Saturday, January 28, 2012
We thought Daddy was going to die in 2001. He was staggering around the house in his underwear, gasping in pain, his eyes hollow, his face slashed from shaving with an old-fashioned safety razor.
He was eighty-two years old. We took him to a doctor, who said his spine was deteriorating, gave him pills, and suggested he pray. A few days later, Daddy fell at the mailbox, bounced his head on the pavement, and crawled up the driveway, scraping the skin off his knees before collapsing on the front steps. Mama sat in her recliner in front of the TV, worried and clueless, until a neighbor called an ambulance. The EMTs got Daddy propped up in his recliner. He refused to go with them. When I arrived, Daddy was gulping down whiskey. I called the ambulance back, and they took him to DeKalb Medical. Doctors found prostate cancer and operated. My sister and I cried, sure Daddy was in his last days.
That was eleven years ago. Since then, Daddy's long goodbye has drained his retirement income and life savings of more than $300,000. Where's that money gone? Assisted living, mostly. Of course, that amount doesn't account for his medical bills, most of which have been paid by Medicare and insurance policies that were part of his retirement. Daddy's income—Social Security, plus monthly checks from two pensions—pays for the facility where he lives, his taxes, his life insurance policy premiums, and such incidentals as a visiting podiatrist to clip his nails.
And he has been kicked out of two hospices for not dying.
Daddy is ninety-three now and wears a diaper, is spoon-fed, and urinates through a catheter, drifting in and out of deep sleep in which he gasps for air and appears to be dead. Trisha, my sister, texted a picture of him in October to one of her daughters, who texted back: "Happy Halloween!" When he wakes up, his caregivers dress him and plop him in a wheelchair. He rolls around like a child until it's time to eat again.
I cannot imagine that this once-dignified Southern gentleman, who clawed his way out of the grit of a Depression-era tobacco farm in North Carolina and bought a snazzy double-breasted suit with one of his first paychecks, would be anything but humiliated by what is happening to him now—if he had all his faculties. Yet as one of his nurses told me, "Your father has no interest in dying." It is not heroic measures keeping him alive; he just keeps ticking. He takes only two medicines: an antibiotic for a urinary tract infection and OxyContin for the pain in his spine.
At sixty-four, I am at the leading edge of baby boomers who have ringside seats to the slow-motion demise of the Greatest Generation, watching our parents pass away slowly and stubbornly, dying piece by piece over a decade or more, often unwilling or unable to share their feelings. Most of us, such as my sister and I, head into the turmoil of caring for an aging Immortal utterly unprepared.
Daddy used to laugh at Trisha and me whenever we suggested discussing assisted living and long-term care insurance with him. He insisted—with the unshakable confidence of a career civil engineer—that he didn't need to make such plans, that he would simply drop dead one day and that would be the end of it. He refused to discuss it further.
It didn't work out according to that plan, and there was no other plan.
Friday, January 27, 2012
The complete content of American Medical News can be found online atwww.amednews.com. The site, updated Monday through Friday, features all the content of the print edition plus Web-only reporting. The print edition is published in a tabloid-size format 24 times a year.
American Medical News is directed to physicians in private practice and physicians on hospital and managed care staffs, in military service and on medical faculties. Of a total print circulation of over 230,000, about 90% are physicians, primarily office-based doctors in five primary-care specialties. A large portion of the nonphysician readers are medical students.
The other nonphysician readers include health regulators; legislators and their staffs; staffs of state, county and specialty medical societies; administrators of health programs; and journalists. These professional watchers of the health policy scene make up a small percentage of print circulation, but their work has an important impact on the medical profession and health care in America.
California's $250,000 noneconomic damages cap -- long considered the gold standard among state tort reforms -- was upheld by an appellate court in September 2011. West Virginia's cap of the same amount was declared constitutional by the state's high court in June 2011.
Such reforms enacted or upheld in these and other states are credited with positive results. Doctors who otherwise would have fled to a better liability climate have stayed put. Liability premiums in tort reform states are typically lowered or at least stabilized.
