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Sunday, August 15, 2010

Early Detection of Alzheimer’s Disease? Not Yet, Thanks.

Alzheimer's disease made headlines this week, first with news about a new biomarker test that is able to diagnose the disease with increased accuracy, then with a follow-up story detailing the collaborative model of data-sharing that contributed to the success of recent research.

As I read the news with interest I couldn't help but feel that in our current climate, the manner in which it was reported was somewhat ironic. Just nine months ago experts on the United States Preventive Services Task Force argued that harm, in the form of anxiety related to the detection of breast abnormalities, was too excessive to warrant screening mammograms in forty-year-old women. Just think of the anxiety that will occur if we begin screening asymptomatic adults for Alzheimer's disease.

The unfortunate reality is that despite recent gains in our ability to accurately diagnose Alzheimer's disease, there is still no therapy that has proven effective in preventing its progression. On August 3, 2010 the Annals of Internal Medicine published a summary of this year's National Institute of Health Preventing Alzheimer's Disease and Cognitive Decline Conference.

Alzheimer's disease, the most common form of dementia, is a critical field of study, given the impact that this condition will have on our aging population. At this point the main benefit of earlier and more accurate diagnosis of cognitive impairment and dementia is that it will promote more research on therapeutics on a population level. However, practically thinking, what about the burden that this type of diagnosis could have individuals who go through testing? Is it worthwhile to detect a condition early for which there is currently no definite effective therapy? What would have happened to Ronald Reagan had he had this spinal fluid test when he was sixty years old? Would he have run for president? Would we have elected him? The test may accurately predict Alzheimer's, but does it tell us when? And will happen to health insurance or long-term care insurance coverage for patients after this test is performed?

MRI's are an also an effective means for detecting changes related to Alzheimer's disease, demonstrating amyloid plaque accumulation in patients with Alzheimer's, and distinguishing these patients from those who have other types of dementia, such as vascular dementia, which might be managed differently. However, what about all of our talk of comparative efficacy? Has performing an MRI been shown to alter the outcome of patients with a cognitive impairment or dementia diagnosis? I doubt that it has. I hate to be a cynic, but who will pay for the spinal fluid test, and the MRI, and the neuropsychological testing? And then, the repeat MRIs, and biomarker tests, and neuropsychological tests when the results of the first tests are inconclusive? How frequently will these tests need to be done? These questions are at the heart of the reality that our country faces with respect to the role of medical progress, cost, and health care. But as a physician I advocate mainly for my patient, not for the health care system, so I make these diagnostic decisions collaboratively with my patients, not necessarily with the population level questions in mind.

The Alzheimer's progress is a perfect example of how our country will have to grapple with balancing exciting innovation with the appropriate use of "evidence-based" diagnostics in the coming decade. But how will diagnostics ever become evidence-based if health plans refuse to pay for them? If industry finances expensive clinical trials, should we really be attempting to regulate the cost of their drugs?

In the wonderful book by Audrey Niffenegger, The Time Traveler's Wife, the time traveler witnesses his future death. His fate is unalterable and torments him. Until there is more effective therapy, I, for one, will not be doing the Alzheimer's test. Instead, I will do my best to remain mentally and physically active, control my cardiovascular risk factors, eat my vegetables, consider taking fish oil, take an 81 mg aspirin when I am 65, and wait to see what the next decade of Alzheimer's research will bring in terms of therapeutics. Hopefully innovation will not be stifled by policy change within our country.

Wednesday, August 4, 2010

Getting Back to Medicine

Two weeks ago I opened a new medical practice. It's been a long haul. One year ago, after 12 years in practice as an academic general internist, I decided to make a change. After sifting through a wide range of opportunities within the Atlanta metropolitan area I made the decision to open a solo general internal medicine practice. Some might consider it crazy, in an era when physicians are increasingly leaving private practice in favor of large employed groups. Employed groups do offer certain advantages for physicians, including being able to negotiate better contractual rates from insurers, cost-sharing with respect to benefits and pricey equipment, including electronic health records, and more opportunity for shared night call and weekend coverage. 

However, I had just left a large employed group and was witness to the kinds of problems with patient care, access, and continuity that can occur in this type of practice setting. Cost reducing practices, implemented under the guise of efficiency, such as off-site call triage centers, tend to reduce doctor-patient communication, in favor of "teamwork" so that doctors can be left to their revenue generating activity of frenetically seeing 20 to 25 patients daily. 

What I was after was a smaller, more personal practice, where I wouldn't have to spend the first five minutes of my fifteen minute doctor-patient encounter apologizing to my patients for systemic problems that affected the care that they were receiving.

