Dr John M

cardiac electrophysiologist, cyclist, learner

Follow-up on my Eight COVID Assertions

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Yesterday’s post generated some good comments.

Two emergency medicine specialists felt that I was both wrong and insulting in saying that hospitals were not overwhelmed.

What I meant in the word ‘overwhelmed’ is the notion of not being able to support a sick patient in the ICU or on a vent. That didn’t happen, but both doctors make important points.

First I mean no insult to my frontline colleagues. It’s the opposite really. As a specialist who deals mostly on the treatment side of things, I’ve held those who must make diagnoses in the highest regard. Their work in the pandemic has only increased that respect.

Second, the point that there were consequences to the “massive and costly” efforts to shift resources is valid. Data in our (cardiology) journals hint at the fact that heart attacks and stroke admissions were way down during the height of the pandemic.

But it’s hard to believe that heart attacks and strokes stopped happening during this stressful period. Post-pandemic reviews will likely show that the efforts to care for patients with COVID19 will have increased unnecessary non-viral deaths due to lack of care. (The counter is that the pandemic also stopped a lot of low-value, potentially harmful care.)

Nonetheless, “overwhelmed,” was a poor word choice. Sorry.

2. My Twitter friend, Dr. Mike Johansen (who is a super-sleuth when it comes to critical appraisal) pointed out that my comparison to NZ and Australia is problematic.

Dr. Johansen’s first point about not using the dichotomy between NZ and the US is well-taken–especially given the surprise of vaccine development.

Response to the pandemic has clearly been on a continuum. As he wrote, countries such as Canada, Germany, Denmark, Finland have done better than the US. And now that we have vaccines, countries that did better with pandemic control will end up with less death due to COVID19.

It’s interesting, too, that the countries mentioned above all have better safety nets than the US. Though, there are many other factors in a country’s response to the pandemic.

This country has to figure out a way to improve our safety net. I realize that people differ on how to get there. But no one can disagree that it is an existential problem.

3. An anonymous commenter pushed back on my assertion #6.

What evidence is there that reductions in IFR are due to masks and distancing?

My thinking is not that masks or distancing affect the IFR directly, but that delaying getting the infection will reduce one’s chance of dying. For two reasons:

It was a novel virus; it took time to learn stuff. So it is clearly better to get the virus in December than in April.

And now there are vaccines.

For a person with risk factors, therefore, it makes sense, now, to stay hunkered down for a few more months. There is an end in sight.

If you have the means, you use online shopping, you avoid weddings and large gatherings, get an N95 mask, do Zoom Christmas and take the vaccine.

But my commenter is right: Social distancing and masks do not affect the severity of illness–though there is a theory that a mask might lower the severity of illness by reducing the amount of virus that gets in your body.

The pandemic forces everyone to think. This is a good thing.

JMM

What I Got Wrong (and Right) about COVID19

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In May, I wrote a column about COVID19 that got some attention.

My reason for writing was the change in messaging about the strategy of flatten-the-curve. We were first told to flatten-the-curve to prevent overwhelming hospitals. But then the thinking changed to flatten-the-curve to save lives. 

I made eight assertions about COVID19. Let’s see how I did. 

Assertion 1: The virus will not be contained. Verdict: Correct.

You might argue that New Zealand and Australia contained the virus, but I would counter that these are not fair comparisons to the US, Canada, and the EU. 

Assertion 2: Tests will underperform. Verdict: Correct.

The US–which is in the midst of its third spike–is n the top-tier of countries for numbers of tests per million people. Test-and-trace is pure folly. I would not be surprised if some people are actually avoiding being tested–so as to keep working.

Assertion 3: Hospitals are in little danger of being overwhelmed. Verdict: Mostly correct.

There are now places under pressure, some are feeling serious pressure, but we have not nor will we see a Northern-Italy-like situation in the US.

Assertion 4: Americans are not stupid; we will socially distance and take common-sense measures. Verdict: Debatable.

While I stand by my early opinion, I understand those who would point to the third spike and holiday travel as evidence I was wrong. 

A brief comment on the current situation. A colleague recently argued with me that we could have been more like Australia; he said Americans were selfish in failing to take measures to control the virus. In other words, he laid much of the blame on the people.

I don’t entirely blame the people. I lay a lot of the blame on messaging. Consider a doctor who has zero success in getting patients to lose weight, or stop smoking, or take their meds. Maybe it is the messaging.