But those strides must be viewed alongside setbacks. In 2010, the Georgia Supreme Court found that state's $350,000 cap unconstitutional, and the Illinois Supreme Court did the same with the Illinois cap of $500,000. Legal challenges are being waged in Missouri, Indiana and elsewhere.
Two recent reports from the American Medical Association provide an even broader reality check on the scale of the challenge that physicians still face.
The first study, issued in November 2011, found that the average expense to defend against a medical liability claim in 2010 was $47,158. That's a 63% increase from 2001. Average expense payments have increased by 43% since 2005. About two in three claims against doctors were dropped, dismissed or withdrawn without payment in 2010, but expenses handling even those dead-end claims average $26,851.
Payments on claims have remained stable, but a small fraction account for a disproportionate share of those payments. Payouts of at least $1 million accounted for 34% of total payments -- a figure the report said underscores the need for caps on noneconomic damages to contain health care costs and premiums.
The second report, released in December 2011, analyzed premium information from 2004 to 2011 collected by the Medical Liability Monitor. Even with improvements in the market, the report shows that many states still have unacceptably high premiums. For example, premiums for obstetrician-gynecologists in some areas of New York hit $206,913 in 2011, a 41% increase from 2004.
Overall stability of premiums, viewed as a generally positive sign, also was reflected in the data. On a national scale, 55% of premiums held steady in 2011, while 15% increased and 30% decreased. The trend of stable rates has held for six straight years.
However, the Monitor survey shows that, despite an overall stable market, premiums vary widely depending on where a physician practices, with general surgeons paying as much as $191,000 in South Florida or as little as $11,000 in Minnesota. Avoiding an increase is relatively slim comfort when it also means being stuck with a six-figure premium from practicing in a liability hot spot.
The toll that medical liability takes on doctors is more than financial. Consider one recent finding: Surgeons who were sued had a 7% higher rate of burnout and a 10% higher rate of experiencing symptoms of depression than those not sued during the two years examined, said a study in the November 2011 Journal of the American College of Surgeons.
The AMA has long fought for tort reforms and continues to pursue solutions to an out-of-whack medical liability environment. The Association is seeking reforms at the federal and state levels, and it supports testing new approaches, such as health courts. Meanwhile, the Litigation Center of the American Medical Association and the State Medical Societies is helping to defend challenges to state caps.
Indeed, it is the states where reforms have been made. Yet the prospect of delivering care under a sound medical liability system should not end at the state line. The two AMA reports and Monitor data present a view of the system as it must be seen and addressed, as a matter of national health policy and tort reform.
Research already demonstrates that physicians are sometimes uncomfortable talking about weight with their obese patients. Now, a new study shows that the doctors' weight makes a difference too.
Physicians who pack on the pounds discuss weight loss less frequently with obese patients than doctors who have normal body mass indexes (18 percent versus 30 percent), according to the report published this week in the medical journal Obesity.
And they're significantly less confident of their ability to provide effective counseling about diet (37 percent vs. 53 percent) or exercise (38 percent vs. 56 percent).
The findings come from an Internet survey of 498 family doctors, internists and general practitioners conducted early last year by researchers at Johns Hopkins. Two-thirds of the physicians were male, almost three-quarters were 40 years old and 53 percent were overweight or obese.
The results matter. More than two-thirds of American adults are overweight or obeseand their medical costs total $147 billion. If heavy doctors won't acknowledge that patients have a problem and offer help, that can be a barrier to effective care, says Sara Bleich, lead author of the new study and an assistant professor of health policy at Johns Hopkins Bloomberg School of Public Health.
A notable finding in the study speaks to the problem: 93 percent of physicians of normal weight said they would be more likely to identify an obese patient when that person was as large or larger than they were. By contrast, this was true of only 7 percent of obese or overweight physicians.
"It seems to be the case that doctors are less likely to diagnose the patient until the patient's weight meets or exceeds their own," Bleich says. This could be because physicians' sense of what's normal changes as they put on pounds and see more excessively heavy patients in their practices, she speculates.
