Friday, May 06, 2011

The Cost Of Diagnosis

There's an odd opinion piece in today's Los Angeles Times, one that gave me some pause over my first cup of decaf. Written by H. Gilbert Welch, a practicing physician and professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice, the article takes the position that one reason for burgeoning health care costs is that doctors are over-diagnosing. They are finding conditions in their patients which in the past would not really be cause for concern or for treatment.

The threshold for diagnosis has fallen too low. Physicians are now making diagnoses in individuals who wouldn't have been considered sick in the past.

Part of the explanation is technological: diagnostic tests able to detect biochemical and anatomic abnormalities that were undetectable in the past. But part of the explanation is behavioral: We look harder for things to be wrong. We test more often, we are more likely to test people who have no symptoms, and we have changed the rules about what degree of abnormality constitutes disease (a fasting blood sugar of 130 was not considered to be diabetes before 1997; now it is). ...

Diagnostic thresholds that are set too low lead in turn to a bigger problem: treatment thresholds that are too low. Diagnosis is the critical entry step into medical care — getting one tends to beget treatment. That's a big reason why we are treating millions more people for high blood pressure, diabetes, osteoporosis, glaucoma, depression, heart disease — and even cancer.

To have any hope of controlling healthcare costs, doctors will have to raise their diagnostic and treatment thresholds. And higher thresholds would be good for more than the bottom line. Less diagnosis and treatment of disease would return millions of Americans to normal, healthy lives. That's right: Higher thresholds could well improve health.

At first reading, I was a little appalled at the doctor's assertions. Surely finding the abnormalities is critical in health care. After reading further and thinking about it, I think Dr. Welch is onto something. A 65 year-old woman typically shows some loss in bone density. She also most likely has a spine which shows arthritic changes, perhaps even some 3 millimeter disc bulges in the lumbar spine. To even get to this point, however, that same woman has had some relatively extensive and expensive diagnostic tests. Then, with that diagnosis, she is now faced with treatment which may not necessarily improve her condition and may actually cause new problems (esophageal ulcers or gastrointestinal problems). If all she came into the doctor's office with were some complaints of a sore low back, one that could easily be cured with time, some rest, and a couple of aspirin, then the various diagnoses really are over the top.

As Dr. Welch points out, there are multiple reasons for these expensive diagnoses. Obviously, the technological explosion makes MRI machines readily accessible and doctors use them a lot. Second, the fear of law suits for missed diagnoses certainly plays into it. But there is more, especially in these days when "death panels" and "healthcare rationing" are phrases thrown around so readily:

The movement to measure healthcare quality, however well intended, exacerbates the problem. Many performance metrics measure whether diagnostic tests and treatments are being ordered. Because good grades typically require action, not inaction, lower thresholds are encouraged. And the advent of electronic medical records has made these actions even easier, as more and more of us have the "one-click" option to order tests and treatments.

While I am uneasy with the concept of raising the threshold for diagnosing a condition, Dr. Welch certainly has made some excellent points.



Blogger shrimplate said...

Sometimes the worst diagnosis is the one your doctor misses.

As a hospital nurse I was once assessing a new patient who had been admitted for an esophageal complaint: annoying acid reflux. He revealed that he also had blurry vision in one eye, which scared the daylights out of me but might have been casually dismissed under other circumstances.

I phoned the doctor immediately. An MRI told us that he had cancer which had metastasized to the brain. That was not a surprise to me; it was what I had feared. His reflux was being caused by a cancerous condition also.

This happens all the time. I can assure you that at this very moment hundreds of people with serious concerns are being ignored, under-assessed, and going untreared for serious concerns.

It could easily happen to you.

4:56 AM  
Blogger PurpleGirl said...

It is easy to complain about the use of MRIs; however, let me say that they have changed some diagnosis and treatment routines for the better. With the MRI films, my neurosurgeon had a picture of exactly where the herniated disk was and an idea about its size. In the periods before CAT scans and MRIs, the test for herniated disks was dangerous and painful (injecting a dye into the spinal fluid without painkillers). MRIs for problems like the one I had do not require dyes and involve no pain. I wouldn't want to return to earlier times. Ditto for finding the torn cartilage in my knee; it didn't show on x-rays and we did both.

And not diagnose high blood pressure or diabetes... is the doctor kidding?

6:09 AM  
Anonymous Elliot said...

For the third strike: my local clinic missed both a heart infection, from which I have lasting heart damage, and pernicious anemia, though I had all the classic symptoms. They nearly killed me and I had to demand treatment; some of the nerve damage from the anemia is also permanent. I didn't fit their profile for congestive heart failure (skinny non-smoker, 53) so they refused to look into it. I even had to fight for the b-12 injections that brought back feeling in my hands and feet. If I were less assertive, and had not come from a medical family, so I knew something was terribly wrong, I would be dead.

But it would have saved the medical and insurance industry money, so they and this doctor would have found it a win, I suppose.

5:06 PM  

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