Apply this thinking to American pandemic messaging: the scolding and scare tactics, mostly from those with the privilege or luck to be able to work at home; the counting of only infections and not the disparate effects of economic shutdowns, and, most of all, the inane rules–like having schools closed for instruction but allowing football.

These have all contributed to a feeling amongst many in the community that goes something like this: screw it, we are done listening.

Assertion 5: Public health surveillance has improved. Verdict: Correct.

While tests have failed to stop the spread of this virus, there are enough tests to inform decision-making at the local level. My hospital has a daily count of cases and have surge plans ready. Indiana, for instance, recently enacted a temporary hold on elective surgeries based on surveillance data. 

Assertion 6: Non-pharmaceutical interventions, such as social distancing and masks, would not lower the infection fatality rate. Verdict: Wrong.

Early on I saw little advantage to delaying infection. I wrote: “the only way fewer people die from COVID19 over time is if the IFR declines.” I then went on to describe the slowness of medical progress.

There have been two major medical developments that (now) argue strongly for delaying infection–especially earlier this year.

First is that clinicians better understand how to care for patients with COVID19 pneumonia. Early intubation is out; steroids have been shown to reduce death in ill patients, and oodles of studies have shown us what not to do.

Second is the huge surprise of vaccine development. I wrote that “COVID19 vaccine development is sobering.” That was dead wrong.

Vaccine development has been intoxicating in its success. With two messenger RNA vaccines with over 90% efficacy, and other vaccines in the works, an optimistic person could have this pandemic ending next year. Adverse effects remain a potential issue, though early data is reassuring.

Assertion 7: The more we test, the lower IFR goes. Verdict: Mostly correct (with caveats).

The US has 16 million known cases. If this number underestimates actual infections by 5, then approximately 80 million Americans have been infected. If you divide by 300,000 deaths, that’s an IFR of 0.3%. 

The two misleading aspects of IFR are the gradient of disease and the morbidity of viral pneumonia. For the young, and those with no risk factors, the IFR is way lower than 0.3%; but for the elderly and the many millions of Americans with obesity, the infection is far riskier. As for COVID morbidity, many survivors of ICU stays face a long road back to normal.

Assertion 8: The harms of pandemic interventions are under-appreciated. Verdict: To be determined.

The intense political divide, the growing intolerance of ideas, the racial unrest, all argue for a pessimistic case that the lives lost from the viral infection will NOT end up being the gravest harm from this contagion.

I do not intend to minimize the loss of life due to viral infection, but I wonder about the degree to which the pandemic interventions have exacerbated the fraying of vital societal bonds. 

A friend sent me this idea via private message: 

The case to be made is the economic consequences of the lockdown on the poorest, and the societal consequences of those economic consequences. It’s not (viral) death vs (non-viral) death. It’s death vs societal collapse. 

I will choose, perhaps naively, to remain optimistic that the pandemic, intolerance and polarization will abate.

JMM

Missing an Obvious Cause of Medical Overuse

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This post introduces my latest column over at Medscape. I hope you go read the full piece. 

Medical overuse bothers me. Consuming medical care that does not improve outcomes makes you poorer, and puts you at risk for being harmed. 

I think a lot about why Americans consume more healthcare than our peers in other countries. This would be a no-brainer if excess spending led to better health. But it doesn’t. 

If you consider healthcare as a simple transaction for health, excess consumption without better outcomes forms a puzzle.

I have written before about the most obvious reasons American healthcare is so wasteful: profit motives of doctors and hospitals in a fee-for-service system, the human bias for action over watchful waiting, and ignorance of medical evidence. 

But maybe there is another more basic force at play. What if it comes down to the hidden motives embedded within human behavior? 

Over the holidays I read a terrific book called The Elephant in the Brain by Kevin Simler and Robin Hanson. It felt like a Eureka moment.

The writers’ core idea is that humans are social animals competing for power, status and mates. Due to evolutionary and social forces, humans are not only capable of acting on hidden motives, the authors write that we are designed to do it. “Our brains are built to act in our self-interest while at the same time trying hard not to appear selfish in front of other people.” 

In short, we signal. Three examples: In education, we say we are going to college to learn, but really, we go to get a certificate to show off our intelligence; in art, we say we appreciate beauty, but really, we use art to signal our cultivated elite status; in charity, we say we give to help people; instead, we use charitable giving to raise our social status and signal our value as an ally.

