Cover Story - February 2006
By Ken Ortolon
Dennis Phariss was just 41 when he suffered a heart attack in 1995. Bad eating habits, heavy smoking, and a high-stress job took their toll on the Odessa television news editor's heart.
For the next 10 years, Mr. Phariss thought his health was fine. But that changed in January 2005.
"After I had the heart attack, I was walking a tight line for a while," he said. "Then I went back to the heavy smoking and the bad eating habits. I went almost 10 years before I had another checkup. I thought everything was great, and then I had a checkup and found out I was on my way to another heart attack."
Mr. Phariss' poor lifestyle choices led to bypass surgery in February 2005. He says that was the wake-up call that finally got him to quit smoking, improve his diet, and start getting regular checkups from his primary care doctor, Odessa general practitioner Richard Bartlett, MD.
Now, Mr. Phariss says he feels great and his prognosis for a long life is good, as long as he sticks to his lifestyle changes.
He is one of a growing number of Americans who are surviving heart attacks and other major heart ailments that might have killed them a generation ago. While that is good news for those heart patients, it also means there is a growing cadre of Americans living with serious heart disease that must be managed to help them avoid future heart attacks.
That, experts say, will lead to a number of consequences that raises serious questions for our health care system, ranging from how primary care physicians will find the time in their busy practices to manage large numbers of patients with complex illnesses and multiple risk factors, to how Americans will pay for the care these patients will demand.
And, ethicists say that will inevitably lead to further questions about how much of our health care resources to devote to these patients as they grow older.
The Good News
Cardiovascular disease (CVD) continues to be the No. 1 killer of Americans, accounting for 38 percent of all deaths in the United States in 2002. But according to the American College of Cardiology, per-capita deaths from heart disease dropped by half over the past 50 years.
According to the Heart Disease and Stroke Statistics-2005 Update [PDF] from the American Heart Association (AHA), the per-capita death rate from cardiovascular disease dropped by 18 percent between 1992 and 2002, even though the actual number of CVD deaths rose by 0.8 percent during the same period.
Meanwhile, the American Cancer Society reports that cancer has surpassed heart disease as the No. 1 killer of people under 85.
Still, the number of Americans living with heart disease is growing. AHA reports that more than 70 million Americans have some type of cardiovascular disease, of which 27 million are estimated to be 65 or older.
Dallas cardiologist Allan L. Anderson, MD, chair of the Texas Medical Association Committee on Cardiovascular Diseases, says there is no question heart disease patients are living longer. He credits advances in technology and pharmaceuticals and a greater emphasis on lifestyle changes and risk factor management that can prevent future cardiovascular events.
"We've got good, effective treatments that allow them to live longer," Dr. Anderson said.
Austin cardiologist George P. Rodgers, MD, agrees. "When I started my training in cardiology in the mid-'80s, basically 90 percent of people with severe congestive heart failure were going to be dead within five years," Dr. Rodgers said. "Today, we can keep those people going for decades, even without heart transplants."
Dr. Bartlett, the Odessa general practitioner who treats Mr. Phariss, says he's seeing an increase in heart attack survivors in his practice, as well as a boost in the number of patients whose heart disease was diagnosed before they ever suffered an attack.
"There's an increased awareness of prevention and being proactive to avoid heart attacks," Dr. Bartlett said. "As opposed to 15 years ago, it's well accepted and actually expected to avoid heart attacks with stress tests and then angiograms if that proves to be necessary."
Whether or not heart patients have actually suffered heart attacks, all of them are going to need to manage a variety of risk factors to avoid future heart events and enable them to live active, healthy lives. That means controlling their blood pressure and cholesterol levels, quitting smoking, and managing their diabetes.
Obviously, not all patients are doing that. A Harris Interactive online survey released in December showed that nearly half of heart attack survivors admit they are not doing everything they can to avoid a second heart attack. That survey was conducted for Mended Hearts, an AHA-affiliated advocacy group for survivors of heart attacks.
While many heart patients will continue to see a cardiologist after a heart attack or other event, much of the burden of managing their risk factors frequently falls on their primary care physician. That, along with caring for growing numbers of patients with other chronic illnesses, is putting a serious time-crunch on primary care doctors.
A study published in the May/June issue of Annals of Family Medicine concluded that physicians would need 3.5 hours per day to care for patients with 10 common chronic conditions, including heart disease, if they adhered to current practice guidelines. And that was for patients whose conditions were well controlled. If all the patients' chronic conditions were unstable, that number would jump to 10.6 hours per day, the study concluded.
Dr. Bartlett says dealing with patients with heart disease definitely adds a level of complexity to the treatment primary care physicians must provide.
"It adds another dimension to patient care because you're all of a sudden having patients who are obligated to be on multiple medicines just to manage their heart disease and to prevent future heart attacks," he said. "It requires more coordination of care. You're working with more doctors now; you're working with a patient who is taking more medications, so you have to watch for drug interactions."
Dr. Anderson says finding time to counsel heart patients about smoking, diet, and nutrition, and controlling other risk factors can be difficult for many physicians, especially in smaller communities that lack specialists or other resources.
"For a primary care physician who's in a smaller community, maybe a rural community, and who's overwhelmed with a large number of patients, that may be a real challenge just because of time constraints," he said. "So for that management to be carried out, they need to use other resources, like nurse practitioners or physician assistants, or partner with other health care organizations to get that done."
And, Dr. Rodgers says, issues such as declining reimbursement and increasing government regulation just add to the pressures doctors face.
