Can heart-rhythm doctors practice parsimoniously?

Two studies published today really gave my thinking brain a workout.

The first study: The prestigious medical group, the American College of Physicians (ACP) provocatively decreed, in its recent ethical guidelines, that doctors have a responsibility to use parsimony in the diagnosis and treatment of patients.

As reported today on the NPR health blog, Shots, using the word parsimony to describe the delivery of medical care turns out to be quite controversial. Defined as the “extreme unwillingness to spend money or use resources; stingy,” parsimony makes many think of rationing.

Writing in an accompanying editorial, Dr Ezekiel J. Emanuel, professor of bioethics at the University of Pennsylvania and frequent adviser to President Obama, called the ACP’s statement “truly remarkable.” He was impressed that a group of medical leaders sometimes known for “banal exhortations” were bold enough to directly confront such a sensitive topic.

The second study: Minutes before reading how it is ethical to practice medicine cost-effectively, I happened onto the most recent defibrillator trial published in Circulation. In an effort to correlate ICD complications with the experience of the implanting doctor, researchers from Stanford and Yale reviewed a national registry of ICD implants from 2006-2010. Not surprisingly they showed experienced doctors did better. That’s not what struck me from the study.

The provocative finding was this: in just four years time, 510,835 ICDs were implanted in participating hospitals in the US. Using a conservative estimate of 50,000$ per ICD (total cost to the healthcare system), one comes up with the very un-parsimonious total of 26$ billion.

26 billion dollars makes you think. Maybe even squint. Or squirm. I can’t help think what 26$ billion could…

…Forget it…I’m not going there.

But I can re-say this about ICDs:

For almost two decades I have witnessed the ICD’s miracles—the years of good life a patient lives after a shock aborts sure death, or the return of vigor after that third lead of a CRT syncs the heart’s squeeze. When ICDs work like this, words like gratifying, affirming and happy come to mind. One of my first ICD implants saved the life of our neighbor. And then Hans went on to bless our family with friendship for more than 7 more years after his first shock. When ICDs are used well, this kind of story is common. One might even call such cases, ‘cost-effective.’

But I have also seen how dubious patient selection amplifies the ICD’s downsides–changing one’s mode of death from peaceful to not. I see the sobering findings of this (not so publicized) NEJM study play out in real life: patients with advanced heart disease live an average of only 162 days after their ICD delivers an appropriate shock. Few heart doctors speak of the bad news of the life-saving shock: that the heart may simply be giving out. Or said another way; it is time. Smartly selecting, and effectively informing patients about an ICD remains one of my greatest challenges.

Then there is the matter of…

26$ billion.

And, parsimony.

I thought a lot today.

JMM