For many years, the standard thinking regarding treatment of patients with atrial fibrillation was that drug therapy to restore sinus rhythm (rhythm control) was superior to drug therapy to slow the ventricular response rate (rate control). That all changed in 2002, when a clinical trial found no difference in survival between patients randomized to rhythm or rate control, and a higher incidence of adverse effects in the rhythm control group.
This trial and other evidence led the American Academy of Family Physicians to issue a guideline that recommended rate control with chronic anticoagulation as the preferred strategy for most patients with atrial fibrillation. A recent AFP review article echoed this guidance, assigning an "A" strength of evidence rating to the following statement: "Rate control is the recommended treatment strategy in most patients with atrial fibrillation. Rhythm control is an option for patients in whom rate control is not achievable or who remain symptomatic despite rate control."
On occasion, however, evidence-based interventions achieve different results in primary care than in clinical trials. A study published earlier this month in the Archives of Internal Medicine used administrative databases in Quebec, Canada to compare mortality between older patients with atrial fibrillation who were initially prescribed rhythm or rate control therapy after their diagnoses. After experiencing similar mortality through 4 years of follow-up, patients in the rhythm control group had a significantly lower risk of death, with 23% lower relative mortality than patients in the rate control group at 8 years. These surprising results beg the question: was this new study somehow flawed? If not, as the subtitle of an accompanying editorial asked, can observational data trump randomized trial results?
Although it is unlikely that treatment guidelines will change any time soon, this study should remind clinicians that management of patients with newly diagnosed atrial fibrillation should be individualized, and the risks and benefits of different strategies discussed in detail before making treatment decisions.
**
The above post was first published on the AFP Community Blog.
Monday, 9 July 2012
Thursday, 5 July 2012
Public Speaking Update
Since I began blogging at Common Sense Family Doctor in July 2009, its posts have been featured in widely read blogs such as KevinMD.com, The Health Care Blog, and Gary Schwitzer's HealthNewsReview, as well as the websites of major national newspapers such as the New York Times, the Wall Street Journal, USA Today, and the Boston Globe. I also wrote the consumer health blog Healthcare Headaches for U.S. News and World Report from August 2010 through September 2011.
Like the vast majority of physicians who blog, I write in my spare time. I have never accepted advertising or paid web links on Common Sense Family Doctor, and the choices of topics for posts are my own and not influenced by financial or other conflicts of interest. In order to support the time I devote to blogging, and to encourage high-quality medical writing and clinical practice, I give lectures and workshops to medical and non-medical audiences on a variety of topics. These include the uses of social media tools in medicine and education, developing and implementing medical guidelines, and the evidence supporting specific prevention recommendations. If you or your organization would like to invite me to speak, please e-mail me at linkenny@hotmail.com or KWL4@georgetown.edu.
Upcoming events:
PSA Screening, Science, and Public Policy (panel discussion)
- Johns Hopkins University Bloomberg School of Public Health
- October 25, 2012
Screening for Osteoporosis: Who, When, and How Often?
Spanish Catholic Center of Catholic Charities of Washington DC
- September 2012
Screening Mammography for Women in their 40s: Exploring the Controversy
NCA Breast Healthcare Improvement Initiative
- July 23, 2012
Past events:
Why You Should Stop Screening Patients for Prostate Cancer
- Ephrata Community Hospital (PA)
Identifying and Using Good Practice Guidelines
- Temple University School of Medicine / Lancaster General Hospital
Cancer Screening: A Primer for Journalists
- National Press Foundation's Cancer Issues 2011
What to Do When Screening Guidelines Conflict: HIV and Mammography
- Grand Rounds, Georgetown University Department of Family Medicine
Overdiagnosed: Making People Sick in the Pursuit of Health
- William J. Bicknell Lecture (panelist)
- Boston University School of Public Health
For Geeks and Geezers: With Social Media Skills You Can Change the World
- Family Medicine Education Consortium Northeast Region Meeting
Screening for Diabetes: What Does the Evidence Say?
- Spanish Catholic Center of Catholic Charities of Washington, DC
Don't Do It! Preventive Health Services That Harm More Than They Help
- District of Columbia Academy of Family Physicians
Using the Medical Literature to Make Decisions About Preventive Health Services
- Medical Library Association Annual Meeting
Medical Blogging and Other Professional Uses of Social Media
- Grand Rounds, Virginia Commonwealth University Internal Medicine
Spilling Ink: An Expert's Guide to Getting Your Work Published
- Society of Teachers of Family Medicine Annual Meeting
Health Promotion and Disease Prevention in Clinical and Community Settings
- Uniformed Services University of the Health Sciences
The Value of Preventive Health Services
- Webinar for Employees of MetLife
COPD Update: A Prevention Perspective
- Maryland Academy of Family Physicians
Like the vast majority of physicians who blog, I write in my spare time. I have never accepted advertising or paid web links on Common Sense Family Doctor, and the choices of topics for posts are my own and not influenced by financial or other conflicts of interest. In order to support the time I devote to blogging, and to encourage high-quality medical writing and clinical practice, I give lectures and workshops to medical and non-medical audiences on a variety of topics. These include the uses of social media tools in medicine and education, developing and implementing medical guidelines, and the evidence supporting specific prevention recommendations. If you or your organization would like to invite me to speak, please e-mail me at linkenny@hotmail.com or KWL4@georgetown.edu.
