Paul J. Hauptman

Just when the initial buzz about the new cholesterol guidelines had died down, along came the new JNC 8 recommendations. The former did a remarkable job of aiming at the LDL target; the latter loosened blood pressure targets for specified subgroups. The times, they are a-changin’.

Still, the publishing of the cholesterol guidelines prompted a flurry of blogs and related commentaries, which upon a quick survey suggest the emergence of a type of "Red State–Blue State" divide. The most rigorous critiques focused on the use of a new global risk assessment tool developed from various observational cohorts to reconfigure the goals of therapy. From the clinician’s perspective, the messages were mixed, as noted in the mirror-image comments on one cardiology Internet site: "Very useful for my every day practice" and "This will make things more confusing in my approach to patients."

With JNC 8 the blood pressure targets are less strict for the older adult: controversial but plausibly more adaptable in a clinical setting.

So, taking a step back, it’s now more difficult to know how we should think about any and all therapeutic targets in the individual patient. We have been in a numbers era for a long time and, as a consequence, we are in a comfort zone where "treatment to goal" is the working paradigm. On the other hand, we should readily accept that a treatment goal is a convenience factor that often makes epidemiologic sense but not practical sense. Back in the "old days," an LDL of 71 mg/dL in a patient with CAD was good enough in my book. Personally, rather than convince the patient to work a bit harder on cholesterol lowering to achieve a level less than 70 mg/dL, I’d prefer to spend an extra minute or two on a discussion about exercise or work life or maybe even something more secular.

Here’s one bright spot with the near simultaneous publication of these new guidelines: They will clearly wreak havoc on the quality indicator mafia. Pay for performance? Try calculating the individualized LDL target now and dinging me on that basis. It won’t be easy.

We can also rest assured that JNC 9, if it ever occurs, won’t be seen for at least a decade. The tsunami has passed; now it’s time to pick up the debris.

1. Stone NJ, Robinson J, Lichtenstein AH et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: A report of the American College of Cardiology/American Heart Association. J. Am. Coll. Cardiol. 2013; doi:10.1016/j.jacc.2013.11.002.

2. James PA, Oparil S, Carter BL et al. 2014 Evidence based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014; doi:10.1001/jama.2013.284427.

Dr. Hauptman is professor of internal medicine and assistant dean of clinical-translational research at Saint Louis University and director of heart failure at Saint Louis University Hospital. He is an associate editor for Circulation: Heart Failure and likes to blog while staring out his office window at the Arch.

Write to Dr. Hauptman at cardnews@frontlinemedcom.com

Just when the initial buzz about the new cholesterol guidelines had died down, along came the new JNC 8 recommendations. The former did a remarkable job of aiming at the LDL target; the latter loosened blood pressure targets for specified subgroups. The times, they are a-changin’.

Still, the publishing of the cholesterol guidelines prompted a flurry of blogs and related commentaries, which upon a quick survey suggest the emergence of a type of "Red State–Blue State" divide. The most rigorous critiques focused on the use of a new global risk assessment tool developed from various observational cohorts to reconfigure the goals of therapy. From the clinician’s perspective, the messages were mixed, as noted in the mirror-image comments on one cardiology Internet site: "Very useful for my every day practice" and "This will make things more confusing in my approach to patients."

With JNC 8 the blood pressure targets are less strict for the older adult: controversial but plausibly more adaptable in a clinical setting.

So, taking a step back, it’s now more difficult to know how we should think about any and all therapeutic targets in the individual patient. We have been in a numbers era for a long time and, as a consequence, we are in a comfort zone where "treatment to goal" is the working paradigm. On the other hand, we should readily accept that a treatment goal is a convenience factor that often makes epidemiologic sense but not practical sense. Back in the "old days," an LDL of 71 mg/dL in a patient with CAD was good enough in my book. Personally, rather than convince the patient to work a bit harder on cholesterol lowering to achieve a level less than 70 mg/dL, I’d prefer to spend an extra minute or two on a discussion about exercise or work life or maybe even something more secular.

Here’s one bright spot with the near simultaneous publication of these new guidelines: They will clearly wreak havoc on the quality indicator mafia. Pay for performance? Try calculating the individualized LDL target now and dinging me on that basis. It won’t be easy.

