Testing a Futile Lifestyle 'Intervention'

The latest big project we've been asked to consider adding on to our practice is a large, government-funded, national study looking at intervening on the highest-risk cardiovascular patients in an effort to prevent future badness.

Essentially, patients are risk stratified based on their future risk of cardiovascular events, using a simple online calculator that takes into account traditional risk factors such as smoking status, blood pressure, cholesterol, and age.

Highest-risk patients, those with greater than 30% risk of a cardiovascular event, are selected for intervention, through enrollment in a registry.

The intervention seems to be offering the provider some tools that show what would happen to a patient's risk if we got them to quit smoking, we got them on a medicine for their cholesterol, we got their blood pressure under control, and more.

This is a long-term study, hoping to find that this intervention decreases cardiovascular events, being done at hundreds of practices throughout the country, under a massive federal grant.

Ignore the fact that we've realized that figuring out which patients are eligible, locating them at the correct time, and then enrolling them involves a lot of extra work for the providers, requiring us to log onto a separate website and manually enter data that already exists in our electronic health record in electronic format.

Forget the fact that this doesn't seem like a very sexy intervention, just measuring some bad stuff and then showing patients how much better off they would be if that stuff wasn't so bad.

Isn't this what we do every day? Do they really think we are ignoring these patients who smoke two packs of cigarettes a day, have cholesterols of 300, blood pressures of 190/120, and are sitting in front of us diaphoretic with crushing substernal chest pain?

Wait, what, cigarettes are bad for you?

I wish someone had told me this years ago.

I never read that Surgeon General's warning on the side of the cigarette pack before.

I would've hoped that the study would be more creative, that the intervention would have been figuring out why these patients, despite being under our care, with our best intentions, still have a risk this high and trying to apply anything proven better than just putting them in a registry and telling them their risk would go down if they quit smoking or got their blood pressure under control.

Under a more patient-centered care model, what would happen to these patients (who we apparently have been ignoring all this time) would be that the rest of the members of the care team would attack them, relentlessly.

We have to figure out how to nag them, annoy them, badger them, break them, until the thought of putting another cigarette between their lips is unbearable.

We need to have a community health worker follow them around and slap their wrist when they enter the fast food restaurant, and drag them to the vegan joint across the street.

When their morning medicine pill bottles have not been opened by 9 a.m., we need to give them an electric shock through their Fitbit or Apple Watch, or at least makes sure they can't get onto Facebook or Candy Crusher until those pills have been taken.

Design an app for their smartphone that detects nicotine levels through their skin and cancels out their remaining streaming data.

Maybe even have our nurses and med techs take them out for a jog.

I know these sound draconian and extreme, and are likely never going to happen, but these seem more likely to prevent the progression of atherosclerotic disease in these high-risk patients than castigating the doctors for not doing a good job, or assuming that we've been ignoring them all along and neglecting to address these risk factors.

I don't think that just entering them in a registry and showing them a little slide graph that shows where their risk could go to if they finally quit smoking or took their medications is really going to do it.

We've tried to voice our concerns about this apparent limitation of the study, about this lack of a real intervention in the intervention group, but the government agency that is funding this seems pretty set in the structure, and whoever designed the protocol feels that this is really going to make a difference.

I remain unconvinced, and I am worried that we are asking our doctors and other providers to pour a lot of energy into a lot more clicking of boxes, that a lot of federal money and a lot of lost opportunity will drift by as we try to show that this non-intervening intervention makes a big difference.

I know that an intervention with teeth on the other end is going to be expensive, but why follow these high-risk patients for years and years when none of us upfront think this is going to make any discernible difference?

Better to intervene with small things we know can help than large things we doubt will move the needle at all.

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