Cardiologist vs Oncology on Stents

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DrCommonSense

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The war of "evidence based medicine" has just BEGUN to heat up for cardiologists where 97% of their stents are largely placed for stable CAD.

It seems that "evidence based medicine" has spoken whereby he found zero utility for almost anything done in medicine.

Interesting times we live in.

http://freakonomics.com/podcast/bad-medicine-part-1-story-98-6/

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IMHO one does not become a really good doc until one realizes that medical trends are more like the fashion industry than science.
 
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IMHO one does not become a really good doc until one realizes that medical trends are more like the fashion industry than science.

We are seeing the difficulty in determining "evidence" considering the vast majority of studies/authors/societies are biased in terms of who pays the bills.

Do you think cardiologists would ever give up stents if proven ineffective without something else to replace that income?
Do you think Ortho docs would cut down on TKR/THR by 95% if it was proven that the vast majority are cost ineffective?
How about spine surgeons?
Urologists for prostate surgery ?

The same is noted by big pharma or big device companies.

Its funny how everyone is for "evidence" on everyone ELSE's stuff but when that "evidence" stuff comes back to them, they amazingly become "skeptical" of the research that doesn't benefit them.
 
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//Its funny how everyone is for "evidence" on everyone ELSE's stuff but when that "evidence" stuff comes back to them, they amazingly become "skeptical" of the research that doesn't benefit them.//
the problem is that unless the people involved in the decision making are good people it is impossible to believe anything they say. no one in the USA is picked for a leadership role if they are a good person. the last thing anyone needs in a bureaucracy is an honest person. for historical reasons that are beyond our control we are living in a place and time when honesty is a hindrance to success. the only way to be sure of anything is to see it with one's own eyes. but acting on that becomes problematic when docs are forced to obey practice rules. i think there may be a partial solution using the internet and reaching the patients directly through education, and we are seeing some of the results of that but there is no way for patients to evaluate what they read on the internet either. i am very pessimistic about a solution that will benefit patients in the near future.
 
Its funny how everyone is for "evidence" on everyone ELSE's stuff but when that "evidence" stuff comes back to them, they amazingly become "skeptical" of the research that doesn't benefit them.
Will you likewise in this position when someone debates the cost effectiveness of ESI, or TF, or SCS?



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Will you likewise in this position when someone debates the cost effectiveness of ESI, or TF, or SCS?



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They have brah.

Maybe you haven't been paying attention to my argument despite stating it almost 1000 times on this forum.
 
so....

the cost effectiveness of ESI, TF, SCS etc. is irrespective of the cost effectiveness of cardiac stents, knee replacements, fusion surgeries.

this argument is, again, nonsequitor.
 
so....

the cost effectiveness of ESI, TF, SCS etc. is irrespective of the cost effectiveness of cardiac stents, knee replacements, fusion surgeries.

this argument is, again, nonsequitor.

Actually its not if its a consistent theme among "efficiency" experts. By their logic, almost all procedural medicine can be shown to be "ineffective" from a cost standpoint.

Also, evidence for "cost effectiveness" needs to be applied EQUALLY across the board, with the BIGGEST drivers of the Healthcare dollar being targeted FIRST.

Which are the biggest drivers of cost in healthcare?
 
What if cost-effectiveness were considered through the lens of "would a patient pay for this out of pocket?" Completely impractical, I know...I just finished with another patient up in arms for a $50 copay. It would account for the relative cost and expected outcome as a measure of "bang for the buck."

