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These patients did the right thing leaving my care. We were wrong for each other, or I had given what I had to offer (at the time) and it was not enough. That does not lessen the feeling that I failed. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

They say dying alone is sad. They also say we all die alone. There is trauma to not dying alone as well.  This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

If you care about AF you will love this conversation. Soren has some interesting ideas about what AF is now vs what AF was in the past. Here are some links:The LOOP Study (which was non-significant). Effects of Atrial Fibrillation Screening According to N-Terminal Pro-B-Type Natriuretic Peptide: A Secondary Analysis of the Randomized LOOP StudySeverity and Etiology of Incident Stroke in Patients Screened for Atrial Fibrillation vs Usual Care and the Impact of Prior Stroke: A Post Hoc Analysis of the LOOP Randomized Clinical TrialSensible Medicine is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.BTW: This is the kind of content we aim to bring you at Sensible Medicine. Thanks for your support. I have some great ideas for future conversations. Feel free to let me know your interests, too. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

The study in question is a randomized clinical trial looking at the Million Hearts Model. This model paid health care organizations to assess and reduce CV risk. Obviously, this is an important goal. Heart disease, specifically, atherosclerotic vascular disease, is a leading killer of humans. Any reduction of heart disease should have a benefit on both a person and a population. But paying health systems to do specific things is a policy intervention. Even though a policy, like this one, makes sense, policies can have benefits and potential harms. (An example is the hospital readmissions reduction program (HRRP), which penalized hospitals for excess readmissions. This resulted in a fewer readmissions but it also associated with an increase in death rates in patients with heart failure.)Both Andrew and I were happy that the nudging of Million Hearts was studied The Trial and ProgramThis was a big pragmatic cluster randomized trial that ran over 4 years. More than 300 organizations were randomly assigned 1:1 to have the Million Hearts model or standard care. There were two parts of the model. First there was $10 for every patient who had their 10-year risk calculated with a risk equation. (ACC/AHA is a simple one you can do in 15 seconds with a smartphone.) Then CMS paid each organization $0, $5, or $10 PBPM for each high-risk beneficiary with an annual risk reassessment, with monthly payment amounts dependent on mean risk score change across all of the organization’s high-risk beneficiaries reassessed.Keep in mind that the only components of the risk calculation that are modifiable are cholesterol and blood pressure. (*smoking cessation for smokers). Foy pointed out that Million Hearts was in many ways an incentive system to nudge providers, who then may nudge patients, to take more BP and cholesterol medicine. Sensible Medicine is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.The authors chose two primary outcomes: one a MACE endpoint with MI, stroke, and TIA. The second primary was the same as the first, plus CV death. They originally planned to include only high-risk patients, but then added moderate-risk patients. This factored heavily in the results. Patients were mostly 75 year-olds, men-women split 2/3rds, 1/3rd. Outcomes were derived from claims data—which is messy when it comes to judging MIs and TIAs and specific causes of death. The Results:The first primary endpoint (MI, stroke, TIA) occurred at a rate of 14.8 per 1000 patient-years vs 17.0 per 1000 patient-years. The Hazard ratio came to 0.97 (90% CI - 0.93-1.0). The P-value was 0.09. (The authors had previously stipulated that the P threshold would be 0.10). The second primary, adding in CV death, was similar. A HR of 0.96 (90% CI 093-0.99) and a P = 0.02. These are positive results. But let’s look further. Drivers of the Results: The results were driven almost exclusively by moderate risk patients. Look at Table 3. Reductions in events rates were largest and significant statistically in the moderate-risk but not high-risk group. That is something we have emphasized here at Sensible Medicine. Even though you would think that high-risk patients have the most to gain, they also have more competing risks and perhaps more chance for treatment harm. Like so many other studies, the sweet spot for primary prevention seems to be in the moderate-risk group. Unintended Consequences: A second finding, noted by Andrew, was the highly significant increase in all-cause hospitalizations in the intervention group. These had the most significant p-values of the entire study. Other Limitations:The Million Hearts model randomization was offered to more than 500 organizations but only 342 accepted. This raises the question of generalizability. Were the 342 organizations special in some way? Another factor is that outcomes were modeled on a sample of events—not raw counts. The choice to use 90% confidence intervals rather than 95% confidence intervals and P thresholds of 0.1 rather than the more standard of 0.05 is a weakness. For instance, the first primary endpoint would have missed significance if this were evaluated in the usual fashion. I did not find a strong justification for this choice. Readers with statistical expertise, please weigh in. Our Conclusions: First, we were both happy that a policy was studied rather than just implemented because it made sense. This should serve as a model for future policy endeavors. Second, there did look to be a modest effect on reducing important outcomes. And, these were driven mostly be moderate-risk (not high-risk) patients. This argues for a heterogenous treatment effect based on co-morbidity. Third, the statistically significant increase in all-cause hospitalizations in the intervention arm suggests that more aggressive attempts at blood pressure and cholesterol levels may have risen the risk of off-target ill effects. In the end, Andrew felt like the study was a wash. He did not feel strongly that the Million Hearts endeavor made a real difference. Comments on our Audio— I think we misspoke about the patient years. We said per 100,000 patient years. It was 1000 patient years. I also think we misspoke about deaths being similar. It was actually slightly lower in the intervention arm. Recall that Sensible Medicine remains a subscriber supported site. Thanks for your generous support. We are excited to bring you content that can’t easily be found elsewhere. I have an excellent recording to post soon on screening for atrial fibrillation. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Friday Reflection 31: Senses, Memories, and MedicineMedical training introduced me to a whole menu of smells -- both diagnostic tools and reminders of times in my career. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Sudden cardiac death due to ventricular rhythm disturbances are rare but highly public. It’s strange and curious because you don’t expect healthy athletes to suffer serious cardiac issues. Recently three prominent athletes have survived sudden cardiac death. Christian Erikson, a Danish soccer player, Damar Hamlin, an American football player and Bronny James, son of Lebron James. These high-profile cases have highlighted the issue of sudden cardiac death of athletes. Dr. Dorian has published extensively on this topic. We had a great conversation. I learned a lot and hope you will too. JMM Sensible Medicine is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.Here are three pertinent articles he has published—note the first is from NEJM. Landry CH, Allan KS, Connelly KA, Cunningham K, Morrison LJ, Dorian P; Rescu Investigators. Sudden Cardiac Arrest during Participation in Competitive Sports. N Engl J Med. 2017 Nov 16;377(20):1943-1953. doi: 10.1056/NEJMoa1615710. PMID: 29141175; PMCID: PMC5726886.Weissler Snir A, Connelly KA, Goodman JM, Dorian D, Dorian P. Exercise in hypertrophic cardiomyopathy: restrict or rethink. Am J Physiol Heart Circ Physiol. 2021 May 1;320(5):H2101-H2111. doi: 10.1152/ajpheart.00850.2020. Epub 2021 Mar 26. PMID: 33769918.Weissler-Snir A, Allan K, Cunningham K, Connelly KA, Lee DS, Spears DA, Rakowski H, Dorian P. Hypertrophic Cardiomyopathy-Related Sudden Cardiac Death in Young People in Ontario. Circulation. 2019 Nov 19;140(21):1706-1716. doi: 10.1161/CIRCULATIONAHA.119.040271. Epub 2019 Oct 21. PMID: 31630535. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

