Advances in clinical practice - column

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Over the past 20 years, there have been dramatic advances in the evaluation and surgical management of carotid artery atherosclerosis. Numerous studies have shown that patients with histories of previous strokes, T[As, and asymptomatic carotid bruits are all at higher risk for stroke than comparable persons without such risk factors. Does this mean that all of these patients would benefit from diagnostic study, and possibly carotid endarterectomy? In a terse, specific position paper, supported by a companion review article, in Annals of Internal Medicine, the ACP recently outlined its recommended approach to coronary artery evaluation and treatment. Neither evaluation or treatment are recommended for persons with asymptomatic bruits, even if they are scheduled for other vascular surgery. *Noninvasive testing should be done only for persons with symptoms in the distribution of the carotid circulation who are otherwise surgical candidates. *Duplex ultrasonography is currently the preferred noninvasive test. *Carotid angiography, preferably using digital subtraction techniques, should precede endarterectomy. Another article supports to the ACP recommendations. Reed and others performed a case-control study of stroke in coronary artery surgery patients. They noted an increased risk of perioperative stroke in patients with carotid bruits but found that the risk was small, 2.9 percent, and comparable to the reported risk of stroke from carotid endarterectomy. They could not support a recommendation for routine preoperative endarterectomy in patients with asymptomatic carotid bruits. (Health and Public Policy Committee, American College of Physicians, "Diagnostic Evaluation of the Carotid Arteries." Annals of Internal Medicine 109(10):8357, Dec. 1988; Feussner, J., and Matchar, D. "When and How to Study the Carotid Arteries." Annals of Internal Medicine 109(10):805-18, Dec. 1988; Reed, G., and others. "Stroke Following Coronary Artery Bypass Surgery-A Case-Control Estimate of the Risk from Carotid Bruits." New England Journal of Medicine 319(19):1246-50, Nov. 1988.) Program Lowers C-Section Rates Physicians at the Mount Sinai Hospital Medical Center, Chicago, Ill., recently reported the results of a two-year program designed to lower their rate of cesarean section in their institution. The C section rate fell from 17.5 percent in 1985 to 11.5 percent in 1987. There was no change in one-minute Apgar scores, fetal mortality, or neonatal mortality during the study period. The program had both educational and control components. There was ongoing peer review and feedback to individual formed without adequate indications, the physicians involved were advised. On a quarterly basis, physicians were also made aware of their personal C-section rates, and how these rates compared to those of their peers. In addition to these measures, there was a mandatory second-opinion requirement for nonemergent cesarean sections and strict guidelines for dystocia, fetal distress, and problem breech presentations. In addition, elective C sections for patient convenience were strongly discouraged. (Myers, S., and Gleicher, N. "A Successful Program to Lower Cesarean-Section Rates." New England Journal of Medicine 319(23):15 116, Dec. 1988.) Comment: Like many other studies now being reported, the Mt. Sinai initiative has shown that intensive efforts can change physician behavior. What is not known is the most efficient way to design such efforts. The pharmaceutical manufacturers seem to feel that broad educational programs, a certain amount of glitz, and one-on-one discussions are all necessary. They might have a point. An interesting side observation by the authors was that this program did not discourage business at the hospital. In fact, perhaps associated with the staff's obvious attention to good obstetrical practice, the private physicians shifted their high-risk cases to the study hospital. In a companion editorial, Battaglia points out the dilemma facing obstetricians: C section rates are rising and infant morbidity and mortality rates are falling. It is tempting to think that these two events are connected and, thus, resist arguments to lower cesarean-section rates out of concern for infant safety. He mentions theoretical reasons why sections might not increase maternal or fetal safety and suggests that one way to address this issue is by stratifying future analyses by neonatal risk factors such as socioeconomic status, birth weight, and gestational age. If such data continue to produce evidence that lower C-section rates are safe, obstricians and neonatologtsts might feel more comfortable with efforts such as those reported by Myers and Gleicher. (Battaglia, F. "Reducing the Cesarean-Section Rate Safely." New England Journal of Medicine 319(23):1540-1, Dec. 1988.) Routine Preoperative intravenous Pyelograms Before Elective Hysterectomy Simel and others used decision analytic techniques to study the need for routine intravenous pyelograms IVPS) in patients undergoing elective hysterectomy for benign disease. They sought to estimate the number of IVPs necessary to prevent one