Asked what might explain heavier doctors' reluctance to discuss weight loss, Bleich says, "It could be that they feel that their advice will not hold a lot of weight with their patients, because they themselves are heavy."
Overweight and obese physicians expressed greater confidence in prescribing weight-loss drugs than other doctors, perhaps because they've had personal experience with the medications or with the difficulty of behavior change, she observes.
This isn't the first time that research has shown a link between physicians' personal characteristics and their willingness to advise patients on lifestyle issues. "We know that physicians who follow healthy dietary practices themselves are more likely to spend time counseling patients about diet," says Dr. Robert Kushner, a professor of medicine at Northwestern University Feinberg School of Medicine and clinical director of Northwestern's Comprehensive Center on Obesity.
Other research has shown that physicians who smoke are less likely to help patients quit.
Bleich and her co-authors close their study by suggesting that doctors, who also report high levels of stress, substance abuse and depression, need to be encouraged to take better care of their health, both for their own sake and patients.
In August, an Ohio law went into effect requiring special licensing for pain clinics and doctors with 50 percent or more of patients being treated with controlled substances for chronic pain. The law tightly regulates record keeping on patients and mandates subspecialty certification and continuing education in pain management for physicians. The law also limits how many pills doctors can dispense and establishes a system for collecting unused narcotics.
A separate study released last month by researchers from Johns Hopkins School of Medicine found that medical school curriculum addressing pain is limited and often fragmented.
Research shows that pain tolerance varies from person to person, according to the Institute of Medicine report, which recommended that pain management be tailored to each patient's experience.
Physicians strive to find the balance of keeping patients comfortable and avoiding dependency on these powerful drugs.
Wednesday, January 25, 2012
In a cohort of older individuals living in Olmsted County, Minn., about one in every five who was cognitively normal at baseline developed mild cognitive impairment within three or four years, according to Rosebud Roberts, MBChB, of the Mayo Clinic in Rochester, Minn., and colleagues.
Compared with women, men had higher rates of both amnestic MCI -- which involves a memory deficit -- and nonamnestic impairment, which does not, the researchers reported in the Jan. 31 issue of Neurology.
"Differences in incidence rates by clinical subtype and by sex suggest that risk factors for MCI should be investigated separately for amnestic MCI and nonamnestic MCI, and in men and women," they wrote.
In an accompanying editorial, Kenneth Rockwood, MD, of Dalhousie University in Halifax, Nova Scotia, said that "finding a difference between men and women in the incidence of MCI is not a small thing."
"That is because much of the interest in MCI stems from its widely confirmed status as a risk for progression to dementia," he wrote. "Given that women tend to have a higher risk of dementia than do men, and that even in Olmsted County, dementia incidence is similar between men and women, it is unclear how to square more men in the at-risk state not translating into more men with dementia."
To explore the sex differences, Roberts and colleagues turned to the Mayo Clinic Study of Aging, which used data from the Rochester Epidemiology Project to prospectively assess the development of MCI in individuals ages 70 to 89 who were cognitively normal at baseline.
Every 15 months, the participants underwent evaluations that included the Clinical Dementia Rating Scale, a neurologic evaluation, and neuropsychological testing. The analysis included 1,450 individuals who completed at least one follow-up evaluation.
Through a median of 3.4 years, 19.6% of the participants developed mild cognitive impairment and 0.8% developed dementia.
The rate of MCI was higher for men than for women (72.4 versus 57.3 per 1,000 person-years; HR 1.40, P=0.004) and for the amnestic versus nonamnestic subtype (37.7 versus 14.7 per 1,000 person-years).
For both amnestic and nonamnestic MCI, rates were higher for men and for individuals who completed fewer than 13 years of education.
In addition, individuals who were never married were more likely to develop nonamnestic MCI compared with their married counterparts (HR 2.92, 95% CI 1.10 to 7.75).
About one-third of participants who tested positive for MCI at one assessment subsequently tested as cognitively normal.