The podcast discusses the disinvitation of Dr. Prasad from a conference and Dr. Sifu's experience with COVID. They explore the importance of academic freedom, controversy over lecture cancellation, tension within academia, Adam's encounter with COVID-19, and the culture of medicine.

Angela Lu is training to be a physician. She’s interested in public policy. As a third year medical student, she teamed up with established leaders to ask a unique question regarding public disclosure of financial relationships. When the Centers for Medicare & Medicaid Services (CMS) issues National Coverage Determinations (NCDs) for services or products, they mean business. Such decisions have huge implications. You cannot go against them. Think #HighConsequences.CMS studies the evidence and publishes a proposed decision. It then allows public comments. People care. The idea behind their study, which made it into the Journal of the American Medical Association, was to study how many commenters disclosed their financial conflicts. Dr. Lu went through more than 680 comments submitted on 4 NCDs—all of which were high cost invasive procedures. I won’t spoil the conversation, but they found a very high percentages of comments asking to expand indications for these procedures and very very low percentages of people who disclosed their relevant relationships. This study was made possible by the Open Payments database. One important note: disclosure of relationships was voluntary. Enjoy the conversation. Thanks for listening. JMM This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Andrew Foy rejoins the Sensible Medicine podcast. We talk first about coronary artery calcium. Andrew is an expert in this area. We have co-written our case against CAC scoring for any cause in the American Family Physician. It’s had little effect as CAC scoring is running rampant. Sensible Medicine is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.The second part of our conversation centers on a big med-ed project Andrew is co-leading at Penn State. He calls it Argue-to-Learn. The idea is to expose pre-clinical students to the value of civil debate. Here is their paper: Student Perceptions of a New Course Using Argumentation in Medical EducationHere is a quote: The absence of argumentation (i.e., a productive exchange of opposing views aimed at improved understanding of a given issue) in medical education may leave physicians susceptible to medical marketing, and incapable of both resolving industry claims and adapting to changing paradigms.Gosh. Gosh. Double Gosh, this is an exciting effort. Listen to Andrew explain. JMM This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe