Friday, May 19, 2006

Timely Treatment for Appendicitis?

Acute appendicitis remains for me just as interesting, sometimes challenging, and rewarding for me as it was when I was an intern. Generally, it presents in a straightforward manner, and the operation relieves the patient's symptoms so well that most are far more comfortable in the recovery room than they were preoperatively. The preoperative pain can be difficult to manage, as it is frequently a gnawing, colicky type of discomfort that never really goes away with narcotics --- sort of like having a red hot chili pepper stuck inside your abdomen. Traditionally, there has been concern that delaying surgery for acute appendicitis may lead to an increased risk for perforation. It has been my habit to take patients with presumed appendicitis to the operating room as soon as it can reasonably be accomplished, in order to decrease the risk of perforation, but also to relieve their discomfort in a timely manner. After all, that is how I would want myself or my family to be treated.

Since acute symptoms do not always present between the hours of 9 to 5, a large number of patients will hit the ED in the middle of the night with appendicitis.....meaning we need to get out of bed and take them to the OR in the middle of the night. Some surgeons apparently feel that is not absolutely necessary, and undertook a study of delaying appendectomy for 12 to 24 hours after presentation; the article Effects of Delaying Appendectomy for Acute Appendicitis for 12 to 24 Hours was published in this month's Archives of Surgery, and came from the Dept. of Surgery at the Hospital of Saint Raphael (New Haven, Conn.). They retrospectively reviewed 309 patients who presented with acute appendicitis; 233 were operated upon within about 12 hours (mean 6.7 +/- 2.7 hours) after presentation, and 76 had surgery 12 to 24 hours after presentation (mean 16.7 +/- 3.6 hours). The delay in surgery occurred for many reasons, including a delay in diagnosis, lack of OR availability, etc. They found that (emphasis is mine):

There were no statistically significant differences between the early and late groups in the length of stay, operative time, the percentage of advanced appendicitis, or the rate of complications.

In selected patients, delaying appendicitis for acute appendicitis for 12 to 24 hours after presentation does not significantly increase the rate of perforations, operative time, or length of stay. It decreases the use of the nursing staff, anesthesia team, and surgical house staff during the night shifts, and it decreases the interruption of the regular operating room schedule.
Now, far be it from me to suggest that such an "evidence-based medicine" approach is a bit whacky, but....well, it's whacky. OK, you can prove that it makes no "statistically significant" difference to significantly delay surgery in the average patient presenting with acute appendicitis. But, does it make any sense to delay a procedure that relieves a patient's discomfort? Especially since it appears that the delay is more about the surgeon's convenience than about patient care? I just don't "get" this approach to patient care --- it seems a bit smarmy. "Yeah, we'll wait to do the surgery until morning! That's the ticket!".

There is another, unspoken part of this argument that bothers me as well; I know that GruntDoc may disagree, but the ED physician does not always make the correct diagnosis (and neither do I). Some patients need to go to the OR with peritonitis, presumed to be from appendicitis, but who actually have perforated diverticulitis, Crohn's disease, perforated ulcer, etc. --- which needs more prompt attention. I worry that this type of "study" will reinforce a rather lazy approach to the evaluation of the patient with presumed appendicitis among surgeons who are a bit reluctant to get out of bed at 2 AM. I agree with one of the physicians who commented on this paper when it was presented at the New England Surgical Society meeting in Sept. of '05 --- he asked if the authors had considered another title: Surgeon Convenience and Elective OR Schedule First, Patients Second.

Sunday, May 07, 2006

The Devil in the Details

I'm not a policy wonk, by any stretch of the imagination, and certainly lay no claim to special insight into the ins and outs of Gov. Mitt Romney's health coverage plan for Massachusetts. However, I have followed its development with great interest --- mainly because it, at least initially, seemed to place what I would consider proper emphasis on individual responsibility.

Unfortunately, it appears that there are some serious flaws with the plan that make it something I could not support. There is a nice, succinct summary of Romneycare's Fine Print in Friday's Wall Street Journal by Betsy McCaughey (type "Romneycare" in the search box and follow the link) that points out a few major flaws, including: (emphasis is mine)

...individuals purchasing their own insurance must buy HMO policies. Preferred provider plans (PPOs) -- which give you more ability to choose your own doctors and treatments -- are not allowed (Section 65). (Why?)

...employers with more than 10 full-time workers to must provide all of them (and their families) with health insurance or opt out of that requirement by paying a $295 annual tax per worker into a state fund..... the $295 penalty is small potatoes compared with the other obligations in the law. Say, for example, you open a restaurant and don't provide health coverage. If the chef's spouse or child is rushed to the hospital and can't pay because they don't have insurance, you -- the employer -- are responsible for up to 100% of the cost of that medical care. There is no cap on your obligation. Once the costs reach $50,000, the state will start billing you and fine you $5,000 a week for every week you are late in filling out the paperwork on your uncovered employees (Section 44). These provisions are onerous enough to motivate the owners of small businesses to limit their full-time workforce to 10 people, or even to lay employees off.

Union shops are exempt (Section 32). (Gee, why in the world would that be, in Massachusetts of all places? Hmm?!)

People should be allowed to buy basic, high deductible insurance without costly extras (something I was unable to do when buying health insurance). The new Massachusetts law allows only people under age 27 to buy such policies (Section 90).

If the goal of public health care policy in this instance is to ensure that every citizen of Mass. is covered by insurance, it would seem to me to be far better to have [1] a level playing field for all employers, unionized or not; [2] the ability to purchase "no frills" health insurance that does not include BS like chiropractic care, aromatherapy, acupuncture, etc; [3] more, rather than less, choice, so that people can pick and choose between PPO, HMO, and "traditional" plans, just as they choose between grocery stores; and [4] a plan that encourages the individual to purchase coverage, rather than requiring it to be provided by employers.

I hope that Congress will eventually adopt a sweeping change in the way that health insurance plans are regulated --- something along the lines that allowed the state of Delaware to become a banking powerhouse several years ago. If for example I live in Minnesota, but prefer a health care plan from Arizona, which might allow health insurance coverage without the expense of covering chiropractic care, massage therapy, etc., then let me buy it! With over-regulation on the part of state insurance boards, and a history of employers being nearly the sole providers of health insurance, there has been a vacuum of true market competition that would eventually keep insurance costs, and health care costs in general, down (IMHO).

Friday, May 05, 2006

You Make the Call

Birthdays, as us older guys are well aware, are not always cause for celebration! And, since I have a (rather large) one coming up this weekend, and since I'm going to be in the hospital on call, this will be one birthday that will go sans fête. However, my younger brother did bring a little fun to the occasion by shipping me one of these:
He, being both younger and smarter than yours truly, is quite the connected computer business whiz, and recently joined the Jedi Knights trying to destroy the Death Star. My son, the littlest surgling, was duly impressed --- "Dad, you got something cool in the mail today!" However, what was in the box under the "Coooool-gle" hat? Why, yes, something with which to display my true inner self:
He must have heard me laughing 1,000 miles away, because he called soon after I put the thing on. The main question remained, however: does this mark me as a nerd, or a geek? I mean, I'm not really sure, but perhaps this means I am advertising myself as an übergeek! And, of course, asking my brother, übergeek if there ever was one, is sort of like a wife asking her husband if the $249 dress she just bought (on sale!) makes her derriere a bit too prominent.

So, I leave it to you --- nerd, or geek?

Tuesday, May 02, 2006

Grand Rounds

Grand Rounds is being hosted at Polite Dissent this week -- a good way to see what the medical blogosphere has to say!