Archives for November 29, 2005

Emergency bypass surgery on angioplasty patients drops 90%

I can go two weeks and not find anything stimulating to comment on, then there’s a day like today.

Emergency bypass surgery on angioplasty patients drops 90% Cardiac Stent: original from

Decline seen at Mayo Clinic even as physicians expanded angioplasty to sicker patients

When life-threatening problems occur during angioplasty procedures, doctors may perform emergency coronary artery bypass graft surgery, but data from the Mayo Clinic indicates that need to send patients to emergency surgery has dropped sharply, according to a new study in the Dec. 6, 2005, issue of the Journal of the American College of Cardiology.
‘Our review of almost 25 years of data on angioplasty suggests that there has been a dramatic reduction of almost 90 percent in the incidence of coronary artery bypass graft surgery following angioplasty; and this is despite the fact that more recently we are performing angioplasty on very high risk patients,’ said Mandeep Singh, M.D., F.A.C.C., from the Mayo College of Medicine in Rochester, Minnesota.

‘We knew there had been a reduction, but the magnitude of the reduction was a surprise to us,’ Dr. Singh said. ‘The bypass surgery rates, which were close to 3 percent, came down to 0.3 percent in the most recent time period.’

Dr. Singh said the fact that angioplasty is being offered to sicker patients now makes the reduction even more remarkable. Patients requiring emergency surgery in the most recent study period had a higher prevalence of high blood pressure and heart failure, and they were more likely to have undergone previous procedures, compared to patients in the earlier study periods.

Dr. Singh said he believes stents may be responsible for much of the reduction in the rate of life-threatening problems during angioplasty procedures.

However, among patients who did suffer serious problems during angioplasty and had to be sent into emergency surgery, the researchers did not see an improvement in survival. Death rates were statistically similar in all three study periods, ranging between 10 percent and 14 percent. Dr. Singh pointed out that there were only 41 deaths among patients who underwent emergency bypass surgery, including just two during the 2000 to 2003 study period. He said such small numbers make it difficult to calculate useful statistical comparisons.

‘The assessment of elective PCI without on-site bypass surgery underway in some states is a step in the right direction. But, choosing the right metrics is challenging. The only meaningful comparison between hospitals with and without on-site surgery is the rate of death or urgent transfer to another facility within a pre-specified period of time after PCI. One proposal that mixes acute events with late endpoints like repeat revascularizations is manipulative and misleading,’ he added.

This is really good news for everyone, cardiac surgeons included (they don’t want to be operating emergently anyway, and especially not on people who are already super-sick with vessels so bad they can’t be opened in the cath lab). I, for instance, really hope that when I have my MI (family probability) they can get me opened and stented in the lab, and not spend an hour in the lab then go and have my chest cracked for a bypass.

Also, this study going on with emergency caths in hospitals without in-house emergency bypass surgery is going to be very interesting to watch. Personally I hope it’s shown to have an acceptable risk/benefit ratio, but that study is only starting.

Good news, and progress, all around.

Stent picture from St. Michael’s Hospital, Tononto, Canada.

From Medscape: Are We Really Better Off With HIPAA?

From Medscape, an editorial by their founder: Are We Really Better Off With HIPAA? There’s a video of Mr. Frishauf reading his editorial, slowly, if you want to watch, but the entire text is under the video box. Original Image from PrawfsBlawg

Are We Really Better Off With HIPAA?

Whether you’re an American clinician or patient, there’s no escaping the Health Insurance Portability and Accountability Act (HIPAA). Republicans and Democrats assured us it would make healthcare better.

But has it?

Unless you’re a HIPAA consultant, a compliance officer, or some other bureaucrat, the answer is generally no.

The thing that bothers me most about HIPAA is its expensive, annoying, and — in the end — meaningless implementation. Clinicians have to get all patients to sign forms, which they then file, or they get into trouble, and could face huge fines. Insurance companies must do the same, but then require patients to forget about their privacy if they want insurance. So most do.

Hospitals cringe at the thought of HIPAA fines. Their well-paid consultants design elaborate, expensive systems to ensure compliance.

I will concede one good thing about HIPAA, and that’s the health insurance portability.
Title I protects health insurance coverage for workers and their families when they change or lose their jobs — and this part of the law is working.

But the much ballyhooed “privacy” parts of the law are a failure that could easily be repealed with financial savings to healthcare and no adverse effects that I can think of. In fact, US medicine without these provisions could be better, as information sharing would be easier. And that usually helps patients a lot more than it hurts them.

