Tuesday, June 10, 2014

We can't afford to ignore the need for efficiency

Archie Cochrane (1909-1988) was a Scottish doctor with a mischievous twinkle who turned his quantitative skills as an epidemiologist to the assessment of medical care, not simply to public health.  
He was a strong advocate for randomised trials.
There is now a Cochrane Library of critical reviews of published medical papers and a Cochrane Centre in Oxford that stand as a tribute to his efforts to sort wheat from chaff when it comes to medical practice. And there is a lot of sorting to do.
I recall hearing Dr Cochrane present doctor numbers and infant mortality data from Africa at a conference in London about 35 years ago.
The presentation noted a direct relation between mortality and the number of doctors in African countries: the more doctors, the higher the mortality.
His presentation caused an uproar. His interpretation was that in resource-poor settings, doctors suck up the resources for healthcare and practise specialised medicine in the big cities with nothing left for primary care in the rural setting.  
In a recent WHO report on the relation of workforce to health, it was said that, "Only 5 of the 49 countries categorised as low-income economies by the World Bank meet the minimum threshold of 23 doctors, nurses and midwives per 10,000 population that was established by WHO as necessary to deliver essential maternal and child health services."
It continued: "Some pregnancy-related services can be delivered by mid-level health workers. Community-based health workers can provide a number of life-saving child health services, such as immunisations and the management of non-severe pneumonia."1
In Australia, questions can and should be raised about the effectiveness of what we as doctors are doing
This is not easily done. An awkward roundtable conversation between the high-profile Harvard surgeon and author Atul Gawande and three other senior clinicians about low-value care, posted online by the New England Journal of Medicine recently revealed the mixed feelings of clinicians.2  
MRI for back pain may be low value, but occasionally an unexpected spinal abscess will show up.
The roundtable acknowledged the Choose Wisely campaign from the American Board of Internal Medicine that has collated 60 lists of 300 recommendations from specialty groups about procedures in common use not judged to be of great value and even harmful.
The clinical ambivalence remained at Dr Gawande's meeting. However, there was acceptance at the close that services harming people need to be identified and their use eliminated.
There is an urgent need for each of us to move into critical appraisal mode about what we are doing.
There may well remain a lot of procedures where value is debatable but we should be able to identify the nonsensical things we do and stop, or be rationed with regard to the full spectrum of our activities, effective and otherwise.
Options? Our colleges and associations should convene working groups to address the question of efficiency in their own backyards, not their neighbours'.
A debate should be stimulated by Federal Health Minister Peter Dutton about efficiency goals in the health system - root and branch.  
Among 10 steps toward a sustainable, effective health system suggested by Steven Lewis, a health policy and research consultant from Saskatoon, at the Canadian Institutes of Health Research, is the following: 
"We must root out useless, burdensome and harmful service use ... The world's best systems ask not just whether something can be done, but whether it should be done. They get to the heart of why intervention rates inexplicably vary, and they clamp down on ineffective diagnostic or therapeutic procedures. 
"All financial incentives that reward both individuals and organisations for inappropriate and unnecessary care should be eliminated. Organisations that prevent health breakdown should be rewarded more handsomely than those that unleash the medical juggernaut to address avoidable failures. 
"It is preposterous to pay physicians more for scheduling multiple appointments to deal with a patient's needs than for addressing them all at once.
Likewise, turn off the tap that excessively rewards the routine use of expensive diagnostic technologies that have a low probability of changing diagnosis, management or outcome."3
Professor Leeder is a member of the Menzies Centre for Health Policy at the University of Sydney, chair of the Western Sydney Local Health District Board and editor-in-chief of the Medical Journal of Australia.