Tuesday, April 21, 2009

How Many Medical Devices Do We Need?

A Times article today announced "Study Backs Specialists Implanting Heart Devices."

Silly me. I thought it was already only "specialists" who did that stuff. The headline suggests maybe plumbers or barbers branching out into medicine. Looking more closely it's about electrophysiologists versus other types of heart specialists.

Over all, the study found that the rate of serious complications like heart attacks or internal bleeding that occurred during the implant of a heart device was lowest — about 1.3 percent — when the procedure was performed by an electrophysiologist, the name for a cardiologist formally trained in device use.

Most implant procedures, about 70 percent, were performed by electrophysiologists, the study reported. The remaining implants were done by other types of cardiologists or other kinds of doctors, including thoracic surgeons. The study found that the highest rate of serious complications, about 2.5 percent, occurred when the implant was done by thoracic surgeons, who accounted for only 1.7 percent of the procedures reviewed.

I'm not good with percentages, odds and stuff, but it looks to me -- a simple layman -- that if seventy percent of the procedures are already being done by the right people and the only measurable difference between those guys and the rest is the almost trivial difference between 1.3 percent of seventy percent and 1.2 percent more of the remaining thirty percent. If my calculations are close, if 100 percent of all procedures were perfoemed by electrophysiologists the resulting improvement would be something in the neighborhood of less than one percent.

That doesn't strike me as statistically significant. So what's this story all about? Is it possible this is a bait and switch smoke and mirrors release aimed at feeding journalists grist for the health care debate?

A big part of health care inflation, it seems, is too many unneeded devices, procedures, and medications. "Unneeded" does not mean "worthless" but that the outcome may not be different. In some cases, implanting technologically wonderful new devices may even be worse for the patient. Consider this from last September.

...in the last two years the number of patients receiving defibrillators has actually declined, as more doctors and patients decide the risks and uncertainties the devices pose may outweigh their potential benefits.

This trend — the first decline since implanted defibrillators were introduced in 1985 — has spotlighted a shortcoming that health experts have struggled with for years. Simply put, there is no adequate tool or test to predict which of the heart patients who might seem good candidates to get the expensive devices are the ones most likely to ever need their life-saving shock.

Same device, different story, and with a very different message.

What makes many doctors and patients increasingly wary, though, is a string of highly publicized recalls in recent years, along with mounting evidence suggesting that a vast majority of people who get a defibrillator never need it.

Industry estimates and medical studies indicate that defibrillators have saved the lives of 10 percent of the more than 600,000 people in this country who have received them, at most. While survivors would no doubt take those odds, 9 of 10 people who get defibrillators receive no medical benefit.One big long-term medical study indicated the odds of a defibrillator saving a patient’s life might be even slimmer — about 1 in 14, over the five-year period studied.
Compare numbers and statistics in these two stories. Has medicine had some great leap forward since last September? I think not, or this morning's article would have talked about that improvement instead of the minuscule difference between electrophysiologists and their cousins in the same field.

Not mentioned in this morning's story is the money involved.

Defibrillators have undoubtedly saved the lives of tens of thousands of Americans. That is why insurers still typically pay for the devices and the surgical procedure to implant them, which can top $50,000 for each patient.

That little nugget was found in last years article focused on the questionable efficacy of so many ICD implants rather than the cost.


Unless something dramatic comes along, I plan to stop posting so much about health care debate and move on to other subjects that interest me. It is clear to me that lots of smart people are on the job that know far more than I about the complexities of the many fields involved. It is equally clear that powerful financial and political forces are engaged in one of the epic struggles of our lifetime as the insurance and drug industries, medical device manufacturers, and professional groups on all sides struggle for control.

My work now as a caregiver for seniors is adding to my knowledge of how the system works for them. It is not remarkable for seniors to take from three to twelve prescription medications up to four times a day. Nearly all I have seen have had at least two or three surgeries, not counting cataract removal or dental procedures. Medical equipment is almost as ubiquitous as corrective lenses, but the difference in cost is breathtaking. And most of it is paid for by Medicare. I learned this weekend that Medicare will pay for one oxygen concentrator per patient but not two (for the convenience of having a second one in another part of the house when a longer oxygen line will do the same thing). One of my clients last year with a broken ankle rented a wheelchair, but when his representative went to return it he was told to keep it because Medicare would not authorize a second rental, and besides the rent had paid for the chair and everyone always kept them instead of turning them in to be reused.

When my mother returned from the hospital on hospice I was asked to choose among five different companies that typically do business at that particular nursing home. I had no idea what a big business it is. She only lived another three weeks but Medicare paid upwards of a thousand dollars for hospice over and above what the nursing home, hospital and other doctors received. From the time it was determined she had inoperable lung cancer until she died the system was able to collect (or pay, depending on one's perspective) thousands of dollars in a few weeks.

I saw somewhere that government pays about fifty cents of every health care dollar. I wonder if the voices yelling for lower taxes but no government involvement in health care have been able to connect those two dots.

Most of the rest is picked up by the insurance industry, embedded in corporate America collecting premiums from the healthiest of us while the unemployed, chronically sick and others with preexisting conditions fend for themselves And of course the same people complaining about government involvement with health care get equally defensive if anyone suggests their company insurance should be shifted elsewhere besides their employers, doing business in a world where competitors from other countries don't have to pay more for steel than for health care (as do US auto makers) or more for coffee than for healthcare (Starbucks) etc.

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