The Doctor Weighs In

Nearly 10 years have passed since I first began to see articles from leading vascular scientists like Drs. Erling Falk and Peter Libby that told us that bypass surgery and angioplasty did not prevent heart attacks in stable patients.  These innovators helped us to understand that aggressive medical therapy was the most powerful intervention to prevent myocardial infarction.  Very soon after that I changed my practice from general internal medicine to what has become a focused practice of vascular medicine.  For 10 years now, I have been treating vascular disease with lifestyle change and medical therapy.

Almost as soon as the South Beach diet came out, I was impressed that it was a more sensible approach to weight loss.  The very low fat diet that was popular at that time naturally emphasized carbohydrates and produced triglyceride elevations.  The very low carbohydrate diet allowed the intake of large amounts of saturated fat and that made no sense for patients with high cholesterol and vascular disease.  The South Beach diet called for a reduction in carbohydrate—especially processed carbohydrate and sugar.  It also called for reduction in fat—especially animal fat.  This seemed much more balanced.  The South Beach diet has been very effective in my patients and has helped hundreds lose weight, lower their triglycerides, lower their LDL, and control their blood sugar.  I knew early on that Arthur Agatson is a physician, but I really did not know that he is a preventive cardiologist.

Dr. Agatson had also become aware of the new science demonstrating the power of lifestyle and medical treatment in the improving arterial disease.  He has been a great innovator and has developed an advanced preventive cardiology program in Miami, Florida.  He developed the technique of coronary artery calcium scoring which correlates with the total cholesterol plaque burden in the artery and the history of arterial plaque ruptures.  In fact, the coronary calcium score is calculated using the Agatson method.

He has written a whole series of books on diet including the South Beach diet and a number of cookbooks.  We can find South Beach frozen dinners in the grocery store.  We can find South Beach items on the menu of chain restaurants.  And now, perhaps the best of all, he has combined all of this in a book called the South Beach Heart Program.  This book is wonderfully well written so that patients can fully understand very complicated topics that are important to assess and treat their vascular disease.

The new science of vascular disease has become irrefutable.  This one physician, Dr. Arthur Agatson, has developed new techniques for education, diet, and disease assessment that have dramatically improved our care for these patients while advancing this new science.  If you have an interest in vascular disease for any reason, you owe it to yourself to read Dr. Agatson’s new book, The South Beach Heart Program.  It is fully referenced and I can tell you after 10 years doing this work—it is right on target.

By William Bestermann MD

Half of health care's $2 trillion dollars is spent on five chronic conditions. Three of those conditions - vascular diabetes, coronary disease and congestive heart failure - are interrelated in their causation. If we simply applied what we have already learned, we could eliminate enormous suffering and significantly reduce the cost of these conditions.

Many professionals in positions of leadership today were educated in the 60s, opposed the Vietnam War, and viewed military intelligence as an oxymoron. But my oldest son, a West Point graduate, has taught me lessons that have changed my life and are relevant to the major conundrum facing medical practice today.

West Point places a primary stress on technical adaptation.  These young cadets are taught “Tactics Lag Technology.”  That is to say if the officer applies tactics appropriate to the last war in the face of more deadly weaponry in the current war, he will likely be responsible for the deaths of hundreds if not thousands of his personal friends, team mates, and countrymen.  Military officers, in their movement upward in rank and responsibility, learn of our own new technical capabilities, those of potential enemies, and how to integrate these into best military practices to minimize casualties while increasing the likelihood of success of the mission.  This is a central focus in military culture.

First, a bit of military history

These cultural attributes of the modern American military officer did not just drop out of the sky.  West Point cadets study the American Civil War in some detail.  That conflict saw the beginning of dramatic technical change including railroads, rifles in large number, and trenches that transformed warfare forever.  Prior to the War Between the States, for thousands of years, generals managed the attacking force in the same way.  The defenders would line up over a broad front, in ranks perhaps two or three deep, over a couple of miles depending on the size of the force. The attacking force would assemble in front of them in full uniform with color guards and regimental bands playing marching music.  Then the attackers would march to within effective range of their weapons.  As the Civil War began, most units were armed with muskets and the effective range was 40 yards.   So the Union and Confederate units would march to within 40 yards, fire one volley or perhaps several followed by a bayonet charge.  The carnage was not terrible and the loser was the one who lost his nerve and abandoned the field.  