In his editorial, Rockwood proposed two explanations for the higher rate of MCI among men, even though women have a higher rate of dementia. First, he said, men generally cannot tolerate deficits as well as women.
"While women might have more things wrong at any age, they can live with them longer than men do; for men, deficits more often are fatal," he wrote. "In consequence, the risk of death might be higher for men with MCI, thereby not allowing them to live long enough to develop dementia."
Another possible explanation, though, is a difference between the sexes in how cognition evolves over time.
"Why men have a higher incidence of MCI but a lower incidence of dementia may come about from how they express the later-life dynamics of cognition," Rockwood wrote.
"For some men, MCI represents incomplete disease expression; alternately, they resist dementia development more," he wrote. "In that way, MCI in men could lend some insight into what prevented dementia might look like. Whether this explanation holds depends, as the authors propose, on further investigation of risk factors for MCI separately in men and in women."
Roberts and colleagues acknowledged some limitations of the study, including possible nonparticipation bias and the relatively homogeneous population of Olmsted County (mostly of European ancestry).
Monday, January 23, 2012
Do women feel more pain than men?
It has long been known that certain pain-related conditions, like fibromyalgia,migraine and irritable bowel syndrome, are more common in women than in men. And chronic pain after childbirth is surprisingly common; the Institute of Medicine recently found that 18 percent of women who have Caesarean deliveries and 10 percent who have vaginal deliveries report still being in pain a year later.
But new research from Stanford University suggests that even when men and women have the same condition — whether it's a back problem, arthritis or asinus infection — women appear to suffer more from the pain.
There is an epidemic of chronic pain: Last year, the Institute of Medicineestimated that it afflicts 116 million Americans, far more than previously believed. But these latest findings, believed to be the largest study ever to compare pain levels in men and women, raise new questions about whether women are shouldering a disproportionate burden of chronic pain and suggest a need for more gender-specific pain research.
The study, published Monday in The Journal of Pain, analyzes data from the electronic medical records of 11,000 patients whose pain scores were recorded as a routine part of their care. (To obtain pain scores, doctors ask patients to describe their pain on a scale from 0, for no pain, to 10, "worst pain imaginable.")
For 21 of 22 ailments with sample sizes large enough to make a meaningful comparison, the researchers found that women reported higher levels of pain than men. For back pain, women reported a score of 6.03, men 5.53. For joint and inflammatory pain, it was women 6.00, men 4.93. Women reported significantly higher pain levels with diabetes, hypertension, ankle injuries and even sinus infections.
For several diagnoses, women's average pain score was at least one point higher than men's, which is considered a clinically meaningful difference. Over all, their pain levels were about 20 percent higher than men's.
Unfortunately, the data don't offer any clues as to why women report higher pain levels. One possibility is that men have been socialized to be more stoic, so they underreport pain. But the study's senior author, Dr. Atul Butte, an associate professor at Stanford's medical school, said that explanation probably did not account for the gender gap.
"While you can imagine such a bias," he said, "across studies, across thousands of patients, it's hard to believe men are like this. You have to think about biological causes for the difference."
An extensive 2007 report by the International Association for the Study of Pain cited studies showing that sex hormones may play a role in pain response. In fact, some of the gender differences, particularly regardingheadache and abdominal pain, begin to diminish after women reachmenopause.
Research also suggests that men and women have different responses toanesthesia and pain drugs, reporting different levels of efficacy and side effects. That bolsters the idea that men and women experience pain differently.
One reason for the lack of information about sex differences is that many pain studies, in both animals and humans, are done only in males. One analysis found that 79 percent of the animal studies published in a pain journal over a decade included only male subjects, compared with 8 percent that used only female animals.
In addition, experiments testing pain in men and women have shown that they typically have different thresholds for various types of pain. In general, women report higher levels of pain from pressure and electrical stimulation, and less pain when the source is from heat.
Melanie Thernstrom, a patient representative on the Institute of Medicine pain committee from Vancouver, Wash., said the newest research "really highlights the need for more treatment and better treatment that is gender-specific, and the need for far more research to really understand why women's brains process pain differently than men."
Some researchers believe the pain experience for women may be even more complicated. Women who have given birth, for instance, may have a different threshold for "worst pain ever," causing them to underreport certain types of pain. The bottom line, Dr. Butte said, is that far too little is known about how men and women experience pain and that more study is needed so that, ultimately, pain treatment can be customized to each patient's needs.
"If doctors have a threshold for when they give a dose or start a medication," he said, "you could imagine that the number they are using is too high or too low because a person may be in more pain than they are saying.
The feverish patient had spent hours in a crowded emergency room. When she opened her eyes in her Manhattan hospital room last winter, she recalled later, she wondered if she could be hallucinating: "This is like the Four Seasons — where am I?"
The bed linens were by Frette, Italian purveyors of high-thread-count sheets to popes and princes. The bathroom gleamed with polished marble. Huge windows displayed panoramic East River views. And in the hush of her $2,400 suite, a man in a black vest and tie proffered an elaborate menu and told her, "I'll be your butler."
It was Greenberg 14 South, the elite wing on the new penthouse floor of NewYork-Presbyterian/Weill Cornell hospital. Pampering and décor to rival a grand hotel, if not a Downton Abbey, have long been the hallmark of such "amenities units," often hidden behind closed doors at New York's premier hospitals. But the phenomenon is escalating here and around the country, health care design specialists say, part of an international competition for wealthy patients willing to pay extra, even as the federal government cuts back hospital reimbursement in pursuit of a more universal and affordable American medical system.
"It's not just competing on medical grounds and specialties, but competing for customers who can go just about anywhere," said Helen K. Cohen, a specialist in health facilities at the international architectural firm HOK, which recently designed luxury hospital floors in Singapore and London and renovated NewYork-Presbyterian's elite offerings in the McKeen Pavilion in Washington Heights. "These kinds of patients, they're paying cash — they're the best kind of patient to have," she added. "Theoretically, it trickles down."
A waterfall, a grand piano and the image of a giant orchid grace the soaring ninth floor atrium of McKeen, leading to refurbished rooms that, like those in the hospital's East 68th Street penthouse, cost patients $1,000 to $1,500 a day, and can be combined. That fee is on top of whatever base rate insurance pays to the hospital, or the roughly $4,500 a day that foreigners are charged, according to the hospital's international services department.
But in the age of Occupy Wall Street, catering to the rich can be trickier than ever, noted Avani Parikh, who worked for NewYork-Presbyterian as in-house project leader when the 14th floor was undertaken. She pointed to the recent ruckus at Lenox Hill Hospital, where parents with newborns in the intensive-care unit complained that security guards had restricted their movements and papered over hospital security cameras in their zeal to please Jay-Z (real name Shawn Carter) and Beyoncé Knowles, whose daughter was born on Jan. 7 in a new "executive suite."
Many American hospitals offer a V.I.P. amenities floor with a dedicated chef and lavish services, from Johns Hopkins Hospital in Baltimore to Cedars-Sinai Medical Center in Los Angeles, which promises "the ultimate in pampering" in its $3,784 maternity suites. The rise of medical tourism to glittering hospitals in places like Singapore and Thailand has turned coddling and elegance into marketing necessities, designers say.
The spotlight on luxury accommodations comes at an awkward time for many urban hospitals, now lobbying against cuts in Washington and highlighting their role as nonprofit teaching institutions that serve the poor. Indeed, NewYork-Presbyterian, which once opposed amenities units, would not answer questions about its shift, and declined a reporter's request for a tour.
In Greenberg, where the visitors' lounge seems to hang over the East River in a glass prow and Ciao Bella gelato is available on demand, the patient who likened her suite to the Four Seasons was not paying for it. She did not want to be identified because her wealthy boss, who picked up the bill, would not want publicity.