In opening my practice there were several keys decisions to make: first, my practice location. I left my old practice with a two year non-compete covenant restricting me from the practice of general internal medicine in the area where I had built my life and home for twelve years. Would I be forced to move? Or, would I add on an extra hour of driving, and practice outside of my non-competition perimeter? I grappled with this decision for six months. It's funny how many of my friends questioned the legality of this type of contract within the state of Georgia. However, the three lawyers that I spoke with felt it was too risky to violate it. Fortunately this issue is now resolved, and I have established my practice close to home and plan to have a good working relationship with the institution that I left.

Another major decision was whether or not to purchase an electronic health record. The final "meaningful use" criteria tying Medicare and Medicaid reimbursement and incentives to the adoption of electronic health records by eligible medical professionals and hospitals were released two weeks ago. Being somewhat of a techno-geek and a relative "early-adopter," I opted to shell out the cash and buy an electronic medical record (EMR), with hopes that a promised link to my main referral center would become functional in the near future. We'll see how this pans out. I am already concerned that the commercial lab that I have contracted with is hesitating on what I thought was an agreement to upload my lab data directly into my EMR.  Apparently EMR providers charge extra to "turn on" this interface.  If the lab refuses I will be left to cover that cost as well. Those of you in the process of purchasing electronic records should be sure to verify in writing all of the links and interfaces that you want to function, and who will cover the costs associated with turning them on.  Meaningful use requires that lab data is entered into one's EMR as structured data, as opposed to scanned in, which makes the data usable when looking for trends and for generating quality reports and automated reminders.   Don't get me wrong, I am still happy with my expensive new "toy," though it's taking me twenty minutes, instead of two, to type in my office note, as opposed to dictating. Hopefully that will get faster. My implementation support has been wonderful, which I am grateful about.

Finally, I had to decide on staffing. I had originally planned to hire an office manager, but with the purchase of my EMR I decided to outsource my billing to the same company, which meant that I had more flexibility. An opportunity became available for me to hire a wonderful LPN with whom I had worked for many years. I feel so fortunate to work with a capable and loyal employee, who "knows my ways," and with whom I have shared common processes and protocols in the past and who is partnering with me in this endeavor. This is the decision that I am most confident about.

As I began to see patients again two weeks ago, I was surer than ever about my career choice to become a general internist. I can only hope that in the near future my practice will become something more than an expensive hobby.  In the meantime I will continue to work on the side at Georgia Tech in student health to make ends meet.

Tuesday, August 3, 2010

Is Distance Running Really Good For Your Heart?

By guest blogger: Kreton Mavromatis, MD, Assistant Professor of Medicine, Emory University, Director of Cardiac Catheterization, Atlanta VA Hospital
It's Sunday morning, July 4th and I have just returned from running a 10K race and I am feeling good.  I run approximately 3 or 4 days per week, and I run a race or two, including a half-marathon, each year, mainly to serve as a training goal. My motivation for running is primarily so that I can afford to eat more food, my favorite daily activity. However, as a cardiologist, seeing people with heart attacks from occluded coronary arteries day-in and day-out, I have always believed that running (and exercise in general) is good for my vascular health. After all, doesn't running lower blood pressure and cholesterol, and haven't studies shown that people who exercise more live longer? In fact, prospective epidemiological studies have suggested a dose related effect, implying more exercise of greater intensity is better.
To my dismay, however, several recent studies have suggested that running may not be good for my heart or arteries after all. Mohlenkamp et al showed that 108 apparently healthy marathon runners had more coronary artery calcium (which is found in coronary artery atherosclerosis) than patients matched for age and Framingham risk score (a commonly used measure of a person's risk for cardiovascular disease based on their risk factor profile). Furthermore, they showed that the amount of coronary artery calcium, as well as the number of marathons run, was directly associated with myocardial (heart) damage, which was detected in 12% of the marathon runners. Finally, four of the runners had cardiovascular "events" over the next 2 years, all of whom had high levels of coronary artery calcium. Similarly, Schwartz et al. showed that 25 marathoners had more coronary artery plaque than 25 non-marathoners who had similar ages, blood pressure and cholesterol levels.
These studies are far from conclusive. The marathon runners may have had more predisposition to coronary artery disease than the non-runners despite similar Framingham risk scores, perhaps due to prior lifestyle differences (i.e. smoking, diet) or a more extensive family history of such disease. On the other hand, there are plausible mechanisms by which running could increase vascular disease. Intensive exercise is well-known to increase oxidative stress and inflammation, which are fundamental to the development of coronary artery disease.
Runners like me like to believe that running is good for our heart and blood vessels, based on the principle of "use it or lose it". However, maybe the cardiovascular system is more like a car (and just about everything else), the more "mileage" it has, the more likely it is to break down.