As the war progressed, both sides replaced muskets with rifles and the defenders dug trenches.  As the Confederates prepared for Pickett’s charge at Gettysburg, the Union troops were behind a stone wall defense and armed with rifles.  Nearly a mile of open field lay between the opposing forces.  The Southern Commander Robert E Lee had ordered the charge, but Corps Commander Longstreet objected, simply knowing by observing the situation that the mission was impossible.  General Lee ordered him to charge the Union force in spite of the objection and Pickett’s Division was cut to pieces in a matter of minutes.

The following spring, US Grant had assumed command of all Union armies.  He was determined to end the war by capturing Richmond and crossed the Rapahannock River to begin what became the Overland Campaign.  In battle after battle, the Union forces charged entrenched confederates, with the same resulting horror the Confederates suffered at Gettysburg.  General Grant suffered 60,000 casualties in the month of May 1864 alone.  The puzzle of the rifle and the trench never was solved in the Civil War.

Amazingly, when WWI started 50 years later, tactics had still changed very little, though the technology of war had changed dramatically.  The forces involved had tanks, airplanes, machine guns, repeating rifles, mortars, breech loading artillery, trenches, and barbed wire at their disposal.  The method of attack had not changed.  The frontal assault was still the order of the day.  The British suffered 60,000 casualties on the first day of the Somme offensive.  The generals still did not get the message and over the new few months 500,000 promising young men were shot down in that single campaign.  WWI ended and the puzzle of the repeating rifle, trench and machine gun was still not solved.

The wrath of the status quo

The terrible carnage of WWI broke the spirit of Europe and there are still residual cultural effects on that continent.  In the aftermath, the promising young American officers Dwight Eisenhower and George Patton wrote infantry journal articles describing a new kind of attack that would later be called “blitzkrieg” or lightning war.  In this assault, all of the heavy weapons of the attacking force would be combined in units actually making the assault.  All of the tanks, artillery, bombers, machine guns, mortars and mechanized infantry would be thrown at the weakest point in the enemy line. They would break through, and turn left and right to “roll up” the force in the trench.  History has shown this to be a brilliant disruptive innovation in warfare and frontal assaults no longer occur.

How did the senior army leadership respond?  The Chief of Infantry called Eisenhower in and told him that his articles did not represent sound infantry doctrine and that if he wrote any more articles of that nature he would be court-martialed.  Billy Mitchell actually was court-martialed for advocating similar valid innovative disruptions in the army air corps.  Thank goodness the innovations advocated by Eisenhower, Patton, and Mitchell were adopted and played a critical role in WWII.

The change from frontal attacks to the attack of supreme violence aimed at a point is a very dramatic example of paradigm change.  The whole dynamic of combat changed from a defense that could not be overcome to an attack that could not be resisted.  The officers directing the blitzkrieg assault were not more diligent, more industrious, smarter, brighter or more dedicated than their predecessors.  No, they were not superior in any way-they had simply used a new system, a new application that was more effective.

So what does all of this have to do with medicine?  

You might think “How could these people be so blind? We would never do such a thing.”

Think again!  The science around medical practice in the treatment of atherosclerotic vascular disease has utterly changed.  The evidence that demands a change in paradigm has become irrefutable.  The technology of vascular medicine has progressed at a pace fully equal to that seen in the military.  The old attack on vascular lesions in stable patients aimed at fixed narrowings – bypasses and stents – are as thoroughly discredited as frontal assaults in the face of machine fire. (More on this in another post.)

The Institute of Medicine is the medical arm of the National Academy of Sciences.  The IOM membership is composed of 1,400 of the best minds in medicine.  In its 2001 report, “Crossing the Quality Chasm,” the IOM summarized what was needed to treat chronic conditions:

“The current systems cannot do the job. Trying harder will not work.  Changing systems of care will.”

This document is the medical equivalent of the infantry journal articles written by Patton and Eisenhower.  It is a call to action and change, yet little in practice has changed since it was published in 2001.  Why?  The Chief of Infantry is alive and well.  Paradigm change has dramatic consequences and, for the leaders of the old order, the changes are negative.