During a reporter's unofficial visits to both units this month, however, some people enjoying the perks expressed uneasiness about those priced out. In space-starved New York, many regular hospital rooms are still double-occupancy, though singles are now the national standard for infection control and quicker recovery.
"The concierges act like butlers," said John Frehse, 37, who was visiting his ailing father, Robert M. Frehse, 86, the retired chief executive of the Hearst Foundations. He and his mother, Dale Frehse, paused in their praise of the care to recall the fate of a family friend stuck for three days in the NewYork-Presbyterian emergency room for lack of a hospital bed last winter. At the time, they recalled, the Saudi king had been granted the whole 14th floor for his entourage.
The younger Mr. Frehse contrasted the unit's mouth-watering menu with the "inedible food" his father faced when he was treated on the non-elite second floor. "Here he has mushroom risotto with heirloom tomatoes," he said.
The hospital said in a statement: "NewYork-Presbyterian is dedicated to providing a single standard of high quality care to all of our patients."
At Mount Sinai Medical Center, where the aesthetic of the Eleven West wing is antique mahogany rather than contemporary sleek, and the best room costs $1,600, William Duffy, the hospital's director of hospitality, said his favorite entree was Colorado rack of lamb, adding, "We pride ourselves on getting anything the patient wants. If they have a craving for lobster tails and we don't have them on the menu, we'll go out and get them."
The 19-room unit, which opened 18 years ago but received a recent face-lift, takes in $3.5 million a year, Mr. Duffy said, estimating that 30 percent of its clientele comes from abroad. If the emergency room is backed up, a regular patient may be upgraded, he added: "Bump 'em up to Business, as we say."
Wayne Keathley, Mount Sinai's president, minimized the unit's role in the 1,171-bed hospital, on Fifth Avenue at 101st Street. "It is not nearly as large or elaborate as some others," Mr. Keathley said. He called the money it brought in "a rounding error in my budget," and said that patients came for the clinical care, not the amenities.
In Eleven West's library on a recent Friday, Nancy Hemenway, a senior financial services executive, was reading the paper in a spa-style bathrobe. "I was supposed to be in Buenos Aires last week taking tango lessons, but unfortunately I hurt my back, so I'm here with my concierge," she said.
"I'm perfectly at home here — totally private, totally catered," she added. "I have a primary-care physician who also acts as ringmaster for all my other doctors. And I see no people in training — only the best of the best."
Mr. Keathley said the lack of interns and residents on Eleven West was a function of clinical judgments and limits to the training program, not the preferences of rich patients.
But even the rainmakers — doctors who bring in such patients — can sometimes resent the tilt toward luxury.
"The one misgiving is patients with Medicare, which pays physicians almost nothing," said Dr. Brian Katz, 59, a laparoscopic surgeon in scrubs who took a break in the same library later. "Yet those patients will come up here and pay to enjoy five-star comfort."
Increasingly, hospitals serving the merely well-off are joining the amenities race. Beth Israel Medical Center near Union Square added a "deluxe unit" in 2008, catering mainly to patients after elective orthopedic surgery. The green-carpeted lobby may be more Radisson than Ritz, but its 12 single rooms starting at $450 feature Bose stereos and flat-screen TVs, and chef-prepared kosher food is served on china.
"A very insignificant portion of our beds are identified as deluxe accommodations," said Gail Donovan, the chief operating officer of Continuum Partners, which includes Beth Israel and St. Luke's-Roosevelt Hospital. "Our mission is really to be the safety net hospitals of our communities."
The conflicts echo those of a century ago, in another era of growing income inequality and financial crisis, said David Rosner, a professor of public health and history at Columbia University. Hospitals, founded as free, charitable institutions to rehabilitate the poor, began seeking paying patients for the first time in the 1890s, he said, restyling themselves in part as "hotels for rich invalids."
"Every generation of hospitals reflects our attitude about health and disease and wealth and poverty," Professor Rosner said. "Today, they pride themselves on attracting private patients, and on the other hand ask for our tax dollars based upon their older charitable mission. There's a conflict there at times."
