Category: Medical Information

The Cardiac Gloves Come Off!

Why is your heart the punching bag?

My cardiologist is just as good as yours.

On the way to my gym on Shelbyville Rd., I noticed a billboard advertising Baptist Health’s cardiology service.  It advises me that “some of the best cardiologists around don’t practice downtown.”  This, of course, is true.  The ad is an obvious riposte to some of the advertisements of downtown hospitals, one of which advised that for your best chance of surviving a heart attack, you should take the next exit.  If corporations are people, it is now getting personal!

It’s hard not to notice that our area hospitals advertise their cardiac services heavily.  Each one is said be the better for you, and amazingly, many can produce reports from external review organizations appearing to back up their assertions.  What is distinctly lacking, in my opinion, is objective evidence in the promotional material to support claims of excellence.  For most of the Fall and Spring of 2008-09, I drove several times a week past the sign (and the exit) on Interstate 65 that promised my best chance of surviving a heart attack.  I wondered on what basis the hospital could make such a claim.  When I learned that Medicare’s Hospital Compare was then calculating risk-adjusted mortality following heart attack, I had to check it out.  In fact, not only did the advertising hospital not have the best survival rate in the city, it had the lowest.  Nevertheless, the sign stayed up for many months.  Today the mortality rates have evened out, but is all such advertising so much puffery?  How are we to know?

Why are cardiology patients fought over?

It is not a state secret why cardiology, cancer, orthopedics, or neurosurgery are advertised so heavily by hospitals. These are among hospitals’ most profitable services. My former hospital lobbyist colleagues were quite open in admitting that cardiology services are overpaid by Medicare and other insurance companies.  According to the bank robber Willie Sutton’s law of medicine, that’s where the money is. I will say more about this in another post because an absence of profitable services is relevant to the financial difficulties of Louisville’s University Hospital.  In my opinion, the other downtown hospitals have helped to keep University Hospital in its place.

The Baptist billboard is clever, and reminds me of the series of billboard ads for hotdogs and whiskey also containing witty one-liners that we all chuckle at.  I would not be surprised if the same advertising agency was responsible for some of the medical ads as well. That is, a very depressing thought however.  At a time when food and dietary supplements are marketed as though they were medicines, medicine is marketed as though it was soap powder.  Are we really that gullible or so easy to manipulate?  I have already told you how I feel about the quality and ethics of some of these advertising campaigns.  If you believe everything you see and hear, you will be badly served. Continue reading “The Cardiac Gloves Come Off!”

On Excellent Medical Reporting

In an earlier entry, I was critical of what I call the “press release” variety of medical reporting in which the news report is based heavily or entirely on a press release by individuals or institutions who have a financial or other vested interest in shaping the presentation.  In many, if not the majority, of these the difference between informing and marketing is not discernible to me.  It is therefore only fair to give credit for what I think is an example of excellent medical reporting. As described below, I was also impressed at the value added to conventional newspaper reporting by its associated Internet capabilities. The article provides an example of the pre-publication embargo system used by some major medical journals with what I think are both positive and negative implications.

The Article and Report.
On Tuesday, February 8, New York Times reporter Denise Grady published an article, “Lymph Node Study Shakes Pillar of Breast Cancer Care.” My sometimes faulty memory tells me I saw her article Monday evening on the New York Times website. The article Ms. Grady reported on was officially published in the February 9 issue of JAMA, the Journal of the American Medical Association: “Axillary Dissection vs No Axillary Dissection in Woman With Invasive Breast Cancer and Sentinel Node Metastasis, ” by Armando E. Giuliano and coauthors; vol. 305:569, 2011. I received my personal copy of the Journal on Wednesday the 9th.

I spent over two hours studying this seven page paper. It was heavy going for me and would have been largely impenetrable to a layperson. It goes against my grain to be paternal, but there is no way for a layperson to understand the significance of the research or how it might relate to them without help. In fact, even I needed some help to put things in perspective, and I confess some of that help came from Denise Grady.

