Extended Time Window for Stroke Treatment. The Public Gets the Wrong Message

The recent presentation and publication of two clinical trials supporting the effective treatment of ischemic stroke as long as 24 hours after onset have been widely disseminated by the press. Articles have correctly hailed this as a major advance in stroke diagnosis and treatment. Both the DEFUSE 3 and DAWN trials have robust treatment effects, in some cases stronger than for patients treated within 6 hours. The studies are presented as a dramatic advance which could be misunderstood as benefiting all stroke patients.

The Washington Post reported “New research will radically change response to strokes”. The article makes the following statement: “The new findings suggest they (doctors) may have as long as 16 hours in many cases”. It is the word many that can be misleading to anyone reading this message. The tone of most articles emphasizes that it will now be possible to treat stroke patients as long as 24 hours after symptoms. What is not generally stated, however, is that this approach will only benefit a minority of stroke patients, and that for most strokes “Time is Brain” still applies, and that a person experiencing stroke symptoms should get to a stroke center as soon as possible to have an opportunity to preserve brain tissue which is at risk.

A patient told me this past week that “I am up to date with the news. I know that I can take 24 hours to get to the hospital if I am having a stroke”. I am certain that this was not the intended message, but this is the way it has been perceived. If I had any doubt, last night a member of our local volunteer EMS called ahead to our ED with a patient whose stroke started 12 hours earlier, commenting that he knew there was still ‘plenty of time’.

The most important information to be derived from these studies is that not all strokes progress at the same rate, and there are now diagnostic studies to find the patients who have blockage of major arteries, but have not yet sustained major damage. These are the patients that were shown to benefit in these treatment trials. And the fact that they can greatly benefit from treatment so late is indeed revolutionary.

These late treatment trials will indeed lead to widespread changes in stroke care, especially in the treatment of patients who wake up with stroke symptoms, and have previously been automatically excluded from treatment. Hospitals in these studies utilized specialized CT scans, with software for automatic analysis that is not yet widely available. As stroke care advances, the ability to get the right patients to centers that can perform the advanced interventional therapies will become widespread. But for now, the extended time windows for treatment will only be available to a small minority of stroke patients.

 

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Using Twitter to Treat Stroke

Yesterday, a 97 year old woman arrived in our emergency department after suddenly becoming unable to speak, and having weakness over the right side of her body. She was brought in by her husband, also in his 90s. We needed to make some immediate decisions about our options for treatment of this devastating condition, but it was necessary to find out when the symptoms started. Treatment for stroke requires having this knowledge, because treatments can only be administered within a narrow time window. The clot dissolving medication, tPA, could not be administered in this patient later than three hours following her first symptoms.

When we asked her husband when this all started, he told us he was uncertain about the time, but he did know one thing – ‘it happened during the seventh inning of the Yankee game’. We needed to find out immediately when the game was in the seventh inning. On to the Internet. A box score was not helpful. I decided to search Twitter for ‘Yankees’, and the line of tweets was immediately traced back to what we wanted. We discovered that the time was two hours earlier. The patient was treated with tPA and, and has demonstrated some improvement.

One more tool in stroke treatment. Twitter.

Saving Medicare: Boomers, Doctors and Legislators Need to Understand

A few weeks ago a patient came into my office referred for evaluation regarding surgery on her carotid artery. Although she had no symptoms, her primary physician had performed carotid ultrasound and found a severe narrowing on one side. She presented the results of this examination, and several additional diagnostic studies that had been performed recently. As it turned out, the doppler was inaccurate and she did not have any narrowing. As I explained this to the patient, I asked her if she understood that this test might not have been necessary. She replied, “He is a nice man, he deserves to make a living”.

Think about what is wrong with this picture and how things can be improved to save Medicare funds.

Unnecessary tests are being performed. This is widely known and understood. It is a way for physicians to generate income that is much easier than seeing additional patients. Patients don’t mind as long as they don’t feel the cost. Physicians do this testing at least partially because they are not paid enough to see patients. Some testing is a result of self-referral, such as the radiology report that says “consider performing the following examination for clarification”.

Physician’s time is not valued. In the case of this patient, I was able to help her avoid a possible surgical procedure and additional testing, saving the system thousands of dollars. In relationship to this visit, I fielded telephone calls from the patient, her children, and the referring physician. Payment for the visit does not compensate for this time. Doctors are unique among professionals in this respect; their time has no value and is regarded as free. Try this with your lawyer, accountant, or plumber.

Medicare beneficiaries don’t want any cuts. A recent study published in the New England Journal of Medicine indicated that most seniors are not willing to discuss any cuts in Medicare.

Everyone knows we are at a critical time. As we accept that resources are no longer infinite, all stakeholders need to accept that they will play a role in the survival of Medicare. Changes in behavior can be promoted by system modification. Some ideas:

Time for Medicine to leave the sidelines and reduce waste. Every medical specialty knows where the waste is in their field. Legislators should challenge medical associations to reduce costs without denying useful services.

