Let’s begin with a couple of clinical questions:
Scenario One: You are discharging a 70-year-old man admitted five days earlier with community-acquired pneumonia (CAP). He has diabetes, class II heart failure, hyperlipidemia, and hypertension. He can perform daily activities, is off oxygen, and is doing well on oral antibiotics. His heart failure and blood pressure are under control, but his finger-stick blood sugars are consistently high (140-190 mg/dL) throughout his stay. You discharge him on his outpatient medication regimen. His next scheduled follow-up appointment is in four weeks.
When would you have him see his primary-care provider?
a. In two days;
b. In one week;
c. In two weeks; or
d. In four weeks.
Scenario Two: You admit a 70-year-old diabetic woman with atypical chest pain. She has described her pain, which is localized under her left breast, as “burning.” It occurred at rest and did not change with activity or eating. It improved about two hours after receiving an antacid. Her EKG and three troponins are normal. Her LDL cholesterol is 125 mg/dL. She is a former smoker and her blood pressure is controlled through use of lisinopril.
What do you do?
a. Order an exercise stress test;
b. Order a dobutamine stress echo;
c. Refer the patient to cardiology; or
d. Discharge the patient to home and have her follow up if she has further symptoms.
Scenario One: We don’t know.
Scenario Two: We don’t know.
Within hours of President Obama’s signing of the new economic stimulus package, I received an e-mail from my dad, who had read online that the new legislation would result in healthcare rationing. Having followed this issue relatively closely, I was puzzled by how the stimulus plan’s direct impact on healthcare—$87 billion for Medicaid, $25 billion for extension of COBRA medical insurance, $10 billion for the National Institutes of Health (NIH), nearly $20 billion for information technology infrastructure, and $1 billion for comparative effectiveness research (CER)—could be interpreted as the rationing of healthcare.
A quick peek at the Internet revealed the answer. A handful of bloggers clearly were interpreting the combination of Obama’s pledge to reduce healthcare costs and the billion-dollar appropriation for CER to mean the government would use the results of this research to limit care based on cost-effectiveness. In other words, a bureaucrat would decide if an elderly patient would receive a hip replacement based on whether it made fiscal sense.
So is healthcare rationing Obama’s solution to healthcare reform?
More Equals Less
There is great variability in the care provided throughout the U.S. There are well-known disparities—within age, race, and sex, for example—but there are also less apparent disparities. Medicare beneficiaries matched for severity of illness receive vastly different care based solely upon where they live. In 2003, per capita healthcare spending was $5,278, $5,661, and $11,350 for patients living in Portland, Oregon; Seattle; and Miami, respectively. That equates to about $125,000 additional lifetime healthcare costs for a 65-year-old treated in Miami compared with the same 65-year-old in Portland.1
And what does the Miamian get for the added cost? The results are surprisingly counterintuitive. It turns out that chronically ill elderly patients treated in more-resource-intense parts of the country do not have improved survival, quality of life, or access to care compared with those in less-resource-intense parts of the country. In fact, across most of these variables, the outcomes appear worse the more we do.2
Discover What Works
The focus in medicine has been to improve outcomes and control costs through the application of evidence-based medicine. The idea is that we can improve outcomes if everyone would just follow the clinical guidelines for an individual disease state. This has become the primary focus of pay for performance and the Joint Commission’s mandates on quality indicators, such as early antibiotics in pneumonia care.
This is sound thinking, until you realize that the vast majority of the decisions we have no definitive answer. For example, BMJ Clinical Evidence estimates that of the 2,500 treatments used for a variety of clinical problems, only 36% of them were deemed “beneficial” or “likely to be beneficial,” while 46% were of unknown benefit.3 In the absence of evidence, we are forced to use our clinical judgment, a surprisingly scary proposition when affordable, high-quality care is the goal.
This clinical judgment is what policymakers refer to as discretionary decision-making. The problem is that there is great variability in what experienced, prudent physicians judge to be appropriate. Recently, 1,275 physicians were asked about their decision-making around clinical scenarios with variable levels of evidential support. When asked when they would recommend a routine follow-up visit for a patient with well-controlled hypertension, 47% of physicians in high-resource-use areas (e.g., Miami), compared with 9% of physicians in low-resource-use areas (e.g., Portland), would recommend followup within three months compared with after three months. Management of an elderly clinic patient with new-onset chest pain was met with similar levels of variability in cardiac testing, referral to cardiology, and admission to the hospital between the higher- and lower-resource areas.
Those results contrasted with the consistent use across all spending groups for relatively proven modalities, such as mammographic screening in patients 50 to 70 years old.4 When the definitive answer isn’t available, we are left to use our clinical judgment, which often results in overuse of resources without benefit, and possibly harm.
We need to augment our focus on adherence to current guidelines with the discovery necessary to develop future guidelines. This requires that we move toward better information about what works and what doesn’t.
Enter the Obama administration’s commitment of significant resources to NIH research and comparative effectiveness research. The former allows for continued discovery of new technologies, while the latter informs clinicians about which technologies work the best for a particular clinical disease state.
Coordinating Fragmented Care
As hospitalists, our daily to-do lists are riddled with the consequences of fragmented care. We spend hours trying to track down primary-care physicians, finding test results from outside facilities, and coordinating complex care with multiple providers across multiple continuums. This results in inefficient and costly hospitalist systems, repetition of expensive tests, and overall worse patient outcomes. Thus, the stimulus bill’s push will be to build information technology (IT) infrastructure, such as electronic medical records, with the goal of making safer, more efficient systems that improve outcomes while cutting costs.
While the devil will be in the details—and with medical IT, the details can be daunting—I think this is a wise investment in our future.
We must get healthcare costs under control and improve the quality of care. There are myriad thoughts and proposals on how to accomplish this. The new administration is betting that discovery and technology will provide the answer to what to do with an acute-chest-pain patient and, in turn, the brewing healthcare crisis in America. That doesn’t sound like healthcare rationing to me, Dad. TH
Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of hospital medicine and the hospitalist training program, and as associate program director of the Internal Medicine Residency Program.
1. Wennberg DE, Fisher ES, Skinner JS, Bronner KK. Extending the PFP agenda, part 2: How Medicare can reduce waste and improve the care of the chronically ill. Health Affairs. 2007;26:1575-1585.
2. Fischer ES, Wennberg, JE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003;138:288-298.
3. How much do we know? British Medical Journal Web site. Available at: http://clinical evidence.bmj.com/ceweb/about/knowledge.jsp. Accessed Feb. 24, 2009.
4. Sirovich B, Gallahger PM, Wennberg DE, Fisher ES. Discretionary decision-making by primary care physicians and the cost of U.S. healthcare. Health Affairs. 2008;27:813-823.