To summarize the paper in an obscenely brief manner, 891 women with breast cancer that had already metastasized as far as the lower lymph nodes in her axilla (armpit) were randomized to 2 different treatment plans. Half the women went on to what was then the standard treatment of extensive removal of all the lymph nodes in their axilla. The other half had no additional surgery beyond the biopsy of the low sentinel node that showed the metastatic cancer. All of the women had a lumpectomy and radiation to the breast, and almost all had additional adjuvant or prophylactic chemotherapy. The patients were followed for as long as eight years. There was no difference in the survival or cancer recurrence rate in either group. Continue reading “On Excellent Medical Reporting”

Area Variation. Is Doing the Most a Good Thing?

On the second day of the new year, the front page of the Courier Journal highlighted the fact that one of our local hospitals was third in the United States in the number of spinal fusions performed.   Since the Louisville business community has identified generating healthcare revenues as a top long-term strategic priority, the headline could easily be interpreted as a success story.  However, the full-page article by John Carreyrou and Yom McGinty reprinted from the Wall Street Journal was not very flattering. (The article is not present on the Courier Journal website, but is available on the Wall Street Journal’s.)

The article emphasized the multibillion-dollar annual market and the medical controversy over when and if this extremely expensive major surgery should be done.  Also highlighted were the large amounts of royalty  money paid by the manufacturers of surgical equipment directly to surgeons who make the decision to operate.  The article reported that five of the surgeons at my local hospital received more than seven million dollars in less than a year from the manufacturer of the implants used in the surgery.  This was in addition to the clinical charges billed.  It was reported that total Medicare reimbursements for spinal fusion at my local hospital were almost $48 million.  The article proposes, and I and would have to agree, that the amounts of money involved are enough to distort the medical decision-making process.  Since the hospital and doctors involved are part of our academic medical center, one might also reasonably assume that young physicians in training will perceive these activities as the standard of care.

There is not room here today to summarize the medical literature pertaining to spine surgery for disc disease and arthritis. Suffice it to say, most national organizations of general physicians and rheumatologists are arguing for fewer operations than in the past.  In my own career as a rheumatologist, I personally recommended spine surgery for only three patients with arthritis. It is possible for you to suspect that I think too much spine surgery is being done in general.  The hospital and doctors involved will likely offer their own explanations: indeed I think they will need to.

What I do want to talk about today, is the methodology that brings such observations to the forefront.  It has been called study of  “small area variations.”    You see these kind of studies all the time.  They were popularized by Dr. Jack Wennberg and the group at Dartmouth.   I have always been drawn to this approach because the mapping of results appeals to my visual sense.  For example, here is one of the earliest health policy studies I ever did. Continue reading “Area Variation. Is Doing the Most a Good Thing?”

Does Medical Reporting Help or Hurt?

Courier-Journal reporter Darla Carter led off New Year’s Day with a front page article “Health news [is a] prescription for confusion.”  I agree with her.   Is coffee bad for you of not?  Should postmenopausal women take estrogens or not?  Should men get a routine PSA test for prostate cancer or not?  When and how often should I get a mammogram?  Should I get chest x-rays to screen for lung cancer or not?   Should my child get immunized or not?  Our daily media is full of headlines and stories that address medical scientific issues and their application to medical care.  Even if one is not paying attention, it is obvious that the recommendations appearing in these news articles and segments conflict with each other on a regular basis.

It is this article that stimulated me to get off my duff with this blog.  For years I have been pulling my hair out about the way medical information is presented to the public.  The volume of health and medical information presented to the lay and professional public daily is overwhelming.  I don’t know about you, but I can hardly stand to watch television any more because of all the drug ads.  The only thing that is worse are the campaign ads, but at least these are with us only part of each year.

We are assaulted by print, broadcast, and electronic media everywhere we go.  The nature of the information ranges widely.  It ranges from “news,”  advocacy sponsored material, through press releases supporting every possible position.  The content passes further down the social-value scale through entertainment, snake oil, and outright fraud.   The overwhelming volume of health-related material with which we are sandbagged is advertising: somebody is trying to induce us to buy something that will translate into income for them.  There is nothing wrong with information: more and better information is badly needed.  But we live in a time when food is sold like medicine, and medicine sold like soap powder.   Which hospital in my town really has an infection control problem?  What is the basis of a claim that a given product or service is the “best,” or even works at all for that matter?   Such information is hard to come by– if it is available to the public at all. Continue reading “Does Medical Reporting Help or Hurt?”