Diagnosis, Therapy, and Evidence: Conundrums in Modern American Medicine

Here are some highlights from this 2009 book:

* Americans are besieged by advice about the efficacy of medical therapies and drugs as well as behavioral and dietary modifications that will presumably prevent disease, promote health, and extend longevity. Scarcely a day passes without revelations about new medical breakthroughs that will presumably overcome the ravages of age-old diseases. Faith in medical progress leads the United States to spend far more than any other industrialized nation on its health care system…

* Most Americans believe that their health care system is the best in the world. Yet they do not recognize the extent to which many claims about the causes of disease, therapeutic practices, and even diagnoses are shaped by beliefs that are unscientific, unproven, or completely wrong.

* For much of human history death was associated with the infectious diseases that took their heaviest toll among infants and children. Beginning in the late nineteenth century—for reasons that are not clearly understood—infectious diseases began to decline as the major causes of mortality. The reduction in mortality among the young permitted more people to reach adulthood and thus to live longer. Under these circumstances it is not surprising that long-duration illnesses—notably, cardiovascular-renal diseases and a variety of neoplasms—became more prominent elements in morbidity and mortality patterns. These diseases were associated with advancing age; the longer individuals lived, the greater the risk of becoming ill or dying from them. In one sense the increasing prominence of long-duration (or chronic) diseases was in part a reflection of the fact that more and more people were enjoying greater longevity.

To be sure, the decline in mortality from infectious diseases preceded antibiotic drug therapy. Yet the introduction of these and other drugs after World War II reshaped both medical practice and public perceptions. If infectious diseases could be conquered by antibiotic drugs, why could not long-duration diseases also be eliminated by new medical therapies? Slowly but surely Americans, for a variety of reasons, came to believe that the medical care system could play a crucial role in conquering disease and extending longevity.

* Americans remain dedicated to their health care system, as is evidenced by the fact that they continue to commit vast resources. Between 1970 and 2006 national health care expenditures increased from $75 billion to $2.1 trillion. During the same period such expenditures as a percentage of the Gross Domestic Product (GDP) rose from 7.2 to 16.0 percent. Changes in per capita expenditures were even more spectacular, rising from $356 to $7,026 in the same period. Nor were the sources of funding unchanged. During these years public funding of health expenditures increased from 38 to 46 percent.

* It is also not clear that prevailing standards of care are necessarily efficacious. The evidence in support of many widely used therapies (e.g., drugs for decreased bone density, statins for cholesterol reduction, surgery for back pain, and various surgical procedures to treat CHD) is hardly impressive, to say the least. Indeed, when the Centers for Medicare and Medicaid Services offered financial incentives to hospitals to adopt guidelines promulgated by the American College of Cardiology and the American Hospital Association to treat acute myocardial infarctions, it found that the adoption of such guidelines “had limited incremental impact on processes of care and outcomes.” Moreover, many technological innovations come into use even when there is little or no evidence that they will benefit patients. The recent introduction of CT (computed tomography) angiography is one such example. Enthusiasm for the procedure grew rapidly after the sixty-four-slice scanners came to the market in 2005. The scan exposes individuals to high rates of radiation. The Centers for Medicare and Medicaid Services became concerned with the absence of clinical evidence to demonstrate better patient outcomes. In general, patients fell into three broad categories. At one end were the “worried well,” individuals who had no symptoms of heart disease and therefore should not undergo the procedure. At the other end were high risk patients suffering from such symptoms as severe unstable angina. For them cardiac catheterization was the procedure of choice. The middle group was composed of persons who were at intermediate risk because of elevated cholesterol or blood pressure levels. n 2007 Medicare proposed to pay for CT angiography for those falling into this group who had either stable or unstable angina. These patients would be enrolled in clinical trials to determine whether the procedure was more effective than cardiac catheterization. Specialty medical societies representing radiologists and cardiologists were outraged, to say nothing about General Electric (manufacturer of the CT scanner), all of whom had a financial interest. The Society of Cardiovascular Computed Tomography (an organization of 4,700 physician members whose goal was to promote CT angiograms), the American College of Radiology, and the American College of Cardiology launched a lobbying campaign that succeeded in forcing Medicare to retract its decision even though the procedure lacked evidence of efficacy for the intermediate group and resulted as well in high costs. Nor is there conclusive evidence that CT and MRI (magnetic resonance imaging) scanning for many conditions results in improved health outcomes. Recent findings indicate that meniscal findings on knee MRIs had little clinical relevance even though those findings led to arthroscopic surgery that provided no benefit.

Equally striking is the fact that there are regional differences in both medical therapies and expenditures. Medicare patients living in Rhode Island undergo knee replacements at a rate of five in one thousand people; in Nebraska the rate is double. Female Medicare enrollees who are diagnosed with breast cancer in South Dakota have seven times the chance of undergoing a mastectomy as compared with Vermont. Age-, sex-, and race-adjusted spending for traditional Medicare in 1996 was $8,414 in the Miami region, as compared with $3,341 in the Minneapolis region.

Such differences in spending, however, are not due simply to regional differences in the prices of medical care, differences in disease prevalence, or socioeconomic status. The evidence strongly suggests that such differences are a function of the more inpatient-based and specialist-oriented pattern of practice that prevails in high-cost regions. Neither quality, access to care, nor outcomes are superior in such regions. Indeed, the more hospitals, physicians, laboratories, and subspecialists in a given geographical area, the more they are used. An examination of Medicare spending and outcomes of care for hip fracture, colorectal cancer, and myocardial infarction found that persons in high-spending regions received 60 percent more care but did not have better quality or outcomes of care. In the 306 Hospital Referral Regions (HRRs) in 2003, the incidence of hip and knee replacement for chronic arthritis and surgery for low-back pain varied from 5.6- to 4.8- and 5.9-fold, respectively, from the lowest to the highest region.

About Luke Ford

I've written five books (see Amazon.com). My work has been followed by the New York Times, the Los Angeles Times, and 60 Minutes. I teach Alexander Technique in Beverly Hills (Alexander90210.com).
This entry was posted in Medicine. Bookmark the permalink.