The consequences of the utter failure of leadership in this case are exactly the same as a frontal assault: thousands of dead and disabled as a monument to our inaction.  Heart attack and stroke accounted for roughly 800,000 deaths in 2003. Many of these deaths were premature and avoidable. The bodies may not lie in heaps before a trench-line, but they mean the same thing: a failure to bring the full benefit of new technology to those we have promised to protect. 

There is a very real price to be paid for our failure to translate our new scientific knowledge about vascular disease into practice.  The Steno II trial compared optimal medical care (that is, drug therapy) in type 2 diabetes to usual care, and reduced the number of vascular events by half.  Only a small percentage of the study's patients had to be treated more aggressively to prevent a heart attack or a stroke.

The type 2 diabetic has a lifetime risk of dying from a vascular event of 65-80%.   Each risk factor - glucose, pressure, and cholesterol - treated to goal using the right medication reduces the risk of a vascular event by half.  Only 7% of type 2 diabetics have all three risk factors simultaneously to goal. 

Our failure to provide more aggressive risk factor management in these patients obviously is very damaging to their health.  The economic cost is equally painful.  Half of health care's $2 trillion dollars is spent on five chronic conditions. Three of those conditions - vascular diabetes, coronary disease and congestive heart failure - are interrelated in their causation. If we simply applied what we have already learned, we could eliminate enormous suffering and significantly reduce the cost of these conditions. In stable angina patients, optimal medical therapy was just as good in preventing a heart attack in a stable angina patient as optimal medical therapy plus a stent—for one third of the cost.

If current trends are any indication, medicine, the insurance industry and government will be slow to lead on transformation.  Patients and businesses that pay the bills must demand better or continue to receive medical care that is not what it could be.

Dr. Bestermann is medical director of the Vascular Medicine Center at the Holston Medical Group in Kingsport, Tennessee.

By Brian Klepper

I generally make a point in my professional writing not to talk about myself, but today I make an exception.

It was 5 years ago today, July 5, 2002, 3 weeks before my 50th birthday, that I had open-heart surgery, where the blocked arteries of my heart were replaced. In medical shorthand, the procedure is called a CABGx5, which means a 5-vessel Cardio-Arterial Bypass Graft. In other words, they used pieces of vein, in my case from my leg, to reroute 5 vessels that carry the blood from my heart to feed the rest of my body. If you think about it, it’s a straightforward piece of mechanics, but of course it really is a modern miracle, the product of great advances in knowledge, skill and technology.

It surprises people when I tell them that having open heart was one of the most positive experiences of my life. But it’s true. How many of us go through an experience that takes us to the edge of death, and then, within a couple of weeks, has us back and engaged in life, physically and emotionally revitalized?

If I had lived 100 years ago, I’d almost certainly have died before my 50th birthday. Only because I had the great fortune to have resources, to live in a wealthy nation, and to live in this era, am I alive to really enjoy and be engaged in life over the last five years. That pleasure was, of course, heightened immeasurably by the just-glad-to-be-here exuberance that I still feel every day.

On this day, I think of the many people I owe great debts to:

• My physicians, Drs. Glock, Schrank and Koster, whose great skill and grave humor pulled me through.
• The Baptist Health System nursing staff, who cheerfully and capably goaded and guided me through my inpatient stay, rehab and home care.
• My great pal Steve Blumberg, who did much more than I was aware of to make sure all would run smoothly, which it did.
• My good friend George Lundberg MD, who called and calmed me with the facts when he heard about what was in store.
• My dear childhood friend Fannie Newman, gone now, who by serendipity called me the night before my surgery, and who, by the example of her own much greater courage, inspired me to face my fear directly and to understand that I could play an active role in my own recovery.
• Brooks and Helen Brown, who sat with Elaine during the entire surgery and provided unwavering support.
• Randy Kammer and my friends at Blue Cross and Blue Shield of Florida, who immediately jumped into the fray and expedited my care.
• My many friends, who came out of the woodwork and made me remember that life is about touching souls.
• And most of all, to my wife Elaine, who really brought me through, and whose presence then and now is the light of my life.
  

Here’s what I wrote in the weeks after my surgery, as I was re-emerging. I was so engrossed in the experience, I recorded it so I would never forget.

Thanks for indulging me on this day.

Brian


August 25, 2002

Recently I received a big surprise, open-heart surgery. For several weeks beforehand, my chest hurt and I was short of breath whenever I mowed the lawn. I procrastinated, then called my doctor.