We can also rest assured that JNC 9, if it ever occurs, won’t be seen for at least a decade. The tsunami has passed; now it’s time to pick up the debris.

1. Stone NJ, Robinson J, Lichtenstein AH et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: A report of the American College of Cardiology/American Heart Association. J. Am. Coll. Cardiol. 2013; doi:10.1016/j.jacc.2013.11.002.

2. James PA, Oparil S, Carter BL et al. 2014 Evidence based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014; doi:10.1001/jama.2013.284427.

Dr. Hauptman is professor of internal medicine and assistant dean of clinical-translational research at Saint Louis University and director of heart failure at Saint Louis University Hospital. He is an associate editor for Circulation: Heart Failure and likes to blog while staring out his office window at the Arch.

Write to Dr. Hauptman at cardnews@frontlinemedcom.com

Just when the initial buzz about the new cholesterol guidelines had died down, along came the new JNC 8 recommendations. The former did a remarkable job of aiming at the LDL target; the latter loosened blood pressure targets for specified subgroups. The times, they are a-changin’.

Still, the publishing of the cholesterol guidelines prompted a flurry of blogs and related commentaries, which upon a quick survey suggest the emergence of a type of "Red State–Blue State" divide. The most rigorous critiques focused on the use of a new global risk assessment tool developed from various observational cohorts to reconfigure the goals of therapy. From the clinician’s perspective, the messages were mixed, as noted in the mirror-image comments on one cardiology Internet site: "Very useful for my every day practice" and "This will make things more confusing in my approach to patients."

With JNC 8 the blood pressure targets are less strict for the older adult: controversial but plausibly more adaptable in a clinical setting.

So, taking a step back, it’s now more difficult to know how we should think about any and all therapeutic targets in the individual patient. We have been in a numbers era for a long time and, as a consequence, we are in a comfort zone where "treatment to goal" is the working paradigm. On the other hand, we should readily accept that a treatment goal is a convenience factor that often makes epidemiologic sense but not practical sense. Back in the "old days," an LDL of 71 mg/dL in a patient with CAD was good enough in my book. Personally, rather than convince the patient to work a bit harder on cholesterol lowering to achieve a level less than 70 mg/dL, I’d prefer to spend an extra minute or two on a discussion about exercise or work life or maybe even something more secular.

Here’s one bright spot with the near simultaneous publication of these new guidelines: They will clearly wreak havoc on the quality indicator mafia. Pay for performance? Try calculating the individualized LDL target now and dinging me on that basis. It won’t be easy.

We can also rest assured that JNC 9, if it ever occurs, won’t be seen for at least a decade. The tsunami has passed; now it’s time to pick up the debris.

1. Stone NJ, Robinson J, Lichtenstein AH et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: A report of the American College of Cardiology/American Heart Association. J. Am. Coll. Cardiol. 2013; doi:10.1016/j.jacc.2013.11.002.

2. James PA, Oparil S, Carter BL et al. 2014 Evidence based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014; doi:10.1001/jama.2013.284427.

Dr. Hauptman is professor of internal medicine and assistant dean of clinical-translational research at Saint Louis University and director of heart failure at Saint Louis University Hospital. He is an associate editor for Circulation: Heart Failure and likes to blog while staring out his office window at the Arch.

Write to Dr. Hauptman at cardnews@frontlinemedcom.com

It seems that the 30s have become the focus of just about everyone. Or, to be a bit more precise, 30 and 35. Now, I do not mean the 1930s or that often very productive fourth decade of life. Rather, it’s the two numbers that decide penalties for heart failure readmissions and for ICD implants.

As a consequence, we obsess over 30 days becoming 31 days and 36 days becoming 35 days, often to the detriment of our patients. Implicit in this thought process is the mindless "painting by numbers" game that we play, as if something magical happens when 31 days pass from an admission for heart failure that makes it fine to admit the patient. Or when the ejection fraction falls from 36% to 35%, and then it’s acceptable to implant an ICD, as if the risk of sudden cardiac death has measurably increased.

