To Evaluate Or Not To Evaluate. That Is The Question

There are two VERY clear cut and distinct types of patient encounters. And they make all the difference in the world in terms of cost to the system.

At my hospital we have very intensive, evidence based protocols for

Pneumonia
Heart Failure
Stroke

These are, interestingly, also the medical conditions that carry with them the pay for performance, or soon to be doc your pay for under performance.

ACEi use
LV assessment
ASA use in MI
Pneumovax
Smoking cessation.

All the stuff that rewards more money for compliance. What the government says is important and determines bonus payments on

They are all built into our protocols. Evidence based? Well Yes.

Money based? Well, yes as well.

Do it right and get more money. The thought being that it provides higher quality care at a lower price. So it should make sense.

How much will it save?

In the grand scheme of things? Probably peanuts.

I think our government has devoted a massive amount of resources towards quality initiatives, that I expect to have a Return on Investment of minuscule financial value.

But I am hard pressed to believe that this type of quality will lead to a significant dent in cost to health care delivery for our nation as a whole.

Cost is more a function of production, volume, and incentives in all the wrong places. Do more, get paid more.

Quality is a moving target. Quality is entirely dependent on how you define it. How do you define quality care?

I have no idea what that means.

Does it mean mortality?

Does it mean cost?

Does it mean achieving target data points?

Does it mean minimizing patient symptoms?

Does it mean patient satisfaction?

Defining quality is probably a combination of all of the above.

If preventing 90% of in-hospital DVT's with a medicine that cost $30 a day was quality, so be it.

What if you could prevent 99% of in hospital DVT's with a medicine that cost $300 a day. Would the 90% be quality or the 99% be quality? What if it cost $3,000 a day to prevent 99.99% of in- hospital DVT's.

Which effort would be considered quality? Who defines the cut off, and at what price?

Cost and quality are intertwined, and must be considered when making decisions on quality care.

But in a perfect world, quality would not be dependent on cost. In the real world it is. Unfortunately, the measures being undertaken for quality initiatives are, from my stand point, minuscule in terms of the overall potential cost savings to the system.

And the reason is simply, at least in my part of the medical physician spectrum, a very large chunk of health care expenditures comes in the form of evaluation, and not management.

This is a very huge distinction and has huge implications regarding the organized government efforts to control costs.

The type of quality initiatives they are using simply ain't going to make a dent. And here's why.

All the quality initiatives introduced involve management of known disease, not in the evaluation of disease.

Evaluation:

Patient has a complaint. A symptom. Or a sign. Or an abnormal objective finding.

The biggest part of a physician work up, and often times, the most rewarding from a professional standpoint is in the workup. Figuring out what is not yet know.

Creating the differential diagnosis.

Whether this involves making a fresh new diagnosis, or evaluating the exacerbation of a known illness. It still represents the evaluation phase of a medical work up.

What are the top ten most expensive diseases in the United States on a yearly basis?

Heart conditions ($76 billion)
Trauma disorders ($72 billion)
Cancer ($70 billion)
Mental disorders, including depression ($56.0 billion)
Asthma and chronic obstructive pulmonary disease ($54 billion)
High blood pressure ($42 billion)
Type 2 diabetes ($34 billion)
Osteoarthritis and other joint diseases ($34 billion)
Back problems ($32 billion)
Normal childbirth* ($32 billion

And all too often the evaluation stage of any illness, includes lots of blood work. lots of xrays and lots of tests, radiology, procedures or otherwise.

Take a look at the list above. The top 3 constitute highly intensive evaluation phases using expensive radiographic or procedurally intense evaluations.

Diabetes, an epidemic, comes in a distant 7th in terms of expense. Why?

Well, there isn't a lot of technology involved in the evaluation of diabetes. Except for a glucometer and some new cutting edge stuff for type I diabetics, it really is quite a boring medical disease to manage, in the grand scheme of things.

In the medical profession, there exists a sense of universal freedom to order tests, xrays, labs, and procedures with a sense of unlimited funding. Somebody will pay for it. My patient sitting in front of me is the center of my attention and their needs supersede all other needs from a social/financial point of view of the nation.

If you were laying in a hospital bed, you would expect that your needs supersede all other needs of the nation as well.

The evaluation of an unknown symptom is highly dependent on a thorough history and physical exam. A risk factor assessment. A determination, in the mind of the physician, of probabilities.

How likely is this patient to have coronary disease?

How likely is this patient to have a pulmonary embolism?

How likely is this patient to have colon cancer?

How likely is this patient to have a stroke?

How likely is this patient to have pneumonia?

Or heart failure?

Or COPD exacerbation?

Or a fracture?

Or meningitis?

Or drug overdose?

Or a retroperitoneal bleed?

The list goes on and on. Everyday. Many times a day. A physician is constantly thinking about what the probability of their patient having illness is.

The evaluation phase of illness is highly dependent on what the patient says.

What they don't say.

What the history and physical says.

How well the patient's history is known

Physician knowledge and understanding.

Defensive medicine practice

Many factors go into determining the likelihood of probability of any defined illness.

Chest pain is not a disease. It is a symptom.

Chest pain can be:

Coronary disease

Heart burn

Esophagitis

Esophageal ulcer

Esophageal spasm

Pneumonia

Bronchitis

Pulmonary Embolism

Musculoskeletal

Rib fracture

pericarditis

pleuritis

shingles

somatic

You get the point. The differential diagnosis. One of the defining roles of physicians is in the evaluation of illness.

Making the diagnosis

And excluding alternative explanations.

So I ask you Dr Government, where is the evidence based recommendations for evaluation of illness?

Where are the government incentives for quality medicine in the evaluation of disease?

Where is your bonus payment for not ordering the heart cath.

For not ordering the CT Angiogram.

Where is your physician bonus payment for not ruling out a low probability DVT.

Or not ordering an EGD.

For choosing watchful waiting.

Where are your quality bonus payments for evaluation of illness?

They simply don't exist. Because doing so would overtly ration the public and create a firestorm.

Coronary disease, once all is said an done, is medical management.

Aspirin

statin

b-blockers

ACEi

For the most part, care on the cheap.

The evaluation part will get you every time.

When should a patient with chest pain get a heart cath?

Should a quality indicator by the government ration who does and who doesn't.

Should the medical care of a patient be made by a physician who carries all the risk of liability for failure to diagnose and all the financial reward for doing more?

The cost in management of chronic disease really is a dichotomous process

1) Stable management

2) Exacerbation management

The stable part on a relative basis, is less costly.

The exacerbation part or complications of exacerbation will get you every time, and that's what lacks any type of consistent uniform guidelines.

You won't find any ER full of evaluation guidelines for chest pain or abdominal pain or headache.

Because this is what you would need:

Only possible in a Star Trek Galaxy Far Far Away

For now, a physician's clinical opinion will have to do.