How does signaling apply to medical overuse? The authors use the example of the mother who kisses the scrape of her toddler. No healing takes place, but both parties appreciate the ritual. Key word: ritual. The ritual is conspicuous caring. 

Think about it: If healthcare was only about health, you would expect people to pay for, and clinicians to prescribe, only treatments in which benefits exceed costs. But conspicuous caring provides a (hidden) reason for demand that leads to consumption beyond the point of value.

The family who pushes the elderly parent to accept aggressive chemotherapy and the healthy executive who insists on silly heart imaging tests. These are signals of conspicuous caring. AF ablation has yet to be proven effective in a placebo-controlled trial. Yet, due its invasive nature, it puts out a big signal of conspicuous caring.

Such hidden motives explain a number of observations. 

Conspicuous caring explains why people shun simple remedies, such as stress reduction and better diet, but embrace fancy care with showy gadgets. (Think robotic surgery.)

Conspicuous caring explains the focus on public rather than private signs of medical quality. For instance, people still prefer doctors over advanced practice professionals for primary care—even though trials show similar outcomes.

Conspicuous caring motives also predict society’s reluctance to openly question medical quality. To the degree that medical care serves as a gift, it breaks a norm to question its quality. References: second opinions are uncommon and skeptical views of medicine carry a bit of a taboo.

The reason I wrote about Simler and Hanson’s idea is that for twenty years of practice I have missed the elephant in the room—or in this case, the elephant in the brain. Of course, John, human behaviors surely lie at the core of why we accept so much low-value care.

The other reason why this idea is important is that policies that ignore hidden motives may completely fail.

Take a look at my column. Read the book.

Let me know what you think. 

Questioning Your Doctor is Ok

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I received a good question(s) from a reader:

In your “Changing the culture” posting there is the comment: “Patients seeking medical treatment should not assume a prescribed therapy is beneficial just because a doctor says it is.”… How then does a patient evaluate a proposed treatment in a way that they aren’t thwarting a doctor from performing what may be a needed course of treatment? … Other writing I’ve seen describes doctors being too accommodative to patients reluctance at a treatment. A bad feedback loop if there was one.

Patients should definitely not assume a treatment (or test) is beneficial just because a doctor says it is. Doctors often practice dogma-based medicine. We get into patterns because that is the way we were trained, or that is the way we have done it for years. One study suggests it takes 17 years for doctors to assimilate evidence into practice.

Take the care of AF patients in the hospital. We, in our hospital and hospitals across the country, are trying to increase the cost-efficiency of caring for patients with AF. The problem is huge variation in care: some docs see a patient, treat her with oral meds, and get her home the same day, while other docs see a similar patient, admit her, put her on IV meds, do many expensive tests and keep her admitted for days.

AF is a variable condition, but one reason there is this much variation in practice is that many doctors don’t keep up. They don’t read the evidence. The other reason for overuse, especially in the US, is that doctors are paid more to do more. Hospitals worry about the latter practice because although they make more money with that approach now, reimbursement will soon favor efficient care rather than more care.

In my last post, I discuss another reason you should not assume a treatment is beneficial even if recommended by a doctor: too often, doctors accept treatments based on weak evidence. Minimally-invasive robot-assisted hysterectomy ended up being 10% worse than traditional surgery. For every 10 women treated with the minimally invasive surgery rather than regular open surgery, one was harmed by having recurrence of cancer.

Doctors–including those who wrote the guidelines–accepted minimally invasive surgery for this indication based on biased weak studies. They thought it was better but when tested in a randomized controlled trial, it was not.

I know questioning a doctor may sound complicated, but it is not. I have written multiple posts (here and here) on the big four questions to ask a doctor about a treatment or a test:

  1. What are the chances it will help me?
  2. What are the chances it will harm me?
  3. What are the alternatives?
  4. What if I do nothing?

Also good news for patients is the democracy of information from the digital age. Take a look at this excellent column the journalist David Epstein wrote for the Atlantic. The title says it all: When the evidence says no, but doctors say yes. Here is a brief quote:

“While he was waiting in the emergency department, the executive took out his phone and searched “treatment of coronary artery disease.”

The point is not that you can be a doctor with a smartphone, but you can look learn basic facts and read guideline statements. For instance, the Cochrane Collaboration, a group of researchers the world over, cull evidence and publish what are called systematic reviews on medical/surgical treatments. Each one of these reviews include plain-language summaries.

