why don't we practice cost-effective care?

An editorial published in this week's edition of the New England Journal of Medicine, asks the question: "Why does cost-effective care diffuse so slowly?" In other words, if we (the medical profession) have demonstrated ways in which we could provide the best care at the lowest price, why don't  more sectors of our society adopt such practices more rapidly?

The authors suggest reasons for each of the following groups being resistant to change practices that could save up to $640 billion. The sectors the authors feel responsible for maintaining the status quo are:

  • Insurance Companies
  • Large employers
  • The public (that would be you and me)
  • Legislators
  • Hospital administrators
  • Physicians
  • Academic Health Centers (hospitals associated with teaching programs for medical students, residents and fellows)
  • medical equipment and drug manufacturers

The authors provide their perspective on what holds each of these groups back from fully embracing cost-effective care, but in the end they clearly come down on the importance of the role of physicians to lead the charge, by making the "right" choices along with their patients and the patients' families, by educating the medical consumer, and by using the most appropriate information to help guide the care and testing of the patient.

Let's look at how this might work in practice.

You undoubtedly have been hearing about issues concerning the over-radiation of children, and the potential risks to which we expose children when we perform "unnecessary" x rays or CT scans. There are guidelines available for when head or abdominal CT scans are most valuable, and when they are unlikely to yield any meaningful results. However, many parents are worried that the examining physician might "miss something" if the child with a minor head injury does not receive the head CT, or the child with abdominal pain does not receive an abdominal CT.

Some parents believe we are trying to withhold critical information if these tests are not performed in the emergency department.

The emergency room doctor may feel compelled to do as the parent requests, and therefore will obtain the requested study.

Why?

There are many factors that put pressure on the physician to do so. Most often quoted in the literature is the fear of being sued if all possible studies are not obtained. In my personal experience that is often not the sole or even most compelling reason physicians give for this behavior.

Most often, the ED physician is limited by time, and constrained by not having an ongoing relationship with the patient or the family.

While he or she knows the data on the value of "watchful waiting" to help with the eventual disposition of the patient, such an approach may not work well in a busy emergency department, where beds and staff may be in short supply, and families may be eager to either have the child admitted for definitive treatment, or sent home to a more peaceful environment.

Every ED bed that is filled with an "observation" patient is unavailable for new and acute patients, thereby limiting the effective patient flow in the ED (and increasing the "wait time" for new patients, a clear patient dis-satisfier). In addition, since ED physicians usually work a limited number of consecutive hours, it is likely that the child requiring observation will not have that performed by the same individual, and the initial doctor does not want to harm the patient by potentially "missing" something as he or she is ready to end their shift. So, the thought goes, how much could it "hurt" to obtain the study that is likely unnecessary for this particular situation, but will help the physician and parent both feel so much better?

It is very hard for an individual physician, treating an individual patient, to understand the population implications of what appears to be a small action. Yet this scenario is played out hundreds of times per day in emergency departments across the nation. Multiply this by other similar scenarios in both children and adults, in hospitals, nursing homes, and outpatient clinics, and you can see how rapidly the costs of providing care increase exponentially. And I have not even mentioned one of the most costly issues in adult care--the overuse of critical care interventions prolonging death at the end of life.

What are the solutions? Do you have any suggestions? What can we do here in Roanoke to make cost-effective care the standard in all of our communities?

Looking forward to your comments, either here or on twitter (www.twitter.com/CloseToHomeMD)

Comments

Below is a comment sent to me by Dr. James Sherman, a pediatric pulmonologist and director of the new-born nursery at Carilion Roanoke Memorial Hospital:

There is an extensive literature that is useful to consider. If a 10 yr old goes to the ER for abdominal pain, there is a definable chance that they will have appendicitis. Say it is 20%. Using a number of criteria (presence of fever, migrating pain, pain localized to the right lower quadrant, presence of vomiting, elevated white blood cell count, etc) you can plug into a formula that refines the statistics. At the end of the data collection, you can then define the chance of appendicitis. If all those factors are present, the chance will be high, perhaps 95%. If none are present, the chance of appendicitis will be low, but never 0%. The proponents of using this approach suggest that anyone with an 85% chance should go to surgery, from 20% to 85% should get an abdominal CT scan (high sensitivity and specificity), and those with less than 20% should be sent home with arrangements for f/u. This approach has been demonstrated to be "cost effective". HOWEVER, it requires patients and parents to accept a certain degree of uncertainty. If I am anxious and worried about my child, I might be willing to accept a 2-3% uncertainty, but not a 19%. I would then want the CT scan even if the risk analysis showed a risk of only 15%. If, however, I am presented with evidence that experts in the hospital have analyzed the evidence and have developed a critical care pathway that says the best care for my child is re-examination in 12 to 24 hrs, I will be more accepting.

Parents generally want minimal "uncertainty". Cost effective health care and avoidance of over-utilization of resources requires the acceptance of some uncertainty. High quality health care attains an appropriate balance between minimizing "uncertainty" and minimizing resource use unless it is required by good care. The use of critical care pathways for common diagnostic issues helps in public acceptance, making them feel that it is not being left to the whim of the physician on that particular day.

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