Stents, Surgery, and Medical Therapy: Will Knowledge Trickle Down?

Larry Husten a Contributor at Forbes has an excellent review “Stents Lose In Comparisons With Surgery And Medical Therapy“. He takes a look at two new meta-analyses in JAMA Internal Medicine looking at alternatives to stents percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG). 

The first of the two papers by Sipahi and colleagues did a meta-analysis of six RCT comparing PCI and CABG in patients with multivessel disease. 

With an average 4.1 years of followup, CABG was associated with significant reductions in total mortality, myocardial infarction, repeat revascularization and the rate of major adverse cardiovascular and cerebrovascular events (MACCE). CABG was also associated with a trend for excess strokes.

Here are the risk ratios for CABG:

Mortality: 0.73, CI 0.62-0.86, p<0.001
MI: 0.58, CI 0.48-0.72, p<0.001
Stroke: 1.36, CI 0.99-1.86, p=0.06
Repeat revascularization: 0.29, CI 0.21-0.41, p<0.001
MACCE: 0.61, CI 0.54-0.68, p<0.001

As noted the authors concluded that “CABG should be the preferred revascularization method for most patients with multi vessel coronary artery disease.”

second paper by Kathleen Stergiopoulos and colleagues looked at studies comparing medical therapy with PCI in >4,000 patients with stable coronary artery disease and documented ischemia and a five year median follow-up there were no significant difference in death, nonfatal MI, unplanned revascularization, or angina. 

“Finally,” the authors write, “these findings call into question the common practice of ischemia-guided revascularization (either using noninvasive testing techniques or FFR) where the presence of myocardial ischemia routinely determines patient selection for coronary angiography and revascularization.”

So we have a changing landscape in the world of stents, CABG, and medical therapy based on an excellent set of studies looking at the current available data. As Husten closes his article with PCI is “a cornerstone of daily practice in evaluation of patients with CAD and endorsed by the American College of Cardiology Foundation AHA and European Society of Cardiology guidelines”. 

Data is pointing a different direction regarding the management of ischemia guided revascularization. Do patients have to wait years until prospective studies are completed to show that this meta analysis was accurate? Will patients with CAD know enough or have enough time to find this data and ask their cardiologist about stents vs. CABG or medical therapy? Will cardiologists step up and present this data to their patients? Is this a case of trickle down knowledge where the gate keepers are the one’s performing the work?

Another Look at Healthcare Spending

Austin Frakt writing at The Incidental Economist “Chart: Health care spending growth factors“. Offers another chart from the JAMA study “The Anatomy of Health Care in the United States“. 

Frakt notes rightly so the majority of the slowdown (interesting word hints that it will pick up) is due to lower use and intensity growth. Which speaks to the economy in part and in part to what I believe are Americans become hypersensitive to healthcare, aging population seeking to improve outcomes, the screaming about the ACA. We can not go a day without a healthcare story slapping us in the face. Which is good. 

Frakt final points to the obvious “price growth remains robust by comparison”. The cynic in me sees this as the price setters are raising prices in response to the slowdown. That’s what occurs in a free market. Or is that as spending slows prices drop since more and more consumers and insurance companies are looking for low cost high value healthcare. 

Dear Hospital Administrator: You Talking to Me? I Am Not Listening.

Dan Dunlop writing on The Healthcare Marketer makes an important observation “Hospitals Failing to Connect with their Audiences” which is based on his review of a post by Dr. Bryan Vartabedian’s 33 Charts.You can talk about yourself which in reality no one gives a flying rat’s butt about or you can speak to issues that are important to your audience. I think the word is patient centric. Here is the link to 33charts

So what is that sound I hear? It’s reality speaking. Hospitals need to behave like responsible marketers who are selling a product in a competitive market. Everything is pointing to where we are going. I am not recommending behaving like Crazy Eddie but more like Apple or Google or any number of smart marketers. Sell solutions to problems. 

And another point that’s clear is that this issue speaks to adult learning. Adults will only learn when they are seeking a solution to a problem. This is particularly obvious in healthcare where we know adults with a chronic illness will invest time and effort on line to find information and seek support. In my view and the view of the team I am assembling our goal is to help providers differentiate their services via problem solving patient centric communication as opposed to me me me.

Speaking of Media Morons: Fox, ACA, and Reality

Aaron Carroll at The Incidental Economist responded to a Fox news story about a family that could not find a healthcare policy for their 1 1/2 year old. And of course they are blaming Obamacare since it was on Fox, no surprise there.

I have turned a deaf ear to these stories and that source in particular. But Carroll took aim and deconstructed it to the point of discrediting the spot so well. Hop to the site and read his five points. The Fox news report seriously shows to what degree the loyal opposition will go to make sure people will not sign up, hate the President, and avoid insurance.

Carroll makes a great point that does a Jon Stewart showing the hypocracy.

I’m sorry, but I find it somewhat hypocritical that only now, after decades of about 50 million people being uninsured every year, that suddenly the media is outraged by stories of people (healthy, mind you) having difficulties finding insurance. Really? Suddenly this is an issue? Didn’t seem like it before… AND THIS STORY IS ALREADY RESOLVED. AND LIKELY NOT ENTIRELY TRUE.

Beyond the Headlines: Drinking Media’s Phone Kool-Aid

Gruber at Daring Fireball pointed to this article in Business Insider by Jay Yarow “Here’s A Problem With The Theory That Android Is Taking Over The World

On average, iOS users spent $127.92 per order on Black Friday compared to $105.20 per order for Android users. iOS traffic reached 28.2 percent of all online traffic, compared to 11.4 percent for Android. iOS sales reached 18.1 percent of all online sales, compared to 3.5 percent for Android.

The above is from IBM scraping millions of transactions and terabytes of data.

Adobe tracked 400 million visits to >2,000 US retailers 

iOS-based devices drove more than $543 million dollars in online sales, with iPad taking a 77 percent share. Android-based devices were responsible for $148 million in online sales, a 4.9 percent share of mobile driven online sales.

…iPads drove the vast majority of online sales with $417 million while iPhones were responsible for $126 million. In comparison, Android-based phones generated $106 million, Android-based tablets $42 million in online sales on Thanksgiving and Black Friday

So every month we see the headlines about Droids taking over the phone and tablet market. Consider this data and who is driving business and what this means to those companies that market to consumers. Be true to thy market. 

And finally, think about the headlines we see on medicine and health. How the world is ending. When we do a deeper dive into the data from reliable sources we often get a bit of clear picture. This makes the case for critical apprasial at all levels.