Obamacare and Its Effect on the Medical Public

The Affordable Care Act (ACA), also known as Obamacare, has triggered a storm of concern in the past two weeks.  The fundamental theme of these medical articles is that patients need to be their own medical advocates.

Three years ago when the president and Democrats controlled both houses of Congress, the Affordable Care Act was passed.  It had over 2,000 pages of descriptions. Then Speaker of the house Nancy Pelosi, when asked what is in the Act, responded “You have to pass it to know what’s in it”.  President Obama publicly stated more than 30 times that if you like your health insurance you will be able to keep it.  If you like your doctor you will be able to keep that doctor.  You should expect to see some reduced premiums. These statements were made multiple times.  As a physician who is concerned about the quality of public health services, I remained skeptical of the claims but kept an open mind.

An estimated 30 million – 40 million people in the U.S. have no medical insurance or medical coverage.  The rationale behind Obamacare was that everyone should have the opportunity to obtain medical coverage.  A fundamental claim by President Obama concerned the ability of individuals to keep their current insurance and their current doctors if they were satisfied with these services.

In the past two weeks, there has been an astonishing revelation that millions of Americans will not be able to keep their insurance and that millions of Americans may not be able to keep the doctors currently treating them.  Particularly disturbing is increasing evidence that the administration has known for the past three years that Obama’s statements were a lie.  Only in the past two weeks has it become clear that the ACA was written so that many existing insurance plans would be disqualified.  The disqualification was based on the exclusions that many insurance companies routinely put into their contracts.  For example, gambling addiction must be included as a covered cost.  If one buys automobile insurance, one is required to purchase the basic minimum coverage for an accident in order to obtain a license.  One may also purchase additional collision insurance which means that even if you damage your own care, with no other party involved, your costs will still be covered.  However, one is not required to purchase collision insurance in order to obtain minimum auto insurance.

The new healthcare law adds all sorts of irrelevant features which disqualifies many existing health plans.  An additional problem is that many of the new insurance contracts will be much more expensive and also require that treatment be by physicians in a particular network.  If your physician is not in that network, you will receive no coverage and have to pay all costs out of pocket.  The biggest threat, however, is that you may not be able to obtain hospital insurance.  A personal friend of mine recently received a $115,000 hospital bill for 8 days of hospitalization.  Fortunately he has a medical insurance company that covered his bill and will fight the charge which amounts to almost $14,000 per hospital day.  If you do not have an insurance company to fight your battle and cannot afford the lawyers, you may be forced into bankruptcy.

The largest cause for personal bankruptcy in the U.S. is due to unpaid medical bills.  Hospital charges bear very little relationship to the reality of hospital costs.  However, only very wealthy individuals and medical insurance companies can afford the battle to settle with hospitals on a reasonable basis.  This is a threat that very few individuals are aware of, if they are able to obtain medical insurance on a timely basis.

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Renal Dialysis Treatments and Government Reimbursement

On August 13, 2013 the New York Times had a front page article with a full page follow up on the subject of renal dialysis and the involvement of lobbyists with regard to reimbursement issues.

Hemodialysis schematic

Renal dialysis is a lifesaving treatment which permits patients to live after their kidneys have totally failed. Without functioning kidneys patients die within a few weeks. Patients undergoing renal dialysis go to special outpatient centers three times a week to have their blood filtered. The filtration process removes excess water as well as other waste products. Because these patients have no kidneys they cannot produce any urine.

One of the complications of renal failure is that a critical hormone called Erythropoietin, or Epo for short, which is produced by the kidney, is lost. Epo is essential to stimulate the bone marrow to make red blood cells. Under normal circumstances red blood cells are destroyed within the body and fresh red blood cells are produced over a 120-day cycle. Patients who receive donated blood cells have a shorter life cycle for their donated cells because of a lack of a perfect cross match, as well as other factors.

When renal dialysis was first developed, patients needed repeated blood transfusions to stay alive. A normal hematocrit in a man is 45%, which means that 45% of the circulating blood is made up of red cells and the rest is made up of plasma, which contains multiple clotting elements, as well as other elements essential to life. Women normally have a 39% hematocrit. Because of the scarcity of donated blood, patients who were originally on renal dialysis would receive blood transfusions to maintain a level of slightly above 20%, or less than half the normal concentration. Blood bankers involved in the treatment of these patients said that one could function with that lower amount of blood and it was unnecessary to transfuse to higher levels. Another consideration was that a large percentage of these patients contracted Hepatitis as well as other diseases from their transfusion because donor screening is incomplete and a donor may test negative for Hepatitis or AIDS and still be infected.

