I Got a Cortisol Blood Test. What I Learned About My Stress Was Important, but Not Fun
After my cortisol blood test, I had a lot of residual questions about cortisol. That's why I spoke with several doctors to find out everything we should all know about cortisol and how it affects our bodies.
What is cortisol?
"Cortisol is an essential hormone produced and released by adrenal glands," said Dr. Sanjay Dixit, medical director of cardiometabolic endocrine and wellness solutions at Quest Diagnostics and medical expert for questhealth.com, in an email. "Many people associate cortisol as being the 'stress hormone,' but it actually has many additional important functions."
In addition to managing the body's response to stress, cortisol regulates blood sugar and blood pressure, the sleep-wake cycle and metabolism while suppressing inflammation.
"It is most commonly known as the 'stress hormone' because it's released in response to stress and works to prepare the body for 'fight-or-flight,'" added Dr. Sajad Zalzala, co-founder and chief medical officer of longevity platform AgelessRx, via email. "It increases glucose availability, which supplies energy and mobilizes stored fats and proteins to provide additional fuel."
Should you get a cortisol test?
Dixit explained that someone could get a cortisol test to see if they have a cortisol deficiency, also known as adrenal insufficiency. Symptoms of this can include:
Fatigue or being overly tired
Worsening muscle weakness
Skin changes (particularly darkening in folds and scars)
Loss of appetite
Unintentional weight loss
Low blood pressure
Another reason a cortisol test may be ordered is to see if a patient has excess cortisol, generally known as Cushing's syndrome. Potential symptoms for this include:
Bruising easily
Unintentional weight gain
Muscle weakness
Fatigue
Rounded and rosy face
Increased fat in the upper back
Impaired glucose tolerance
"[Impaired glucose tolerance is] something that can be particularly noticeable in type 2 diabetic patients who have trouble managing their glucose levels even with adherence to prescribed medication," said Dixit.
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What is a cortisol blood test?
Before my blood was drawn for this test, I had my yearly physical with my primary care provider. I notified her that I would be getting this test and asked to have my other preventative blood tests taken simultaneously. I want to mention this because it's important to run any health-related tests by a doctor who knows you and your health history.
According to Quest, you must be at least age 18 to buy a test, which is unavailable in Alaska, Arizona or Hawaii. For select tests, you will be asked to answer relevant medical questions. Before a test order is submitted for processing, your purchase and answers will then be reviewed by a telemedicine doctor affiliated with the national clinician network PWNHealth to ensure this test is medically appropriate for you.
You must also schedule the cortisol test between 7 a.m. and 9 a.m. "Cortisol levels naturally change throughout the day," Quest answered in an FAQ, stating that since cortisol levels usually peak in the morning, this particular level would be the best indicator of a cortisol problem.
No fasting is required. But I had to fast for the other blood tests ordered by my doctor.
According to Dixit, it is also important to note that "a blood test for cortisol can be inaccurate in some cases." Inaccurate results, for example, can happen if a person is taking oral contraceptives or steroids, such as prednisone.
Once I bought the cortisol test on Quest's website -- it ordinarily costs $89 with a $6 physician service fee -- I was sent an email with my order number and a link to schedule an appointment at a nearby Quest location. I scheduled my appointment for 8:20 a.m. at the facility closest to me.
On the day of my appointment, I was texted a link to check in when I arrived and was admitted within 5 minutes. (I highly recommend scheduling beforehand so you don't have to wait.) I get particularly anxious about blood tests, so I notified my technician and asked if I could lie on an exam table. She assured me that many people get nervous about blood tests and, after I signed off on my tests, did a great job talking to me as a distraction while my blood was drawn.
Later that night, I received the results of my cortisol test. As for the results from the tests ordered by my doctor, I received them five days later. Quest reports that processing times vary, but it generally takes up to eight business days to receive results.
