Primecuts-This Week in the Journals

December 28, 2009

champagneKevin Hsueh, MD

This week finally sees the passage of a belated, but significant milestone in healthcare reform in the United States.  On Christmas Eve ’09, the Senate passed its version of the healthcare reform bill,  potentially setting in motion a radical shift in the way health coverage is provided in the United States.  Of course, significant political wrangling still is yet to be done, as both the House and Senate versions need to be reconciled prior to the bill being signed into law.  Luckily for those of us tired of the endless partisan bickering, post-vote rancor has been somewhat muted, as lawmakers, lobbyists, and TV commentators have all taken off for the holiday recess.  It will have to wait till the new year to see how contentious the debate becomes now that reform is that much closer to realization.

Like the healthcare debate, healthcare news has also been largely subdued in the holiday lull.  One notable exception has been The New York Times’  December 23rd front-page report on the debate over the costs and benefits of aggressive medical treatment.  The article highlights a new study in the November 2009 issue of the journal Circulation, which was written largely as a response to the results of the Dartmouth Atlas of Health Care,  a study of Medicare recipients with chronic diseases in their last two years of life.

The Dartmouth Atlas matched the amount spent on these Medicare recipients by various hospitals with various performance indicators such as patient satisfaction, length of stay, number of hospitalizations, and industry standard quality of care indices.  It found a startlingly wide variation in the aggressiveness of care between different locales and institutions, and noted no significant benefit (and indeed possible detriment) to highly aggressive care and its concomitant cost.  In its last report in 2008, the Dartmouth Atlas emphasized its findings with a pointed analysis of hospitals in the LA region, concluding with the statement that “Los Angeles hospitals used 81% more hospital beds than needed;106% more ICU beds; 110% more FTE physicians; and required 75% more registered nurses” amounting to “a lot of wasted effort and unnecessary care.”

The Circulation study directly attacked the methodology of the Dartmouth Atlas.  Presented by a group of researchers from six University of California hospitals as well as LA’s Cedars-Sinai Hospital, the article found fault with the Atlas’ decision to review only data from those who had died during the study period, noting that doctors did not have the ability to separate those who would soon die from those who would not, and that a true study of the efficacy of high-intensity health care should look at all patients with chronic disease, not just those who happened to die.  As an example, the team examined 3999 hospitalized patients diagnosed with heart failure.  What they found was that, when looking at total patients, high intensity hospitals had an overall mortality benefit at the 180 day (almost 10 percent).  They also compared total patients with only those that would have been selected by the Dartmouth Atlas methodology, and showed that the Atlas’ method exaggerates certain performance markers such as length of hospitalization and cost per patient, markers which tend to normalize when surviving patients are included in the analysis.

In other news, early repolarization abnormalities may not be as benign as traditionally thought.  A study in the New England Journal of Medicine examined 10,864 Finnish middle aged subjects, stratified based on the level of J-point elevation in their EKGs.  They followed these patients for 30 years and found that there was a 28% increased relative risk of death by cardiac causes even for 0.1mV changes, with 0.2mV changes associated with almost triple the risk of death by cardiac causes in that time frame (298% compared to the control group).  It stands to see how useful this knowledge is, in that the large number of event free patients who present with the abnormality would make the specificity of such a test relatively low.

Alzheimer’s is the theme of the week in JAMA, which presents two original articles on the disease.  One is a randomized, double-blind, placebo controlled trial of the new anti-Amyloid-β peptide (Aβ42) drug tarenflurbil which unfortunately shows no benefit on the cognitive decline or improvement in ADL ability in patients with mild alzheimer’s dementia.  The second is a prospective analysis of 785 non-demented Framingham study patients who had had their levels of the adipokine leptin checked in the 22nd Framingham study cycle (1990-1994).  They stratified these patients according to sex and leptin level, and found that patients with the highest levels of leptin had only a 6% absolute risk of developing dementia over the next 15 years, while those with the lowest levels had a 25% risk.  This may lead to leptin being used as a marker for dementia risk, and the researchers posit that leptin itself may have neuroprotective effects.

Lastly, as the year ends, Science reviews the legacy that this year’s H1N1 flu will leave us with.  While H1N1 has not become the lethal epidemic that some of its predecessors have been, government response and public hysteria has graphically illustrated the flaws in the global epidemic response system.  However, with these flaws so evident and so public, perhaps they can be fixed in time for the next disease emergence.

References

1.    Pear, Robert. Senate Passes Health Care Overhaul on Party-Line Vote. The New York Times. Published online December 24, 2009 http://www.nytimes.com/2009/12/25/health/policy/25health.html?ref=policy

2.    Abelson, Reed.  Weighing Medical Costs of End-of-life Care.  The New York Times.  Published online December 22, 2009 http://www.nytimes.com/2009/12/23/health/23ucla.html?_r=1&ref=health

3.   Tracking the Care of Patients with Severe Chronic Illness: The Dartmouth Atlas of Health Care 2008 from the Dartmouth Atlas of Health Care http://www.dartmouthatlas.org/atlases/2008_Chronic_Care_Atlas.pdf

4.   Ong MK, Mangione CM, Romano PS et al. Looking Forward, Looking Back: Assessing Variations in Hospital Resource Use and Outcomes for Elderly Patients With Heart Failure.  Circ Cardiovasc Qual Outcomes 2009; 2 ;548-557; originally published online Oct 13, 2009.http://circoutcomes.ahajournals.org/cgi/content/abstract/2/6/548

5.   Tikkanen JT, Anttonen O, Junttila MJ et al.  Long-Term Outcome Associated with Early Repolarization on Electrocardiography.  New England Journal of Medicine 2009;361;2529-2537; December 24, 2009. http://content.nejm.org/cgi/content/short/361/26/2529

6.  Green RC, Schneider LS, Amato DA et al.  Effect of Tarenflurbil on Cognitive Decline and Activities of Daily Living in Patients With Mild Alzheimer Disease, A Randomized Controlled Trial. JAMA. 2009;302(23):2557-2564. http://jama.ama-assn.org/cgi/content/full/302/23/2557?home

7.  Lieb W, Beiser AS, Vasan RS et al. Association of Plasma Leptin Levels With Incident Alzheimer Disease and MRI Measures of Brain Aging. JAMA. 2009;302(23):2565-2572. http://jama.ama-assn.org/cgi/content/short/302/23/2565?home

8.  Enserink M, Cohen J.  Virus of the Year:  The Novel H1N1 Virus.  Science 2009;325;1607. http://www.sciencemag.org/cgi/content/summary/326/5960/1607

Image Courtesy Wikimedia Commons

Kevin Hsueh is a second year internal medicine resident at NYU Medical Center

Faculty Peer Reviewed By: Danise Schiliro-Chuang, MD Contributing Editor, Clinical Correlations

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