Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

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Politics, PAT, and Outcome-Based Medicine

As the cost of providing health care in the U.S. has risen we have been bombarded with new terms and new ideas as “experts” attempt to solve our “Health Care Crisis”. In truth doctors, nurses, and other health care providers in the United States are dramatically better at treating and curing diseases than their counterparts anywhere else in the world. We really don’t have a “Health Care Crisis” in the U.S. What we have is a “Health Crisis” (our people are not as healthy as they could or should be) and a “Health Care Cost Crisis” (treating all of this poor  health is very expensive).

Major challenges exist when we begin to tackle this “Health Care Cost Crisis” (I think I’ll just call it the Cost Crisis hereafter). How do we reign in the cost of providing this international “best in class” medical care? How do we do so without creating either rationing of disease care, or the appearance of rationing? Regardless of the direction that our health care system may take, how do we prevent the politicization of a process that should be driven by those who are in the trenches providing that health care?

There is another term that is now ubiquitous in my world as a physician, one that is cropping up more and more in the non-medical media: Outcome Based Medicine (OBM). OBM is a rather loosely defined term which essentially boils down to medical care that has been proven to work. Pretty simple, huh? Unfortunately, OBM is getting rather fuzzy around the edges as it is used (or ignored as we will see) to achieve economic or political goals in addition to achieving the best possible medical outcomes. You know, stuff like a longer, better, healthier life.

The very first prospective (forward, not backward, looking), randomized (some folks were treated and some were in a control, or un-treated group), double-blind (neither the doctors treating nor the patients being treated knew which group was which) was actually an ophthalmology study. The Diabetic Retinopathy Study or DRS was published in the late 1970’s. It showed that using laser treatment to the retina of those patients with severe diabetic retinopathy saved more vision than doing nothing. Outcome-Based Medicine proven in a clinical trial.

Subsequent medical trials have proven the beneficial effect of innumerable medicines, surgeries, and treatments.  Other trials have been launched to provide a head-to-head comparison of competing treatments. Right now there is a trial in ophthalmology evaluating the effectiveness of two medicines, made by the same company, in the treatment of the most devastating type of macular degeneration. Macular degeneration (AMD) is a potentially blinding disease of the elderly which will become more and more common as our population ages. One very expensive medicine has been approved for the treatment of AMD and the other, inexpensive medicine has been approved for other uses and adapted by retinal specialists because it works. The hope underlying this study is that the doctors treating AMD will be allowed to generate a conclusion about which medicine works on which people in what circumstances in order to provide guidance on the most cost-effective EFFECTIVE treatment of AMD without the interference of politicians, bureaucrats, or accountants for the company that makes the medicines.

Which brings us to Pre-Admission Testing (PAT) and OBM, and an example of why I am fearful of the abuses that may befall this process. PAT is a process that some patients are asked to undergo prior to having anesthesia for surgery. The one and only reason to undergo PAT is to determine if there is any medical or health condition that will make the anesthesia more dangerous, to help prepare the anesthesiologist in the quest to prevent anesthesia complications. There is NO OTHER REASON to do PAT.

I am an ophthalmologist, an eye surgeon. I operate on people to save, restore, or enhance their vision. Many of these people receive anesthesia as part of their OR experience. After more than 10 years in which my OR patients were simply screened with a phone call by anesthesia I was recently informed that all of my patients receiving any anesthesia in the OR would now require PAT. Why? Essentially because the hospital said so. “That’s how the in-patient division does it so that’s how the out-patient has to.” The Joint Commission said that Medicare wants it.” ” Why do you care? It’s no more work for you.” And other such non-answers.

Well…I DO care. PAT is expensive, even though no one ends up paying for the physical exam part. EKG’s and lab work cost money. Patients and their families must take off work, go to a hospital or clinic, endure needles and disrobing. All for something that doesn’t matter. All for something that doesn’t contribute to better medical or health outcomes. Because you see, there WAS a study that looked at that EXACT question. Does routine PAT have any effect on the outcome of cataract surgery done on an out-patient basis? (Schein, et al. NEJM January 2000, Vol. 342, No. 3, 168-175).Turns out the answer is “NO”.

18,000 patients undergoing cataract surgery were split into two groups, one undergoing PAT and the other receiving no PAT. There was no difference between the two groups in intra-operative or post-operative events. There were no differences between the groups in complications. The firmly stated conclusion: Routine medical testing before cataract surgery does not measurably increase the safety of the surgery. PAT, in 2000 costing roughly $200-250 Million /year, before cataract surgery is a WASTE OF MONEY.

OBM at its very best. Ignored. Ignored by the hospitals who get paid to do the tests (although free-standing surgery centers typically do not do PAT). Ignored by Medicare, because we all know there’s lots of free cash floating around in the Medicare till just looking for a place to be spent. Ignored by the bureaucratic minions who skitter and twitter about the OR with their checklists and their rules and their regs. Who pays? Well, every patient  or family member who has to miss work or make a co-pay, and of course you and me through our taxes.

In the end Outcome-Based Medicine is only as good as the people who are reading and reacting to the results of the studies. When good research (my goodness…18,000 patients! The New England Journal of Medicine!) is ignored in a situation where there is little political capital on the line, what hope is there for us when someone sees votes (nationalized health care?) or real money (cholesterol and heart disease?) on the line?

What do you think THAT outcome will be?

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