My cortisol blood test results
Unsurprisingly, my cortisol blood test results came back as "high" at 33.2 mcg/dL. Quest reports that a normal range between 7 a.m. and 9 a.m. is 4.0-22.0 mcg/dL. To be frank, this freaked me out. I had a feeling that my cortisol levels would be high because of my general anxiety and heightened nerves around blood tests, but actually seeing that "high" result and not fully understanding it ironically increased my stress levels even more.
Quest allows you to discuss your results with an independent physician, so I took advantage of this offer. I called Quest's customer service line and was emailed to schedule my appointment with a physician at PWNHealth via Everly Health Solutions, a digital health company that acquired PWNHealth in 2021. When scheduling my appointment, I provided context about my cortisol blood test. I was then told that a physician would call me within 4 hours during business hours.
Within 4 hours, a PWNHealth physician called. I asked the doctor if my cortisol level was in line with the fact that I have anxiety and was stressed about the blood test. She said that it could be why my cortisol was acutely high, but that chronically high cortisol levels could be concerning and caused by other conditions, certain medications or pregnancy. She added that it could be related to an adrenal gland condition.
I also asked about how high cortisol levels can go and she stated that there is no "highest point," especially since it varies from person to person, depending on the condition. She added that people with adrenal gland conditions typically show higher cortisol levels, but there isn't a specific cutoff.
Though the doctor stated that my high cortisol was likely due to anxiety, she recommended that I follow up with my primary care physician. Afterward, I was able to download my Quest results as a PDF and send them to my PCP.
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What are normal cortisol levels?
"The 'normal' reference range varies slightly with the lab that's doing the testing," said Zalzala. "Quest reports a normal a.m. (7 to 9 a.m.) blood level of 4.0 to 22.0 mcg/dL, whereas Labcorp reports normal a.m. blood level of 6.2 to 19.4 mcg/dL."
As for why cortisol varies throughout the day: "Cortisol is very important in helping a person transition from sleep to wakefulness," Zalzala explained. "This triggers a 'morning cortisol surge' -- a rapid rise in cortisol levels within 20 to 30 minutes of waking, which jumpstarts alertness and prepares the body for the day."
Over the course of the day, our bodies will also experience mini peaks in cortisol levels to help us maintain energy and alertness. These peaks typically occur around noon and in the early evening. "Interestingly, these peaks often align with standard meal times, playing a key role in supporting our body's ability to metabolize food and regulate energy levels," said Zalzala.
Dr. Betul Hatipoglu, MD, professor of medicine at Case Western Reserve University's School of Medicine and medical director of the Diabetes and Metabolic Center at the University Hospital Cleveland Medical Center, stated in an email that there is a "normal, what we call 'circadian rhythm' for cortisol." As the day goes on, cortisol levels will gradually decrease and become lowest closer to bedtime.
How high can cortisol levels go?
"Cortisol levels could go as high as or closer to 40 [mcg/dL] in individuals who are extremely ill, such as people in intensive care," Hatipoglu said. Zalzala added that a normal adult can generate cortisol levels up to 50 mcg/dL, which is about two to three times their morning surge level, during times of stress.
Zalzala also mentioned Cushing's syndrome, a rare disorder in which "the adrenal gland starts making cortisol on its own (adrenal tumor) or in response to a pituitary gland tumor that makes too much ACTH [adrenocorticotropic hormone, which regulates cortisol] and ignores the feedback cycle." For those with this disorder, cortisol levels can go as high as 100 mcg/dL.
In cases where someone is extremely ill, such as with septic shock, Zalzala stated that levels can be as high as 1,000 mcg/dL.
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Can anxiety affect cortisol?
I shared my results with all the doctors I consulted to see if I could get a better understanding of how anxiety could affect my cortisol levels -- and any other factors that may be at play.
"High cortisol in a normal individual can be a sign of stress in your case," said Hatipoglu. "However, sometimes other hormones can affect the cortisol levels. For example, if someone is taking oral contraceptives or estrogen therapy, this can increase total cholesterol, which is what you have been tested for."
