More on Predatory Guidelines

May 6th, 2008 by DrRich

The Wall Street Journal Health Blog informs us that on Saturday last, participants at an American Psychiatric Association symposium apparently castigated the new American Heart Association guidelines on the need to do cardiac pre-screening of children with ADHD. (See DrRich’s previous posting on predatory guidelines, and on the new AHA recommendations.)

A pediatric psychopharmacologist from Harvard (DrRich wonders if any such exist anywhere else) named Timothy Wilens insisted there is no evidence that medication for ADHD causes sudden death. He referenced a recent report in the New England Journal of Medicine showing that the risk of sudden death in children on ADHD drugs is only 0.2 to 0.5 per 100,000 patient years, compared to a risk of 1.3 to 8.5 per 100,000 patient years in athletes under 18. Wilens jokingly suggested that perhaps “Parents should get an EKG for their child before yelling at them.”

Wilens then reluctantly admitted that at Harvard, the cardiac pre-screening recommended by the AHA has already been instituted in order to avoid legal problems.

So, by this graphic example, even when imposed guidelines are clearly believed to be completely unnecessary, even when that belief is strongly supported by published statistical evidence, and even when the guidelines have been promulgated in a demonstrably predatory manner that is more likely an invasion of professional turf than a protection of patients, guidelines are guidelines and must be obeyed.

We can fully expect to see many more examples of predatory guidelines, dueling guidelines, and all manner of other guidelines reflecting utter anarchy. Why? Because the manufacture of guidelines works.

DrRich rests his case.

Posted in Guidelines, Abuse of | 1 Comment »

Why We Can’t Do Cardiac Screening In Athletes

February 29th, 2008 by DrRich

DB has put up an interesting post today about the need to do cardiac screening in athletes. He points us to an article in the New York Times that describes an athletic screening program now in place at the University of Tennessee. According to the Times,

Cardiologists and other heart experts say that the screenings could help save the lives of the 125 American athletes younger than 35 who die each year of sudden cardiac death. Most show no symptoms of heart disease until it becomes fatal.

DB correctly points out that the reason cardiac screening (which requires ECGs and cardiac echocardiography) is not widely used is the expense. “If one did a careful cost-effectiveness analysis, the results may argue against routine echocardiograms.”

This is most assuredly the case. Making the very conservative assumption that 1 million young Americans participate in athletic competition each year, and that (as the Times reports) the average cost of screening is $1000, then screening would cost us $8 million to save one life. That’s pretty a steep cost-effectiveness challenge by any standards.

But Dr. Douglas Zipes (the perennial New York Times expert on matters cardiac) speaks for many of us when he says, “If it were my son playing ball, I would like him to have an echo, even though it is cost inefficient.”

In truth, the cost-effectiveness analysis here presents a problem only because the kind of screening being used is judged to be a medical procedure, and thus ought to be paid for from some centralized pool of money (whether the pool is controlled by insurance conglomerates or the government).

If we were to do a similar cost-effective analysis on seat belts, smoke alarms, or CO detectors, we would reach a similar conclusion: Yes, those several thousand preventable deaths from house fires are indeed a tragedy, but we simply can’t afford to pay for smoke alarms for all those millions of American families, just to save those relatively few lives.

The difference, obviously, is that we don’t expect smoke alarms, etc., to be paid for out of general funds. We expect individuals to do their own cost-effectiveness calculation, and decide whether to buy smoke alarms from their own resources. Since individuals tend to place a much higher value on their own lives than the value assigned by society (the self-assessed value often approaching infinity), many people indeed find the cost-effectiveness calculation to be in their favor, and thus smoke alarms to be a reasonable investment.

If Dr. Zipes wants his son screened by echo, by all means have it done. I agree it would be entirely worthwhile. But don’t ask me to pay for it.

The technology exists to place cheap, portable echo machines in the office of every primary care doctor, and every primary care doctor could be easily trained in less than an hour to rapidly screen athletes for hypertrophic cardiomyopathy (the chief cause of risk). For probably less than $100, parents like Dr. Zipes could have their children screened with this kind of limited echo and an ECG at the same time they’re getting their flu shots.

But we can’t do this because a) professional groups like the American College of Cardiology will do everything they can to block the democratization of guild-based procedures like the echocardiogram (start-up companies that have developed such echo machines have been very disappointed with the response of the cardiology community to their products), and b) such screening is a medical service, so it’s a travesty to ask individuals to pay for it.

And if such obstacles result in the sudden deaths of a hundred or so young athletes each year (most of whom, by the way, are participating in pick-up or intramural sports, rather than the semi-pro variety we watch on TV every March), well, it’s too bad there’s nothing we can do about it.

Posted in Healthcare economics | 2 Comments »