Upcoming events:
PSA Screening, Science, and Public Policy (panel discussion)
- Johns Hopkins University Bloomberg School of Public Health
- October 25, 2012
Screening for Osteoporosis: Who, When, and How Often?
Spanish Catholic Center of Catholic Charities of Washington DC
- September 2012
Screening Mammography for Women in their 40s: Exploring the Controversy
NCA Breast Healthcare Improvement Initiative
- July 23, 2012
Past events:
Why You Should Stop Screening Patients for Prostate Cancer
- Ephrata Community Hospital (PA)
Identifying and Using Good Practice Guidelines
- Temple University School of Medicine / Lancaster General Hospital
Cancer Screening: A Primer for Journalists
- National Press Foundation's Cancer Issues 2011
What to Do When Screening Guidelines Conflict: HIV and Mammography
- Grand Rounds, Georgetown University Department of Family Medicine
Overdiagnosed: Making People Sick in the Pursuit of Health
- William J. Bicknell Lecture (panelist)
- Boston University School of Public Health
For Geeks and Geezers: With Social Media Skills You Can Change the World
- Family Medicine Education Consortium Northeast Region Meeting
Screening for Diabetes: What Does the Evidence Say?
- Spanish Catholic Center of Catholic Charities of Washington, DC
Don't Do It! Preventive Health Services That Harm More Than They Help
- District of Columbia Academy of Family Physicians
Using the Medical Literature to Make Decisions About Preventive Health Services
- Medical Library Association Annual Meeting
Medical Blogging and Other Professional Uses of Social Media
- Grand Rounds, Virginia Commonwealth University Internal Medicine
Spilling Ink: An Expert's Guide to Getting Your Work Published
- Society of Teachers of Family Medicine Annual Meeting
Health Promotion and Disease Prevention in Clinical and Community Settings
- Uniformed Services University of the Health Sciences
The Value of Preventive Health Services
- Webinar for Employees of MetLife
COPD Update: A Prevention Perspective
- Maryland Academy of Family Physicians
Monday, 2 July 2012
Guest Post: Reports of the ACA's death were greatly exaggerated
Marya Zilberberg, MD, MPH is an independent physician health services researcher with a specific interest in healthcare-associated complications and a broad interest in the state of our healthcare system. I recently reviewed her excellent book on evidence-based medicine, Between the Lines. The following post was first published on her blog, Healthcare, etc.
**
This was a big day for President Obama's signature legislation, the Affordable Care Act. The Supreme Court upheld its constitutionality, and the punditdom thinks that further challenges are unlikely. On the other hand, if Romney takes the White House in the next election... Well, you can guess what will happen then.
It has been interesting to watch the run-up to this decision. Most recently I have been amused by surveys finding that on the one hand, many American people are in favor of the pre-existing condition inclusion (this part of the bill forbids insurance companies to discriminate against people with prior health conditions), as well as the provision that allows young adults to stay on their parents' insurance policies through a certain age. On the other hand, the majority of Americans are against the healthcare law itself, and most also oppose the individual mandate provision (this is the part where everyone has to buy insurance or pay a tax). Given this imbalance in the public opinion, a more pertinent survey should have assessed how well people understand these provisions in the first place. And this would have had to establish how well the public gets our whole healthcare "system."
To start from the beginning, any healthcare system can be judged on three criteria:
1. How accessible is it?
2. Is it of adequate quality?
3. How expensive is it?
The answer to the first question provides one of the rationales for the individual mandate. Currently there are about 50 million people without health insurance in the US, and, hence, without adequate access to the system. Many of these people are the young and the healthy who gamble on staying young and healthy. And many are consigned to relying on expensive emergency care when this gamble fails. Some of them go bankrupt trying to pay for it, while others become "safety net" cases, where the institution that cares for them swallows the costs. These institutions do get some public dollars for providing safety net care, but not nearly enough to break even. Since many of the 50 million don't buy health insurance because they cannot afford it, the healthcare bill provides a way to create more affordable insurance products.