Patients need to feel the cost of medical care. Before every test and procedure, patients should be informed of what the system will pay. The idea of annual coverage limits on ambulatory diagnostic services is not unthinkable.

Doctors should be paid for their time. The technology is available to allow physicians to be paid for actually talking to patients, in person or by telephone. Appropriate systems can control abuse; there are only a limited number of hours in the day.

Payment systems need to be implemented that prevent abuse and fraud. The credit card companies know how to do this, and it is long past due in healthcare. We have written about this previously.

It is time for the providers and consumers of healthcare to face the fact that they have allowed insurers and legislators to dictate changes in the healthcare system that do not improve healthcare or control costs. Soon it will be too late. Medical societies should step forward, doctors should present the facts to their patients, and legislators should encourage the achievement of these goals.

Credit Cards and Medicare Savings

I live in New York. Last week my daughter in Chicago called to say that a five dollar charge had been refused at a local coffee shop. My credit card company had identified an unusual pattern of purchases, and had put a hold on the card.

No similar process exists for the Medicare system, where cost savings could be realized by systems that identify unusual patterns of charges and outright abuse by providers of medical services and equipment. A single basic change in the way the system operates has the potential to both save money and improve the care of patients.

When a Medicare patient has a service provided, the service is billed after it is done. A physician, for example, may bill a charge to Medicare one hour, one month, or one year after it is performed. There is no approval at the time of the charge, as there is with the credit card. Take the example of a 70 year old woman who sees her primary physician in New York for a regular visit. As part of his/her preventive practice, an ultrasound of the carotid arteries may be performed to assess her risk for stroke (no comment on whether this represents appropriate practice). The result is normal. Several months later, spending the winter in Florida, she sees a physician for monitoring of her blood pressure. Another Doppler study is performed. Who will get paid for performing the Doppler study, the first or second physician, or both? Well, it may depend on who bills the charge first, and several other factors.

A Credit Card for Medicare

If the Medicare card were like a credit card, the service would need to be approved before the charge was billed. And sophisticated software, such as the fraud detection systems used by credit card processors, could be utilized to identify duplication of services and potential patterns of fraud.  Both ethical and political opposition to such a change would be significant.

Changing the system to have Medicare charges approved before the service means sometimes saying ‘NO’ to a patient that is already at their doctor. Any hint of curtailing Medicare benefits has led to violent reactions (‘death panels’) by the opponents of such change. And the public may be justifiably fearful of choices made by committees or bureaucrats who have no knowledge of Medicine. Is there any way to make this work?

Doctors Need to Step Forward

Physicians know their business. Professionals in every medical field and specialty are aware of what their colleagues are doing, and where savings can be achieved without harm to patients. Patterns of abuse by sellers of durable medical equipment (wheelchairs) are recognized. But there has never been any reasonable incentive for physicians to lower costs. Doctors, after all, are paid for the services they perform.  And the legal environment makes it dangerous at times to withhold services.

Medical societies in each specialty should create groups to analyze practice patterns, and suggest ways to identify potential savings. A percentage of the cost savings must then be returned to establish and increase reimbursement to physicians for direct contact with patients. This would include an increase in payment for office and hospital visits, and payment for telephone communications and emails. This would be a win-win for patients, physicians, and the society.

A credit card company such as MasterCard or American Express could easily handle the processing of Medicare charges. Card reading devices are standardized and ubiquitous, and they have experience with sophisticated fraud detection systems.

It is time for creative ideas that originate from the providers of healthcare, and not from government or insurers. The real partners in the healthcare system are patients and providers. They need to work together to improve systems of care.

Should Patients Adjust Blood Pressure Medicines?

We are no longer surprised when a patient is asked if they take their blood pressure medicines every day, and we are told “it depends”. Yes, it can be amusing to hear how one member of a couple decides that they know more than their physician, and makes decisions based on home blood pressure measurements. Sample quotes may include “she thinks she is a doctor”, or “I decide what to give him/her after I take the pressure”. This can not only be amusing, but frustrating to the physician attempting to achieve blood pressure control in order to reduce the risk of heart disease and stroke, among other conditions.

Now British physicians have published a study in a prestigious medical journal, The Lancet. Their study, Telmonitoring and Self-Management in the Control of Hypertension (TASMINH2) was reported in July. They showed for the first time that patients adjusting their medications according to rules specified by their physicians could do a better job of controlling blood pressure. This study was well designed, and included several key elements.

Patients were first trained in how to adjust medicines, and which ones to adjust. The schedules for measurement and adjustment were agreed upon with their physicians. The blood pressure was only measured for one week per month. If the readings were above a target blood pressure on two consecutive months, an adjustment could be made.  Blood pressure readings were transmitted to the physicians conducting the study.

What has happened here is very important. It demonstrates the power of educating patients, and of giving them responsibility for their own care. With the correct type of patient, this is a powerful way to improve care. It may not apply to every patient, however. More work will be done to see how these techniques can apply to people of various educational levels and ethnic backgrounds. These studies are in progress.

The health care system will need to change in order to support physicians and nurses that are ready to implement these changes, and involve the patient more closely in their own care.