Due to fasting, anxiety and being stressed about my blood draw, Zalzala said that combination could have caused my morning cortisol level to be higher than normal. He added, "Studies have shown that stress or acute anxiety can drive cortisol levels significantly higher, often to values similar to what you experienced."
What other cortisol tests are there?
"I usually would check a random cortisol before 9 a.m. in the morning to make sure the level is not low," said Hatipoglu. "If we are concerned about high cortisol, it is usually recommended that we actually do different evaluations."
To understand whether elevated cortisol levels are a normal reaction or an abnormal increase, Hatipoglu may then want to do testing such as a milligram dexamethasone suppression test (which measures whether cortisol secretion by the adrenal gland can be suppressed) or a 24-hour urine cortisol test (which measures the amount of cortisol in a person's urine over a day). However, if a patient is on birth control, stopping it for a few months and then repeating the cortisol test may help show their body's actual cortisol levels.
Zalzala, on the other hand, stated that he rarely recommends a single morning cortisol test unless a patient is believed to have Addison's or Cushing's disease. Addison's is a rare endocrine disorder caused by damaged adrenal glands that can't produce enough hormones.
"For those people who want to use cortisol levels as a tool to make lifestyle adjustments and to monitor other interventions (like therapy or sleep medications), then the saliva cortisol level is the one I would recommend," stated Zalzala. "Studies indicate that salivary cortisol levels show a reasonably strong correlation with serum cortisol."
For my "high" result specifically, Zalzala stated, "While this result aligns with the stress factors you've described, cortisol levels above 20–25 µg/dL [which is the same as mcg/dL] in the morning can sometimes prompt further evaluation, particularly if symptoms suggest additional hormonal imbalance."
If I were to take supplementary tests under less stressful conditions and my cortisol continues to be elevated, Zalzala said I should explore other factors with my healthcare provider. "They may consider repeating the test using alternative methods, like a 24-hour urinary free cortisol or late-night salivary cortisol test, which are less affected by immediate stress responses."
While this particular cortisol blood stress hormone test can be a good first step, Dixit acknowledges that it may not necessarily be the last one. He suggested that a person concerned about their health should talk to their doctor -- even if the test results don't show anything wrong.
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What happens if a cortisol blood test is abnormal?
"I think the best way here would be to see a physician, a nurse practitioner or a healthcare provider to get an evaluation," Hatipoglu said. "[This is] done to understand if it is true [cortisol] elevation or is it stress-induced."
Dixit specifically recommended that in addition to a primary healthcare provider, one could see an endocrinologist, a doctor specializing in diagnosing and treating health conditions that affect the endocrine system. "That's because testing for excess cortisol is not as straightforward as a single blood test," he said, adding that a healthcare provider could perform an evaluation, recommend additional tests and consider other potential causes.
However, if additional tests remain abnormal, a trained clinician must be consulted for further diagnostic decisions. "Most conventionally trained physicians would initially evaluate for Cushing's or Addison's disease," Zalzala said. "If these are ruled out, a thorough clinician would then investigate other contributing factors affecting cortisol levels. Conversely, a less attentive approach might dismiss the patient without addressing the underlying issues."
If a doctor does determine that there are problems with excess cortisol or adrenal insufficiency, Dixit stated that the methods used to address the issue depend on the root cause. For example, with Cushing's syndrome, medication or surgery may be required since the disorder can be caused by a tumor on the adrenal or pituitary glands.
What can cause abnormal cortisol levels?
"I think it's useful to talk about the ways the normal cortisol cycle can be disrupted, that could show up on salivary testing if done at the right times of day," said Zalzala, who listed the following as common causes for a disrupted cortisol cycle:
For cortisol levels that remain low and flat throughout the day: Chronic stress, adrenal fatigue, burnout and some chronic inflammatory conditions.