One of the greatest medical discoveries made by the Amgen Corporation was how to manufacture the complex hormone Epo for injection. This semi-miraculous breakthrough enabled patients to be treated with this hormone instead of requiring repetitive transfusions. One of the most remarkable events that occurred with the availability of Epo was that patients began to be treated to hematocrits of 30 – 35%. These patients had a remarkable improvement in their strength and well being. Prior to that it was claimed, almost universally by blood bankers, that patients needed hematocrits of only 20%, half the normal level, to function. When dialysis patients were treated to these higher levels, there was such a remarkable improvement that some patients stated they felt like zombies prior to this treatment.

In recent years dialysis centers have been paid a set fee for the dialysis procedure and a separate fee for administering Epogen. They were reimbursed based on the doses they administered. In recent years it was alleged that some of these patients were being over treated because clinics could make significantly more money on administering the medications than from the dialysis treatment itself. Medicare had an estimate of how much money would be saved by reducing what they considered excess use of Epogen. The results are now in. The use of Epogen for renal dialysis patients has been reduced even more than Medicare estimated. What does this mean? The reimbursement formula is as clear as could exist. Clinics working on relatively narrow margins are now being asked to pay for a very expensive drug without any extra reimbursement. As a result, not surprisingly, patients have had a drastic reduction in the amount of Epogen and undoubtedly a drastic reduction in their level of red blood cells. Not a single study has been published examining the changes in blood levels and clinics, and the effects of longevity in the patient. Renal dialysis patients have a very poor life expectancy rate, 65% of them are dead within 5 years of beginning dialysis. The patients who are treated at renal dialysis centers have no choice in the decision of whether to be treated with Epogen, or the levels to which they are treated. There is nothing that prevents a renal dialysis patient from obtaining an independent consultation and evaluation of their red cell blood levels. Patients can obtain an independent blood test to determine whether their blood levels are very low. They can also demand restoration of the treatment of their Epo. They can go to an independent physician to treat them with Epo. In simple words, they need to be their own advocate to make certain they are receiving optimum medical treatment.

There are so-called non-profit foundations related to kidney disease. To date we have not heard from any of them regarding evaluating the effects of this drastic reduction in this medication which so dramatically changed the treatment and symptoms of renal dialysis patients.
25% of renal dialysis patients have a so-called crash episode. This is an episode where their blood pressure collapses after undergoing dialysis. These types of episodes occur because physicians only measure the red cell concentration in a patient’s blood. This does not tell them how much blood a patient has at the start of renal dialysis, nor does it tell them how much fluid should be removed. Dr. David Goldfarb from New York University performed a study on a limited number of renal dialysis patients which demonstrated there was a wide variation in the source of fluid removed from a patient during renal dialysis. This study involved actual measurements o the patient’s blood volume prior to dialysis and after dialysis. With that type of information patients can actually be treated on a more precise protocol to avoid a so-called crash episode and collapse of the circulation. To date, however, no major facility is employing such technology


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Arthur Ashe and Blood Banking

Arthur Ashe

The U.S. Open Tennis Tournament opened on August 26 and the New York Times had a special front-page sports article about Arthur Ashe, for whom the stadium is named.  This is the third article in a series about being your own medical advocate in a dangerous environment.

Today’s topic has special personal significance for me.  Arthur Ashe was a young vigorous athlete when he was discovered to have coronary artery disease.  He was advised to have coronary artery bypass surgery.  Such surgery involves dilution of the patient’s blood for use in a special machine which pumps blood to the body while the patient’s heart is stopped and repairs are made.  Significant amounts of blood are lost during such procedures.

A major study from Duke University published in the New England Journal of Medicine on  February 8, 2001) reported that 40% of the patients undergoing such procedures have permanent memory loss.  Another article was published in the New York Times entitled “Saving the Heart Can Sometimes Mean Losing the Memory, published September 19, 2000). Sudden permanent memory loss is a precursor to ultimate dementia.