Having information helps you get more out of a visit with your doctor. The doctor’s role is changing. More and more, we are becoming advisors rather than prescribers. Good doctors offer the needed context for the information you have learned. They can help you make the best decision for you.

Finally, on the last part of the question: what if having good information leads to patients not taking a treatment?

This is ok. For instance, It happens all the time with clot-blocking drugs to prevent stroke in patients with AF. When people learn how much (or, for some people, how little) the drug reduces the risk of stroke and increases the rate of bleeding, they decide not to take it. Others hear the same statistics and decide to take it.

I say this all the time during lectures on shared decision making and informed consent: doctors may be the experts in medicine, but patients are the experts in what is important to them.

JMM

Grander Lessons from a Failure of Robotic Surgery

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This week on my podcast, I deviated briefly from cardiology to discuss a shocking and sad study highlighting the vital nature of doing randomized controlled trials in the practice of medicine.

The reason I mentioned a trial comparing 2 types of hysterectomy (removal of the uterus) in women with early stage cervical cancer was not to opine on matters of cancer, but because the tragic story shows the harm doctors can do if we incorporate therapies without proper testing.

The New England Journal of Medicine published a trial in which women with early cervical cancer were randomized to two types of hysterectomy:

  • One was the type you see on billboards: minimally invasive laparoscopic robotic surgery
  • The other group got traditional open surgery.

The investigators measured the rate of disease-free survival at 4.5 years. They put about 300 patients in each group.

The results were shocking: 86% of women in the minimal-invasive arm were free of disease vs 96.5% in the open surgery. The difference was a whopping 10.6% worse. In other words, the minimally invasive surgery vs the standard approach harmed one in ten women.

In the introduction of this paper, the authors write that current guidelines say either approach to this cancer is acceptable and “these recommendations have led to widespread use of a minimally invasive approach for radical hysterectomy, although there is a paucity of adequately powered RCTs.” Translation: doctors embraced this approach, hospitals advertised it and patients accepted it without proper evidence.

The message here transcends just one medical condition. It’s a message about doctors’ hubris–our excess confidence in accepting new therapies that have yet to be tested.

Cohort studies, small studies, retrospective studies should not lead to widespread acceptance of a new therapy. If you don’t randomize patients and blind the judges, you can’t be sure the treatment works. New approaches ought to be tested in this way.

Doctors need the courage to put our beloved therapies to the test. Patients need the knowledge to ask whether a proposed treatment has been tested in an RCT. Regulators could help by more often tying reimbursement to evidence generation. Viz: They could say, ok docs, you want that new device? We will pay for it if you enroll patients in a trial.

Finally: whenever you hear someone in medicine say we do something because it’s in the guidelines, I urge you to go to that document, find the paragraph and look at the citation. If it goes to anything besides a randomized controlled trial, be very skeptical.

JMM

Thoughts on the Apple Watch

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Apple products are cool. I love them.

But (even) Apple will struggle delivering health.

Making healthy people healthier is fraught with problems.

At the core of this issue are the many snags of screening people for disease.

Here are 600 words I wrote for Medium: I’m a Heart Doctor. Here’s Why I’m Wary of the New Apple Watch

Here are my thoughts in the Wall Street Journal:  https://www.wsj.com/articles/apple-adds-heart-monitoring-fall-detection-features-to-its-watch-1536792518

And the Washington Post:  https://www.washingtonpost.com/technology/2018/09/14/what-cardiologists-think-about-apple-watchs-heart-tracking-feature/?utm_term=.3dd8d07c74f0

And The Atlantic:  https://www.theatlantic.com/technology/archive/2018/09/the-new-apple-watchs-heart-monitoring-is-complicated/570115/

And MarketWatch:  https://www.marketwatch.com/story/apple-watch-wants-to-monitor-your-hearts-health-and-cardiologists-say-it-could-make-you-worry-instead-2018-09-13

Even Slashdot:   https://science.slashdot.org/story/18/09/14/2125223/what-cardiologists-think-about-the-apple-watchs-heart-tracking-feature

My colleague Patrice Wendling from theheart.org |Medscape Cardiology captured some of my positive comments on the watch: https://www.medscape.com/viewarticle/902018

If you like academic prose, here is an editorial I co-wrote on AF-screening for the influential medical journal, JAMA-Internal Medicine: Screening for Atrial Fibrillation Comes With Many Snags

JMM

Also … You can hear my thoughts on the five top cardiology stories each week on my podcast: This Week in Cardiology. The link on iTunes is here: https://itunes.apple.com/us/podcast/this-week-in-cardiology/id991125169?mt=2

How Hubris Impairs the Care of the Elderly

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An elderly man with atrial fibrillation (AF) asks whether to continue taking a clot-blocking drug to prevent stroke.