Chronic stress, adrenal fatigue, burnout and some chronic inflammatory conditions. For lower morning cortisol levels that then peak in the evening: Chronic stress, sleep disorders, shift work and certain mental health conditions (for example, PTSD).
Chronic stress, sleep disorders, shift work and certain mental health conditions (for example, PTSD). For normal morning cortisol levels that increase in the evening: Anxiety, high-stress lifestyle, evening exposure to artificial light (such as from screens) and late-day caffeine or high-stress activities.
Anxiety, high-stress lifestyle, evening exposure to artificial light (such as from screens) and late-day caffeine or high-stress activities. For a lower or absent rise in cortisol upon waking, or Cortisol Awakening Response): Chronic stress, depression, PTSD, burnout and shift work.
Symptoms of high cortisol or cortisol deficiency can also be connected to non-cortisol-related conditions and health issues, according to Dixit. That is why consulting a doctor about your results and symptoms is essential.How can high cortisol affect health?
While social media may oversimplify all things cortisol as a means of clickbait, Zalzala said it should not be dismissed. That's because dysregulated cortisol has the following long-term health impacts:
Mental health issues such as anxiety, depression and mood instability.
such as anxiety, depression and mood instability. Cognitive impairment such as memory problems and impaired executive function.
such as memory problems and impaired executive function. Metabolic disorders that involve weight gain and obesity, insulin resistance, increased risk of metabolic syndrome and type 2 diabetes and blood sugar instability (such as hypoglycemia or hyperglycemia).
that involve weight gain and obesity, insulin resistance, increased risk of metabolic syndrome and type 2 diabetes and blood sugar instability (such as hypoglycemia or hyperglycemia). Cardiovascular issues like hypertension, arterial stiffness, inflammation and heart disease, raising the risk of heart attacks and stroke.
like hypertension, arterial stiffness, inflammation and heart disease, raising the risk of heart attacks and stroke. Immune system impairment that can include increased susceptibility to infections and autoimmune conditions such as rheumatoid arthritis or lupus.
that can include increased susceptibility to infections and autoimmune conditions such as rheumatoid arthritis or lupus. Bone health issues and muscle wasting like osteoporosis and muscle loss.
like osteoporosis and muscle loss. Sleep disruption and fatigue , including insomnia, chronic fatigue, low motivation and difficulty managing stress.
, including insomnia, chronic fatigue, low motivation and difficulty managing stress. Digestive issues such as gastrointestinal inflammation contributing to conditions like irritable bowel syndrome and exacerbating symptoms of inflammatory bowel diseases like Crohn's disease, and gastric ulcers.
Should people be concerned about their cortisol levels?
The question that's on everyone's mind. After mentioning all of the social media videos circulating saying that people should be worried about their cortisol levels, I asked doctors if there is any legitimacy to these claims or if it's just fearmongering.
"I don't think it is fair to say people should be concerned about their cortisol levels -- as you can see, cortisol constantly fluctuates," said Hatipoglu. "The fluctuation occurs so many times that it is sometimes even difficult to know what is very normal or very abnormal." However, if you are concerned about your cortisol, she recommends seeing a doctor to see if a test is needed first instead of having it tested randomly.
While Zalzala acknowledges that there is some truth to the concept of "minding your cortisol levels," since there are medical conditions that can cause abnormal cortisol levels, he believes "social media often oversimplifies this, turning cortisol into a scapegoat for various health issues." He specifies that cortisol imbalances are typically caused by deeper issues such as poor sleep, unhealthy habits, unmanaged stress and substance abuse, in which case "cortisol is more of a symptom than the root cause."
"Cortisol levels, as a tool, should be used in conjunction with other tools like a CGM sensor or a sleep monitor," concluded Zalzala.
How can you naturally reduce cortisol?
"I usually recommend important, basic lifestyle management, [including] nutritious meals and good nutrition; movement exercise like yoga, walking and swimming; a good night's sleep, meditation and mindfulness; good vitamin D; and stress management for day-to-day stresses of life," said Hatipoglu. "And last, as much as possible, eliminating smoking and excess alcohol."
