BLOGS Voices Follow

5 Mar 2012

Selections from Richard Lehman’s Weekly Review: Week of March 5th

CardioExchange is pleased to reprint selections from Dr. Richard Lehman’s weekly journal review blog at BMJ.com. Selected summaries are relevant to our audience, but we encourage members to engage with the entire blog.

Week of March 5th

NEJM  1 Mar 2012  Vol 366

Goal-Oriented Patient Care (pg. 777): There is no JAMA this week, and the best things in the New England Journal come right at the start. Whether you are a British GP contemplating another set of humiliating idiotic directives and the imminent destruction of the NHS, or an American physician wondering how your crazy health system can ever be turned into something rational and sustainable, or an academic wondering how much more futile research you have to grind your way through and pretend to be interested in, here is the boost you need. Goal-Oriented Patient Care — An Alternative Health Outcomes Paradigm. For the battle-weary GP, an affirmation of the central value of what you came into medicine to do – to help patients to achieve goals that they choose for themselves, in a continuing dialogue about the possible and the practical. For the American system, a model of care that puts the patient at the centre and emphasizes joined-up, affordable care. For the academic, a new research agenda based on what will best inform shared decision-making with patients and society. Download this article by David Reuben and Mary Tinetti at once and keep it under your pillow.

The NEJM lets you have this free, and also the companion pieces which follow – about shared decision-making and defining patient-centred care. Both good, but the Reuben/Tinetti is a gem.

Arch Intern Med  27 Feb 2012  Vol 172

Stenting vs. Medical Therapy (pg. 312): Doctors and patients love to share simple mechanistic explanations of diseases and cures. Angina pectoris is caused by blocked pipes: unblock the pipes, preferably leaving behind something to keep them open, and you have cured the problem; whereas if you just keep on pushing tablets, you’re just treating the symptoms without dealing with the cause. Most of us shared this belief with cardiologists and with patients, until the COURAGE trial came along in 2007 to prove otherwise (and the trial was nearly never done because many interventional cardiologists considered it unethical). This meta-analysis looks at this and 7 other trials and confirms the counter-intuitive conclusion that “Initial stent implantation for stable CAD shows no evidence of benefit compared with initial medical therapy for prevention of death, nonfatal MI, unplanned revascularization, or angina.” Collusion in mechanistic certainty is one of the great barriers to progress in medicine, and it may cause direct harm to patients, as the next paper illustrates.

Patient Satisfaction and Mortality: There isn’t much else of note in this week’s printed Archives, but hidden in the Online First section awaiting paper publication is a remarkable study of patient satisfaction in relation to outcomes. This is worth spending some time on. In the USA, the highest quartile of patient satisfaction is associated with 9% higher inpatient care and drug costs, and – wait for it – 26% higher mortality. What is killing America’s most satisfied patients? Is there some hidden confounding here (as the editorial hints)? The authors adjust for everything obvious, such as age and health status; so perhaps the kind of medicine these patients are getting really is 26% more dangerous. But this exceeds even the most pessimistic predictions of those of us who have long held that the overprovision that American patients are programmed to demand might be dangerous. Costly, futile, yes: but as lethal as this? I intend to spend an hour with my brilliant group of young overseas doctors at Yale picking over this paper. If nothing else, it will have some lessons on what to avoid in their own health systems. I firmly believe that all health provision should be judged by the experience of patients, but the simple criterion of fulfilled expectation is clearly inadequate, and may be positively dangerous in societies which ratchet up demand for medical services while ignoring costs and harms.