This is the gist of a case my colleague Dr Anish Koka recently posted on Twitter. It’s a great thread. Click here to get to the discussion.

The first question Anish raised was whether you would keep a 101-year-old man with AF on an anticoagulant. For the sake of argument, you could make him a her, or you could make him or her 91 years old.

Let’s just say it is a very old person with AF.

The pro-side of using the drug is that the more elderly one is, the more the risk of stroke, and the more devastating a stroke would be. Age is a major predictor of stroke.

The scenario here is similar to the quandary we had with thrombolytic (clot-busting) therapy for heart attacks in the era before stenting: older patients with heart attacks had more risk from the blockage (death, heart failure) but they also had more risk from the clot-dissolving drug (brain bleeding.) Because of the high consequences, the drug delivered greater risk reductions but at the cost of a greater chance of devastating bleeding.

Use of the anticoagulant in an elder therefore provides a robust degree of probability benefit in the future.

The down side of keeping an elder on an anticoagulant is the higher risk of bleeding. Older people have a higher rate of harm (bleeding) from the drug.

Evidence cannot help us here. There are no studies that include patients in their ninth or tenth decade. The word for using evidence acquired in 60 year-olds to the very elderly is… foolish.

Also foolish is the idea of letting the patient decide. How the hell is the patient supposed to know the right answer? The way we frame this decision will surely sway the patient. Yes, it’s right to share the decision with the patient, but the advisor need be square on the decision at hand. Giving patients a menu of choices is akin to abandonment.

This decision, like so many in medicine, requires judgment. It also means resisting hubris.

The typical hubristic reasoning in this case means considering two potential errors. An error of omission occurs here if we choose not to use the anticoagulant and the man has a stroke. We omitted the drug and that omission played a role in his stroke. An error of commission occurs if we choose to use the anticoagulant and he suffers catastrophic bleeding. We committed him to preventive therapy and that commission played a role in his demise.

Many doctors struggle with this choice.

The struggle exposes our hubris. We are falsely confident that we control outcomes of a person who has lived for decades.

I strongly believe we do not control this person’s outcomes.

One need not consult actuarial tables to assess the chance of a 90 or 100 year-old person dying in the next year. It’s high–whether we recommend preventive therapy or not.

That being said, I would not take the nihilistic view that there isn’t a correct answer.I believe there is a best answer.

It is: do not use an anticoagulant.

During a recent trip to the University of Calgary, my electrophysiology colleague Dr George (Yorgo) Veenhuyzen taught me an important lesson about decision making under uncertainty. It applies to this scenario.

The lesson goes like this: when there is true equipoise of a treatment (a complete counterbalance), and that treatment has potential harm and added cost, the right answer is not to treat.

Of course it is. The doctor’s golden rule is first, do no harm.

In the very elderly, there is no proven benefit of anticoagulant drugs. This would require a study of very elderly people. There isn’t one; nor will there ever be. There is however a well-known increased risk of harm due to bleeding and added cost of the drug.

I would also add to my Canadian friend’s logic that people who have been lucky enough to live to old age deserve the right to avoid iatronegensis–or harm brought by us.

In this particular case, Anish tells us the elderly man did not continue with the anticoagulant. He went on to suffer a stroke.

Anish tempts us with further choices: should we “do nothing” or should we recommend clot extraction using the new devices.

This is an easier question to answer. The same thinking applies, only with a special caveat. Of course, I would not recommend a femoral access and invasive procedure in a very elderly man. The studies of these devices were done in much younger patients. Plus, it takes little experience to know the difficulties and potential harm of threading catheters up the blood vessels of 90+ year-olds.

But I would also argue that “do nothing” is not the alternative. One of the greatest errors of our time, one that frustrates me immensely, is the idea that not doing invasive procedures equates to doing nothing. How many times have I heard a nurse or doctor say “we have nothing to offer?”

We have plenty to offer people at the end of life. We can offer caring. Nowhere in the definition of caring is doing invasive procedures.