"Minimize caffeine and sugar intake, especially later in the day," Zalzala recommended. "Both can elevate cortisol and disrupt the normal rhythm, making it harder to wind down at night." Excess sugar and starch can cause a spike in blood sugar followed by a crash. This can occur in the middle of the night, disrupting your sleep.
If you maintain a consistent sleep schedule and evening routine without screen time or intense exercise (which can elevate cortisol and disrupt sleep) but still struggle to fall asleep, Zalzala recommends mild sleep aids like melatonin or L-theanine before moving on to stronger options like passionflower or California poppy. "If these aren't effective, consult a doctor about medications like trazodone or doxepin and rule out conditions like sleep apnea," he said. "Always discuss sleep therapies, including OTC supplements, with a doctor."
The bottom line
While the results of my cortisol blood test did stress me out, I'm glad I tried it because it helped me learn more about cortisol. It also gives me even more of an incentive to increase my stress and anxiety management. While I've always prioritized my health and wellness, since getting the cortisol blood test, I've started exercising more than before, going to bed earlier, thinking up new ways to lower my stress levels and paying closer attention to having a well-balanced diet.
As for ordering the test through Quest, I thought the process was smooth, and it's nice to have control over the health tests you can get done (if approved, of course). I also appreciated having the option to speak with an independent physician about my results. However, as both Quest and the doctors I consulted advised, it is best to do any health tests under the supervision of a healthcare provider, who can then help with diagnosis and potential treatment. I'm glad I told my doctor about the test and that it was easy to send her my results. And now, I'm way more informed about what the next steps could be if further testing is needed.
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But both were hugely lower than the AI model, which accurately called cath lab activation (CLA) in 89%. Doctors most frequently misclassified the de Winter pattern, transient STEMI, hyperacute t-wave OMI, and bundle branch ECGs The Queen of Hearts AI algorithm misclassified only two ECG types: left bundle branch block OMI (Sgarbossa (+) LBBB*) and left ventricular aneurysms. These same ECG types also challenged physicians, with only 14 % and 58 % of physicians correctly interpreting them, respectively. Finally, EM docs missed 41 % of true OMIs (195/477) and overcalled 32 % of non-OMIs (133/415), whereas Queen of Hearts AI missed only 11 % and overcalled 11 %. Overall physician accuracy was low (66 %), consistent with prior studies reporting 70% accuracy using fewer ambiguous ECGs. There were nearly identical accuracies between EM doctors and cardiologists (65.6% and 65.5%, respectively; P = .969). The ECG types most frequently misinterpreted include LBBB (±OMI), transient STEMI, and hyperacute T-waves as well as de Winter T-waves The Queen of Hearts AI algorithm was more accurate than physicians (89% vs. 66%, P < .001), correctly classifying all ECGs except left ventricular (LV) aneurysm and LBBB with OMI, indicating potential to improve care and resource utilization. I find this a remarkable study. The AI is clearly better. The ECGs were hard, but they are real, and I've seen them reviewed in peer review meetings as missed STEMI. No one misses the 3-4 mm tombstones ST elevations. It's the subtle STEMI mimics that are tough. If you are a patient with an occluded left anterior descending (LAD) artery but not a conclusive ECG, you hope either for a) luck or b) a master ECG reader, or c) a really good AI algorithm. Scientifically, I wonder if the best solution is smart doctors who have seen the patient and have Bayesian priors based on history and general appearance (MIs often look like MIs from the door) plus AI vs just AI. It's a false comparison because I don't think that study will ever be done, as it's hard for me to envision an emergency room without a doctor. (But I could not have imagined medicine with smartphones before smartphones). Nonetheless, I have no idea why the FDA would not approve such a device for use. It looks like an important adjunct for getting to the proper diagnosis. I see it as similar to point-of-care ultrasound for central venous access. Sure. You get into a central vein without ultrasound, but why would you? In the case of ECGs and