In 1979 Arthur Ashe suffered a heart attack, which surprised the public in view of his high level of fitness as an athlete. His condition drew attention to the hereditary aspect of heart disease. Ashe underwent a quadruple bypass operation on December 13, 1979. A few months after the operation, Ashe was on the verge of making his return to professional tennis. However, during a family trip in Cairo, Egypt, he developed chest pains while running.  Ashe discontinued playing competitive tennis.   In 1983 Ashe underwent a second round of heart surgery to correct the previous bypass surgery.

In September 1988, Ashe was hospitalized after experiencing paralysis in his right arm. After undergoing exploratory brain surgery and a number of tests, doctors discovered that Ashe had toxoplasmosis, a parasitic disease that is commonly found in people infected with HIV. A subsequent test later revealed that Ashe was HIV positive. Ashe and his doctors believed he contracted the virus from blood transfusions he received during his second heart surgery.  Arthur Ashe died from AIDS in 1993 at the age of 50.

According to the American Medical Association the only safe blood is one’s own. Had Arthur Ashe donated blood to himself when he was stable and stored it in a frozen state, he might be alive today and be 70 years old.   Donated blood is stored in a refrigerated state and must be used within 42 days or less.  There has been technology available for over 50 years which enables blood to be frozen with the use of a special cryopreservative at 150o below freezing and maintain its usefulness for at least 10 years.   This technology has rarely been encouraged by blood banking groups despite the evidence that physicians are very reluctant to transfuse patients unless there is clear evidence of extreme blood loss.  Unfortunately the standard test in common use only measures the concentration of an individual’s blood cells, not the actual volume of a person’s blood.

Every surgeon is aware that at the end of an operation these tests grossly underestimate the actual quantity of blood loss and surgeons, therefore, rely on relatively inaccurate estimates of how much blood a patient has lost.  Sometimes the first sign of excessive blood loss is a sudden collapse of the blood pressure with inadequate time to transfuse the patient.  This may result in a stroke, heart attack, or even the death of the patient.  Patients, particularly women, should do everything they can when faced with elective surgery to make sure that they do not enter surgery in an anemic state.  Women have 18% less red blood cells than a man of equal height and weight and are, therefore, particularly susceptible for complications from severe blood loss.

There are medications such as Epogen that can boost a patient’s blood count, which could be beneficial to increase an anemic patient’s blood level to normal prior to surgery.  One of the less optimal concepts is to donate one’s own blood just prior to surgery.  Donating blood to oneself a week or two prior to surgery usually leaves the patient in an anemic state because there is inadequate time to restore the blood and increases surgical risks.  Surprisingly, some hospitals do not even transfuse a patient with their own blood despite having lost a significant amount of blood during surgery.    Individuals who donate blood to themselves prior to surgery should be certain they will receive their own blood if they lose blood during surgery.

I stated at the beginning of this essay that I have a particular interest in what happened to Arthur Ashe because my father, Carl Feldschuh, had two transfusions for major colonic surgery.  One transfusion was from myself and the other was from a general donor.  Within a few months it became obvious that my father had contracted Hepatitis from his transfusions despite the screening of the blood.  Over the next seven years his liver shrunk and he eventually wound up weighing 104 pounds before dying a painful death in 1988.

It has been known for decades that blood donors being tested for Hepatitis may be infected but not test positive for up to six months.  The FDA is so concerned about this that they will not permit anyone who has received a blood transfusion to donate blood for up to one year after the transfusion to make certain they did not contract Hepatitis from their transfusion.  As a result of my personal experience I helped develop the first long-term frozen autologous blood bank in the United States, Idant Blood Bank.  The logical time to donate blood for oneself is well before the possibility of its need arises.  Unfortunately these blood bank service are rarely utilized and it has been a financial loser since its inception.  It is one of the only truly non-profit blood banks in the United States.

I had originally intended to have a different topic for the next subject in the series about being your own medical advocate.  However, reading about Arthur Ashe and the dedication at the recent U.S. Open, I decided this was the proper subject.

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The Myth of Excessive Medical Testing

By: Joseph Feldschuh, M.D., F.A.C.C., F.A.C.P.

This is the second article in a series of medical columns focusing on the need for patients to be their own medical advocates. The previous column focused on inherent conflicts of interest in medical establishments. Unfortunately financial interests hidden from the patients are a major factor in how medical care is administered today.