ureteral injury. In constructing their model, they made a number of simplifying assumptions that tend to understate the costs or overstate the benefits of IVPS. The analysis suggests that routine IVP studies in such cases are not appropriate. The authors estimate that 833 IVPs would be necessary to prevent one ureteral injury. Assuming that 5 percent of ureteral injuries result in death, the cost was $3.33 million to avoid one death, or $95,000 per year of life saved. As noted in the last issue of Physician Executive, this is many times the cost of other programs, such as hypertension screening $30,000 per year of life saved), hemodialysis for end-stage renal disease ($32,000), or coronary artery bypass grafting ($10,000). The authors recommend that preoperative IVPs be used for women with a high likelihood of a ureteral abnormality, such as those with a uterine size more than 12 weeks, or an adnexal mass. (Simel D., et al. Routine Intravenous Pyelograms Before Hysterectomy in Cases of Benign Disease: Possibly Effective, Definitely Expensive." American Journal of Obstetrics and Gynecoloy 159(5):1049-51, Nov. 1988.) Outpatient Cardiac Catheterization Comment: Several studies have now reported uncontrolled series of patients successfully and safely undergoing outpatient cardiac catheterization. Block et al. have added to this information by performing a randomized trial to determine the safety of this procedure in selected patients. They studied 381 patients in 3 Boston area catheterization centers. Patients with unstable angina, valvular heart disease with CHF, renal insufficiency, or several other serious medical conditions were excluded. Also excluded were elderly patients and those unable to undergo outpatient catheterization because of travel or lodging problems. The authors estimated that about 20 percent of those undergoing catheterization at the three centers were eligible for the study. Of the 192 patients assigned to outpatient study, 23 were subsequently admitted to the hospital because of complications (17) or for other reasons (6). After adjusting for differences in baseline risk factors, there was no significant difference between the outpatient and inpatient groups in any of the complications studied. The authors note, however, that 5.2 percent of the patients undergoing outpatient catheterization were found to have stenosis of the left main coronary artery. Thus, the absence of other risk factors did not guarantee that these patients had mild coronary artery disease. There were considerable differences in the costs associated with outpatient vs. inpatient study. The total charges per patient were 25 percent less for those assigned to outpatient catheterization. The authors estimate that performing even 15 percent of the catheterizations done in the United States annually on an outpatient basis would save approximately $51 million in catheterization-related charges. (Block, P., and others. A Prospective Randomized Trial of Outpatient Versus Inpatient Cardiac Catheterization." New England Journal of Medicine 319 19): 1515, Nov. 1988.) Cystoscopy in Women with Asymptomatic Microhematuria Microscopic hematuria can be an indicator of important nephrologic or urologic disease, including cancer. The medical literature generally advises complete investigation in patients with any level of persistent hematuria. The current edition of Harrison's Principles of Internal Medicine (1987 edition, p. 194) recommends: "The source of isolated hematuria must always be ascertained, and this means a detailed examination of the urinary tract by cystoscopy, retrograde pyelography, and arteriography to disclose tumor, stone, cysts, or other cause." Bard has reported a prospective study of 125 women evaluated for asymptomatic microhematuria. Another 52 cases were added on the basis of retrospective review. The majority of these women (128) had complete follow-up data, and 72 were followed for more than 7 years. Patients with demonstrated urinary tract infections were excluded from the study. Virtually all patients (more than 90 percent) underwent repeat urinalyses, studies of urine cytology, intravenous urography, and cystourethroscopy. The author noted abnormal urologic findings in 63 percent of the patients but found no malignancies. There were only two serious abnormalities noted, unilateral hydronephrosis and a calcified renal mass, and these were detected by the urogram. No cause could be found for the microhematuria in 37 percent of the women studied. Bard suggested that previously reported conclusions about the likelihood of serious abnormalities occurring in patients with microhematuria may have reflected a higher frequency of such abnormalities in men. When considered separately, his series of women did not appear to support the need for routine cystoscopy. He recommended that women with asymptomatic microhematuria be evaluated by repeat urinalyses, urography, and two sequential voided -urine cytologic examinations only. (Bard, R. "The Significance of Asymptomatic Microhematuria in Women and Its Economic Implications-A Ten-Year Study." Archives of Internal Medicine 148(12):26292632, Dec. 1988.)

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