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  •  that is not my point (0+ / 0-)

    and btw, my mother had stents in the early days and underwent cardiac bypass surgery in 2002 at the age of 75. I'm not saying let anyone die.

    And I can remember, back in the day, when I was a med student and a well-known nonagenarian patient was admitted with chest pain. The attending cardiologist was quite the hotshot (he was one of the first really aggressive invasive cardiologist, I wouldn't be surprised if the term "cath jockey" was coined to describe him as I've been told previously) but was very unwilling to take that particular patient to the lab (this was in the days before stents) because the doc was very concerned about the risk of coronary rupture or dissection. But the patient began to have an acute infarct overnight and the doc came in, wound up taking the patient to the lab for angioplasty, and he did just fine.

    But the question is whether multiple drug eluting stents are better than bare metal stents alone. Or, frankly, in many cases whether cardiac procedures are at all more beneficial than medical therapy. The costs are exponentially higher. And I've reviewed the data. The outcome data is not statistically significantly better for the DES than the BMS. But the cost is much higher. Not to mention the potential for complications of having to be on long term anti-platelet agents. The cardiologists who are frankly unable to look at the bigger picture, i.e., the whole patient, routinely refuse to allow patients to come off of those drugs even when needed for life saving surgery, and frequently surgeons won't operate if patients are on those drugs. I've seen it multiple times. Talk about your hidden costs.

    We need comparative effectiveness research. We need to look at outcomes data. We need, frankly, to look at the number needed to treat and the cost per number to treat to prevent certain outcomes. It shouldn't have to be a hard and fast number. I'm not saying every 80 year old should not receive dialysis. I am saying, however, if that 80 year old is demented, contracted, and living in a nursing home, and comes to the hospital in renal failure, that patient should not receive dialysis. Even if she's your mother. Or mine. There is a thing called medical futility and we, as physicians, and as patients, need to recognize that there are times when treatments serve no true useful purpose, and we also need to recognize that sometimes the costs outweigh the benefits. Again, if we had to bear the true costs, we would make those decisions readily, on an individual basis as well as a societal one.

    Of course, there needs to be flexibility, as in the case of the 95 year old with coronary disease.

    And here's one other thing, and it's something we physicians often forget: everything we do has some cost to the patient, even if it's drawing blood which incurs some kind of pain. Some patients are more willing to bear that than others. But we are often not honest with patients about what kind of burden they will bear with the treatments we suggest.

    It is not always appropriate to offer the newest, most fancy, most 'advanced' treatment, when an old treatment will work as well or frankly almost as well.

    Diversity may be the hardest thing for a society to live with, and perhaps the most dangerous thing for a society to be without - W S Coffin

    by stitchmd on Sun Jul 26, 2009 at 01:27:39 PM PDT

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    •  We mostly agree... (0+ / 0-)

      except who should think it should be some central planner like in Canada...I think it should be the doctor along with the patient...

      But we mostly agree on that it should be the most effective treatment with the least amount of side effects and risk...I just believe that should be regardless of think cost should come into the picture..

      The other thing I vehemently disagree with is looking at procedures only based on should also be based on the overall comfort and benefit to the patient...

      So if there are 2 procedures one being bypass that has a 4 month recovery and one being angioplasti which has a 2 week recovery and they are equally effective...then the less invasive procedure should be used...

      Obama - Change I still believe in

      by dvogel001 on Sun Jul 26, 2009 at 02:32:29 PM PDT

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      •  but in the latter case (0+ / 0-)

        there are clear guidelines about who should be referred for cardiac surgery. There are far less clear guidelines about who should get stents, and there are no guidelines about who should get multiple drug eluting stents, and the outcomes data does not show a benefit of multiple DES over BMS. And many patients will have a similar outcome with medical therapy alone.

        What I am saying is not that there should be a central decision maker, but we need guidelines, evidence based guidelines, that allow us to make proper decisions for the individual patient. I would not have wanted my active 75 year old mom to not have had surgery based on some arbitrary decision maker, anymore than you would. The problem with evidence based medicine, as I've always said and have always taught the residents, is that studies are done on populations in aggregate, but that the patient in the bed is an individual. You can't determine their particular outcome, just discuss the risks.

        But we don't have enough data out there to even begin to counsel patients appropriately. That's what we need.

        I don't disagree with you, mostly, on what you say about the issues of comfort. When the spouse blew a disk and had neurologic problems related, I knew that if there was a good response to the physical therapy, it would save several weeks of being off work and laid up in recovery - and would still have required PT at the back end. So we saved the costs of surgery, not only monetarily but also in terms of time and pain of surgery. However, had there not been some improvement, let me tell you I would have been on the phone to my friend the neurosurgeon pronto.

        But too many people think the first thing is to cut, and the idea of watchful waiting is not acceptable. A few years back, my mom, again, had problems with her knee. She'd had problems with her knee for a long time, but it got worse over a several week period. My parents called their regular doc who suggested she see a particular orthopedist, who was supposed to be the best in the area. But it was going to take several weeks to get in to see him, and my dad found that to be unacceptable, so he got her in with another doc, who also had a good reputation. Unfortunately my mom had a bad outcome. Would it have been better had she been to the original doc? Maybe. But this wasn't an acute, life threatening problem and waiting a couple of weeks might have led to a better outcome, of course, it might not have either.

        I tend to be a therapeutic minimalist, and I like to deal with specialists who are very conservative and don't do things unless they are indicated. And I have attracted patients who have a similar mindset. People who want treatment now, right now, don't tend to stick around in my practice, but there are plenty of people in Baltimore who will accomodate them. Too many, probably.

        Diversity may be the hardest thing for a society to live with, and perhaps the most dangerous thing for a society to be without - W S Coffin

        by stitchmd on Sun Jul 26, 2009 at 03:24:11 PM PDT

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        •  Believe me... (0+ / 0-)

          as someone who has been through 3 major by all means it should be a last resort...and that is why when my condition started...the last person I spoke to was a surgeon...

          Obama - Change I still believe in

          by dvogel001 on Sun Jul 26, 2009 at 05:14:48 PM PDT

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