The American Association of Retired Persons (AARP) recently published an article on what it considered unnecessary tests. Among the tests it focused on was the stress echo. This is a type of test which provides information of a predictive nature. Patients who have an abnormal stress echo test are considered to be at higher risk for heart disease. There are many other examples of similar tests which provide information that a patient is at an increased risk. The test itself, however, does not provide any specific information as to how to alter that disease.

In recent years there has been increasing criticism of the use of laboratory tests in both non-hospitalized and hospitalized patients. One of the benefits of detecting increased risk in a patient for a particular disease is that it may lead to a change in the patient’s therapy to alter that prognosis.

The increasing focus on cost savings will inevitably lead to poorer care of patients and increased complications and deaths.

While there may be obvious examples of tests being conducted primarily to increase income for physicians or hospitals, there is also strong evidence that patients may be under tested to save money in an environment where cutting costs often takes precedence over the quality of patient care. Hospitals today are reimbursed on the basis of what is called diagnostic related guidelines or DRGs. This means a hospital is reimbursed for a particular diagnosis at a fixed cost. For example, a hospital might be reimbursed $10,000 for the treatment of congestive heart failure. The hospital, therefore, gets reimbursed the same dollar amount if they discharge the patient in 2 days after admission of if they discharge the same patient in 12 days after admission. There is obviously great incentive to discharge the patient early even if the patient is not in optimal condition for discharge.

The best example, however, of the general myth of unnecessary testing relates to the treatment of diabetes. Until approximately 25 years ago the common treatment of diabetes with insulin was based on a physician performing a blood sugar test once a month in his office and then prescribing a specific dose of short or long acting insulin. Patients were instructed to check their urine for sugar. When an individual’s blood sugar reached a certain high level, the kidney would pass some of that sugar out of the body via the urine. Unfortunately finding sugar in the urine did not tell an individual how high the blood sugar was or whether the timing of the insulin was appropriate. Patients were not infrequently admitted to the hospital in different types of diabetic comas. Sometimes the complications were caused by extremely high blood sugar levels. At other times the complications were caused by extremely low levels of blood sugar. Both types could cause brain damage, particularly extremely low blood sugar levels. Other complications of uncontrolled diabetes included gangrene of the lower extremity requiring amputation, blindness, strokes and heart attacks.

Approximately 25 years ago small portable glucose monitors began to be developed by medical technology and pharmaceutical firms. With these small monitors a patient could prick one of their fingers, obtain a tiny drop of blood, and measure their own blood sugar. As these monitors were gradually adopted by more physicians, it became apparent that patients were having very wide swings of their blood sugar – both very high and very low. With the use of blood sugars sampling 2 to 5 times a day, the prescription of insulin was drastically changed to avoid these types of fluctuations. In a month, a patient might check his blood sugar between 60 and 150 times instead of one time per month at the doctor’s office.

The ability for patients to monitor themselves in conjunction with their physicians resulted in a drastic improvement in the control of diabetic patients. The frequency of emergency admissions for patients because of extremes in blood sugar levels markedly dropped. There was a significant reduction, but not a total elimination, of the complications of diabetes.

What was the prime factor in this marked improvement? The prime factor was the ability to inexpensively test one’s blood sugar 60 – 150 times a month instead of one time a month. No longer did physicians use semi-educated guesses based on a single monthly blood sugar sample as to what the appropriate dose of insulin should be for a patient. Diabetes, therefore, is a classic example that extra testing and management vastly improves outcomes for patients. Previous testing was a gross under treatment of diabetes, resulting in serious complications and increased death rates. Diabetes is a classic example of a common medical condition where inadequate testing resulted in grossly inferior care as well as ultimately much higher medical costs due to complications.

There are many conditions, particularly in hospital situations, where testing has been drastically reduced for financial considerations. Patients need to be made aware of this so they can have input into whether they are being optimally treated or whether they are being treated to minimize expenses and profits to those treating them. The concept that a medical facility is a so-called non-profit only means that it does not pay taxes. It is no assurance that the patients are getting the best treatment.




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Conflict of Interest in Healthcare

By: Joseph Feldschuh, M.D., F.A.C.C., F.A.C.P.

