September 4, 2014
In order to bring you more of the news you want to read, RightCare Weekly summarizes and interprets three important articles and provides headlines linking to the many other articles and editorials you’ll find interesting. As always, RightCare Weekly presents articles related to moving our healthcare system toward the right care for all patients.
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A study this week in the New England Journal of Medicine finds that LCZ696, a new drug for treating heart failure, reduced rates of death or hospitalization for the disease. (If results hold up, 35 people will need to be treated to prevent one death. By comparison, 82 patients with heart disease need to be treated with a statin to prevent one death. Statins are considered highly effective for such patients.) The reaction to the NEJM study of LCZ696 has been enthusiastic. However, cardiologist Vinay Prasad points out in CardioExchange a veritable parade of red flags in the trial design (including a run-in period in which some patients dropped out, and possible under-dosing of the comparator drug) that have the potential to seriously bias the results. Harlan Krumholz, MD, a member of Lown Institute’s Clinical Advisory Council, has noted at Forbes that the trial data is still held by Novartis, which funded the trial.
The Dartmouth Atlas and other researchers have shown repeatedly that where patients live has a lot to do with how they’re treated. It turns out, the same goes for where doctors train and how they practice. A paper in the current JAMA Internal Medicine finds that physicians who did their residencies in regions of the country where the prevailing pattern of care is high-intensity scored lower on the sections of board exams where the correct choice was the most conservative (i.e. least invasive or intensive) option. (For an explanation of what high-intensity care is, see here.) In other words, a culture of care that says more is better leads to trainees who often don’t know when doing less is better. Interestingly, students who trained in low-intensity areas scored just as well as those from high-intensity areas on questions where the correct answer was the most intense treatment option. The trend toward better conservative management among trainees from low-intensity programs held across all tiers of overall medical knowledge. For an overview of how treatment patterns vary across some of the most prominent residency programs, check out “What Kind of Physician Will You Be?”
Better conversations can be an essential tool for physicians to help patients avoid invasive and uncomfortable treatments, especially when those treatments can’t extend or improve patients’ lives. Pam Belluck writes in the New York Times that Medicare is currently considering a request from the AMA to reimburse physicians for time spent talking to patients about their plans and preferences for end-of-life care. Lown Institute Clinical Advisory Council member Diane Meier, MD, is quoted in the story.
Meanwhile, Kaiser Health News and NPR report that companies like Vital Decisions are trying to lower the barriers to difficult end-of-life conversations by connecting patients with social workers by the phone, rather than with physicians in person. If the conversations focus on building relationships with patients and helping them get care that accords with their values, great. However, there are clear potential incentives for a company (especially one hired by an insurer) to push patients toward lower-cost care regardless of preference. If the model is to expand, it will need to seriously address the trust issues.
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