Is Less Really More?

The smart folks at the American Board of Internal Medicine Foundation have published an additional 90 procedures (to the 45 that they listed last year) that they feel are overused and often times unnecessary. This is part of the Choosing Wisely initiative to encourage patients to ask more questions about the tests that they are having and the reasoning behind it.

Unfortunately, we have become a test-happy medical society in the US and the reasons for this are myriad. Firstly, old habits die hard. Doctors in a given specialty see similar diagnoses and have been doing the same testing routines for years. It is difficult to get physicians to change their diagnostic/therapeutic habits when they have been doing it with success for eons.

Secondly, medicine is a business. And for doctors, it has not been a very good one of late. Reimbursement rates for everything from office visits to echocardiograms have plummeted and physicians are not immune to the squeeze of earning less money for the same amount of effort. Already, we are beginning to hear murmurs of doctors objecting to answering phone calls in the middle of the night when they're not getting paid for it. This used to be part and parcel of being a "patient of the practice" but this old style of long, personal relationships with your physician is waning. Five years ago less than 10% of all cardiologists were employed by a hospital and as of 2012, more than 60% of US heart doctors have some formal business relationship with a hospital system. Healthcare providers are having to see more patients in less time and modalities like telemedicine, pharmacy consultations, outpatient phone calls and remote monitoring will become more and more important in the years to come.

Finally, many tests and procedures are done for fear that the doctor may miss something and pay a much steeper penalty than wasting a few health care dollars on a test. Most patients that come in to the ER with chest pain can very readily be diagnosed with a good history and physical. Heart attack symptoms can be tricky but there are some universal features that put patients at higher or lower risk. However, the fear of missing any diagnosis, no matter how unlikely prompts serial blood draws, CT scans, stress tests and increased length of stay. Attempts to lessen the threat of lawsuits and financial demise from medical management have been met with a great deal resistance and so doctors will consider doing CT angiograms of every young woman who presents to the ER with shortness of breath and happens to be taking oral contraceptives - even if they have a very low likelihood pulmonary embolus.

Initiatives like ChoosingWisely.org are a great start in changing the consensus opinion of how patients should be managed and allowing the doctors who choose not to over-test to fall back on educated and validated medical opinions confirming that sometimes a good history and physical in addition to carefully selected testing (or perhaps no testing at all) is the best thing that can be done.

If nothing else, a perusal of this list of overused and over-ordered tests can give you good reason to ask your physician more questions about exactly why they are ordering the test and what will change as a result of the outcome? Is the test safe, what are the risks? The ChoosingWisely website also has answers to specific questions like 'Do I need a Chest XRay before surgery?' and 'When do I need a stress test?' It is a very worthwhile stop on your Internet travels so give it a read and take more control of your medical care.

Catheterization from the Wrist Taking Over

Just recently, cardiac catheterization from the wrist, or transradial cardiac catheterization, was featured on the Dr. Oz show and immediately we were fielding questions about it in the office and reading about it on the blogs.

Now, even more impactful, was the recent recommendation from the European Society of Cardiology that the radial approach should be considered as the first-line access site:

“The radial approach for percutaneous coronary interventions (PCI) was developed 20 years ago and is used for more than 50% of procedures in France, Scandinavian countries, the UK, Spain and Italy. Despite the advantages of radial access some countries in Europe such as Germany use radial access for fewer than 10% of PCI….

“Evidence has accumulated in the literature showing the benefits of radial over femoral access for PCI including reduced bleeding and improved survival. In addition, the development of smaller and thinner devices has made the radial approach increasingly practical.”

For most of us in the interventional cardiology world, the radial approach has been slowly gaining traction over the past 5 years in the US. As of 2007, less than 2% of all coronary stent procedures were done from the wrist but in 2012, according to the National Cardiovascular Data Registry (NCDR) more than 11%  were done radial style.

Patient safety and comfort are always a concern to physicians and the radial approach has shown superiority to the femoral (groin) approach in both categories. In terms of safety, numerous studies have shown significantly less bleeding complications as compared with the femoral approach. This is in large part due to the fact that unlike the radial artery, which is bordered by bone and connective tissue, the femoral artery lies right next to a large caliber femoral vein and complications can be difficult to identify at first because of the large potential space for blood to go, i.e. the thigh or abdomen. Women are actually at higher risk of groin complications from cardiac cath and currently Dr. Safirstein is the Principle Investigator of SAFE-PCI, a multicenter, randomized control trial looking at the benefits of the radial approach in women, run in collaboration with more than 25 of the best coronary centers of excellence across the US.

Comparing comfort of the 2 techniques, it is not hard to see why patients have preferred radial more than 90% of the time. Cath from the wrist allows patients to sit up immediately after the procedure (even when a stent is placed) with a pressure dressing over the small puncture site on the wrist. The femoral approach demands anywhere from 4-8 hours of lying flat so as not to disrupt the clot that forms over the femoral puncture site. This becomes particularly relevant in patients who have back pain issues or cannot lie flat for any reason.

From a cost standpoint, less complications mean less money spent on follow-up imaging studies, blood products that might be required, consults with other specialists, and of course, length of stay. The radial approach has been shown to save both hospitals and patients money and time in the hospital.

Drs. Safirstein and Fusman both are proficient in radial cath and Dr. Safirstein served as the Director of Transradial Intervention at Morristown Medical Center. Later this year, he will be Course Director for the annual Mid-Atlantic Radial Symposium (MARS2013), hosting world-renowned experts who will educate both physicians and cath lab staff from NY/NJ/PA on everything transradial!

Nutritional Value of Equine Cuisine

There has been a lot of banter recently about the use by fast food royalty, Burger King, of horse meat in their burgers. Morally and objectively, it seems not "right" to use Mr. Ed and his relatives as a source of sustenance, but then again, there have been a few famous pigs on the big screen as well - and we mean real pigs, of the porcine sort. If we can look at this scientifically, we might find that equine-based foodstuffs may actually have some benefits.

Firstly, there are many countries, not just the 3rd world sort that actually do eat horse meat -

just look to our northern neighbors where horse is frequently featured on the menu. “Horse is delicious,” says David McMillan, Joe Beef’s co-chef. “It’s like health food compared to beef! It makes you a strong lover, too,” he adds.

Also, according to NutritionData.com, the strip steak has about the same amount of calories as horse (117 vs 133 calories per 100 grams), though many other cuts of beef have significantly higher calorie counts. The meats also have very similar amounts of fat, cholesterol and protein when lean cuts are compared. Where the meats really differ is iron concentration, with horse meat having double the iron (21% vs 10% DV) that beef contains. Horse meat also contains substantially more vitamin B12 (50% vs 21% DV), but less B6, niacin and folate. But the most striking difference is the omega-3 fatty acid concentration in horse meat, which contains 360 mg (per 100 grams) compared to just 21 mg in strip steak.

Now, we are not advocating for you to start eating horse meat and understand the stigma attached to it but it always helps to know the facts before siding with the neigh-sayers. Sorry, couldn't resist.

Read more: http://ideas.time.com/2011/12/28/the-case-for-eating-horse-meat/#ixzz2Jfr9WGkG