The term “conflict of interest” is often used with respect to financial transactions, financial advice and healthcare issues. The government has mandated financial disclosure concerning doctors who receive benefits from companies in the healthcare industry. This is probably a good idea, as open disclosure enables individuals to judge for themselves whether there might be any bias in the advice they are receiving.

Sometimes, however, gross conflicts of interest are not obvious and not disclosed. For example, there are ongoing discussions about ever-escalating costs of healthcare. Health management organizations (HMOs) were designed to provide a structure where medical groups are motivated to control so-called “unnecessary” tests and procedures. These organizations underwent enormous criticism after various patient groups realized that they were not infrequently being treated, with the withholding of important tests and procedures from which they might benefit.

Hospitals have been under increasing pressures to limit costs. In the New York region many small hospitals have gone bankrupt or out of business in response to these pressures. Many of the most prestigious hospitals in the area have survived by charging private patients with private medical insurance higher fees than they receive from government insurers such as Medicare. Even a major medical center such as St. Vincent’s Hospital, which was founded in 1849, was forced to declare bankruptcy and go out of business in 2010 because of cost pressures. Some of these prestigious hospitals also receive important contributions which supplement their fees and enable them to continue their services.

The government, via Medicare, has mandated in recent years a fundamental change in the way hospitals are reimbursed. In previous years hospitals were reimbursed on the basis of the number of days a patient spent in a hospital, or the number of days that a patient spent in an intensive care unit. As might be expected, because of the extra nursing care and staff, a day in intensive care unit is significantly more expensive with respect to hospital costs than a day in a regular hospital bed. Under the new system, in recent years, hospitals are now reimbursed based on a concept called Diagnostic Related Guidelines (DRGs). This means that Medicare will determine what the median number of days of care for a specific diagnosis are and pay the hospital a set fee for that diagnosis. For example, a patient admitted for congestive heart failure might be treated and discharged in two days, or might be treated and discharged in 10 days. Medicare pays the hospital the same fee for the patient who has been treated for two days as for the patient treated for 10 days. Not surprisingly this has led to a drastic change in the way hospital medicine is practiced.

More and more physicians, especially in large hospitals, are direct employees of the hospital. They are paid a fixed salary with some possible bonus incentives related to how they function. One of the most obvious incentives from a hospital perspective is to reward physicians who discharge patients for a specific condition earlier than the usual length of stay. In the case of congestive heart failure, this type of practice has led hospitals to discharge patients at the earliest sign that the patient appears stable. If the patient proves to be, in reality, less stable and requires readmission, the clock starts all over again under the DRG system. If the patient is discharged in 2 or 3 days and returns a week later, the clock would start again. In order to discourage this type of practice, Medicare has now mandated a financial penalty to hospitals for congestive heart failure patients readmitted within 30 days of discharge. Former Mayor Ed Koch of New York was admitted to the #1 hospital in New York, Columbia Presbyterian Medical Center, for congestive heart failure four times within a 6-month period. On his third admission he was discharged within a week and made to feel he was so stable on a Saturday that he would be able to return to his office on Monday. Instead, on Monday, he was readmitted to the hospital. On Tuesday he was transferred to the intensive care unit, and two days later he expired. The hospital will receive a financial penalty for readmitting him within 48 hours after he was discharged. The obvious question is, how stable was he at the time of discharge two days before requiring readmission? This is the dilemma that is faced by many hospitals and physicians on a daily basis.

Patients need to understand the very serious conflicts of interest involving millions of dollars with respect to how they are treated by the physicians in hospitals. Physicians are under many constraints with respect to the treatments and durations of stay they can provide under the current healthcare system. Hospitals are under enormous financial pressures to provide healthcare at the lowest cost.

One hospital has figured out that by readmitting congestive heart failure patients to a hospice they can avoid readmitting the patient to the hospital. A hospice is designed to treat patients with minimal medication for terminal care. We wonder what will happen when patients’ relatives become aware of this practice of admitting congestive heart failure patients to a hospice to avoid readmitting them to a hospital. This is particularly significant when patients realize that in a hospice they will be getting minimal treatment except for alleviation of pain. Hospice care is usually reserved for patients receiving terminal care. Patients need to be their own advocates and also to develop connections to consumer medical advocates who can protect their interests.


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New York Times and Unnecessary Medical Tests

A recent letter to the editor of the New York Times on April 1, 2013 discusses unnecessary tests which are supposedly related to physicians concerned about malpractice.

In the current environment there are all sorts of regulations such as the Stark Laws which prevent physicians from referring patients to facilities where they might obtain a financial benefit. In addition, more physicians than ever are becoming salaried employees of hospitals.

Some of these medical practices are under so-called managed care guidelines, otherwise known as health maintenance organizations (HMOs). There is an obvious conflict of interest between a physician who makes increased income from an imaging procedure every time he orders such as test. That does not necessarily mean that the test is inappropriate. Dr. Genden cites specifically “expensive evaluations” such as PET scans, MRI scans, and CAT scans that will have no effect on the patient’s outcome. He notes that 40% of the images that are ordered at Mt. Sinai are ordered for the purpose of surveillance.

Dr. Eric Genden, an otolaryngologist and director of the Mount Sinai Head and Neck Cancer Center, seems to be unaware of some of the uses of PET scanners for definitive treatment. For example, I recently saw a patient of mine from an upstate community who was found to have a solitary lung tumor. The patient has previously been diagnosed with a gastrointestinal tumor. The patient was about to undergo surgery and the physicians wanted clearance from me for the operation. Instead of clearing the patient for the surgery, I sent her for a PET scan, also known as Positron Emission Tomography. This is a specialized type of imaging which can detect hyperactive areas of metabolism within the body such as typically found when patients have metastatic cancer, meaning multiple areas of cancer. The patient’s PET scan showed that the patient actually had five definite areas of metastasis. Removing the tumor in part of the patient’s lung would have certainly made the patient sicker and lowered her overall immunity and would have accelerated the growth of the metastatic tumors. Confronted with this information, the surgeon immediately cancelled the surgery and I referred the patient to a leading oncologist so she could receive chemotherapy which would reach all areas of the patient’s cancer. The patient is alive almost a year later with only minimal side effects from her chemotherapy.

Ordering truly unnecessary tests for purely financial gain is obviously inappropriate. Failing to order tests which result in serious physician damage to the patients with the idea of minimizing costs is much more immoral and needs to be closely monitored in an era where the focus is on so-called unnecessary tests.

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Death of Ed Koch from Congestive Heart Failure – Was It Avoidable?

By US Government Printing Office [Public domain], via Wikimedia Commons

I had met Ed Koch on a number of occasions including the time when he was a U.S. Congressman and we were both on a television program.  Mr. Koch was a beloved New York City mayor who was not afraid of tackling controversial subjects.

I am going to raise a controversial subject, namely “Did Ed Koch receive the best treatment?”  He was treated at the world famous Columbia Presbyterian MC ranked as the #1 hospital in the New York, New Jersey, Connecticut region.  He had well recognized cardiologists managing his care.

In the past 6 months Mr. Koch had 4 admissions for congestive heart failure at the hospital.  He was also closely monitored on an outpatient basis.  On January 19, 2013, Koch was admitted to the hospital because he was lethargic and had swollen ankles. He was released on January 26. It was the third time in the previous six months he had been hospitalized. Two days after his release, he was readmitted into New York–Presbyterian Hospital after complaining of shortness of breath and fluid on his lungs. He was moved to the Intensive-care unit (ICU) on January 31. He died at approximately 2:00 a.m. on February 1, 2013 with a diagnosis of congestive heart failure.

Medicare, as of January 1, 2013, is imposing financial penalties on hospitals that readmit patients within 30 days or less for heart failure.  Columbia Presbyterian undoubtedly will receive such a penalty on its reimbursement rates for readmitting Mr. Koch.

The statistics for heart failure are very terrible.  Many hospitals report death rates of 30 – 45% within one year for patients who are admitted for congestive heart failure.

The most fundamental derangement in congestive heart failure is the accumulation of excess water and sodium salt within the body.  A major symptom of heart failure is the accumulation of fluid in the legs and lungs, which can make a person feel as if they are drowning.  Mr. Koch was described as having fluid in his legs and lungs when he was admitted to the hospital for his third admission.  Apparently his doctors felt comfortable enough with his progress to send him home on Saturday.  A TV reporter said Mr. Koch had 16 lbs. of fluid removed.  He told reporters he would be at work on Monday.  Instead he was readmitted on Monday and died within 72 hours.

A question that might be considered is “Did Mr. Koch receive optimum treatment?”  He was at the leading hospital facility in the region.  Its cardiology section is world famous for its advanced cardiac surgery.  It might appear to be presumptuous to even question whether he had anything but optimum treatment.

Approximately 10 years ago the cardiology department at Columbia performed some landmark studies involving the measurement of blood volume utilizing the BVA-100 in Class III/Class IV cardiac patients.  Congestive heart failure patients have 4 levels of gradations.  Patients who are considered Class IV are the most seriously ill and have symptoms of shortness of breath while they are even at rest.  Such patients are often candidates for a cardiac transplant, which are rarely available, or mechanical ventricular assist devices (VADs) which are implanted as secondary hearts into a patient.  The hospital performed a two-year study involving 43 patients on their transplant or VAD waiting lists.  They measured the blood volumes of these patients and also asked the experienced cardiologists to estimate, based on their standard laboratory tests and diagnostic procedures such as CAT scans and echocardiograms, whether these patients had a normal blood volume, an expanded blood volume, the usual state in untreated patients, or a shrunken blood volume.  The experienced physicians were only correct 51% of the time in their estimates of what the patient’s blood volume status was and wrong 49% of the time.

Fundamental to The treatment of congestive heart failure are the use of powerful drugs called diuretics which block the ability of the kidney to absorb salt and water.  Other drugs called vasodilators / are used relax the blood vessels so as to not overload the weakened heart’s pumping action.  Diuretics may improve the patient’s symptoms by causing excess water to be excreted by the kidneys.  Over treatment with diuretics, however, may shrink the patient’s blood volume to a point where kidney failure may be precipitated.  The blood pressure may also collapse from excessive loss of volume.

Among the additional problems seen in heart failure patients is anemia.  Heart failure patients are frequently put on anticoagulants which may cause subtle unrecognized bleeding.  In the first study involving 43 patients, the blood volume measurements were taken but not used to direct therapy.  At the end of one year 39% of the patients who still had an excessive blood volume, despite treatment, were dead.  All of the patients who had a normal blood volume or slightly reduced blood volume were still alive.  At the end of two years, when the study was completed, 57% of the patients who had an expanded blood volume were dead but all the pts with a normal blood volume were still alive.

The Guidelines of the American Heart Association/American College of Cardiology specifically state to treat to euvolemia (meaning a normal blood volume.)  Koch had four admissions to Columbia Presbyterian Medical Center for congestive heart failure within 6 months.  Was he treated to a normal blood volume before he was discharged?  Ed Koch did not have a blood volume measurement performed on any of his four admissions.  Despite the fact that the landmark studies documenting how inaccurate experienced physicians are in evaluating the blood volume derangements in congestive heart failure patients were performed at this institution, he never had this fundamental test performed.  Further evidence of how inaccurate his physicians were in assessing his clinical status is that he was admitted to Columbia Presbyterian Hospital for seven days, apparently diuresed to have excessive fluid removed, and on discharge told well wishers he expected to be back in his office on Monday.  In point of fact on Monday he was readmitted to the hospital and a day later moved to the ICU and within 72 hours of admission he died.

We do not know what the terminal cascade of medications he was treated with in the last 48 hours of his life, but they obviously did nothing to reverse the situation which apparently had worsened unexpectedly.  Most likely the terminal event was a collapse of his circulation.

How could his physicians have misjudged his actual clinical status during the third admission days before his death?  The basic reason is that patients who are treated on the basis of clinical impressions and guesstimates do not do well.  Why is there a 25 – 40% death rate within the first year of admission for heart failure?  The reason is that patients are not optimally treated.  There is a great irony that the hospital which performed the first landmark studies validating the Guidelines of the American Heart Association does not perform blood volumes except for research purposes on congestive heart failure patients.  Under-treatment for congestive heart failure predisposes a patient to death.  Excessive treatment of heart failure with potent drugs also predisposes the patient to sudden death.  In a life-and-death situation, patients should be treated with the most precise diagnostic tools available.

As the Medicare guidelines mandate financial penalties for readmission for congestive heart patients begins to impact hospitals, this may have a beneficial effect because it will cause hospitals to finally come to grips with the sub-par care and high death rates for congestive heart patients that have been routinely accepted.

Blood volume derangement is fundamental to the maladaptive changes in CHF patients.  Patients should be treated on the basis of direct measurement and not guesstimates.

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