I'd venture a guess that you have a lot more patients signing up for "our" interventions than coughing up 10s of thousands for a surgery.
 
first, these articles you are posting clearly show that efficiency experts are also concerned about cost effectiveness on cardiac stents, knee and hip replacements - or there wouldn't be articles to post.



second, assuming that a knee replacements cost 30K, and an epidural actually only costs, on average, $300, all the knee replacements in the US would cost $7.3 billion and all the epidurals would cost the US $2.7 billion. more expensive, but its in the same ballpark. the major difference is that, for the most part, people are getting only 1 knee replacement, rather than having this cycle repeat yearly. if you take the extreme of costs, however, then all knee replacements (244,000 at 40k a pop) would max out at 9.76 billion, while epidurals at the $2K per injection average that some websites have reported (Forbes I believe) would max out at 18 billion.



third, it appears your "argument" is to attack other procedural medicine and lack of cost effectiveness there, since efficiency experts have targeted IPM. show how they are not cost effective, so, um, what? they will forget or forgive IPM?

attack by diversion, misdirection...

this seems to be avoiding the true argument, and justifying oneself by saying that someone else is worse than you. it doesn't justify IPM...

what would go further towards justifying IPM would be to quote articles that show that injections like ESI or RFA are cost effective compared to usual therapy or surgery...

(yes, these articles do exist, even outside the hallowed grounds of Paducah).
 
first, these articles you are posting clearly show that efficiency experts are also concerned about cost effectiveness on cardiac stents, knee and hip replacements - or there wouldn't be articles to post.



second, assuming that a knee replacements cost 30K, and an epidural actually only costs, on average, $300, all the knee replacements in the US would cost $7.3 billion and all the epidurals would cost the US $2.7 billion. more expensive, but its in the same ballpark. the major difference is that, for the most part, people are getting only 1 knee replacement, rather than having this cycle repeat yearly. if you take the extreme of costs, however, then all knee replacements (244,000 at 40k a pop) would max out at 9.76 billion, while epidurals at the $2K per injection average that some websites have reported (Forbes I believe) would max out at 18 billion.



third, it appears your "argument" is to attack other procedural medicine and lack of cost effectiveness there, since efficiency experts have targeted IPM. show how they are not cost effective, so, um, what? they will forget or forgive IPM?

attack by diversion, misdirection...

this seems to be avoiding the true argument, and justifying oneself by saying that someone else is worse than you. it doesn't justify IPM...

what would go further towards justifying IPM would be to quote articles that show that injections like ESI or RFA are cost effective compared to usual therapy or surgery...

(yes, these articles do exist, even outside the hallowed grounds of Paducah).


Once again the point I was making was clearly stated in multiple posts about procedural medicine throughout various threads.

My argument is that these "efficiency experts" are mostly BS hacks with zero clinical experience that are being used to basically attack all of procedural medicine on questionable grounds.

However, I am showing that this is easily done to basically ANY area of procedural medicine.

Ergo, by their rationale, all of procedural medicine should be toast.

P.S. Plenty of articles have been published by the guy from Peducah concerning the cost effectiveness of IPM in the opposite direction of of guys like Chou. Its all about how you massage the data and which studies to include in the metaanalysis.
 
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1. do you honestly believe that you pointing out, from your biased position, is going to change efficiency expert opinion? they don't read this thread. and if you try to argue with one of the insurance carrier "efficiency experts" after an IPM has been denied that "ANY area of procedural medicine" is also not valuable, I think they will hang up on you.

2. not all procedural medicine would be "toast". indubitably, completely off the cuff, the following procedural medicine (in its appropriate context) is without doubt of high clinical value:
xrays for fracture
surgical stabilization of pilon fracture, hip fracture/ open fracture, etc.
rapid strep test
EKG for acute chest pain
Chest xray for pneumonia
splints/casts for fracture care
treating deep lacerations
skin cancer excision
brain MRI for acute stroke symptoms

3. my opinion stands - trying to "expose" the potential fallacy of any other procedural medicine does nothing to "justify" IPM. furthering this position will only allow IPM to be thrown out with all other procedural medicine if and when that particular day of reckoning occurs, and gives no ground in saying that IPM has value unlike other procedural medicine.
 
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By allowing the measured endpoint to be cost effectiveness, you have already ceded the argument to the bureaucrats.

The only measure physicians should care about is efficacy. Unless the cost is outrageous, that should be somebody else's problem.
 
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1. do you honestly believe that you pointing out, from your biased position, is going to change efficiency expert opinion? they don't read this thread. and if you try to argue with one of the insurance carrier "efficiency experts" after an IPM has been denied that "ANY area of procedural medicine" is also not valuable, I think they will hang up on you.