After some tests, he became alarmed. There was a widening in the thoracic aorta, and he worried it might be an aneurysm. It was late Friday afternoon, so he sent me over to the emergency room for a CT scan. Elaine joined me for some anxious waiting, and then the discovery that it was “just” a hiatal hernia. When my doctor joined us in the ER suite, we already had the news and were in full celebration mode. I announced we were going right home to have a steak, some Rocky Road ice cream, and then we were going to fool around.

He was unimpressed. "No," he said. "You passed the first hurdle, but we still don't have a good explanation for the chest pains. Monday you’ll see a cardiologist, and Tuesday you'll have a cardiac catheterization."

"Rats," said I. "I was counting on the Rocky Road."

Three of my grandparents died of cardiovascular disease. A heart attack killed my maternal grandfather at 48. My mother occasionally remarked that my grandmother had murdered him with chicken fat. A month shy of my 50th birthday, it didn't bode well.

The catheterization frightened me. But they put me under, it went off without a hitch and didn't hurt afterwards. That said, it typically takes 15-30 minutes, and they spent an hour and a half on me.

They called Elaine in after reviewing the images. The doctor was pointed. “Your husband has serious advanced cardiac disease.” She says she did a double-take, as in “Him? The healthy guy over there?”

They woke me and the cardiologist walked over. "You have a problem,” he said. “One vessel’s completely occluded and four are more than 75%. We need to do a multiple vessel CABG."I had an important business meeting coming up, and I protested for time. Elaine suddenly popped into my field of vision, pressed her nose next to mine, and said sweetly, firmly, filled with resolve, “Honey, you’re not going. You can put that out of your mind.” I knew I’d lost.

In recovery, the surgeon dropped by to introduce himself. He was pretty straightforward. “Look. You’ve had a load of crap dumped on you. We have to dig you out.” Charming or not, the metaphor drove the point home. I agreed.

They set me up for 3 days later, after the big holiday. As a parting shot, I asked the surgeon what would happen if I made love before the operation. He didn’t miss a beat. "You'll likely go out in blaze of glory."

I had a few days of anticipation. I read up on the procedure, how they'd saw my sternum in half, take a vein out of my leg, and sew me back together. They do nearly half a million of these procedures a year. The complication rate is less than 2%, lower than for tonsillectomies.

The Big Day, Elaine and I arrived at 5:30 AM for the 6:30 surgery. I undressed and they shaved me from stem to stern. This done, we had the chance for a little small talk. With nothing to do but wait, I wallowed in a little self-pity, whining aloud why I, who don't smoke, eat a good diet and am relatively fit, am going through this. An old black nurse sidled up and gave me a pitying look, "Sometimes," she said, "it just BE'S that way." Elaine meant it when she said, “That’s probably the smartest person in this hospital.”

When the anesthesiologist showed up, I told him I have friends who counseled me to ask for Versed. I said, "As long as I'm here, give me the good drugs." Elaine rolled her eyes. He smiled. Suddenly, I don't remember anything more.

Elaine says that after the Versed but before things got rolling, I sat up on the gurney. She told me to lie down, but I said I couldn't because I didn't have a pillow. Then I turned to the anesthesiologist and asked whether he followed protocols. Elaine said he started laughing, and said he did. I don't remember any of this, but I apologized later.

When I regained consciousness, one tube was down my throat and another stretched from my nose to my stomach. A clock on the opposite wall said 8:30. My hands were bound, a holdover from escape attempts a couple hours earlier. They woke me, but I struggled and tried to pull out my tubes. Later I apologized for this too. The nurses were good sports and said it happened all the time.

My bladder felt like it was going to explode. During the operation they stop your heart and transfer circulation and breathing to a machine, which infuses fluid into your system. I gained nearly 30 pounds during the operation. Elaine says I became very round, like a cartoon character.

In the confused aftermath of the surgery, I couldn't remember whether I had a bladder catheter, even though they had told me beforehand that I'd have one. A frantic internal discussion went something like this. "WOW! I really need to go! Did they put a Foley in me? They must have. Well, I'm going to let ‘er rip!" Which I did, and guiltily felt for spreading dampness that, gratefully, never materialized. It wasn't easy, but the relief was titanic.

In the first week after the procedure, you metabolize the fluid and urinate to beat the band. Once unhooked from the catheter - a blessed moment - you start tracking the fluid, and can't help being impressed by the volume.