In the absence of good data, we just make it up. We draw false lines and construct false metrics that provide four walls for decision making but do not have any medical significance or relevance to patients. I suppose that there is nothing new here. If the speed limit was lowered from 60 to 59, would we drive any differently, and would there be any impact on rates of accidents? If a round of golf had 17 holes, would Tiger Woods have won more, or fewer, major tournaments?

Still, it is a remarkable state of affairs. Hospitals will engage in intensive interventions for patients with heart failure, but on day 31, the interest wanes. It is akin to Secret Service protection for the major party presidential candidates. On the morning after the election, the losing candidate loses the large contingent of Secret Service agents.

Personally, based on my very careful review of the world’s literature, I think a 29-day readmission rate and a 29% ejection fraction make the most sense.

After all, the 20s are the new 30s.

Dr. Hauptman is professor of internal medicine and assistant dean of clinical-translational research at Saint Louis University and director of heart failure at Saint Louis University Hospital. He is an associate editor for Circulation: Heart Failure and blogs while staring out his office window at the Arch.

It seems that the 30s have become the focus of just about everyone. Or, to be a bit more precise, 30 and 35. Now, I do not mean the 1930s or that often very productive fourth decade of life. Rather, it’s the two numbers that decide penalties for heart failure readmissions and for ICD implants.

As a consequence, we obsess over 30 days becoming 31 days and 36 days becoming 35 days, often to the detriment of our patients. Implicit in this thought process is the mindless "painting by numbers" game that we play, as if something magical happens when 31 days pass from an admission for heart failure that makes it fine to admit the patient. Or when the ejection fraction falls from 36% to 35%, and then it’s acceptable to implant an ICD, as if the risk of sudden cardiac death has measurably increased.

In the absence of good data, we just make it up. We draw false lines and construct false metrics that provide four walls for decision making but do not have any medical significance or relevance to patients. I suppose that there is nothing new here. If the speed limit was lowered from 60 to 59, would we drive any differently, and would there be any impact on rates of accidents? If a round of golf had 17 holes, would Tiger Woods have won more, or fewer, major tournaments?

Still, it is a remarkable state of affairs. Hospitals will engage in intensive interventions for patients with heart failure, but on day 31, the interest wanes. It is akin to Secret Service protection for the major party presidential candidates. On the morning after the election, the losing candidate loses the large contingent of Secret Service agents.

Personally, based on my very careful review of the world’s literature, I think a 29-day readmission rate and a 29% ejection fraction make the most sense.

After all, the 20s are the new 30s.

Dr. Hauptman is professor of internal medicine and assistant dean of clinical-translational research at Saint Louis University and director of heart failure at Saint Louis University Hospital. He is an associate editor for Circulation: Heart Failure and blogs while staring out his office window at the Arch.

It seems that the 30s have become the focus of just about everyone. Or, to be a bit more precise, 30 and 35. Now, I do not mean the 1930s or that often very productive fourth decade of life. Rather, it’s the two numbers that decide penalties for heart failure readmissions and for ICD implants.

As a consequence, we obsess over 30 days becoming 31 days and 36 days becoming 35 days, often to the detriment of our patients. Implicit in this thought process is the mindless "painting by numbers" game that we play, as if something magical happens when 31 days pass from an admission for heart failure that makes it fine to admit the patient. Or when the ejection fraction falls from 36% to 35%, and then it’s acceptable to implant an ICD, as if the risk of sudden cardiac death has measurably increased.

In the absence of good data, we just make it up. We draw false lines and construct false metrics that provide four walls for decision making but do not have any medical significance or relevance to patients. I suppose that there is nothing new here. If the speed limit was lowered from 60 to 59, would we drive any differently, and would there be any impact on rates of accidents? If a round of golf had 17 holes, would Tiger Woods have won more, or fewer, major tournaments?

Still, it is a remarkable state of affairs. Hospitals will engage in intensive interventions for patients with heart failure, but on day 31, the interest wanes. It is akin to Secret Service protection for the major party presidential candidates. On the morning after the election, the losing candidate loses the large contingent of Secret Service agents.

Personally, based on my very careful review of the world’s literature, I think a 29-day readmission rate and a 29% ejection fraction make the most sense.