His perspective on McKeen's amenities unit, where afternoon tea is served daily, is colored by the emergency room experience of one of his graduate students on the same hospital campus this month, he added. She spent two days on a gurney in terrible pain from herniated disks, he said, until a dean intervened to get her a room. "She hadn't even been given a bed pan," he said.
Sunday, January 22, 2012
Why does an appendectomy in Germany cost roughly a quarter what it costs in the United States? Or an M.R.I. scan cost less than a third as much, on average, in Canada?
Americans continue to spend more on health care than patients anywhere else. In 2009, we spent $7,960 per person, twice as much as France, which is known for providing very good health services. And for all that spending, we get very mixed results — some superb, some average, some inferior — compared with other advanced nations. Why this is true isn't easily answered.
Health reform is supposed to control costs, but there is no simple avenue of attack. Our aging population has played a role in driving up medical costs, but Germany, Italy and Japan have much bigger percentages of elderly people while spending much less per capita on health care.
The spread of health insurance, which shields patients from price sensitivity, has played a role in driving up our spending. But almost all other advanced industrial nations cover virtually everyone, while we leave 50 million uninsured.
Administrative costs are high here — no surprise given the hordes of clerks and accountants needed to deal with insurance paperwork. And technological advances, which are sometimes highly beneficial and sometimes not, often cost a lot more than standard treatments. (Surprisingly, American doctors lag far behind their counterparts abroad in using electronic health records, which can help avoid costly errors and duplications.) Insurance companies' profits and the high pay of their executives may account for some of the cost differences with other countries, but there is little good data on this.
A recent report from the Organization for Economic Cooperation and Development, a 34-member group that includes the most advanced industrial nations, concluded that spending is high here partly because the prices charged by American doctors and hospitals are higher than they are anywhere else.
The International Federation of Health Plans, in its 2010 comparative price report, documented just how large the price differential can be for a wide range of services. While it's difficult to get data that is truly comparable from one country to another, the trends show Americans paying a lot more than people in other countries for the same services.
Measuring how effectively we spend health care dollars is hugely complicated. But cross-national surveys offer some clues. We're good at giving patients what they want — if they ask for it. So Americans can see a specialist or get elective surgery a lot faster than patients in other countries, according to surveys by the Commonwealth Fund. The surveys also show that Americans are more likely than people in other advanced nations to experience medical errors or problems with uncoordinated care, and to forgo care because it's too expensive.
The O.E.C.D. report rates America at or near the top for survival rates in breast and colorectal cancer but slightly below average in cervical cancer. We rank in the middle of the pack in the percentage of heart attack patients who die in the hospital within 30 days of admission. And we have alarmingly high rates of hospital admissions for asthma and uncontrolled diabetes — an indicator that many patients don't have good primary care, which can prevent costly hospital stays.
Most other advanced countries hold down prices through government regulations. We set prices in Medicare and Medicaid programs. But in private markets, reform has to rely on other means, such as financial incentives for providers to curb costs by coordinating care and improving efficiency. One demonstration program significantly reduced spending by bundling payments to hospitals and doctors to cover all in-patient services connected with heart bypass surgeries.
The idea at the heart of the reform law is that such strategies, once proved effective, could be carried out on a large scale — and eventually bring total spending under control.
Slender, in her 60s and possessing the stoicism of someone who had single-handedly raised children in the toughest section of the city, our patient faced a difficult challenge of the medical kind. She had diabetes and such severe peripheral vascular disease that even the strongest antibiotics could not heal a long-standing foot infection. She needed an operation.
This grandmother who regularly held court in her hospital room with her extended brood also suffered from high blood pressure and heart disease, and all of us on the surgical team knew that operating would be no easy feat. We could amputate her infected foot, a relatively quick operation that would carry few risks, but she would never walk again. Or we could do an arterial bypass, a more complex operation that would save her leg but that might disable or even kill her before her surgical scars ever healed.