Drained and able to focus on the larger picture, I remember thinking, "I'm ALIVE!" I really meant this, and realized I honestly hadn't expected to be here when it was done. I was exhilarated.

I turned my head to the dimming light out the window to my left and recognized the scene. This located me in space, but more importantly, convinced me that I was aware. That was comforting.

Two nurses began to bathe me, gently, firmly, and VERY thoroughly. I felt no inhibitions, and it was utterly comforting and warm. By the time they were done, I was ready to marry them.

They told me to rest. Then another woman said it would be about a half hour before they could extubate me. I nodded. This seemed like an OK idea. I could certainly be patient for a half-hour. I kept my eyes on the clock, though. About 45 minutes later they removed the tube, which makes you gag but isn't terrible. A little after that, they withdrew the nasal-gastric tube, also an improvement but a bit of an ordeal.

In addition to the bladder catheter, I had three "fire hoses" (Elaine's term) draining my chest, a central line (a large IV half the length of a soda straw) in my neck, and an IV in my hand. I was plumbed or, to use Elaine's Human Resource term, "completely outsourced."

The nurses said Elaine had waited for me to waken, but had finally gone home. She would be back first thing in the morning. I knew she'd needed the rest. I later learned that, during surgery, several friends had sat for a long while with her. One was a pal, a VP at the hospital who "just wanted to make sure that no barriers arose." Another was a retired surgeon and his wife who knew the value of comfort. Elaine doesn’t mind being alone in circumstances like this, but I was particularly glad for these kindnesses.

Elaine arrived the next morning. Early in the afternoon, a nurse arrived with a walker and told me to get out of bed, that I was going for a walk. I looked at her and asked whether she’d been doing acid. She gave me a look that suggested she wasn’t in the mood to fool around, and that I’d better get in gear. Elaine came over and we went for a walk down the hall. Considering somebody had fiddled with my ticker the day before, we both thought this was incredible.

I remained in Cardiac ICU the next 2 days. Every half hour, the nurses took measurements, made me blow into an inspirometer, wiggle my toes, roll over. I was sore and stiff, but it wasn't bad, and they gave me drugs to keep the pain in check. Now and then there was nausea or weakness, but all in all it was a breeze.

The 3rd day, I moved to a regular room. I had a lot of visitors, calls, books and magazines. My room looked like the Ituri Forest from the plants and flowers. I'd walk around the halls, and go a little farther and faster than the day before. I watched movies or read in the quiet times. Each evening, Elaine sent out a slightly smart-alecky report on my progress to a list of friends, and the following day would bring in highlights from the emails. ("Damn! Five vessels? VERY respectable!" or “Isn’t this going a little far to study the health care system?” or “Is there no end to your histrionics?!”) It was a gratifying outpouring of support, and it meant a lot for my spirits.

They spung me in the early afternoon of the fifth day. They wheeled me down to the pick-up circle, and I eased into the back seat. You avoid airbags after this type of surgery, just in case they deploy. Elaine somehow picked the bumpiest route and I felt every jolt, but soon we were home. We placed a chair in the shower, and she gave me a luxurious shampoo and a long wash. Then we took a nap in our own bed and realized we were finally home again, together, through it.

It’s seven weeks now since the surgery, and I’ve returned to my routine. It’s oddly satisfying to noticeably feel your strength return. I began a regimen by trudging around the block. That’s progressed to a brisk 3 mile walk every morning and, sometimes, another slightly shorter one in the evenings. Now I’ve added workouts at Cardiac Rehab.

People went out of their way. A few days after arriving home I looked out the window to see my neighbor Budd – a paunchy chain smoker – cheerfully mowing my lawn. I think the irony escaped him. “So don’t expect a card,” he said.

Elaine returned to work. Colleagues would drop by with extravagant lunches: tabouli with hummus, or homemade leek soup with tomato pasta on the side. The braver ones asked to see my incision – my “scratch” as the surgeon called it – and would ooh and aah appropriately.

There are phases. Body hair is slow to return, and it’s prickly. “Like sleeping with a porcupine,” was Elaine’s comment. Friends would join me for a walk, and I’d have to slow them down. There’s the day you drive again, scary but sweet with liberation. Or the moment you realize the day passed without a nap.

