{"id":27055,"date":"2012-03-05T10:53:54","date_gmt":"2012-03-05T15:53:54","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?post_type=voices&p=27055"},"modified":"2012-03-05T10:53:54","modified_gmt":"2012-03-05T15:53:54","slug":"selections-from-richard-lehmans-weekly-review-week-of-march-5th","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2012\/03\/05\/selections-from-richard-lehmans-weekly-review-week-of-march-5th\/","title":{"rendered":"Selections from Richard Lehman\u2019s Weekly Review: Week of March 5th"},"content":{"rendered":"

\"\"CardioExchange is pleased to reprint selections from Dr. Richard Lehman\u2019s weekly journal review blog<\/a> at BMJ.com<\/a>. Selected summaries are relevant to our audience, but we encourage members to engage with the entire blog<\/a>.<\/em><\/p>\n

Week of March 5th<\/strong><\/p>\n

NEJM\u00a0 1 Mar 2012\u00a0 Vol 366<\/strong><\/p>\n

Goal-Oriented Patient Care (pg. 777):<\/strong> There is no JAMA this week, and the best things in the New England Journal come right at the start. Whether you are a British GP contemplating another set of humiliating idiotic directives and the imminent destruction of the NHS, or an American physician wondering how your crazy health system can ever be turned into something rational and sustainable, or an academic wondering how much more futile research you have to grind your way through and pretend to be interested in, here is the boost you need. Goal-Oriented Patient Care \u2014 An Alternative Health Outcomes Paradigm. For the battle-weary GP, an affirmation of the central value of what you came into medicine to do \u2013 to help patients to achieve goals that they choose for themselves, in a continuing dialogue about the possible and the practical. For the American system, a model of care that puts the patient at the centre and emphasizes joined-up, affordable care. For the academic, a new research agenda based on what will best inform shared decision-making with patients and society. Download this article<\/a> by David Reuben and Mary Tinetti at once and keep it under your pillow.<\/p>\n

The NEJM lets you have this free<\/a>, and also the companion pieces which follow<\/a> \u2013 about shared decision-making and defining patient-centred care. Both good, but the Reuben\/Tinetti is a gem.<\/p>\n

Arch Intern Med\u00a0 27 Feb 2012\u00a0 Vol 172<\/strong><\/p>\n

Stenting vs. Medical Therapy (pg. 312):<\/strong> Doctors and patients love to share simple mechanistic explanations of diseases and cures. Angina pectoris is caused by blocked pipes: unblock the pipes, preferably leaving behind something to keep them open, and you have cured the problem; whereas if you just keep on pushing tablets, you\u2019re just treating the symptoms without dealing with the cause. Most of us shared this belief with cardiologists and with patients, until the COURAGE trial came along in 2007 to prove otherwise (and the trial was nearly never done because many interventional cardiologists considered it unethical). This meta-analysis<\/a> looks at this and 7 other trials and confirms the counter-intuitive conclusion that \u201cInitial stent implantation for stable CAD shows no evidence of benefit compared with initial medical therapy for prevention of death, nonfatal MI, unplanned revascularization, or angina.\u201d Collusion in mechanistic certainty is one of the great barriers to progress in medicine, and it may cause direct harm to patients, as the next paper illustrates.<\/p>\n

Patient Satisfaction and Mortality:<\/strong> There isn\u2019t much else of note in this week\u2019s printed Archives, but hidden in the Online First section awaiting paper publication is a remarkable study of patient satisfaction<\/a> in relation to outcomes. This is worth spending some time on. In the USA, the highest quartile of patient satisfaction is associated with 9% higher inpatient care and drug costs, and \u2013 wait for it \u2013 26% higher mortality. What is killing America\u2019s most satisfied patients? Is there some hidden confounding here (as the editorial hints)? The authors adjust for everything obvious, such as age and health status; so perhaps the kind of medicine these patients are getting really is 26% more dangerous. But this exceeds even the most pessimistic predictions of those of us who have long held that the overprovision that American patients are programmed to demand might be dangerous. Costly, futile, yes: but as lethal as this? I intend to spend an hour with my brilliant group of young overseas doctors at Yale picking over this paper. If nothing else, it will have some lessons on what to avoid in their own health systems. I firmly believe that all health provision should be judged by the experience of patients, but the simple criterion of fulfilled expectation is clearly inadequate, and may be positively dangerous in societies which ratchet up demand for medical services while ignoring costs and harms.<\/p>\n","protected":false},"excerpt":{"rendered":"

This week’s topics include goal-oriented patient care, stenting vs. medical therapy, and patient satisfaction and mortality.<\/p>\n","protected":false},"author":475,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[972,801,611,1160,437],"class_list":["post-27055","post","type-post","status-publish","format-standard","hentry","category-general","tag-medical-therapy","tag-mortality","tag-patient-care","tag-patient-satisfaction","tag-stents"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/27055","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/475"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=27055"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/27055\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=27055"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=27055"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=27055"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}