The final decision hinged on our assessment of her likely course, or prognosis. If she was unlikely to live long, we would amputate, because it wouldn't make sense to put her at risk of other life-threatening complications just to save her leg. But to throw out some ballpark figure, an actual number of the weeks, months or years this woman we had grown to care about had left to live, meant shouldering the responsibility none of us were eager to be reminded of – that is, our potential role in hastening her death because of poor clinical decisions based on the wrong prognosis.
A week after her bypass operation, our patient died of a heart attack. The prognosis of her senior surgeon and our entire team — that she would tolerate the surgery and survive long enough to walk again — had been incorrect.
While not all assessments of how long someone has to live result in life-or-death clinical decisions, addressing prognosis remains a challenge for most doctors. And after struggling for several years with determining their own patients' prognoses, a group of physicians at the University of California in San Francisco set out to collect and study all the research that had been done on so-called prognostic indexes, tools that help with determining general prognosis in older patients.
Given the growing use of age-based treatment and preventive care guidelines, the doctors assumed there would be plenty of data to help decide whether, for example, an 80-year-old patient might live long enough to benefit from a colonoscopy, a cancer screening procedure that can have its own set of complications.
But they found little.
Prognosis was rarely, if ever, alluded to in the most popular medical textbooks and on clinical Web sites used by practicing physicians. Even the widely used medical database PubMed, maintained by the National Library of Medicine, had no specific indexing category for prognosis, making finding any published study on the subject like searching for a book in a library before the Dewey Decimal System.
While the researchers were finally able to single out 16 indexes that hold promise in helping doctors predict how long a patient might live, there was"insufficient evidence at this time" to recommend any of them for widespread clinical use. None of the indexes had been tried with groups of individuals other than the initial test group to confirm reliability, and every single one had a potential source of bias. Some studies were never able to follow up on the final outcomes of a substantial subset of patients; others used researchers intimately involved with the development of the prognostic tool, and not impartial observers, to validate findings.
"There's a need for much more research in this area," said Dr. Eric W. Widera, one of the authors of the study, which appeared in The Journal of the American Medical Association. "Compared to diagnosis and treatment, prognosis is like the unloved stepchild of medicine."
A century ago, predicting a patient's life expectancy was an essential part of doctoring. Details relating to the art and science of "prognosticating" occupied a prominent position in textbooks, journals and conversations with patients. That emphasis began to shift as technology advanced, with doctors focusing more and more of their time on treatment and diagnosis.
Economic forces reinforced this new emphasis, as it became clear that while the ability to predict the timing of a patient's death was useful, the tools to treat and diagnose were profitable.
Perhaps even more important, prognosis has now become a potent symbol of the limits of medicine. With a growing array of successful treatments at hand, doctors often have the power to forestall death. But thinking about prognoses means recognizing not only fallibility but also possible culpability.
"Even in the privacy of their own minds, doctors don't like to think about prognosis," said Dr. Nicholas A. Christakis, a professor of medicine and medical sociology at Harvard Medical School and author of "Death Foretold"(University of Chicago Press, 2001), a book on the sociocultural issues of prognosis.
With so little research on how to predict how long a patient might live and few resources to turn to, physicians often end up relying on intuition. But studies have shown that these "guesstimates" can be wildly inaccurate, and that inaccuracy can adversely affect an older patient's quality of life and care. Doctors who are too optimistic may prescribe unnecessary and painful procedures and treatments; those who are too pessimistic may neglect to offer adequate care.
Most current clinical guidelines sidestep considerations about prognosis by relying on simple age-based cutoffs. The United States Preventive Services Task Force, for example, uses 75 as the age to stop routine colon cancer screening. "But age is an incredibly blunt tool," Dr. Widera noted. "We all know of 65-year-olds who are much sicker than some 95-year-olds."
While the authors of the study have created a Web site, www.eprognosis.org, to help physicians and patients access available prognostic tools, they are quick to acknowledge that this interactive tool is only a small part of what doctors and patients need. More work and resources must be devoted to creating accurate assessment tools, testing the reliability of those that exist and teaching doctors once again the art and science of determining, and talking about, prognoses.