When Less Would Have Been More
This is from a post by Marya Zilberberg at The Health Care Blog. Good explanation of Bayesian statistics follows:
The case in question is one of a middle-aged woman presenting to the emergency room with vague symptoms of chest pain. Although from reading the paper it becomes clear that the pain is highly unlikely to represent heart disease, the doctors caring for the patient elect to do a non-invasive CT angiography test, just to “reassure” the patient, as the authors put it. Well, lo’ and behold, the test comes back positive, the woman goes for an invasive cardiac catheterization, where, though no disease is found, she suffers a very rare but devastating tear of one of the arteries in her heart [as a result of the procedure]. As you can imagine, she gets very ill, requires a bypass surgery and ultimately an urgent heart transplant. Yup, from healthy to a heart transplant patient in just a few weeks. Nice, huh?
Gives a whole new meaning to the idea of iatric unjury.
This is awful.
Dr. Zilberberg makes an interesting point. It does make sense to take into account the likelihood of a given problem before ordering a test and performing a procedure. However, I’m not sure I can necessarily agree the non-invasive CT angiography test was for “humanitarian” reasons to just “reassure” the patient. Third-party payment and our litigious society creates a powerful incentive to over treat patients — sometimes to the benefit of providers rather than merely to reassure the patient (although third-party payment also induced patients to demand more care than they otherwise would).
The tragedy caused to this woman is only made worse when you think about how much all of this cost.
Devon, I agree. Physicians strive to practice in the eye of a hurricane. We struggle to maintain a rational decision-making process while all around us swirl turbulent and often contradictory incentives and disincentives. (including third party payment systems, reimbursement, questionable ‘scientific’ papers, patient self-diagnosis, distorted perceptions fostered by self-help websites and pharmaceutical ads, politicians trying to “fix” the system, tort lawyers, peer pressure of the least common denominator type, depersonalization of health care delivery, recommendations of professional organizations, poorly-designed “best”-practices algorithms, etc, etc, etc)One thing is for sure, the solution will not be provided by politicians applying hypocritical ideas, but by men and women of integrity applying Hippocratic ideas.
The original article is part of a “Less is More” series. In its conclusion, it states that the patient suffered a rare complication from cardiac catheterization in its conclusion. The body of the article does not discuss the tradeoffs involved in sending this patient home.
The article says that the woman presented with atypical chest pain. She was 52, overweight, hypertensive, and had started an exercise program several weeks earlier.
According to the article, CCTA showed LAD luminal stenosis. This means that the woman had coronary artery disease. The evidence-based risk factors were wrong, again.
During cardiac catherization, “Mild ‘staining’ of contrast was noted in the left coronary cusp of the aorta, and an ascending aortogram revealed a dissection of the aortic root extending into, and result in compromise of, the left main coronary artery.”
One question is whether the dissection was caused by the cath or was there already. A case report [Hirose, 2009] says that the prevalence of spontaneous coronary artery dissection is between 0.1 and 0.2% among those who undergo coronary angiographies. Iatrogenic prevalences are on the order of 0.07% in the limited studies available.
Spontaneous dissection can occur without coronary risk factors. In fact, one of the main symptoms appears to be sudden intense chest pain. Most of the reported patients are young to middle aged women without any risk factors. Sudden increase in blood pressure due to heavy exercise can cause spontaneous coronary dissection.
Why the authors say that CCTA, a noninvasive test to rule out coronary artery disease, was the cause of her problems is puzzling. She presented with atypical pain. Do the guidelines proposed by the “Less is More” evidence-based believers now call for telling female patients with atypical chest pain to take two asprin and go home?
The commentary at heartWire on this article is not, shall we say, complimentary. http://www.theheart.org/article/1164425.do
The paragon of unersdtanding these issues is right here!