469720?1388149949
Lee Kirksey, MD  
Male
Cleveland , OH

Specialties: Peripheral Arterial Disease, PAD

Interests: vascular, specialist, treatment options
All Journal Entries Journals

Do medical innovations always improve patients outcomes-Controlling healthcare costs

Jul 27, 2013 - 0 comments
Tags:

Lee Kirksey

,

vascular surgery

,

Cleveland Clinic

,

Holistic Health

,

Stroke

,

Heart Attack

,

limb salvage



The Medical device and healthcare industry like other industries in a capital market are driven by profit.  In the ideal scenario, the techology, provider and financial backer for a product or technology would be rewarded for  innovation which improves patient outcome. Unfortunately, that is increasingly less common and a new New York Times article suggests that up to 40% of established medical practices when studied show no benefit and may even be harmful.

In vascular surgery, one example is the use of arterial stents. It makes intuitive sense that if a patients has a study performed which reveals a blood vessel to be blocked--the blockage should be opened to make the patient better.  The reality is, that it requires clinical judgment. Merely the presence of the blocked blood vessel is less important than eliciting a careful history which discerns the symptoms, if any, that a patient is experiencing.

For example, a patient with none or very mild symptoms might be better off with serial monitoring and no procedure.  What's known is that the performance and durability of stents varies depending upon what blood vessel they are placed within.  In some vessels the risk for restenosis of occlusion of the stent within 12-24 months approaches or exceeds 50%. In some cases when this occurs, the patient may actually get worse symptoms than they started with. So in many cases it requires prudent judgment by the physician to determine if this procedure is actually warranted.  And in a situation where there is a perverse incentive for the physician to do more, the set up can predictably lead to more procedures. Especially as procedures become less invasive and less risk to perform, the threshold for doing them may be lowered.

In some areas, we see a rapid escalation in the number of procedures done as new technology is introduced and patient demand begins to drive the utilization. Many times before long term studies are performed in different patient types. This can lead to significant increased and wasteful healthcare expenses. All with no real long term benefit to the patient.

Unfortunately, sometimes referring physicians actually feed into this process by telling patients that they need a treatment or surgery without the referring physician necessarily understanding the nuances of the decision making process. The patient shows up saying " I trust my doctor and he said that I need this procedure"

One major benefit of the Cleveland Clinic physician compensation model is that all physicians are employed and not compensated on a per case productivity scale. In theory, I make as much money if I dont do a procedure so I dont have pressure to produce. I don't have to persuade myself subconciously that because something is minimally invasive, it should be done.

From the NY Times:

We usually assume that new medical procedures and drugs are adopted because they are better. But a new analysis has found that many new techniques and medicines are either no more effective than the old ones, or worse. Moreover, many doctors persist in using practices that have been shown to be useless or harmful.

Scientists reviewed each issue of The New England Journal of Medicine from 2001 through 2010 and found 363 studies examining an established clinical practice. In 146 of them, the currently used drug or procedure was found to be either no better, or even worse, than the one previously used. The report appears in the August issue of Mayo Clinic Proceedings.

More than 40 percent of established practices studied were found to be ineffective or harmful, 38 percent beneficial, and the remaining 22 percent unknown. Among the practices found to be ineffective or harmful were the routine use of hormone therapy in postmenopausal women; high-dose chemotherapy and stem cell transplant, a complex and expensive treatment for breast cancer that was found to be no better than conventional chemotherapy; and intensive glucose lowering in Type 2 diabetes patients in intensive care, which not only failed to reduce cardiovascular events but actually increased mortality. source


Post a Comment