Faculty peer reviewed
It is time for the first Primecuts of April and the signs of spring are all around us. But before we spring forward into this edition of Primecuts, let us take a look back and reflect on “March Madness.” With all apologies to fans of Butler and Duke, this year “March Madness” was all about the historic battle for health care reform and passage of the Patient Protection and Affordable Care Act two weeks ago. In the face of what some would call the greatest victory thus far for President Obama in Washington, the President has remained on the offensive, recently travelling to Maine and then Massachusetts to continue to drum up support for the legislation (1). The choice of these states was not random; Maine seats two moderate Republican senators who opposed health care reform legislation and Massachusetts is home to Senator Scott Brown, the Republican whose election in January was felt at that time to be a massive blow to health care reform and the Democratic agenda. Obama’s message remains clear; he continues to contend that those who support repeal of the legislation would essentially be taking away tax credits for small businesses and putting “the insurance industry back in the driver’s seat.” The Republican National Committee, however, responded to Obama’s rhetoric by dismissing his assertions as “a bad April Fools’ joke.”A recent article by Christopher Jennings focused less on the political aspects of health care reform and more on its implementation (2). He suggested that the “stakeholders” in health care reform (health insurers, medical product manufacturers, health care providers, consumers, businesses, and organized labor) will all support successful implementation of the administration’s policies, regardless of whether or not they were initially opposed to the legislation. He reasons that the implementing agencies, such as the Department of Health and Human Services, will have unprecedented decision-making power that would undoubtedly affect the interests of these stakeholders. However, if these stakeholders do not agree with some of the implementation strategies, they may provide more financial support to the Republicans, publicize problems associated with the program, and undermine implementation decisions. Therefore it is important that the reforms are implemented effectively in ways that maintain the support of all interested parties and build on positive public opinion. This will take commitment on the part of many individuals and skilled leadership; many of these people will have to be well-versed in the language of both health care and public policy, and many of them may come from within the physician community itself.
Moving on, the New England Journal of Medicine highlighted a futuristic diagnostic tool that may soon become part of the routine diagnostic workup of a number of conditions. Lupinski et al. used whole-genome sequencing to make a specific genetic diagnosis in a family in which four siblings were affected by Charcot-Marie-Tooth (CMT) disease, a peripheral polyneuropathy (3). The investigators sequenced the entire genome of one affected subject and identified variations from a reference sequence, finding common and novel variants. When they examined genes known to be mutated in CMT disease, they found two mutations in SH3TC2, which causes an autosomal recessive form of the disease. This powerful demonstration raises issues beyond just the diagnosis of Mendelian genetic disorders. Specifically, could whole-genome sequencing be used to find susceptibility loci that may predispose healthy patients to diseases such as diabetes and cancer? Further, if susceptible patients could be identified, would it be possible to initiate preventive measures to reduce the chance of phenotypic manifestation? In the past, one of the concerns over whole-genome sequencing was that the data could be used by employers or insurers to exclude people from jobs or coverage based on pre-existing (or would they be pre-pre-existing?) conditions. One relief is that with the new health care reform legislation in place, insurers could no longer exclude patients based on pre-existing conditions, regardless of how pre-existing they may be.
In an article from the Archives of Internal Medicine, Porapakkham and colleagues conducted a meta-analysis of B-type natriuretic peptide (BNP) as a guide to heart failure therapy (4). They looked at eight randomized control trials, enrolling a total of 1726 patients who were studied for a mean duration of 16 months. The authors found that BNP-guided therapy reduced all-cause mortality in patients younger than 75 years with chronic heart failure (relative risk 0.52; 95% confidence interval 0.33-0.82; p=.005); they found no significant difference in mortality for patients over the age of 75 years. They hypothesize that part of the survival advantage may have resulted from increased use of angiotensin-converting enzyme (ACE) inhibitors and beta-blockers to lower BNP levels. In fact, the percentage of patients achieving their target dose of ACE inhibitors beta-blockers in the BNP-guided group was 2-fold higher (21% versus 11.7% for ACE inhibitors and 22% versus 12.5% for beta blockers). The authors did not find a reduction in all-cause hospitalization (with data from three of the eight trials) or an increase in survival free of hospitalization (with data from two of the eight trials). It appears that an important lesson from this meta-analysis is that regardless of whether or not we target lower BNP levels in our heart failure patients, achieving target doses of ACE inhibitors and beta-blockers should continue to be a primary goal in our management of these patients.
A study by Lee and colleagues in the Journal of the American Medical Association (JAMA) examined the association of different amounts of physical activity with long-term weight changes in 34,079 women with a mean age of 54 years over 13 years of follow up (5). Average weight gain over the course of the study was 2.6 kg. The authors found that women who gained less than 2.3 kg over the follow-up period averaged about 60 minutes per day of moderate-intensity activity throughout the study. Interestingly, and perhaps alarmingly, physical activity was associated with less long-term weight gain only among women whose baseline BMI was lower than 25. Women who were overweight at the initiation of the study could not prevent weight gain even when they exercised to equivalent levels as those with a lower BMI. The results of this study suggest that weight gain may be difficult to avoid later in life, but that maintenance of baseline weight in and of itself may be a sign of a successful exercise regimen.
Finally, Dr. Rita Redberg, editor of the Archives of Internal Medicine, discussed the results of President Obama’s recent physical exam (6). Though Dr. Redberg applauded Obama for his exercise regimen and healthier eating, she had some issues with the fact that the physical examination included both an electron beam CT scan for coronary calcium and CT colonography, tests that are not recommended by the U.S. Preventive Services Task Force and that have exposed the President to unnecessary radiation. Dr. Redberg concludes that the performance of these two tests highlights some of the key challenges facing health care reform today, namely, the idea that “more care is not necessarily better care.” Unnecessary tests not only expose patients to potential harms without proven benefits, but they also incur a greater financial burden on both the individual patient and on society as a whole. Curtailing costs will be a major goal as we spring forward, and avoidance of unnecessary testing can be a useful first step that we as physicians can impact upon directly.
Dr. Parikh is a 2nd year resident at NYU Medical Center.
Peer reviewed by Michael Poles MD, NYU Division of Gastroenterology
1. Baker, Peter. Obama Challenges Republicans on Health Care. New York Times. 2010 April 1.
2. Jennings, CC. Implementation and the Legacy of Health Care Reform. NEJM. Epub 2010 March 31.
3. Lupinski JR, et al. Whole-Genome Sequencing in a Patient with Charcot-Marie-Tooth Neuropathy. NEJM. 2010;362:1181-1191.
4. Porapakkham P, et al. B-Type Natriuretic Peptide-Guided Heart Failure Therapy: A Meta-analysis. Arch Intern Med. 2010;170(6):507-514.
5. Lee I, et al. Physical Activity and Weight Gain Prevention. JAMA. 2010;303(12):1173-1179.
6. Redberg, RF. First Physical. Arch Intern Med. Epub 2010 March 8.