We can care for this man by attending to his needs and by trying to relieve any of his suffering.

Another thing we can do is reframe our thinking. Rather than bemoan this man’s fate, we could celebrate the fact that he lived a long life, one that will be mostly compressed without much morbidity. That is, assuming he receives adequate palliative care.

Finally, in this era of death denial and increasingly invasive medical technology, it would be wise to heed the words of the late Ivan Illich, a critic-philosopher, and once catholic priest.

In his prescient book Medical Nemesis (circa 1975), Illich wrote of three forms of iatrogenesis wrought by the medical establishment. Clinical iatrogenesis is harm from medical error. Social iatrogenesis is the medicalization of normal life.

But the most insidious form of harm from the medical guild is a cultural iatrogenesis–or medicalization that corrupts the essence of what it is to be human.

Illich wrote that “the medicalization of society has brought the epoch of natural death to an end. Western man has lost the right to preside at his act of dying.”

JMM

Flat-of-the-Curve Cardiology Practices

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If you think about it, you can’t get much done. So you don’t think about it. You just shake your head and keep tapping on the computer; the next patient awaits.

To avoid moral distress, to remain employed as a doctor, you don’t think about the high cost and waste of cardiac care.

Dr. Andrew Foy is a friend and cardiology researcher at Penn State College of Medicine. He and I wrote about the rising economic burden of delivering cardiology care in the United States.

What follows is a summary of our chapter published in the academic journal Primary Care Clinics. 

We first put numbers to what everybody sort of knows: heart disease is a major health problem and it costs bunches to treat. Men, for instance, have a 1 in 2 chance of getting heart disease over a lifetime. It’s a little less (about 1 in 3) for women.

In the US we spend about $457 billion on cardiac care. For reference, that is equal to more than half of what the US government spent on education ($812 billion); more than two-thirds of what it spent on defense ($622 billion); and more than what was spent on welfare ($320 billion) and transportation ($229 billion).

The second part of our chapter considers how these growing costs affect people. The short answer is…negatively.

Higher costs of care mean higher insurance premiums. We found evidence that higher costs of insurance premiums play a major role in wage stagnation. Think about it: you get a higher salary, but your employer extracts more to pay for insurance. The net is no gain or less gain in take-home pay.

Another negative effect of higher costs is the threat to government programs like Medicare and Medicaid. We explain that Medicare spending has far exceeded its originally intended revenue source of payroll taxes, requiring ever-increasing premiums and general revenue transfers to maintain solvency. Medicaid is even more vulnerable because it’s run by states, which cannot operate deficits and therefore limit costs by reducing payments. Herein lies the worst part of wasteful care: overuse exacerbates underuse and inequity of care. 

The second half of the chapter explores the causes of expensive cardiac care. Three big factors here include 1) an aging population, 2) tech advances, 3) supply induced (flat-of the-the curve) medical care and its resultant medical overuse.

While life expectancy has increased about 13% (6% for women) over the past half-century, spending on health care has increased more than five-fold. What’s worse is that most experts think direct spending on health care contributes only about 10% toward population health.

The question is: why do Americans spend so much for so little? And the answer—at least in cardiac care—is that the fee-for-service system is perfectly designed to deliver the results it achieves. In this model, those who provide and pay for care have little incentive to restrain service use and/or limit unnecessary costs.

Here is where we introduce flat-of-the-curve medicine. These are medical practices that create little to no health benefit.
Flat-of-the-curve medical care is “supply-induced.” This means it’s driven by supply rather than demand.

Flat of the Curve Spending

Cardiac stress testing provides a great example. Stress tests come in many varieties: a plain treadmill test is least expensive while stress tests that use drugs and echocardiograms or nuclear scans are far more expensive. In general, all stress tests perform roughly the same—they are designed to detect blockages and help sort out the risk of future events.

In a normal market, the cheapest test would be the most common. But that’s not what happens in a fee-for-service system. Doctors order far fewer regular stress tests. One study we cited reported it was 65% to 14% for nuclear vs regular stress tests.

The use of tests to find heart disease has greatly expanded over the last two decades. Consider that the percentage of nuclear stress tests with evidence of blockages has declined from 30% to 5%. Think about that: we are doing more testing and the vast majority are negative tests. That defines flat of the curve practice. Big costs but no benefit.

Look at this graph.

