High Resolution CT scans lead to higher costs

I became aware of these high resolution CT scans at Dr. Rita Redberg's talk last year at a UCSF conference called eontroversies in Women's Health" and wrote about it here. This article refers to a new paper released today in JAMA questioning the benefits of all the additional tests, as well as the costs. First do no harm except when there's money to be made...

High-resolution CT scans having costly follow-ups

Victoria Colliver, Chronicle Staff Writer

Wednesday, November 16, 2011

Patients who had high-resolution CT scans to check for heart disease ended up having far more invasive tests and follow-up procedures for a cost of $4,000 more per patient than those who underwent basic stress tests, according a study by Stanford researchers.

What the study, published in today's Journal of the American Medical Association, didn't determine was whether those extra tests and surgeries translated into healthier outcomes.

CT angiography uses high-resolution computed tomography technology to take pictures of the heart to help doctors see blockages. Researchers questioned whether the high-quality images might reduce the need for additional tests, particularly when they ruled out disease.

"We show pretty clearly, especially in the Medicare population, it actually leads to more testing," said Dr. Mark Hlatky, senior author of the study and professor of medicine and health research and policy at the Stanford University School of Medicine. "What we don't know is out of all those extra procedures and all extra angioplasties and all those surgeries, did they do good for the patients?"

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Radiation Risk and Coronary CT Scans

During the presentation by Dr. Rita Redberg on Coronary Artery Disease during the "Controversies in Women's Health Conference" last week, she discussed the use of CT scans for screening and diagnosis of CAD. They are used to detect coronary calcium. She stated the astonishing fact that an estimated 1 in 270 women who have one of these scans at the age of 40 years will develop cancer from that CT!! She also said that based on CT scans done in 2007 alone there would be 30,000 cancers and 15000 excess deaths. She gave a horrific case study about a woman who was having abnormal chest pain that was unlikely to be angina. But, to reassure the patient, they did a coronary artery CT scan. They saw something suspicious and went to coronary cath. Her cath was normal without disease, but they dissected her Left Anterior Descending coronary artery and they had to go to emergency coronary artery bypass. She ended up with a heart transplant.
This underscores Dr. Redberg's admonition that less is more, and that "reassurance" is not sufficient reason to order a study. First do no harm.

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Some sanity, at last, on Statins

I just attended the annual UCSF conference on Controversies in Women's Health. This conference is well done, in that it alerts practitioners to issues that are being discussed at the "Task Force" level. For example when I was at the conference 2 years ago I first heard about the mammography controversy, that the science was showing that there was no added benefit to mammography in younger women and that there were increased harms. Of course this caused a huge uproar in the subsequent two years. I won't go into the particulars of either side. But this was one of the first times I had actually been aware of the medical community admitting that there might be a downside to too much intervention.
This year, Professor Rita F. Redberg gave a thoughtful and informative talk on cardiovascular disease entitled "Prevention and Treatment of Cardiovascular Disease in Women:When is Less More?" Any readers of this blog know that this is an approach that I take seriously; to evaluate interventions carefully to make sure there is no harm being done, and to be highly suspicious of new, lucrative, and highly touted treatments. Dr. Redberg has a column in the Annals of Internal Medicine entitled "Less is More" and solicited contributions to the column via Deborah Grady, MD, section editor, Less is More, Annals of Internal Medicine. She asked specifically for cases, commentary, original investigation. What a great concept!
So as to the topic of Statins, I've been suspicious of them since the beginning because of the triad I just mentioned, new, lucrative and highly touted. My patients were coming in saying that their physicians were extremely enthusiastic about these medications, many even saying that they wished that they were in the water supply (!) (No worries, they probably are in our creeks and rivers by now, just like Prozac and antibiotics.) I also heard from patients that since they started taking them they had muscle problems and backaches. They were sure that they were from the statins, but their doctors insisted that they were fine. From Dr. Redberg's presentation, statins do cause muscle aches and pains, weakness, and memory loss. Her unequivocal position was that there is no data that statins reduce cardiac events or chronic heart disease mortality in women. Furthermore, there is no data that statins reduce all cause mortality in men or women.
She has a quote from one of her patients saying,

"Since stopping the Welchol, my leg muscle weakness has stoppend and I am able to walk down the stairs normally. I am also not experiencing memory loss. My thinking feels sharper."

First do no harm. Hopefully, with this latest consensus, people will feel more comfortable taking themselves off the statins, and physicians will not be so gung ho prescribing them. Dr. Redberg also said that cholesterol levels are clearly related to diet and physical activity, and it is unclear if the same benefits accrue via cholesterol lowering by medications.

(To read more about acupuncture and my practice, please click here.)