CLA, sure, you can do it without AI, but why would you? The STEMI equivalents and mimics aren't rare and the Queen of Hearts looks quite good. Technology is amazing. Eli Lilly, the maker of tirzepatide, a GIP/GLP-1 dual agonist, announced results of the SURPASS-CVOT trial comparing tirzepatide (Mounjaro) to dulaglutide (Trulicity) in patients with diabetes and established cardiovascular disease (CVD). The trial began in 2020, enrolled about 13,000 patients and the company reported the topline results this week. Dulaglutide was shown to reduce cardiovascular outcomes in patients with type 2 diabetes (T2D) and established CVD or high risk for CVD in the REWIND trial, The Lancet 2019. The results were close on the primary endpoint of MI, stroke, CV death — 12% in dulaglutide group vs 13.4% in placebo. HR 0.88 (0.79-0.99) and P = .026. In the SURPASS CVOT trial, Lilly says the risk of cardiovascular death, heart attack, or stroke was 8% lower for tirzepatide vs dulaglutide (hazard ratio: 0.92; 95.3% CI, 0.83-1.01), P = .086, meeting the prespecified criteria for non-inferiority. Tirzepatide showed consistent results across all three components of the MACE-3 composite endpoint. The rate of all-cause mortality was 16% lower for tirzepatide vs dulaglutide (hazard ratio: 0.84; 95% CI, 0.75-0.94). There were also positive results in secondary endpoints: slower slope of estimated glomerular filtration rate (eGFR) decline, more reduction of A1c, and -12% vs -5% body weight reduction with tirzepatide vs dulaglutide. Key opinion leader Muthiah Vaduganathan wrote on Twitter that 'the game has changed' — SURPASS CVOT meets its primary and secondary endpoints in first head-to-head CV outcomes trial. He emphasized the 16% lower risk of all-cause mortality. Yet, the always reasonable Sanjay Kaul on Twitter notes that SURPASS was powered for 15% RRR in MACE. And the PEP comes out only 8% lower with the 95% CI of 0.83-1.01 barely containing the HR 0.85. Kaul also notes that the superiority of the comparator dulaglutide has not been established in this patient population. What? I told you the REWIND trial of dulaglutide vs placebo was positive. Yes, it was, but Kaul notes that the subgroup of patients with established atherosclerotic vascular disease (about a third of patients) the HR of dulaglutide vs placebo was 0.87 (0.74-1.02). Kaul also asks what to make of the 16% reduction in all-cause mortality. It's a good question because you only have an 8% reduction in MACE, and Lilly tells us that tirzepatide reduced A1c, weight, and slowed CKD but no significant difference in CV events? My two cents are that all-cause mortality is likely a noise issue. The P value was not adjusted for multiple testing, but more important is that if a drug is a cardiac disease modifier, then CV death and CV outcomes should drive the reduction in death. We need to see the full results. Another issue is that tirzepatide was titrated to max dose and dulaglutide was fixed at one dose. Furthermore, I have a real problem with a non-inferiority design here. Non-inferiority designs are to be used for interventions that offer something less invasive, less costly or less risky. None of that is true with tirzepatide. In these early trial results, my take-home message is that tirzepatide failed to show superiority of dulaglutide. The HR was only 8% relative risk reduction and the CI went above 1, with P value well above .05. We will wait for the trial results at the European Association of Diabetes. Doctors' Own End-of-Life Choices Defy Common Medical Practice BMJ Journal of Medical Ethics published a survey of physicians' preferences for their own end of life. The survey included doctors from Belgium, Italy, Canada, the United States, and Australia. More than 1100 responses were analyzed. Physicians rarely considered life-sustaining practices a very good option (in cancer and Alzheimer's respectively: cardiopulmonary resuscitation, 0.5% and 0.2%; mechanical ventilation, 0.8% and 0.3%; tube feeding, 3.5% and 3.8%). About half of physicians considered euthanasia a very good option (respectively, 54.2% and 51.5%). Physicians practicing in a jurisdiction with a legal option for both euthanasia and physician-assisted suicide were more likely to consider euthanasia a very good option for both cancer (odds ratio 3.1) and Alzheimer's (odds ratio 1.9). I cover this paper because I continue to be struck by the severity of illness in hospitalized patients. Nothing has changed from when I started 29 years ago. I used to remember coming home and telling my wife Staci how