are Going To Stop Accepting Medicare

Monday, September 21, 2009

Smokers finding air becoming rare in which to indulge

Saturday, April 25, 2009

This post will not teach you about syncope

Thursday, March 19, 2009

A disparity you can do something about

Monday, March 9, 2009

Depression linked to cardiac death

Wednesday, February 25, 2009

What's your poison?

Monday, February 23, 2009

Temper, temper

Tuesday, November 25, 2008

How depression breaks the heart

Monday, November 10, 2008

Don't forget your history

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