After all, the 20s are the new 30s.

Dr. Hauptman is professor of internal medicine and assistant dean of clinical-translational research at Saint Louis University and director of heart failure at Saint Louis University Hospital. He is an associate editor for Circulation: Heart Failure and blogs while staring out his office window at the Arch.

Erik Compton, a PGA Tour member 2 years in a row, currently has $626,000 in earnings – good for 117th on tour. He finished in a tie for fourth at a tournament in March 2013.

So what, you might ask?

Erik Compton has had two heart transplants, the second in 2008, and he was back at a PGA Tour event 5 months later.

I cite his example to patients who are on a trajectory for listing and to friends who may have a jaundiced eye about advances in cardiovascular medicine. When a patient told me recently that he took up golf only after his transplant, I joked that we had used Ben Hogan’s heart in the surgery.

In any event, Compton’s achievement is truly remarkable, a tribute to his care team but mostly to the golfer himself.

I’d be thrilled to caddy for him. Here’s hoping I can track his 300-yard drives!

Dr. Hauptman is professor of internal medicine and assistant dean of clinical-translational research at Saint Louis University and director of heart failure at Saint Louis University Hospital. He is an associate editor for Circulation: Heart Failure and blogs while staring out his office window at the Arch.

Erik Compton, a PGA Tour member 2 years in a row, currently has $626,000 in earnings – good for 117th on tour. He finished in a tie for fourth at a tournament in March 2013.

So what, you might ask?

Erik Compton has had two heart transplants, the second in 2008, and he was back at a PGA Tour event 5 months later.

I cite his example to patients who are on a trajectory for listing and to friends who may have a jaundiced eye about advances in cardiovascular medicine. When a patient told me recently that he took up golf only after his transplant, I joked that we had used Ben Hogan’s heart in the surgery.

In any event, Compton’s achievement is truly remarkable, a tribute to his care team but mostly to the golfer himself.

I’d be thrilled to caddy for him. Here’s hoping I can track his 300-yard drives!

Dr. Hauptman is professor of internal medicine and assistant dean of clinical-translational research at Saint Louis University and director of heart failure at Saint Louis University Hospital. He is an associate editor for Circulation: Heart Failure and blogs while staring out his office window at the Arch.

Erik Compton, a PGA Tour member 2 years in a row, currently has $626,000 in earnings – good for 117th on tour. He finished in a tie for fourth at a tournament in March 2013.

So what, you might ask?

Erik Compton has had two heart transplants, the second in 2008, and he was back at a PGA Tour event 5 months later.

I cite his example to patients who are on a trajectory for listing and to friends who may have a jaundiced eye about advances in cardiovascular medicine. When a patient told me recently that he took up golf only after his transplant, I joked that we had used Ben Hogan’s heart in the surgery.

In any event, Compton’s achievement is truly remarkable, a tribute to his care team but mostly to the golfer himself.

I’d be thrilled to caddy for him. Here’s hoping I can track his 300-yard drives!

Dr. Hauptman is professor of internal medicine and assistant dean of clinical-translational research at Saint Louis University and director of heart failure at Saint Louis University Hospital. He is an associate editor for Circulation: Heart Failure and blogs while staring out his office window at the Arch.

Yes, you probably know about this already but it is still worthwhile to thank Stephen Soumerai and his colleague Ross Koppel for their recent piece in the Wall Street Journal entitled "A Major Glitch for Digitized Health-Care Records."

In case you missed it, the authors trash the idea that electronic health records (EHRs) lead to increased efficiency. It took two accomplished scientists to make the case with data: The math simply does not add up.

iStockphoto.com

Full disclosure requires mention of the fact that Steve Soumerai and I worked on a quality improvement project in the mid 1990s and, much to our surprise, we found that the use of key opinion leaders did not impact care as much as we anticipated.

Steve is data driven. In the WSJ article he and Dr. Koppel characterize themselves as "applied researchers and evaluators." Indeed, that is the case.