much we were torturing old people in ICUs. That was in the 1990s. Well, nothing has changed. I see consults nearly every day at our place and many of the people we are asked to see because of ventricular tachycardia (VT) or atrial fibrillation (AF) or bradycardia are weeks or months from dying—not of the arrhythmia, and not of one disease, but rather a multitude of diseases, resulting in severe frailty. So you read this survey of docs, and you get the impression that since doctors know better, they would not be stuck in the loop of hospitalizations and ICU stays. But whenever one of these surveys on doctors' preferences comes out, I go back to Dan Matlock's paper in 2016. It's titled, 'How U.S. Doctors Die: A Cohort Study of Healthcare Use at the End of Life.' They found that when looking at actual Medicare data of US physicians, doctors spent the same number of days in the hospital and ICU in the last six months of life as did non-doctors. Doctors in this study spent a few more days in hospice than non-MD's but the take-home was that while doctors may express a desire not to have futile care at the end-of-life, in reality they suffer as much as non-doctors. No idea I have had gets stronger than this one: the challenge of modern cardiologists is not having something to do for people, but whether we should do it . With every new advance, percutaneous valve procedures, pulsed field ablation (PFA) for AF ablation, and chronic total occlusion percutaneous coronary intervention (CTO PCI) procedures, the question of using these procedures in older sicker patients gets harder and harder. We can do transcatheter aortic valve implantation and open valves, put in pacemakers and fix bradycardia; we can put in cardiac resynchronization therapy devices and reverse LBBB, and now with PFA, we can ablate about anything in the left atrium. But in many of the inpatient consults I see, none of what we can do will fix the dying process of old age. It's super hard. I don't have an answer for all this suffering we inflict in the last months or years of life. Take VT ablation, one of the sexiest new movements in EP. You see tons of it on Twitter. Gorgeous pictures of diastolic buffets of e-grams and colorful 3D maps. But I will tell you that, in reality, many of these patients have VT because of end-stage cardiomyopathy. You want to, of course, have the skills to ablate VT because a minority of patients have an isolated scar that can be ablated, and that patient can then live years of good life. But gosh, many of these patients have VT because they've successfully survived an MI and heart failure 20 years ago. They've had a great run. I don't mean to be preachy in this topic; in reality, I often don't know when to stop. But I do know that stopping is often the right choice. I would remind listeners that all of us have end dates, and the job of the modern physician is to help people have a good life and a good death. We are much better at the former than the latter. I want to close today with another chapter on well-meaning policies that make great sense. It's one of the most dangerous concepts in healthcare. A few years ago, there was an uproar about access to care in VA hospitals. Veterans often live far from a facility. There are substantial wait times. So, Congress passed the MISSION act, which stands for Maintaining Internal Systems and Strengthening Integrated Outside Networks. This allowed veterans who lived longer than an hour drive to get care outside the VA, closer to home, because that makes sense. Well, JAMA has published a very interesting observational study of cardiac outcomes from the MISSION act. The authors, led by a team in Philadelphia, did a retrospective difference in difference cohort study of veterans who had PCI, CABG or AVR between 2016 and 2022 in non-VA hospitals covered under the MISSION act or in VA hospitals. The two outcomes were MACE (MI, stroke or hospitalization for CV cause or death within 30 days of the procedure) and travel time. This was a huge database study looking at the three procedures. Tens of thousands of patients in each group. The two main groups were far and near patients. The first finding was that after MISSION act implantation, for PCI, coronary artery bypass grafting (CABG) and aortic valve replacement (AVR), there were much larger percentages of far rather than near patients who received these procedures in non-VA hospitals. The second finding — and hint — is that far patients who received procedures at non-VA hospitals were more likely to receive care at