Diabetes Care: The Spectrum of Success

Today’s Managing Health Care Costs Indicator is  8.3%

Diabetes is a major killer in the US – the disease strikes about one in twelve  Americans ( 8.3% in the entire population; one in four over age 65), is responsible for over 70,000 deaths, and is the leading cause of blindness and kidney failure.   The Centers for Disease Control and Prevention estimates that the annual cost of diabetes in the US is $168 billion in medical treatment, and $58 billion in lost productivity.

I’m struck by two studies published in the last week that use diametrically opposed approaches –and both appear to work.  (Both studies are small, though , so it’s possible that the results will not be sustained in larger samples).

The NEJM  published two studies showing that intensive surgical intervention helps.   Italian researchers showed that bariatric surgery (the most invasive surgical treatments) could “cure” diabetes in 75-95% of those treated, compared to NO cures in the medically treated group.  American researchers showed that those who had less-invasive surgical treatments were three times as likely to have an excellent diabetes control (Hemoglobin AIC of <6).   The conclusion –for diabetics with morbid obesity, surgical treatment is strikingly effective.  Other  studies have shown that bariatric surgery can pay off in a few years in the general population – this set of studies provides further evidence that we should cover this expensive ($11-$26,000) procedure for those with morbid obesity.

The Annals of Internal Medicine published an elegant study  which randomized 118 African American veterans with diabetes to usual care, financial rewards ($100-$200), and peer mentoring.  The financial reward for better HbAIC led to a 0.4% average decrease in HbAIC, while the peer mentoring led to a 1.1% decrease in HbAIC.

There are often many roads that lead to the right outcome in health care – and these studies are all small and did not include similar groups – so shouldn’t be compared.   It’s nice to know that both high tech and low tech solutions can have a substantial impact, and have the potential to decrease diabetic complications in our increasingly-obese population.

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End of Life Discussions: Too Late and Still Too Infrequent

Today’s Managing Health Care Costs Indicator is 73%

Site of End of Life Discussions

 Click image to enlarge. Source

We know end of life care is responsible for an outsize portion of the total medical budget. Many people express a desire to avoid extensive intervention at the end of their lives; nonetheless, a majority of Americans die in hospitals, and there is unbearable variation in how Americans are cared for at the end of life.

Medicare spends about a quarter of all of its dollars on patients in the last six months of their lives.   For most deaths, though, we don’t know in advance exactly when the clock starts ticking on that last six months.    However, those who have Stage 4 metastatic lung and colon cancer have median survivals of 4-8 months and 12-24 months. 

Even in those with diseases known to be associated with high likelihood of early death, there is huge opportunity to improve physician discussion with patients about their preferences for end of life (EOL) care.

This week’s Annals Of Internal Medicine has a painstaking study of end-of-life care discussions with over 2100 patients with end stage lung or colon cancer. The results are not as disheartening as some past studies – and almost three quarters of all patients had either a conversation reported by the patient (or family member) or a conversation documented in the medical record.   The research did not grade the meaningfulness of this conversation, and interviews focused on resuscitation and hospice care only, while record review also included venue for dying and palliative care

The results aren’t pretty

·       64% of patients (or surrogates) reported a conversation with a physician on end of life care preferences; 58% of medical records reported such a conversation.  The concordance rate was 65% - and the authors state that most of the discordant cases involved lack of medical record documentation of the end of life care conversation. 

·       Most of the end of life conversations (64%) happened in the hospital.  Even general physicians had these end-of –life discussions in the hospital 73% of the time.  This means these conversations were likely when the patient had  an acute deterioration.  It also means that few of these discussions were between t he long-time primary care physician and the patient, as many are now cared for by hospitalists.

·       Most of these discussions happened in the final weeks of life.  The first discussion took place a median of 33 days before death among those with documented EOL discussion who died during the study.  Even among those whose cancers were diagnosed over 12 months before their deaths, 29% of patients who had a discussion had this within 30 days of their deaths.