As I hinted recently, we are faced with contorted logic that states: If "A" sounds good, it must be good, so we should do "A." Forget waiting for a study that proves "A" leads to "B," as in cost savings, improved efficiency, and better patient care. In a data-driven profession such as medicine, it’s rather shocking that this "A" is "A" logic won out. But not really, since politics and business intervened, at great cost to the health care system. As the authors point out, EHR adoption occurred despite a lack of standards and coordination. Rather, we witness a strange situation in which "government agencies ... serve as health IT boosters."

As an aside, I wonder, how many of those boosters no longer work for the U.S. government but instead consult for the IT industry?

In any event, I do not intend to convey a message denying the possibility that at some point, in a galaxy far, far away, in a health care system that is smaller, and where the incentives are more noble, EHR can work.

Or that in 10 years, and after many more billions are spent, we can find our way into a more user friendly system.

But until that point is reached, EHR has outwitted us. May the force be with you.

Yes, you probably know about this already but it is still worthwhile to thank Stephen Soumerai and his colleague Ross Koppel for their recent piece in the Wall Street Journal entitled "A Major Glitch for Digitized Health-Care Records."

In case you missed it, the authors trash the idea that electronic health records (EHRs) lead to increased efficiency. It took two accomplished scientists to make the case with data: The math simply does not add up.

iStockphoto.com

Full disclosure requires mention of the fact that Steve Soumerai and I worked on a quality improvement project in the mid 1990s and, much to our surprise, we found that the use of key opinion leaders did not impact care as much as we anticipated.

Steve is data driven. In the WSJ article he and Dr. Koppel characterize themselves as "applied researchers and evaluators." Indeed, that is the case.

As I hinted recently, we are faced with contorted logic that states: If "A" sounds good, it must be good, so we should do "A." Forget waiting for a study that proves "A" leads to "B," as in cost savings, improved efficiency, and better patient care. In a data-driven profession such as medicine, it’s rather shocking that this "A" is "A" logic won out. But not really, since politics and business intervened, at great cost to the health care system. As the authors point out, EHR adoption occurred despite a lack of standards and coordination. Rather, we witness a strange situation in which "government agencies ... serve as health IT boosters."

As an aside, I wonder, how many of those boosters no longer work for the U.S. government but instead consult for the IT industry?

In any event, I do not intend to convey a message denying the possibility that at some point, in a galaxy far, far away, in a health care system that is smaller, and where the incentives are more noble, EHR can work.

Or that in 10 years, and after many more billions are spent, we can find our way into a more user friendly system.

But until that point is reached, EHR has outwitted us. May the force be with you.

Yes, you probably know about this already but it is still worthwhile to thank Stephen Soumerai and his colleague Ross Koppel for their recent piece in the Wall Street Journal entitled "A Major Glitch for Digitized Health-Care Records."

In case you missed it, the authors trash the idea that electronic health records (EHRs) lead to increased efficiency. It took two accomplished scientists to make the case with data: The math simply does not add up.

iStockphoto.com

Full disclosure requires mention of the fact that Steve Soumerai and I worked on a quality improvement project in the mid 1990s and, much to our surprise, we found that the use of key opinion leaders did not impact care as much as we anticipated.

Steve is data driven. In the WSJ article he and Dr. Koppel characterize themselves as "applied researchers and evaluators." Indeed, that is the case.

As I hinted recently, we are faced with contorted logic that states: If "A" sounds good, it must be good, so we should do "A." Forget waiting for a study that proves "A" leads to "B," as in cost savings, improved efficiency, and better patient care. In a data-driven profession such as medicine, it’s rather shocking that this "A" is "A" logic won out. But not really, since politics and business intervened, at great cost to the health care system. As the authors point out, EHR adoption occurred despite a lack of standards and coordination. Rather, we witness a strange situation in which "government agencies ... serve as health IT boosters."

As an aside, I wonder, how many of those boosters no longer work for the U.S. government but instead consult for the IT industry?

In any event, I do not intend to convey a message denying the possibility that at some point, in a galaxy far, far away, in a health care system that is smaller, and where the incentives are more noble, EHR can work.

Or that in 10 years, and after many more billions are spent, we can find our way into a more user friendly system.

But until that point is reached, EHR has outwitted us. May the force be with you.