"Because we have declining reimbursement, primary care doctors are seeing more and more patients," he said. "Instead of seeing 10 in an afternoon, now they'll see 20 in an afternoon. So you've got these very complex patients who are coming through the office and are on multiple medications and now instead of having 20 minutes to see them, you have only 10. It is really tough."
Both Drs. Anderson and Rodgers say coordinating care between the primary care doctor and the specialist sometimes gets overlooked. Making sure laboratory studies, prescription information, and other issues concerning a patient's care are being fully shared is essential to making sure everyone is on the same page, Dr. Rodgers says.
Measuring the Cost
The good news that heart disease patients are living longer does not come without cost. As these and patients with other chronic illnesses live longer lives, they also are going to consume more health care.
"There is a real cost to keeping people alive and maintaining a quality of life," Dr. Rodgers said.
"One of the things we lose sight of is that with our success in treating heart disease, and as people get older, they may not have a mortality from the heart disease, but it may shift their disease burden to something else - cancer, neurologic disease, dementia, stroke," added Dr. Anderson. "This is particularly true of what I'd call the older Medicare population: the group of people who are over 80 and maybe even over 90 whose numbers are increasing very rapidly."
Heart disease and stroke cost Americans nearly $394 billion in 2005 in both direct patient care costs and lost productivity, according to AHA and the U.S. Centers for Disease Control and Prevention. That was up substantially from an estimated $351 billion in 2003 and was expected to continue to rise.
The cost of caring for an aging population that increasingly suffers from underlying chronic diseases could put a severe strain on programs such as Medicare and force society to make some tough decisions about how health care resources are allocated, some physicians say.
That already is happening in other countries. Britain's National Institute for Health and Clinical Excellence recently recommended that some patients in Britain be refused some treatment because of their age, particularly in cases where age affects the benefits or risks of treatment.
Dallas internist and medical ethicist Robert Fine, MD, says it may be appropriate to question the wisdom of providing care based on the expected benefit to the patient. No one would question implanting a defibrillator into the chest of a 40- or 50-year-old heart patient, but what about a 90- or 95-year-old?
"At some point many people would say, 'Well, isn't there a time to be born and a time to die?'" Dr. Fine said. "Is it appropriate to implant a device in somebody's chest at this age or is it simply too expensive or is it simply thwarting the natural order of events?"
Dr. Fine says our health care system always has rationed some care later in life. For example, physicians won't perform some organ transplants in patients of a certain age. But Dr. Fine says he would not set strict age restrictions.
"I think most of us would prefer to think of biological age," he said. "You can be a 40-year-old going on 80 because of multiple organ failures or you can be an 80-year-old who's got the heart and lungs of a 40- or 50-year-old. You need to look at functional status and the patient's ability to benefit from the treatment and how long that benefit might last."
Other physicians, however, say the final decision on what care should be rendered ultimately must rest with the patients and their families.
"As physicians, we don't have a lot of wiggle room for triaging and rationing," said Tyler family physician John W. "Bill" Scroggins, MD, chair of TMA's Board of Councilors. "We have to serve our patients as best we can. But as we counsel our patients in various stages of their lives, we work with reality and we can tell them about the cost and benefits and possible futility of procedures and treatment programs."
Dr. Anderson says physicians have to engage patients and their families in discussions that help guide them to appropriate decisions about the efficacy of further care.
"Is our job ultimately to prevent mortality or to improve the quality of life or both? We often need to have a dialogue with patients and their families about that."
Still, Dr. Scroggins says the cost issue cannot be ignored by society. "This question of cost and burden is not so much an individual thing but it is a societal burden. The issue we're going to have to discuss is how much we can afford as a society."
"Physicians should be involved with all of these questions and potential answers," Dr. Scroggins added. "We should represent our patients when we try to make these societal decisions. These are going to be big decisions made by a debate, and not everybody's going to be happy with them."
Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email at Ken Ortolon.
America's Health Improving
The overall health of the nation continues to improve, according to a report issued in November by the U.S. Department of Health and Human Services (HHS).
While Americans are living longer, however, there are concerns about trends in infant mortality and obesity among both children and adults, HHS officials concluded in Health, United States, 2005, published by the National Center for Health Statistics (NCHS).
In 2003, life expectancy at birth for the total population reached a record high of 77.6 years, up from 75.4 years in 1990.
Between 1950 and 2003, the age-adjusted death rate for the total population declined 43 percent to 831 deaths per 100,000 population. This reduction was driven largely by declines in mortality from heart disease, stroke, and unintentional injury.
Mortality from heart disease, the leading cause of death, declined almost 4 percent in 2003, continuing a long-term downward trend. The 2003 age-adjusted death rate for heart disease was 60 percent lower than the rate in 1950.
The NCHS data, however, showed that in 2003 there was a small but statistically insignificant decline in infant mortality. That followed an increase in infant mortality in 2002, the first since 1958.
And NCHS found that between 1999 and 2002, some 9 percent of persons aged 20 years and older and about one-fifth of adults aged 60 years and older had diabetes.
"Of particular concern in recent years has been the increase in overweight and obesity, which are risk factors for many chronic diseases and disabilities including heart disease, hypertension, and back pain," the report stated. "The rising number of children and adolescents who are overweight and the high percentage of Americans who are not physically active raise additional concerns about Americans' future health."
The full report can be found on the U.S. Centers for Disease Control and Prevention Web site at www.cdc.gov/nchs/data/hus/hus05.pdf [PDF].
February 2006 Texas Medicine Contents
Texas Medicine Main Page