BETTER GUIDELINES, FEWER TESTS

Let’s take a breather on global calamity and return to a subject near and dear to me—health care. It’s easy to speak in generalities about what can and should be done to shore up the failing health care system, but in truth, we need specifics. Supernaturally, a year ago to the day I penned this rant I bloviated on how physicians might be compelled to examine their utilization practices in a non-punitive fashion by having the professional societies forward to them their actual statistics, as well as their standing among their peers. I saw and still do see this as a way of auto-regulating practice patterns that get out of hand both through practice drift (which tends, often necessarily in these times, to follow the money, but may be influenced by local culture), malpractice fears, greed and clinical deficiencies.

From my lone vantage point I estimate (unscientifically) that 20-30% of what we do in this country in managing health care is waste due to overutilization. I’ve discussed this in the past, so I don’t want to beat it to death, but in speaking to my colleagues in other specialties I get a sense they see the same thing. Today I’d like to propose another concrete method by which the medical profession can streamline practices. Each specialty should set up a committee of respected experts to look at the actual triggers for further testing and make specific recommendations. Studies should be funded to assess outcomes that would provide physicians with more precise guidelines on how to proceed. Now, there are already countless panels and guidelines out there filling voluminous pages, and they are of some help. But we need to go beyond this to specifics in areas of high utilization. Let me illustrate with a common scenario:

When a patient comes to the emergency room for chest pain that cannot obviously be attributed to heart disease, a test known as a D-dimer is frequently done to help exclude a diagnosis that can be difficult to make on clinical grounds alone: pulmonary embolism, or blood clots to the lungs. Studies have shown that a normal D-dimer has great negative predictive value, allowing the clinician, with a great deal of certainty, to abandon further testing for this diagnosis. However, slight elevations of the D-dimer are seen frequently in the absence of blood clots. They lead to oodles of CT pulmonary angiograms, a relatively noninvasive, expensive, high radiation test with some risk to the kidneys, and that almost always comes back normal. I often joke that some cash-strapped radiologist developed the test. Kidding aside, this is just one example where further study and guidance clearly is needed.

Sometimes even doing cost-effectiveness studies doesn’t help. Years ago I recall reading that intrauterine monitoring of fetuses was shown to insignificantly affect outcomes, and a year or so ago I discussed this with an obstetrician I know and he confirmed it. Yet this has become standard-of-care. Patient expectations and litigation fears often trump science.

Unfortunately, even physician education isn’t infallible. A study by Gibbons and colleagues reported in the cardiology journal Circulation this year concluded that a quality improvement project directed at physician education and feedback did not reduce the rate of inappropriate SPECT studies (a form of cardiac stress testing utilizing nuclear isotopes and heart scanning).

So, are we doomed to stumble along this well-trod path of overutilization forever? I believe if we look specifically at the greatest areas of over-use we can come up with ways to dramatically reduce spending without decreasing—even increasing—quality.

One final note: I walk a fine line when I lambaste physicians. The overwhelming majority are hard-working and simply trying to do the right thing in an increasingly challenging environment. There is no “time-and-a-half” for seeing a sick patient in the middle of the night, and indeed, there is no guarantee of payment at all. When was the last time someone didn’t pay for a Botox treatment or breast augmentation? The public needs to move away from the attitude, fostered by the burgeoning and over-worked medical insurance system, that the most value accrues to the treatments and procedures that are needed the least.

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