We used data from a paper in the journal Circulation to make that image. Doing more cardiac procedures used to diagnose and treat blockages have not associated with a reduced the rate of heart attacks. More flat-of-the-curve practices.

Why does this happen?

One reason is that cardiac tests are driven by supply rather than demand. We cited a study showing that use of cardiac procedures in elderly patients after heart attack had risen more rapidly in the United States than in Quebec–but both areas had equal declines in death rates. Another group found rates of stent implants (for stable conditions) was 2.3 times higher in New York compared with Ontario. The authors speculated this may have been due to a higher density of interventional facilities in New York.

I’ve seen this during my career. Hospital systems build a hospital and business comes. That would be fine if there was a signal that it improved outcomes. We can’t find one. This is not right. Cardiology care should be driven by demand not supply.

The last sentence of our chapter speaks to physicians:

Continued growth in health care spending limits spending in other areas, and although physicians may not be able to directly change health policy, they can limit unnecessary spending by avoiding flat-of-the-curve practices and optimizing the use of tests and procedures.

To patients and to my colleagues: please think about that curve.  Is the stuff you are doing on the steep part of that curve or the flat part.

If it’s on the flat part, consider doing less of it. It’s like turning off your lights when you leave the house. Not wasting money is the right thing to do.

Here is another picture of the curve–with examples of high value and low value cardiac practices:

JMM

References can be found in the chapter, which I hyperlinked above.

Foy AJ, Mandrola JM. Heavy Heart: The Economic Burden of Heart Disease in the United States Now and in the Future. Primary Care: Clinics in Office Practice. 2018;45:17-24.

Recap of 2017 in Cardiology

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Hi all.

TheHeart.org | Medscape Cardiology published my picks for the top stories of 2017. Here is the link: Mandrola’s Top 10 Cardiology Stories of 2017

I called it the year of the medical reversal. Medical reversals occur when a superior study contradicts current practice.

I love medical reversals. First, they make you think about history. History teaches us a lot. Second, reversals reduce hubris–always a good thing. Finally, writers must have controversy. Controversy is our canvas. Reversals and doctors’ delay in accepting the new practice is fun to watch and write about.

Some highlights from 2017:

Doctors were shocked to the core that stenting a major blockage did not relieve chest pain any better than a sham procedure. That’s shocking because we already knew stents used in patients with stable disease don’t reduce the odds of a heart attack or death. Now, if they don’t even relieve chest pain. OMG. Billions are spent looking for and fixing blockages.

Another reversal of recent years was the failure of a special kind of stent, called the BVS. The name is not important. The idea was that the cage would disappear over time. Vanishing stents promised to make the artery healthier in the long run. BVS failed. Miserably. But we knew this in 2016. The story in 2017 was that experts denied to accept the failure. When key leaders don’t admit error and they keep promoting a treatment that harms people, that breaks our trust. The medical profession needs trust.

One of the biggest reversals of our lifetime may be the revelations on fat intake. I discussed the issues in point 3 of the piece.

Sucking clots out of blood vessels seems like a good idea. Nope. Studies showed it doesn’t work any better than standard care. Yet here is the thing: doctors keep doing it because “they know” it works.

Since I began cardiology, we have tried to prevent kidney injury from contrast agents given to show blood vessels. This year, two studies found that three common practices to protect the kidneys did not work. Yet, you guessed it. Doctors still do it. Even crazier: one of the practices shown not to work is considered a marker of healthcare quality.

(Imagine that: a practice used to grade doctors and hospitals on quality was proven useless and actually slightly more harmful than doing nothing. My friends, here is a pro-tip: most quality measures, star ratings and the like are a total farce. I have never been more convinced that many quality measures reduce quality.)

Speaking of farces, that we say patients with pacemakers and defibrillators must have special devices (called MR-conditional) to undergo MRI scans is also utter nonsense. This year, a major study, and an expert consensus statement from Heart Rhythm Society (I was an author on it), showed that old thinking needs revision. Another truth: almost any cardiac device is safe in an MRI if the scan is done with a protocol and supervision.

Opioids made the top-ten. Tragic is the best word to describe what’s happening to youngsters afflicted with infections in the heart from IV heroin.

Inflammation made the list. So did a possible (emphasis on possible) new way of ablating heart tissue without invading the body.

Finally, there was no big news in atrial fibrillation in 2017. We still don’t understand the condition. We still ablate in the same inelegant way. I still see tons of overuse and misuse of AF treatments.