The answer to the second question is not related directly to the individual mandate. Since much of this blog is devoted to the issues of healthcare-associated harm, I do not wish to belabor this point here. Suffice it to say that the bill does try to address this catastrophic situation, though it remains to be seen if it will succeed.
The third question is the crux of the story. Many have said that the escalation of healthcare costs is unsustainable, and I subscribe to this notion: I am not sure how much more than $2.6 trillion/year we want to pay for this insatiable beast. Yet judging by the near-revolt that "death panels" rhetoric caused, the citizenry is not interested in being thoughtful about what services make sense. The vehement knee-jerk to the "R" word shuts down the discussion before it even starts. So, OK, how do we pay this ever-increasing bill? Moreover, since we are all happy with the government mandate for all insurance to pay for pre-existing conditions, how do we propose to pay for this additional coverage? Short of printing money (not generally a good idea) or creating a single-party payer system that regulates these expenditures, the only way is to broaden the pool of revenue. The way the ACA has proposed to broaden this pool is through the very individual mandate that is anathema to our American way of life. But without it, there is no broadening of coverage, and there is no paying for every intervention that we seem to feel entitled to.
I doubt very much that the ACA will substantively contain healthcare costs. I even doubt that it will solve the quality problems, but I am willing to wait and see on that. This bill is but a band-aid on an arterial bleed. However, I do believe that upholding this legislation allows us to take the first steps toward a reasonable national dialog about the kind of healthcare system we need. This dialog will not be helped by stupid surveys that reinforce our willful ignorance. We have the opportunity to move this conversation to a higher level, where people begin to understand the issues we are up against more deeply. Let's take it.
**
This was a big day for President Obama's signature legislation, the Affordable Care Act. The Supreme Court upheld its constitutionality, and the punditdom thinks that further challenges are unlikely. On the other hand, if Romney takes the White House in the next election... Well, you can guess what will happen then.
It has been interesting to watch the run-up to this decision. Most recently I have been amused by surveys finding that on the one hand, many American people are in favor of the pre-existing condition inclusion (this part of the bill forbids insurance companies to discriminate against people with prior health conditions), as well as the provision that allows young adults to stay on their parents' insurance policies through a certain age. On the other hand, the majority of Americans are against the healthcare law itself, and most also oppose the individual mandate provision (this is the part where everyone has to buy insurance or pay a tax). Given this imbalance in the public opinion, a more pertinent survey should have assessed how well people understand these provisions in the first place. And this would have had to establish how well the public gets our whole healthcare "system."
To start from the beginning, any healthcare system can be judged on three criteria:
1. How accessible is it?
2. Is it of adequate quality?
3. How expensive is it?
The answer to the first question provides one of the rationales for the individual mandate. Currently there are about 50 million people without health insurance in the US, and, hence, without adequate access to the system. Many of these people are the young and the healthy who gamble on staying young and healthy. And many are consigned to relying on expensive emergency care when this gamble fails. Some of them go bankrupt trying to pay for it, while others become "safety net" cases, where the institution that cares for them swallows the costs. These institutions do get some public dollars for providing safety net care, but not nearly enough to break even. Since many of the 50 million don't buy health insurance because they cannot afford it, the healthcare bill provides a way to create more affordable insurance products.
The answer to the second question is not related directly to the individual mandate. Since much of this blog is devoted to the issues of healthcare-associated harm, I do not wish to belabor this point here. Suffice it to say that the bill does try to address this catastrophic situation, though it remains to be seen if it will succeed.
The third question is the crux of the story. Many have said that the escalation of healthcare costs is unsustainable, and I subscribe to this notion: I am not sure how much more than $2.6 trillion/year we want to pay for this insatiable beast. Yet judging by the near-revolt that "death panels" rhetoric caused, the citizenry is not interested in being thoughtful about what services make sense. The vehement knee-jerk to the "R" word shuts down the discussion before it even starts. So, OK, how do we pay this ever-increasing bill? Moreover, since we are all happy with the government mandate for all insurance to pay for pre-existing conditions, how do we propose to pay for this additional coverage? Short of printing money (not generally a good idea) or creating a single-party payer system that regulates these expenditures, the only way is to broaden the pool of revenue. The way the ACA has proposed to broaden this pool is through the very individual mandate that is anathema to our American way of life. But without it, there is no broadening of coverage, and there is no paying for every intervention that we seem to feel entitled to.
I doubt very much that the ACA will substantively contain healthcare costs. I even doubt that it will solve the quality problems, but I am willing to wait and see on that. This bill is but a band-aid on an arterial bleed. However, I do believe that upholding this legislation allows us to take the first steps toward a reasonable national dialog about the kind of healthcare system we need. This dialog will not be helped by stupid surveys that reinforce our willful ignorance. We have the opportunity to move this conversation to a higher level, where people begin to understand the issues we are up against more deeply. Let's take it.
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