Commentary by Josh Olstein MD, Associate Editor, Clinical Correlations
This week, the most popular health-care related story in the lay press was the news about Medicare’s plan to no longer cover the additional costs of treatment for many hospital-related complications such as catheter related infections and decubiti. The plan drew sweeping support from consumer advocacy groups who welcome any policy that would lead to increased patient safety and quickly caught the attention of hospital administrators and physicians. Administrators were unsurprisingly wary of the plan and suggested that patients may be subject to additional testing upon admission to assess for the presence of pre-existing conditions. Others contend that not all conditions are completely preventable despite receiving appropriate care. Once Medicare enacts this change, scheduled for 2008, it is likely that private insurers will follow. Ultimately, the goals of improving patient safety and quality of care are of critical importance, however one must wonder if financial penalties are the appropriate means to that end. See the article and accompanying letters in The New York Times.
This week’s New England Journal featured two independent studies examining the effect of bariatric surgery on mortality, both with positive results. The Swedish Obese Subjects study prospectively followed roughly 2000 bariatric surgery patients and 2000 non-surgical controls for an average of 11 years with an astonishing 99.9% follow-up rate. Average sustained weight loss among the surgical patients was 14-25% of body weight based on surgical technique, with essentially negligible weight loss among the controls. The primary end-point was all cause mortality with 129 deaths in the control group and 101 in the surgical group (P=0.04). The second trial looked retrospectively at a larger group of patients (~8000) who underwent gastric bypass, the most common bariatric surgical procedure, and matched controls. The primary outcome examined was death rates between the groups. The surgical patients again had significantly lower death rates (37.6 vs. 57.1 deaths per 10,000 person years, P <0.001). There were also significant differences in deaths attributed to diabetes, coronary artery disease, and cancer between the groups. Of note, >80% of the subjects in both studies were women.
While bariatric surgery seems to have a mortality benefit in the obese, a study from this week’s issue of Circulation examined the impact of gout on mortality and risk for coronary artery disease in a large population of mostly white men. Using survey data from a large cohort of male heath professionals, the occurrence of death or the diagnosis of coronary disease (MI, angina, or CABG) was compared among those with and without gout. The relative risk of death among men with gout was 1.28 (95% CI, 1.15-1.41). There was also a significant increased risk of fatal coronary artery disease. The study does not have data about serum urate levels so we can’t assume that urate-lowering therapy will change outcomes, but it does identify a group of patients who may deserve more aggressive risk factor modification to prevent coronary disease.
Finally, more data to fuel the debate on the questionable association of statin use and cancer. A study published in this month’s issue of Gastroenterology examined the prevalence of prescriptions for a statin among 5,686 patients with colon cancer and 24,982 matched controls using a database with records from 454 general medicine practices in the United Kingdom. There was no significant association of history of statin prescription with the development of colon cancer. Additionally, no identifiable trend was detected with increased number of prescriptions for a statin. While an obvious strength of this study is the number of patients included, no data is available about how much medication was actually taken or the LDL levels of the patients studied.