A Great Example of the Difference Between Usual Care and Optimal Medical Treatment
This site is all about optimal medical treatment (OMT) for chronic diseases— the combination of interventions, systems, and payment models that produce the best results in various long-term illnesses. If you want to live a longer and healthier life, this is the most important medical topic for you. If are an employer that pays the bills for thousands of patients, OMT is the key to having a healthier work force for less money. Optimal medical treatment for patients with heart disease and related conditions is very well-defined. It reduces mortality by up to 90% while reducing costs by tens of thousands of dollars a year in patients who have had a heart attack when compared with usual care—the care that most patients receive.
The best demonstration of OMT benefits is found in these high-risk patients and others like them. If a group of patients has a high risk of heart attack, stroke, sudden death, and other major cardiovascular catastrophes, it is much easier to show the benefits of OMT vs. usual care. Patients who have already had a heart attack are at very high risk for having another one. The study participants in usual care are having heart attacks and strokes at such a rapid rate that you can show a big difference in results in 4 or 5 years with relatively few patients. OMT is so advanced in cardiovascular disease that 15 studies have shown OMT is the best medical intervention to keep you from having a heart attack or dying suddenly. In patients with stable heart artery disease, adding a stent or bypass to patients who are on OMT provides no additional protection from sudden death or heart attack.
Every one of these OMT studies included statin treatment in optimal medical treatment. Statins are proven to benefit patients who have artery disease. The evidence is clear. People who don’t take a statin after a heart attack are 50% more likely to have a second heart attack. Statin benefit in this setting has been confirmed in hundreds of journal articles and a mountain of research. Other medications fit in that same category. ACE inhibitors like lisinopril or ARBs like losartan for hypertension, metformin for diabetes, and aspirin to prevent clot are all essential elements of OMT. In combination with statins, they reduce mortality by 90% in patients who have had a heart attack. Since these studies were done, spironolactone for high blood pressure and empagliflozin for diabetes are additional OMT tools that should help us produce even better results. Calorie restriction, intermittent fasting, carb restriction and exercise also help.
Here is the problem. In usual care, statins are only used in half the patients who are eligible to receive them. The highest risk patients are those who have established atherosclerotic artery disease. They already have an arterial blockage somewhere in their body. If they have artery disease in their leg, they also have cholesterol deposits in arteries that supply the heart and brain. Those deposits can rupture and lead to a clot that blocks the artery in seconds causing a heart attack or a stroke. Statins stabilize those deposits within a matter of weeks so that they are much less likely to rupture. Statins dramatically reduce the risks of heart attacks, strokes, sudden death, and other sudden disasters in these patients. Yet only 58% of patients with known artery disease are on a statin and only a third of those are on a high-intensity statin which offers the most protection. The statistics are even worse in women and the disadvantaged. This is one of the best examples in medicine of the huge gap between evidence and practice. It is hard evidence of the difference between OMT and usual care and it points to a much broader problem. Patients with other conditions are no more likely to receive OMT. Only about one third of patients who had a heart attack with extensive heart damage and heart failure are on spironolactone. Only 4% of patients with prediabetes who should be on metformin have a prescription for that medication. Our system is not set up to make sure every patient gets every OMT treatment every time it is appropriate. Americans are dying, becoming disabled, and going bankrupt every day because of this failure.
The group that reduced deaths by 90% developed the systems to be certain that every patient who had had a heart attack received OMT. As a consequence, 91% of their patients are on statin treatment. That difference is no accident. Our entire medical system uses a payment model that does not support this work. American primary care doctors in the fee-for-service system are paid to produce widgets. They are paid to walk into a room and write a note in the computer that documents their examination of the patient and their discussion. That is it. That is what we pay them for. We don’t pay them to solve problems, we pay them to create notes. Our primary care doctors make more money when they move from room to room rapidly and generate more notes. There is an obvious problem with this payment model.
An elderly family member just saw her primary care doctor. This individual has back pain, vertigo, insomnia, chronic diarrhea, knee pain, arthritis, diabetes, high cholesterol, high blood pressure, gout, and a recent history of both breast and uterine cancer. That is 12 problems. When she saw the doctor, she said, “ I have several things I need to talk to you about.” The doctor responded, “We can discuss three.” Of course, my family member was immediately anxious and under pressure to determine which of her problems had the greatest priority. This is typical of elderly people with chronic disease. Disadvantaged Medicare patients have 5-7 health problems on average. If their back pain and insomnia are making them miserable that is going to take up the 10 minutes devoted to their visit and their poorly controlled blood pressure is not addressed. This problem is so common there is a specific term for it—clinical inertia. That means there is a clinical problem that is obvious and is not addressed during the visit. For example, the blood pressure is 160/100 and the treatment is not changed because other issues took up the time. There are hundreds of journal articles on clinical inertia in medical journals. We should stop writing articles and create teams to provide OMT for patients with chronic disease.
Our system produces what it was designed to produce. It produces visits and notes. It does not address chronic problems effectively. Kaiser Permanente developed a team to make certain every heart attack consistently receives OMT. That is the team mission. They have designed their process to make sure they have enough time with patients with multiple chronic conditions to work through their problems. Excellent care depends on a team approach that includes the patient. Effective care cannot occur without trust and relationship. Building trust and relationship takes contact and time. It requires focus. They reduce mortality up to 90% and save tens of thousands of dollars per patients per year. They have another team to make sure blood pressure is controlled. They achieve a 90% control rate in hundreds of thousands of patients. British guidelines for patients with heart artery disease have incorporated the science we developed. They specify OMT delivered by primary care doctors for anyone with this condition. It is no accident they live longer for half the money. Singapore has teams that focus on high blood pressure, cholesterol, and diabetes. They live longer for one fourth the money. This is not that complicated. It is the usual problem. Money and power stand in the way.
We can have better health for less money. We can live longer and healthier lives. The research has been done. Community practices have proven it works. The facts are clear. More Americans need to understand the promise of OMT, and it should be available to everyone. There are many of us who want to move to a system that meets our needs better. Please share this material and sign up for a free subscription to receive updates. Our health and lives depend on it.