Normally I was buoyant, filled with the euphoria of still being alive. But there were intermittent blues too, when I was tired of not feeling like me. The psychological path is uphill and requires a purposefulness not always easy to sustain.

My 50th birthday arrived just short of 3 weeks after discharge. Once Elaine was out of the house and couldn't stop me, I drove out to the Ichetucknee River, a pristine, crystal clear ribbon of fresh water coursing through the North Florida jungle. I’ve swum this river for 35 years. I slowly swam and drifted a mile and half, watching the fish and the grasses. It was the cleansing I was looking for, and I was renewed in all kinds of ways. Arriving home, inevitable as death and taxes, and just as sobering, my AARP card was waiting.

Trauma shrinks your world, narrows your view. Early in my recovery, I was utterly disinterested in news or work. Gradually, though, I returned to my upstairs office and the world expanded again. It was organic, natural, and passed almost without notice.

All in all, it would be hard to have had a better experience. It didn't really hurt, I have a new lease on life, and I'm regaining strength daily. My family, all wonderful, stood by with a clear-eyed unwavering support. And at a time when I could really use it, I was awash in the glow of my friends' warmth and good wishes.

Could anything be better?

Dr. Klepper is a health care analyst and founder of the Center for Practical Healthcare Reform.

This is Dr. Bill Bestermann's first post as one of the TDWI writers (A Big Welcome, Bill!).   Dr. Bestermann makes it clear that there is a long way to go, baby, before the diagnosis and treatment of heart disease in women gets to where it should be...hey! ladies, let's WISE up!  Here you go:

The evidence has become irrefutable that life-style change and medications aimed at vascular risk factors outperform bypass surgery and stenting in prevention of heart attack. Not only that, but non-invasive strategies have positive benefits on the entire vasculature that prevent stroke, nerve damage, eye damage, kidney damage and amputation.

Women are different

These differences may be even more important for females. For some time now, there has been discussion of women being different in the manifestation of vascular disease. Women are generally smaller in stature and so would have smaller vessels. They are protected by hormonal factors and experience fewer vascular events prior to the menopause. Now it seems that women really are quite different in how they deposit atherosclerotic plaque and that this difference is important in their diagnosis and treatment.

Men are more likely to develop focal stenoses in addition to more diffuse disease. These localized narrowings may interfere with flow and lead to the classic anginal symptom of chest pain relieved by rest. Women, on the other hand have more diffuse disease that does not cause a vascular narrowing as often. Therefore, their pains are more atypical, may not be related to exertion at all, and may indicate a tendency to increased vascular reactivity and spasm. Women develop plaque and their plaque burden may be quite high, but their deposition of cholesterol is concentric, symmetrical and diffuse with the result that the vessel appears “small”.

The WISE Study

The recent WISE (Women’s Ischemia Syndrome Evaluation) Study sponsored by the National Institute of Health-National Heart Lung and Blood Institute underscores these differences. Even today, the cardiac catheterization is considered the “gold standard” when testing for the severity of heart artery disease. A woman with chest pain who has a cardiac catheterization that is normal is considered “cleared” as far as coronary disease goes and told that there is some other cause such as stress, depression, or gastrointestinal disease.

In the WISE Study 673 women had cardiac catheterizations done for the evaluation of possible coronary artery disease. 45% of these women had persistent chest pain. Women with no coronary obstruction and no chest pain had a very low rate of coronary events. Women with recurrent chest pain and normal coronary arteries had a significant 20% six-years risk of developing heart attack, cardiovascular death, stroke or congestive heart failure. This reflects the fact that plaque in women is deposited in a symmetrical fashion along the length of the artery making it appear small. In this high-risk group, only 9% of women were on lipid lowering therapy and 14% on antihypertensive treatment one year after the catheterization. Obviously, for these patients medical therapy is their only hope and they are receiving the benefit of this treatment far less often than should be the case.

The Takeaway Message

The takeaway message is that the current method of evaluating coronary arteries in standard practice may give the patient a false sense of security if there is no blockage found. There is no way that a stress test or catheterization can adequatly reassure us that that patient is low risk. The woman with persistent chest pain should be evaluated with other modalities. If coronary intravascular ultrasound is available at the time of the catheterization then that is very helpful. If not, calcium scoring correlates directly with the amount of plaque in an artery. The calcium score coupled with the Framingham risk score is a practical way to get a much better idea of the risk in a stable patient

The data indicating a need to improve risk assessment and risk factor management in these patients is clear. Still the system continues to function much as it has for over three decades. This may be the best example of how actual practice lags changes in knowledge and technology. The pace of change in how we deal with these patients has been so slow that it is hard to explain. There is always a resistance to the new way and in this case perverse financial incentives aggravate the situation.

