June was negative-to-ambiguous: an opinionated take on NEJM highlights for June 2017


Stent news

First there was angioplasty, then bare stents, then drug-eluting stents, and now the next generation: bioresorbable stents: each generation commanding a significant price premium for the manufacturers (but only for a few years). But, while bare stents and drug eluting stents were clear improvements on the previous standard of care, the case is not at all obvious for bioresorbable stents.  Now the latest news is that the Absorb stent (Abbott), instead of showing a benefit over the previous standard of care, appears to lead to a higher rate of device thrombosis.  A reminder that it’s hard to improve on a device that works amazingly well… Bioresorbable Scaffolds versus Metallic Stents in Routine PCI; Device Thrombosis with Bioresorbable Scaffolds (subscriber access)


Lessons in Value-Based Purchasing

The ACA readmission reduction program stimulated a tremendous amount of effort to address patients bouncing back and seems to have been successful.  But what of the more comprehensive value-based purchasing program implemented by CMS? A look comparing the trajectory of hospitals exposed to the program vs. a set that was not (critical access hospitals) seems to indicate no difference. In a way that confirms something that has long been recognized by consulting firms and corporate entities: a small incentive spread across many metrics has no impact because it is thoroughly diluted. Even so, forcing the collection and review of operational diagnostic metrics – which the program did — helped lay the foundation for change.  After all, it is hard to improve what you don’t measure. But the culture needs to catch up with the availability of data.  Changes in Hospital Quality Associated with Hospital Value-Based Purchasing (subscriber access)


Tickling the brain

Like many (including it seems a robust population posting on reddit), I have been curious about transcranial stimulation (through electrodes placed on the scalp), wondering where these techniques are going to end up in the spectrum between established therapeutics and quackery. Well, it’s not quackery, but it’s not clear what it is going to become either. An impeccably double blinded controlled Brazilian trial in depressed patients comparing direct-current stimulation to an SSRI and placebo showed the following: both brain stimulation and the SSRI were statistically superior to placebo in relieving depression.  However, the claim of non-inferiority of stimulation to SSRI could not be statistically confirmed.  So now, what?  Pills are so deeply entrenched in psychiatry that it will take a tremendous amount of data to change practice. On the other hand, there seems to be a substantial DIY movement out there, and you can easily buy what you need on Amazon. One major area where this approach could have a strong future is in very low income countries where the burden of mental health is frequently underestimated and the cost of a simple device used on many could be much less than that of a daily pill and the supply chain that it requires.    Trial of Electrical Direct-Current Therapy versus Escitalopram for Depression; Noninvasive Brain Stimulation for Depression — The Devil Is in the Dosing (subscriber access)


The New England Journal of Medicine is a premier weekly medical journal covering many topics of interest to the health sector. In this monthly series we offer an opinionated perspective on selected highlights that might be of interest to our clients and others.