Inappropriate use of large healthcare structures

The healthcare system has many resources that can be used appropriately, or not. Think of the child with fever who leaves the paediatrician’s office with a prescription of antibiotics, the elderly lady who ends her days in an intensive bed, when, in their case, a palliative action would have been more appropriate or the person with a moderate headache, without other neurological manifestations, which, by insistence, ends up undergoing a tomography. George Halvorson, in "Health care will not reform itself", echoes an investigation that, after reviewing 5 million medical records, concluded that waste due to clinical practices that don’t add value could be considered to reach at least 25% of the total health expenditure.

This waste affects practically all areas of healthcare, but now I would like to focus on what happens with the inadequacy of the use of large health structures: operating theaters, emergencies units, intensive care units, wards and primary care.

Four ways to make Sutton’s law a reality

It occurs to me that there are four possible approaches to address Sutton's law (remember that this law tells us that we have to go after the waste to raise funds for activities that really provide a health value to people, see post March 28th) and I think we need the four approaches at once:

1. Medical service based on patient preference (see post February 27th)

There is a report from a Cochrane review that says that when patients have contrasting information, other than from their doctor, they have a tendency to choose more conservative therapies within the range that is offered with their diagnosis. And, according to some researchers, up to a 20% reduction in some scheduled surgical procedures can be expected with this method.

2. The role of scientific associations in addressing evidence-based medicine

The difficulties in the practice of medicine begin in the gap that exists between the scientific evidence and the reality of clinical practice. In this area there is a missing link that causes a striking variability in clinical practice and the utilization of health care resources. For this reason, in recent times interesting professional initiatives are being observed (which we will discuss further in later posts), of which highlight "Do not do" from NICE in the UK and "Choosing Wisely” from ABIM Foundation in USA.

Preference sensitive health care: the causes of variations

There is a case-mix part (25% according to Wennberg) such as inguinal hernia, cataracts, metrorrhagia or knee osteoarthritis, for which modern medicine has an effective surgical response, although in the application of the technique there is often a margin for the doctor’s interpretation, another margin for the subjectivity of the patient, such as pain perception or adaptation to the lack of visual acuity, as well as a very important factor: the decision of the patient himself. There are men who prefer to wear a brace to hernia surgery and women who prefer to live with their uterus, provided that the degree of the discomfort and metrorrhagy allows them to.

After this introduction, let’s see the Variations in Health Care, the good, the bad and the inexplicable report by John Appleby and his collaborators, published by King's Fund in 2011, which states that variations in hospitalization rates are pervasive and persistent, and even affect common interventions known to be effective such as hip replacement for advanced osteoarthritis cases.

                Distribution rates of hip replacement in England 2009/10