nonteaching, smaller, rural, and for-profit hospitals than near patients receiving non-VA care. The third finding was to look at outcomes before MISSION act: October 1, 2016, to June 5, 2019. The difference in travel times, probability of choosing VA, and 30-day MACE showed no statistically significant difference-in-differences between the 2 groups. That's important, because it provides support for the preintervention parallel trends assumption critical to the validity of difference-in-differences analyses. After the MISSION act, implemented in 2019, travel times increased a tiny bit in near patients but decreased by a lot in far patients. I think travel time increased a bit in near patients because it was not just distance but also wait times could allow veterans to go to other hospitals and non-VA hospitals may be farther away than the VA. Indeed PCI, CABG and AVR volume in VA hospitals decreased quite a bit after MISSION implementation. Here is the key result: Far patients undergoing PCI had a 2.3 percentage point adjusted mean increase in 30-day major adverse cardiovascular events (MACE) rates compared with a 0.5 percentage point adjusted mean decrease in MACE rates among near patients (difference in differences, 2.8 percentage points; P < .001). Far patients undergoing CABG had a 1.6 percentage point adjusted mean increase in 30-day MACE rates compared with a 6.5 percentage point adjusted mean decrease among near patients (difference in differences, 8.1 percentage points; P < .001). Both near and far patients undergoing AVR had similar adjusted mean increases (2.2 percentage points vs 3.4 percentage points; P = .45) in 30-day MACE. The authors concluded that: 'MISSION Act implementation was associated with substantial decreases in travel times among veterans who became geographically eligible for non-VA care. For these patients undergoing PCI or CABG, MISSION Act implementation was also associated with worsened 30-day MACE rates.' I remember thinking this was going to be the likely result. Yes, it's nice to get care closer to home. I often see rich endurance athletes who travel to see me. If they should have a procedure, I tell them to get it close to home. Because AF ablation is a well-practiced procedure that can be done in all major cities. But PCI, CABG, and AVR are procedures that not only require a skilled doctor but also a skilled team and a system. And while VA hospitals may not have great food or great decorations, they often have great processes and dedicated staff. In fact, in the introduction of this paper, the authors cite three observational studies finding that VA cath labs have better mortality rates than non-VA cath labs. I don't find this a surprising finding at all. So, the MISSION act focuses on improving access to care. And it does. Veterans have shorter drive times to get care. But increasing care outside the VA results in worse results — at least for PCI and CABG. I should add that this is observational and there may be confounding. While baseline characteristics in the two groups were similar, those who live farther from the VA may be sicker. I doubt this because if there is one thing US hospitals are good at, it is making patients look sicker on paper. So I find these results highly likely. Care in the US has lots of variability. VA care is standardized. I see a similarity to say Canadian healthcare. When I visit Canada, I am struck by how cardiac procedures are done in small numbers of hospitals. This means Canadians having procedures have doctors and teams who do a lot of the procedure. They may have to travel and wait, but when they have the procedure, it is done by experts. In the periphery of major cities in the US, it's the Wild West. For instance, in Louisville, there are about 8 or 9 centers doing AF ablation. You may get a skilled doctor in the US who has tons of experience, but you may not. This paper suggests the policy of allowing veterans to seek faster and closer care resulted in worse outcomes. The lessons are both specific and general. Specifically, it was a bad idea to think that in the US, more convenient healthcare was a positive. And generally, it would have been far better to implement this policy in RCT pilot form first. Then, instead of looking back and seeing the harm it caused, policymakers could have adjusted midstream and mitigated harm. I don't why we feel that trials are needed for new drugs and devices but not policies. In fact, policies may affect more people than drugs and procedures, and I think it's even more important to study these in RCT form.
