Outcome measures

Atul Gawande has a tremendously important article in the 1 June 2009 issue of The New Yorker, which should be read by everyone, regardless of ideological bent, who cares about health care reform in both the United States and Canada. It is very enlightening: does spending a lot of money on health care actually produce better outcomes for patients? (Answer: no! but not for the reasons you might think.)

The truly telling part, for me, was the discussion about overutilization:

I gave the doctors around the table a scenario. A forty-year-old woman comes in with chest pain after a fight with her husband. An EKG is normal. The chest pain goes away. She has no family history of heart disease. What did McAllen doctors do fifteen years ago?

Send her home, they said. Maybe get a stress test to confirm that there’s no issue, but even that might be overkill.

And today? Today, the cardiologist said, she would get a stress test, an echocardiogram, a mobile Holter monitor, and maybe even a cardiac catheterization.

“Oh, she’s definitely getting a cath,” the internist said, laughing grimly.

I was floored by this passage — and by the later discussion about the motivational role that money plays in clinical decision-making. (That’s an educational piece that probably should be saved for another day.)

What’s really interesting to me, though, is what this implies about scarcity and resource allocation. One of the more annoying complaints from Republicans and their proxies on this side of the border is that Canada’s health care system has shortages of all kinds of stuff, and that you’ll have to get in line to have your MRI or whatever, and it’ll take six months. Ok, fine, that’s probably true a lot of the time, and in the United States you could probably have that test, and a whole bunch more, within a matter of hours. (I think Phoenix has more MRI suites that the entirety of western Canada.) But what I want to know is this: how many of these tests, more freely available in the United States than in Canada, are clinically relevant, how time-sensitive are they, and (this is the critical part) how many fail to turn up anything of significance? Great, so you catheterized that patient, and the coronary arteries were clear. Yay. What have you done? What value have you provided the patient? (We’ll ignore the very real risks of cardiac catheterization here.)

I don’t get it. But that might be why I work here, not there.