2. not all procedural medicine would be "toast". indubitably, completely off the cuff, the following procedural medicine (in its appropriate context) is without doubt of high clinical value:
xrays for fracture
surgical stabilization of pilon fracture, hip fracture/ open fracture, etc.
rapid strep test
EKG for acute chest pain
Chest xray for pneumonia
splints/casts for fracture care
treating deep lacerations
skin cancer excision
brain MRI for acute stroke symptoms

3. my opinion stands - trying to "expose" the potential fallacy of any other procedural medicine does nothing to "justify" IPM. furthering this position will only allow IPM to be thrown out with all other procedural medicine if and when that particular day of reckoning occurs, and gives no ground in saying that IPM has value unlike other procedural medicine.


1) Im not arguing with an insurance company on this thread, so nice straw man argument

2) EKG, Chest Xray for PNA, etc are basically not procedural medicine and aren't big cost generators in the overall healthcare costs. Ergo, another strawman argument

3) My argument remains that "efficiency" experts can basically show "no value" for almost anything in procedural medicine with manipulation of the meta analysis, RCTs and/or which studies to include as "high quality vs low quality". I have shown countless examples of this and will continue to do so to show the bias in this stuff.
 
By allowing the measured endpoint to be cost effectiveness, you have already ceded the argument to the bureaucrats.

The only measure physicians should care about is efficacy. Unless the cost is outrageous, that should be somebody else's problem.

How long does benefit have to occur for "clinically significant benefit" and who makes that determination? Thats the million dollar question.

For instance, if an ESI is effective for 8 weeks, is this only "short term" benefit if it allows the patient to undergo rehab more effectively?

According to guys like Chou, unless the person essentially does marathons and has years of benefit from an injection, it is useless.

Magically, Lyrica that has a less than 3% benefit on VAS scores for "fibromyalgia" despite having untold side effects and needs to be be taken forever is FDA approved for that indication.
 
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1) Im not arguing with an insurance company on this thread, so nice straw man argument

2) EKG, Chest Xray for PNA, etc are basically not procedural medicine and aren't big cost generators in the overall healthcare costs. Ergo, another strawman argument

3) My argument remains that "efficiency" experts can basically show "no value" for almost anything in procedural medicine with manipulation of the meta analysis, RCTs and/or which studies to include as "high quality vs low quality". I have shown countless examples of this and will continue to do so to show the bias in this stuff.
1. you are the one trying to make an argument to affect what efficiency experts are touting. I gave a warning of what not to try when an "efficiency expert" denies one of your requested procedures.
2. EKGs and CXR are not big cost generators - for you.
when I was in ER, the big push by the hospital was to document the initial read of xrays and EKGs, because that was lost money.
the average cost of an EKG is $800 (higher than an epidural hmm...). at minimum, at least 1.5 million people are admitted to the hospitals in the US with "Acute Coronary Syndrome". admittedly "funny math", but its quite possible that at least $1.2 billion are spent on these admission EKGs alone. factor in the other 3.5 million people who are seen in ER for chest pain, outpatient studies, etc.

yet oddly, I have not seen a single lawsuit stating that an EKG shouldn't have been done. (and also fyi, physician fee in the read averages $50-100).
3. imho, your reports only heighten the awareness of how poor the literature is out there to support interventional pain medicine.
4. most of the lay public really believe that caths, stents, angioplasty, etc. are necessary to save lives. they put IPM at a lower level. if the lay public really believes that these "lifesaving" procedures are worthless, what will they think of procedures that are of potentially equal low quality evidence that aren't lifesaving?

I would favor having an honest discussion on IPM and highlighting studies that are good quality, with hopefully favorable results, rather than attack and distract.

whatever. clearly you disagree, so cool beans to you, bro.
 
