Failing Complicated Care, What's Next?
Submitted by Dr. JG Kaplan on Tue, 2010-04-06 18:27
Comorbidity: Are we prepared to care for people with chronic or complex conditions?
The more chronic conditions, the greater the likelihood of the following : "unnecessary hospitalizations; adverse drug events; duplicative tests; conflicting medical advice; and, most important, poor functional status and death.1-5 Approximately 65% of total health care spending is directed at the approximately 25% of US population who have multiple chronic conditions.2 Individuals with multiple chronic conditions also face financial challenges related to the out-of-pocket costs of their care, including higher prescription drug costs and total out-of-pocket health care spending.2"
Fee-for-service (FFS) medicine hardly incentivizes care coordination, and in some cases, the opposite: "duplication of services, rehospitalizations, and additional unnecessary care." We now see Congress proposing legislation that "includes experimental and pilot approaches to realigning such incentives and payments." Nevertheless, is the complex patient going to be compliant, especially if there is poor care coordination and no "medical home"? "It is not clear whether the potential benefits of chronic disease self-care management; personal health records; and other health information exchange platforms, such as secure messaging, are being fully realized to maximize patient participation and health." However, the is hope in "evidence-based clinical decision making in the care for patients with comorbidities."
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Please read the following JAMA article for further information:
Parekh AK*, Barton MB "The Challenge of Multiple Comorbidity for the US Health Care System." JAMA. 2010;303(13):1303-1304.
* Office of the Assist. Sec. for Health, US Dept. of Health and Human Services, 200 Independence Ave SW, Washington, DC 20201
Does having evidence-based medicine or comparative-effectiveness research guarantee that the right thing will be done?
Obviously not, and here's a poignant example of how perverse incentives can be:
2007 was the final year of data reported in a study by Deyo et al wherein clinically risky and unnecessarily expensive substitute practices that could not be justified by the clinical evidence are at work in spinal surgery.
"Overall, surgical rates declined slightly from 2002-2007, but the rate of complex fusion procedures increased 15-fold, from 1.3 to 19.9 per 100 000 beneficiaries. Life-threatening complications increased with increasing surgical invasiveness, from 2.3% among patients having decompression alone to 5.6%among those having complex fusions. After adjustment for age, comorbidity, previous spine surgery, and other features, the odds ratio (OR) of life-threatening complications for complex fusion compared with decompression alone was 2.95 (95% confidence interval [CI], 2.50-3.49). A similar pattern was observed forrehospitalization within 30 days, which occurred for 7.8% of patients undergoing decompression and 13.0% having a complex fusion (adjusted OR, 1.94; 95% CI, 1.74-2.17). Adjusted mean hospital charges for complex fusion procedures were US $80 888 compared with US $23 724 for decompression alone."
Deyo RA, Mirza SK, Martin BI; et al. "Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults." JAMA.2010;303(13):1259-1265.
Note that "Consumer Reports has rated spinal surgery as number 1 on its list of overused tests and treatments. This was a harsh rebuke given the benefit associated with many common spinal surgeries. However, the findings from the study by Deyo et al should not only remind patients, surgeons, and payors that the efficacy of basic spinal techniques must be assessed carefully against the plethora of unproven but financially attractive alternatives, but also should serve as an important reminder that as currently configured, financial incentives and market forces do not favor this careful assessment before technologies are widely adopted. When applied broadly across medical care in the United States, the result is a formidable economic and social problem."
On Apr 7, 2010, at 11:24 AM, Fredrick H (MD, PhD, JD) wrote:
There's certainly no point in doing riskier, more expensive surgery unless it's more effective. Unfortunately, this study didn't even examine the question of effectiveness. Thus, it leaves the impression that the only reason surgeons choose the riskier procedure is because it makes them more money. That may be true, but without the effectiveness data, we can't know.
From jgk: Actually, the editorial to that paper does give a more complete picture of the risk-benefit ratio, as follows:
"A minority of patients with symptomatic spinal stenosis have a combination of spinal deformity, such as degenerative spondylolisthesis or scoliosis, which complicate the spinal stenosis pathology. Decompressive surgery alone in these instances (removing the bone, ligament, and facet joint materiel compressing the spinal root) may destabilize the spine and result in progressive deformity. Spinal fusion, for cases in which only 1 or 2 levels of instability are present appears to be a worthwhile addition to the decompression procedure in some patients. Results with simple fusion techniques often appear to give highly reliable and durable results.4 However, the available evidence suggests little or no advantage in routinely applying more complex fusion techniques such as instrumentation, bone graft augmentations, or combined anterior and posterior approaches.5"
The aforementioned Deyo article in JAMA states: "the rate of spinal stenosis surgery in the Medicare population has remained more or less stable, but the rate of complex surgery for this disease has increased from negligible levels in 2002 to nearly 15% of all spinal stenosis surgeries in 2007. These more complex surgeries are also reported to be independently associated with increased perioperative mortality, major complications, rehospitalization, and cost.
The findings do not provide explanations for the increase in complex surgery that has occurred during the past 6 years. Ideally, because the complex surgical techniques are used to treat complex deformities, the data should show that patients undergoing these procedures usually have these complex deformities. The diagnoses reported, however, do not support this "ideal" explanation; 50% of these new complex fusion operations were performed in patients with spinal stenosis alone and no deformity. Spinal stenosis with scoliosis by coding, accounted for only 6% of the complex fusions performed."
Source: Carragee EJ. "The Increasing Morbidity of Elective Spinal Stenosis Surgery; Is It Necessary?" JAMA. 2010;303(13);1309-1310. EXTRACT | FULL TEXT
4. Martin CR, Gruszczynski AT, Braunsfurth HA, Fallatah SM, O’Neil J, Wai EK. The surgical management of degenerative lumbar spondylolisthesis: a systematic review. Spine (Phila Pa 1976). 2007;32(16):1791-1798.
5. Abdu WA, Lurie JD, Spratt KF; et al. Degenerative spondylolisthesis: does fusion method influence outcome? Spine (Phila Pa 1976). 2009;34(21):2351-2360.
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