So, what should we do?

Patients (that means you) and payors (health plans, governmental agencies, and employers) are going to have to insist that they receive the benefits of the new science before we see improved care at reduced cost.

Bill Bestermann, MD

I have a file full of warranties on things I have purchased. They give me peace of mind. Sometimes, they even save me money. Now, a hospital system – The Geisinger Health System in central Pennsylvania -- is providing warranties for heart surgery. You don’t have to pay extra to get your defects related to surgery repaired if they occur within 90 days of the operation. Brilliant idea!

Only in health care, with its many perverse financial incentives, do you have a situation where a provider has the opportunity to make more money by providing shoddy care than providing good care. What do I mean by that? Let me give you an example. If you are admitted to the hospital and get an infection related to inadequate infection control. Treatment of that hospital-acquired infection prolongs your hospitalization and you use more expensive services, such as intravenous antibiotics. In a fee-for-service world, that means more revenue for the hospital. Not only does this generate extra costs, it also fails to provide an incentive to do things right the first time (and every time).

Starting in 2006, Geisinger Health System began exploring how to make elective heart bypass surgery flawless. And, to put there money where their mouth is, so to speak, they combined their quality improvement efforts with a 90 day warranty.

Doctors at Geisinger reviewed all of the steps in these elective surgeries and identified 40 as essential to achieve good outcomes. Then they created procedures to ensure these 40 steps are always followed, not matter who the surgeon or where the operation is performed. Hmmm….sounds like the checklists pilots use to make sure everything is in order before the plane takes off.

Here is the checklist:

1. Preadmission documentation:

a. Document the American College of Cardiology/American Heart Association indication for surgery

b. Screening for and consultation regarding IMI (inferior myocardial infarction)/RV

(right ventricular) involvement

c. Record treatment options and patient preferences

d. Determine and document the need for anticoagulation with warfarin – Anterior MI (myocardial infarction) or WMA (wall motion abnormality)

e. Record whether the patient is a current user of anticoagulation medications (clopidogrel or warfarin)?

f. Screen the patient for risk of stroke

g. Obtain a carotid doppler ultrasound exam (test for stroke) if the test is indicated

h. Obtain a vascular surgery consultation if indicated

i. Obtain and/or record the ejection fraction

j. Screening for need to use intra-aortic balloon pump (IABP)

k. Screening using epiaortic echo as indicated

l. Document that the patient did not take anticoagulation medications (clopidogrel/warfarin) in the 5 days before the operation

2. Operative documentation:

a. Did the patient receive the correct dosing of beta-blocker (pre-op)

b. Was there correct use of intra-aortic balloon pump (pre-op -->post-op)

c. Did the patient receive appropriate and timely pre-op antibiotics within 60 minutes of incision; if Vancomycin within 120 minutes)

d. Record any blood cardioplegia (on-pump patients)

e. Document epiaortic echo of the ascending aorta and the peer consult

f. Obtain and record intra-operative hyperglycemia screening

g. Apply correct insulin management (as indicated; per protocol)

h. Use of LIMA (left internal mammary artery) for LAD (left anterior descending)

grafting

3. Post-Operative patient documentation:

a. Anteroapical MI within prior 7 days: post-op echo

b. Monitoring for atrial fibrillation for >48 hours

c. Anticoagulation therapy (as indicated)

d. Were antibiotics administered post-op for 24-48 hours

e. Was aspirin given six hours post-op or 24 hours post-op

f. Was a beta-blocker given within 24 hours post-op

g. Was a statin administered post-op

h. Document any surgical debridement and revascularization of any sternal wound infection

i. Obtain a plastic surgery consult regarding ongoing management of sternal wound

j. Tobacco screening and counseling

4. Discharge documentation:

a. Referral to cardiac rehabilitation

b. Discharge medications (e.g., beta-blocker)

c. Discharge medication: aspirin

d. Discharge medication: statin

5. Post-Discharge documentation:

a. Is the patient correctly taking beta-blocker?

b. Is the patient correctly taking aspirin?

c. Is the patient correctly taking statin?

d. Is the patient correctly administering anticoagulant?

e. Did patient resume smoking?

f. Is the patient enrolled in cardiac rehabilitation?