1. you are the one trying to make an argument to affect what efficiency experts are touting. I gave a warning of what not to try when an "efficiency expert" denies one of your requested procedures.
2. EKGs and CXR are not big cost generators - for you.
when I was in ER, the big push by the hospital was to document the initial read of xrays and EKGs, because that was lost money.
the average cost of an EKG is $800 (higher than an epidural hmm...). at minimum, at least 1.5 million people are admitted to the hospitals in the US with "Acute Coronary Syndrome". admittedly "funny math", but its quite possible that at least $1.2 billion are spent on these admission EKGs alone. factor in the other 3.5 million people who are seen in ER for chest pain, outpatient studies, etc.

yet oddly, I have not seen a single lawsuit stating that an EKG shouldn't have been done. (and also fyi, physician fee in the read averages $50-100).

3. imho, your reports only heighten the awareness of how poor the literature is out there to support interventional pain medicine.

4. most of the lay public really believe that caths, stents, angioplasty, etc. are necessary to save lives. they put IPM at a lower level. if the lay public really believes that these "lifesaving" procedures are worthless, what will they think of procedures that are of potentially equal low quality evidence that aren't lifesaving?

I would favor having an honest discussion on IPM and highlighting studies that are good quality, with hopefully favorable results, rather than attack and distract.

whatever. clearly you disagree, so cool beans to you, bro.

1) I am clearly showing the absurdity of these "experts" being applied across VARIOUS medical specialities. I thought my analysis was pretty clear but I guess not considering you continue to miss it and add strawman arguments.

2) I am sure there will be questioning of EKGs being needed in the future if the costs go up too much (just like MRI for back pain, CTs of headaches, etc)

3) By that logic, the literature is "poor" for all of procedural medicine not just IPM if you want to argue only long term level 1 evidence based medicine "efficacy". There are zero LONG term studies showing the efficacy of most of orthopedics, interventional cardiology, etc over "years" of time in the vast majority of patients treated.

However, I disagree with the end point parameters and how efficiency experts determine "short term" relief for IPM.

For instance, no one has EVER argued a simple LESI will cure someone for "years" and make them run marathons. Apparently, that is basically the standard guy's like Chou are determining to be "clinically significant".

Why would an LESI for instance that can help for 3 months in 60% of patients with a disc herniation not be "significant"? If these patients are helped into a rehabilitation program that they weren't able to do previously (huge number of patients I see), why not use this method? Its another "tool" in the toolbox.

Considering 60-70% of disc herniations can resorb themselves, the LESI should be considered an adjuvant procedure that helps along this process. IPM should only be practiced in a multidisciplinary fashion without being either a needle shop or a pill mill.

The other question is if we don't use IPM, what are the alternatives?

Well, according to Chou, its massage/Chiropractic/Acupuncture/Yoga. The problem is Chiropractic "care" never ends EITHER and can costs thousands per year (I know because most of my patients have previously gone through Chiropractic care in the past)

Acupuncture will often cost 90 dollars/15 min session and will need MANY sessions on a chronic basis. If an LESI is "short term" in terms of benefit, acupuncture is SUPER short term comparatively.

Mind you, most of my patients have done MANY of these modalities before coming to our group and we NEVER lack for patients.

The other alternative is more fusion surgery at >50-100K/pop without complications.

Or we have can have these patients flood the ER at 1000 visit WITHOUT imaging costs.

Not as simple as Chou makes it out to be with some staged and isolated "analysis"

4) Most of the "lay public" has been fooled if they think stents are "life saving procedures" in the vast majority of cases they are implanted. This is why I posted that ONCOLOGIST TWITTER account who clearly shows that it is dishonest for the cardiologists to present STENTS this way.

Where is the evidence of this "life saving" effect?

STENTS have zero evidence for mortality benefit in HUGE RCT trials that have tracked them now for >10 years in literally 10s of thousands of patients in the COURAGE study.

Also, considering the complication rates of STENTS are FAR HIGHER than that of medication management with similar benefit, you can argue that STENTS are literally causing far more harm than good.

Also, by that logic, most of Orthopedics offers procedures with very "weak" evidence by RCTs over a long term period (>1 year) for the vast majority of patients for "diseases that aren't deadly" either.

Please name ANY RCTs that show TKR are beneficial for >1 year out for the VAST MAJORITY of patients they are done on in the USA?
 
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