JMM

Thoughts on the Apple Watch and Mobile ECG

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Last week I wrote a column on theheart.org | Medscape Cardiology on the new Apple Watch ECG and Kardia Band.

The Tweet I sent out on Saturday has done well — 74 Retweets (without any robots) is pretty good.

Here is an overview of some of the points I made in the column.

One is that Apple’s interest in AF is huge. The company has partnered with Stanford researches and has started the Apple Heart Study. Any owner of an Apple Watch can volunteer to participate.

The excitement of mobile ECG technology is that it allows for rhythm screening–mostly AF. The thinking: stroke is a major health problem; AF associates with stroke and we have treatments (anticoagulants). Thus it would be good to know one’s heart rhythm.

You know how simple thinking about screening works in medicine. Yes, there are snags. One problem now is accuracy. In the column, I attached two AliveCor tracings that mistakenly labeled premature beats as AF. Both patients suffered anxiety from the fake AF.

I did list many upsides of mobile ECG technology.

  • Marc Cuban himself tweeted on my timeline that he had AF and likes the peace of mind of knowing what his rhythm is.
  • A man from Romania, where access to doctors is less than it is here, made the point that mobile ECGs allowed him to get faster responses from doctors.
  • My friend Dr. Gopi Dandumudi from IU believes that empowering consumers to be involved in their healthcare is a good thing in the long run.
  • And I have often prescribed the AliveCor to confirm diagnoses and monitor for side effects from drugs.

Indeed the device is useful for specific tasks.

Of course, its proponents (and marketing team) hype it as a revolutionary tool for health. This may be true someday, but I have many concerns in the interim.

Here are four challenges.

One is that the causal link between AF episodes and stroke is less certain than you may think. This argument gets complicated. There was once a researcher named Bradford Hill who came up with nine criteria that should be fulfilled if one factor is thought to cause another.

AF does fulfill some of these criteria, but it clearly does not fulfill others. For instance, one of Hill’s criteria is correlation in time. AF fails this criteria because there are multiple studies showing poor correlation between the timing of AF episodes and stroke event. (I explain more in the column.)

Another challenge is that we don’t whether clot-blocking drugs (anticoagulants) will benefit patients with shorter-lived or non-symptomatic AF (EPs say subclinical AF) in the same way it does those patients with longer-lasting or symptomatic AF. The studies showing anticoagulant benefit were done in people with clinical AF or AF seen on multiple, regular in-office ECGs.

The reasons to doubt anticoagulants will benefit many of the people with short-lived AF is that plenty of studies observe very low untreated stroke rates in these patients. That is key because it’s hard for any treatment to lower an already low event rate. Remember, too, anticoagulants don’t come free: they do increase the risk of bleeding. No doubt these drugs are beneficial in higher stroke-risk patients, but the mobile ECG will greatly expand the pool of lower-risk people.

The most scary challenge of the mobile ECG is that the greater numbers of AF diagnoses will occur in a US healthcare system that pays hospitals and doctors to test and treat. If you combine fee-for-service payment models and most doctors’ fear of anything heart related, it’s easy to predict a massive increase in overtreatment and overdiagnosis. Think here of the children’s book: If you give a mouse a cookie. Proponents rightly point out that this problem is not the fault of technology.

Finally, the big problem with any new technology is its ability to distract us. Here I believe the distraction is from already proven ways to prevent stroke: read the article. I explain what those are.

JMM

The Truth on Cancer Screening

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This week is Cancer Screen Week. It’s a one-sided campaign sponsored by industry and the American Cancer Society that urges people to get screened.

The truth is that the scientific evidence for cancer screening is not convincing. What’s more, screening comes with potential harms.

I know; it’s counter-intuitive, but it’s what the evidence says.

Benjamin Maser is a medical doctor (pathologist) and writer at Yale.

Check out our editorial on WBUR> Does Cancer Screening Save More Lives Overall? Not Necessarily

By the way, you may be thinking: what does a pathologist and a cardiologist know about cancer screening?

My answer is that one need not be a cancer specialist to interpret basic studies. The controlled trials compare a group of people who got screened vs those who do not. These studies, which we cited in the editorial, show that overall mortality is essentially the same in both groups.

That’s not complicated. Nor is understanding the notion of over-diagnosis and over-treatment.

In the article, we favor honesty, balance and informed decisions–not fear and bullying.

JMM