There are real social and cultural reasons why we delay talking to patients about their EOL preferences. As physicians we want  to promote hope, and as human beings we are optimistic.  But the cost of our reticence is that many get care which they want to avoid, at a very high cost.   The debate in 2010 around  “death panels” doesn’t make this issue any easier.  Lead author Jennifer Mack and her colleagues have given us good evidence that we have to improve our capacity to talk frankly about end of life with our patients.

This issue of the Annals also has an interesting survey showing that physicians are highly likely to order inappropriate screening tests for ovarian cancer.   More on that in a future post.

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Internists Step Up to the Plate and Identify Low Value Tests

Today’s Managing Care Indicator is 37

Last May, a group of intrepid oncologists identified five behavior changes and five attitude changes that could allow oncologists to increase the value of health care, largely by not performing certain tests and not administering chemotherapy in certain circumstances.  This is an important effort, encouraged by the Institute of Medicine.

The American College of Physicians, the professional society of internists, has followed suit with an expert panel that identified 37 diagnostic tests that should not be provided to patients.  Each of these tests does little to decrease uncertainty, and many of them are likely to lead to false positives which induce further unnecessary tests.   

The list is at this URL, which is unfortunately behind a paywall. That’s especially unfortunate, because ACP also announced that it would invite physicians and the public to comment on this list.  This is a great example of how to improve a document through crowdsourcing and leveraging the “wisdom of the crowds,” but it will only work if ACP puts the article and the survey outside of the paywall!

Examples of tests that should be avoided:

-       Annual lipid profile for those at low risk and not on therapy

-       Screening tumor marker tests for ovarian cancer in those at low risk

-       Screening for colon and prostate cancer in those over 75

-       Repeating colonoscopy in less than five years for those with benign adenomas

-       Doing too many tests on people who faint but have a normal neurologic exam or patients with migraine headaches

-       Echocardiography for those with innocent-sounding murmurs

-       Many preoperative tests on those at low risk

-       “Screening” EKGs for those at low risk

Some tests that require more judgment:

-       If risk of heart disease is high, go directly to cardiac catheterization with angiography (more invasive.) If risk is low, instead do exercise stress tests. In all instances, do nuclear imaging with the stress test only if the patient cannot exercise or if his/her EKG is sufficiently abnormal that the EKG alone would not give a clear reading.  If the risk is very, very low –don’t do any test at all!

-       For patients with suspected blood clots, do a sensitive blood test for those at low risk, and do an ultrasound test for those at higher risk

Physicians must estimate the pre-test likelihood of a diagnosis before ordering a test. If the pre-test probability is very low, the likelihood of a false positive is often unacceptably high.  If the pre-test probability of a test is very low, the likelihood of a false negative is high, and the physician should often go directly to a more invasive test.   This makes it even more  important to take a careful history and understand underlying risks.  Physicians must be more conversant with the mathematics of test results – and the likelihood of false positives and false negatives based on pre-test probability. See a post from last year on our misguided quest for ‘certainty.’

This kind of evidence-based medicine is anything but a “cookbook.” It takes considerably more meaningful decision-making to follow these rules than to simply do an EKG on every adult.   Exerting this kind of decision-making can lower the cost of health care, and can also increase the meaning of physicians’ work.

An accompanying editorial in the Annals suggests these decision-making rules for physicians to consider before ordering tests (slightly condensed)

·      Did the patient have the test previously?  (If so, is the result likely to be different and can I get the result instead of repeating the test?)

·      Will the test change my care of the patient?

·      What are the probability and consequences of a false positive?

·      Is there short-term danger of not ordering the test right away?

·      Is this primarily for patient reassurance (and if so, is there a better way to reassure the patient?)

This work to identify tests often ordered unnecessarily is an excellent follow-on to the new ACP Ethics Manual, which states:

Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available.

Following these decision-making rules and eliminating these unindicated tests can help lower costs and improve the quality (and value) of health care delivery in the US.

 

Available at URL -but behind paywall. Click image to enlarge.

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