Tuesday, November 8, 2011

MRIs, clinical judgement and access to health care: Where is the money best spent?


Sports medicine said to overuse MRIs”, by NY Times health reporter Gina Kolata, October 29, 2011, begins by reporting on an unpublished (as far as I can tell) study by an orthopedic sports medicine physician from Florida, Dr. James Andrews, who scanned the shoulders of 31 asymptomatic, uninjured professional baseball pitchers and found that all were read as “abnormal”. The article goes on to quote a long list of leading sports medicine physicians who find fault with the overuse of MRI scans in both professional and casual athletes. They are particularly concerned that doctors substitute the readings of these scans for history and physical examination and professional judgment. One problem is, according to Dr. Bruce Sangeorzan from the University of Washington, is that the MRI “...is a very sensitive tool, but it is not very specific.” Sensitivity and specificity are terms that refer to the characteristics of a test. The more sensitive a test, the more likely it is to find something that is actually wrong; the more specific the test, the more likely it is to be normal when there is not actually something wrong. Dr. Sangeorzan’s point is that the MRI scan is likely to be abnormal even when there is no actual problem with the person.

This assessment is echoed by most of the physicians interviewed. “‘It is very rare for an MRI to come back with the words “normal study,”’ said Dr. Christopher DiGiovanni, a professor of orthopedics and a sports medicine specialist at Brown University. ‘I can’t tell you the last time I’ve seen it.’” The article profiles a person who injured his knee skiing and had two different doctors tell him that the MRI (ordered even before he was examined) indicated he had a torn anterior cruciate ligament (ACL) and needed surgery. Another orthopedic surgeon, Dr. Freddie H. Fu of the University of Pittsburgh, found he had no tear using a more sensitive MRI – which he ordered because, after seeing the patient, his story and exam was inconsistent with a torn ACL: “He could never have continued skiing with a torn A.C.L. The diagnosis ‘made no sense,’ Dr. Fu said.”

Such overdiagnosis can lead to excess surgery, with all the concomitant risks of these procedures. One concern is the financial conflict of interest that can exist. The physician who reads the MRI gets paid a fair amount, and the owner of the machine (which may be a hospital or a physician or group of physicians, either radiologists or orthopedists) get paid even more for doing the scan. And, if there is surgery, both the surgeon and the facility (hospital or outpatient surgicenter) where it is done make money. The other issue is that both doctors and patients believe that technology is “better” in most cases, and want both a definitive diagnosis and treatment. The danger, of course, is that the diagnosis may wrong and/or the treatment unnecessary.

Many of us have been told by a car mechanic that we needed a repair (new brakes, transmission, valve job), a diagnosis often made with the assistance of computer technology. Sometimes we have brought the car to another mechanic to have the diagnosis confirmed, and sometimes been told that the procedure was not necessary. Then we get angry and believe the first mechanic was a “thief”, out to make money. The reality is, however, that even if they are, all it costs is money; the car may not have needed new brakes quite yet, but the new brakes are not going to harm it. The same is not true for surgical intervention on a knee or shoulder or any other part of the body. Replacing the parts of a human-constructed car is different from cutting into and replacing the parts of a person. While both can have complications from being done badly, surgery on a person can have complications even when done right.

The counterpoints to this article are in the same issue of the NY Times. They are a series of letters addressing “The debate over routine mammograms”, which evidence the fascination that the public has with “making a diagnosis”. Some were written by representatives of advocacy organizations, who repeat the idea that saving a life is worth any cost; “The $5 billion spent annually on mammography screening is worth it to the women who are saved,”, one of these letters declares. This argument is flawed on many levels. Sure, if I am “saved” by having had a mammogram (putting aside, for the moment, any other questions of false-positive tests, treatment options, etc., and assuming the mammogram alone is the reason for my salvation), I am pleased. But $5 billion? Could we have done it for $2.5 billion? Or could we do a better job for $10 billion? Am I unhappy because I had a negative mammogram but the money spent on doing these tests meant that it wasn’t spent on treatments for something I do have, perhaps diabetes, or drug addiction, or for prevention through prenatal care or efforts to ban indoor smoking?

The US Preventive Services Task Force (USPSTF) recommends routine mammogram screening (“screening” means in women who are asymptomatic, and does not include those who have had previous cancer or abnormal mammograms or lumps or bleeding, etc.) every two years. In my hospital, we are trying to set the criteria by which our electronic medical record will remind us to do screening. Initially, we decided to use USPSTF guidelines. But now some physicians are saying that they think we should order mammograms yearly. Oh. If we are not going to use the recommendations based upon the most thorough use of the existing data, why yearly? Why not every six months? Every week? 

Well, in part it is cost. To screen every woman every week would cost a lot. But it would also be inconvenient for those women. And there are, in addition to complications of treatment, results of questionable screening tests to further define what is going on, and these add more costs, discomfort, uncertainty, and risk. I have discussed these issues, with particular emphasis on another screening test that the USPSTF has recommended against using at all, the PSA test for prostate cancer, in recent blogs, most recently PSA redux: The USPSTF finally recommends NOT getting it!, October 14, 2011. For mammography, if less frequent routine screening of everyone with targeted screening of individuals who are at high risk, can have the same positive results without the high costs, both financial and in terms of risk to people, that is a better strategy.

Most important, however, is that arguments such as “The $5 billion spent annually on mammography screening is worth it to the women who are saved,” pretends that such spending occurs in a bubble. There is limited money, and it is getting more limited since the financial crisis and is likely to get worse with the “cut, cut, cut” attitude toward programs for the most vulnerable being the apparent mantra in both Congress and the states. Even in the best times for the economy, there were millions of people not getting the most basic health care, not getting well-established screening tests done, not getting treatments that were proven effective for conditions that they had (and maybe didn’t know they had) because they didn’t have access – insurance, geographic access, access from the perspective of cultural, language and health literacy, whether they were “legal” or many other factors. As these cuts increase, those millions are joined by millions, tens of millions, more. Access for everyone to proven effective interventions must be a priority over access for some to possibly effective interventions, and certainly over access for anyone to those where the danger exceed potential benefit.

The very same issue of the NY Times contains a column by Charles Blow, “America’s exploding pipe dream”, in which his words-to-table ratio is even less than usual, emphasizing the data in the table he attaches. But here are some important words: "We have not taken care of the least among us. We have allowed a revolting level of income inequality to develop. We have watched as millions of our fellow countrymen have fallen into poverty. And we have done a poor job of educating our children and now threaten to leave them a country that is a shell of its former self. We should be ashamed."  Clearing up that shame, taking care of the “least among us”, should be our watchword.

1 comment:

kennylin said...

Great post, Josh. Former Senator Tom Daschle made a great point in his speech at APHA last week: in most other "advanced" nations in the world, spending begins at the bottom of the health care pyramid (on primary care) and continues up to the top (specialty and hospital care) until the money runs out. In the U.S., in contrast, we start spending at the top of the pyramid and let the money run out long before we get to the bottom. The upcoming 27% cut in Medicare reimbursement being a prime example of this dumb spending "strategy."

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