Gisinger calls this new program “ProvenCare.” That is because the 40 items on their check list are supported by medical evidence. Imagine that…design protocols based on evidence and follow them to get better results.

According to a story about Geisinger in the NY Times, the system was only documenting the performance of all 40 steps 59% of the time before implementing ProvenCare. Now an operation is cancelled if any of the pre-operative measures have not been done. Recently, Geisinger’s surgical teams have had scored 100% in following the recommended steps before, during and after surgery. And it has paid off in terms of reducing complications:

• 35% of patients had any type of complication after compared with 39% before ProvenCare
• Only 16% of patients required supplemental blood products compared with 23% before
• 19% of patients were not able to be discharged directly to their homes before the program; only 9% after
• There were fewer readmissions within 30 days, fewer pulmonary complications, fewer re-operations for bleeding, fewer readmissions to the ICU, and a lower in-hospital death rate (in fact, it was 0 after implementing the program.

So how does the warranty work? Geisinger charges a fixed fee for the surgery and half of the historical costs of related care provided in the ensuing 90 days. If the patient has to be readmitted, Geisinger absorbs the costs. If they do a great job and there are no problems, they have a larger profit. Now that is aligning financial incentives with good patient outcomes.

Geisinger is developing similar approaches for other types of medical care, such as hip replacements. It will be interesting to see how far and how fast they are able to go with this new model. I hope this is not a one-shot wonder. The concept of standing behind your work by offering a warranty could prove to be a powerful driver of health care quality improvement and patient safety.

Great work, Geisinger

Pat Salber, MD

Remember how shocked we were when we first heard about Dr. Moon and Dr. Realyvasquez. These are the heart doctors who performed unnecessary cardiac procedures, including coronary artery bypass surgeries, at a Tenet Hospital in Redding, California.

These guys may have been at the far end of the spectrum when it comes to driving inappropriate cardiac care, however, a study in the March 7, 2007 issue of JAMA adds to the growing body of evidence that suggests that cardiac procedure rates are strongly influenced by competitive market dynamics and not just patient need.

A group of well-respected health services researchers, led by Brahmajee Nallamothu at the University of Michigan Medical School took a careful look at the impact of introduction of specialty heart hospitals in geographic areas that represent distinct markets for tertiary (advanced) cardiac care. As opposed to general hospitals, specialty heart hospitals provide services for, and generate revenue from, a narrow spectrum of diseases.

Some health policy gurus have argued that such specialization could lead to greater efficiency and better quality of care. However, others worry that adding excess capacity could drive demand, particularly if the owners of the hospitals are doctors in that same specialty. It doesn’t take a brain surgeon to understand that filling beds, operating rooms, and catheterization labs with high revenue patients is better for the bottom line than leaving them unused.

Of course, it is possible that new specialty hospitals would just compete with existing facilities in general hospitals, taking volume from them, but keeping the overall rates of services the same. But that doesn’t appear to be what happens when one of these cardiac specialty hospitals opens in a community. Instead, the JAMA study documents that there is an incremental increase in the number of coronary revascularization procedures performed after a specialty heart hospital opens. Capacity increases and more people get these procedures.

Now this study doesn’t prove that all of this capacity was supply-driven. In fact, some of the increase may be due to meeting unfilled need. The researchers tried to understand if this was indeed what was happening by comparing what occurred when a general hospital increased its capacity compared to what happened when capacity is increased via the opening a new specialty heart hospital. What they found was a greater increase in certain cardiac procedures in communities with a new heart hospital compared to those communities with a new cardiac program at a general hospital.

Of note is the finding that there is no increase in the number of PCI (percutaneous coronary interventions) in the subset of heart patients who might benefit most from that procedure (those coming into the hospital because of a heart attack), but there was a dramatic increase in the number of PCIs being done for individuals not having heart attacks, a situation in which there may be more discretion in deciding whether to do the procedure or not.

For all of you who think, more is better when it comes to health care, I suggest you read about Drs. Moon and Realyvasquez. They had some of the highest rates of coronary procedures in the country, but some of their patients would have been better off with nothing at all.

Pat Salber