That’s my opinion, and I’m Peter Frishauf, founder of Medscape.

That’s my opinion as well. Mountains of paperwork, which serve only to further erode public trust in government (another meaningless form you HAVE TO SIGN, thanks for watching out for my rights) and put one more impediment in the wheels of progress.

Also, let’s not forget that the first (and as far as I can tell by Googling, only) use of HIPAA was to convict a hospital employee of identity theft. He should have gone to jail, but there’s already laws against identity theft.

And, it’s here to stay. The continuous creep of government intrusiveness into our lives continues no matter which part is in power in Washington. There’s no chance this will be overturned, politicians lack the “Oh, that was a mistake, and we’ll fix it” gene.

Image from PrawfsBlawg. Don’t want to tick off the lawyers.

MedBlogs Grand Rounds 2:10

It’s Time For Grand Rounds

Just when you thought you couldn’t stomach anymore Thanksgiving goodness, it’s the Thank-You-Kindly edition of Grand Rounds! (Version 2.10, but who’s counting.) Publicized in part by Medscape, thanks!

A nice job, and a lot of links!

New York EM Docs Sacked

I think this is entirely wrong, unless actual wrongdoing is alleged:
this pink slip's for you!

NUMC to fire ER staff

November 29, 2005

Nassau University Medical Center officials yesterday announced plans to replace nearly all their veteran emergency room doctors within six months, saying the physicians’ training and credentials are not up to today’s standards.

Union leaders who represent the doctors immediately accused administrators of violating a deal to forgo layoffs at the public hospital in East Meadow. They said the firings are the first step in an effort to privatize the emergency room. The hospital entered into an affiliation agreement with the nonprofit North Shore-Long Island Jewish Health System in the summer.

[ Interesting local hospital politics, only partially hinted about, removed ]

The hospital has decided to hire doctors with national medical board certification and residency training in emergency medicine, who could handle a wider array of cases, Kane said.

Dr. Joan McInerney, who was asked to step down as chairwoman of emergency medicine, broke into tears and declined to comment on her job yesterday, saying she had to call her lawyer.

But McInerney said she disagreed with the decision to replace all the doctors at once, and advocated hiring emergency specialists gradually. “None of them deserve that,” McInerney said of the doctors.

Officials said their move would create more flexibility in a department that sees 80,000 patients a year.

The hospital’s 20 full-time emergency room doctors specialize in non-emergency fields, including internal medicine, surgery, gynecology or pediatrics. Only two doctors have the training and certification in emergency medicine that would now allow them to stay.

Asked whether the doctors would be offered other jobs in the hospital, Kane said, “I don’t know that there will be vacant positions elsewhere that they would qualify for.”

McInerney was asked to step down by Kane and Dr. Steven Walerstein, the senior vice president for medical affairs but she has not yet done so, said Ron Gurrieri, the union’s first vice president. McInerney is board certified in emergency medicine, but does not have residency training in that area.

The field of emergency medicine developed in the 1960s. The first certification was not until 1980, and there were few residency training programs then. About 62 percent of practicing doctors are board certified or residency trained in emergency medicine, according to the American College of Emergency Physicians. Older emergency room doctors often specialized in another area.

At Nassau University Medical Center yesterday, the emergency room doctors said they could not comment, for fear of retribution.

“We’re outraged,” said one doctor who spoke on condition of anonymity. “Obviously we feel that we’ve provided good services to the hospital, and now they’re changing our terms of employment, and they want to get rid of us.”

For the record, I believe new hires in ED’s should be EM Residency Trained, and Board Eligible / Certified, with an expectation that those who are eligible will get themselves certified. That having been said, I’m not in favor of sacking an entire ED physician cadre based on ‘changing standards’. If they’ve been credentialled at their hospital, then they shouldn’t be removed unless some cause is shown. (I don’t have that protection, by the way, most EM docs don’t. I’m speaking of the Ideal World here).

Have a look at their ED’s site. I’ve never worked in an ED that had this level of division, and wonder if this isn’t what the move is about. [Speculation alert] Consolidating the operations of 7 separate EDs into one (or two, Surgeons are notorious turf-defenders) could possibly save some money, and EM trained docs can staff all the areas they describe. [/Speculation].

A bunch of CVs are getting polished tonight and faxes will be flying tomorrow.