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Caring When Conditions are Complex/Chronic/Both

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Are we prepared to care for people with chronic or complex conditions like those with comorbidities?

The more chronic conditions, the greater the likelihood of the following: "unnecessary hospitalizations; adverse drug events; duplicative tests; conflicting medical advice; and, most important, poor functional status and death.1-5 Approximately 65% of total health care spending is directed at the approximately 25% of US population who have multiple chronic conditions.2 Individuals with multiple chronic conditions also face financial challenges related to the out-of-pocket costs of their care, including higher prescription drug costs and total out-of-pocket health care spending.2"

Fee-for-service (FFS) medicine hardly incentivizes care coordination, and in some cases, the opposite: "duplication of services,rehospitalizations, and additional unnecessary care."  We now see Congress proposing legislation that "includes experimental and pilot approaches to realigning such incentives and payments."  Nevertheless, is the complex patient going to be compliant, especially if there is poor care coordination and no "medical home"? "It is not clear whether the potential benefits of chronic disease self-care management; personal health records; and other health information exchange platforms, such as secure messaging, are being fully realized to maximize patient participation and health."  However, the is hope in "evidence-based clinical decision making in the care for patients with comorbidities."


Please read the following JAMA article for further information:

Parekh AK*, Barton MB  "The Challenge of Multiple Comorbidity for the US Health Care System." JAMA. 2010;303(13):1303-1304.

  * Office of the Assist. Sec. for Health, US Dept. of Health and Human Services, 200 Independence Ave SW, Washington, DC 20201

Does having evidence-based medicine or comparative-effectiveness research guarantee that the right thing will be done?

Obviously not, and here's a poignant example of how perverse incentives can be:

2007 was the final year of data reported in a study by Deyo et al wherein clinically risky and unnecessarily expensive substitute practices that could not be justified by the clinical evidence are at work in spinal surgery.

"Overall, surgical rates declined slightly from 2002-2007, but the rate of complex fusion procedures increased 15-fold, from 1.3 to 19.9 per 100 000 beneficiaries. Life-threatening complications increased with increasing surgical invasiveness, from 2.3% among patients having decompression alone to 5.6% among those having complex fusions. After adjustment for age, comorbidity, previous spine surgery, and other features, the odds ratio (OR) of life-threatening complications for complex fusion compared with decompression alone was 2.95 (95% confidence interval [CI], 2.50-3.49). A similar pattern was observed for rehospitalization within 30 days, which occurred for 7.8% of patients undergoing decompression and 13.0% having a complex fusion (adjusted OR, 1.94; 95% CI, 1.74-2.17). Adjusted mean hospital charges for complex fusion procedures were US $80 888 compared with US $23 724 for decompression alone."

Deyo RA, Mirza SK, Martin BI; et al. "Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults." JAMA.2010;303(13):1259-1265.

Note that "Consumer Reports has rated spinal surgery as number 1 on its list of overused tests and treatments. This was a harsh rebuke given the benefit associated with many common spinal surgeries. However, the findings from the study by Deyo et al should not only remind patients, surgeons, and payors that the efficacy of basic spinal techniques must be assessed carefully against the plethora of unproven but financially attractive alternatives, but also should serve as an important reminder that as currently configured, financial incentives and market forces do not favor this careful assessment before technologies are widely adopted. When applied broadly across medical care in the United States, the result is a formidable economic and social problem."

On Apr 7, 2010, at 11:24 AM, Fredrick H (MD, PhD, JD) wrote:
There's certainly no point in doing riskier, more expensive surgery unless it's more effective.  Unfortunately, this study didn't even examine the question of effectiveness. Thus, it leaves the impression that the only reason surgeons choose the riskier procedure is because it makes them more money. That may be true, but without the effectiveness data, we can't know.
From jgk:  Actually, the editorial to that paper does give a more complete picture of the risk-benefit ratio, as follows:

"A minority of patients with symptomatic spinal stenosis have a combination of spinal deformity, such as degenerative spondylolisthesis or scoliosis, which complicate the spinal stenosis pathology. Decompressive surgery alone in these instances (removing the bone, ligament, and facet joint materiel compressing the spinal root) may destabilize the spine and result in progressive deformity. Spinal fusion, for cases in which only 1 or 2 levels of instability are present appears to be a worthwhile addition to the decompression procedure in some patients. Results with simple fusion techniques often appear to give highly reliable and durable results.4 However, the available evidence suggests little or no advantage in routinely applying more complex fusion techniques such as instrumentation, bone graft augmentations, or combined anterior and posterior approaches.5" 

The aforementioned Deyo article in JAMA states: "the rate of spinal stenosis surgery in the Medicare population has remained more or less stable, but the rate of complex surgery for this disease has increased from negligible levels in 2002 to nearly 15% of all spinal stenosis surgeries in 2007. These more complex surgeries are also reported to be independently associated with increased perioperative mortality, major complications, rehospitalization, and cost. 

The findings do not provide explanations for the increase in complex surgery that has occurred during the past 6 years. Ideally, because the complex surgical techniques are used to treat complex deformities, the data should show that patients undergoing these procedures usually have these complex deformities. The diagnoses reported, however, do not support this "ideal" explanation; 50% of these new complex fusion operations were performed in patients with spinal stenosis alone and no deformity. Spinal stenosis with scoliosis by coding, accounted for only 6% of the complex fusions performed."

Source: Carragee EJ. "The Increasing Morbidity of Elective Spinal Stenosis Surgery; Is It Necessary?" JAMA. 2010;303(13);1309-1310.

4.  Martin CR, Gruszczynski AT, Braunsfurth HA, Fallatah SM, O’Neil J, Wai EK. The surgical management of degenerative lumbar spondylolisthesis: a systematic review. Spine (Phila Pa 1976). 2007;32(16):1791-1798. 

5. Abdu WA, Lurie JD, Spratt KF; et al. Degenerative spondylolisthesis: does fusion method influence outcome? Spine (Phila Pa 1976). 2009;34(21):2351-2360.

From: Harvey Frey, MD, PhD, Esq.
Date: December 16, 2015 at 2:14:37 PM EST
To: dialog <>
Subject: When a $50 cure is just as good as a $2,000 one

I wouldn't rule out the possibility that some of those doctors [referred to in the report, below] are prescribing the higher priced drug because 4% of $2000 is more than 4% of $50. Actually, Why should a doctor be paid a percentage of the cost of a drug? It takes no longer to write the prescription.


"Doctors must step up and — other things being equal, as in the case of a miracle eye drug — choose the cost-effective option. 

I’m a doctor with a miracle drug. Three of them, in fact. Their names are Avastin, Lucentis and Eylea. I use them to treat the No. 1 cause of blindness in Americans over 65: wet age-related macular degeneration (AMD). Calling them a miracle is no understatement. If your doctor delivers the unlucky news that you’ve developed wet AMD, it means blood vessels under your macula have started to leak or bleed, robbing you of the sight you rely on to read books, see faces, watch TV or drive.   

Enter the miracle drugs — eye injections that limit those leaking submacular vessels, giving us our first treatment capable of bringing vision back. But somehow, these drugs have become among the most controversial in all of medicine.   

All three treat wet AMD very effectively. Their most significant difference is cost. Lucentis and Eylea cost approximately $2,000 and $1,850 per dose, respectively. Avastin? Only $50.   

Medicare covers them all, so retina doctors and their patients are free to choose whichever medication they wish. A recent survey of our field showed that 64.3 percent of us choose Avastin as our first-line drug. Yet about 35 percent of retina specialists continue to use the expensive medicines as their first treatment of choice. Why?" 

Lam A. "When a $50 Cure iI Just as Good as a $2000 One."

The military had the Food and Drug Administration conduct a study of drug expiration dates--What do they mean?

Findings: "90% of more than 100 drugs, both prescription and over-the-counter, were perfectly good to use even 15 years after the expiration date."  So the drug expiration date isn't "a point at which the medication is no longer effective or has become unsafe to use. Medical authorities state expired drugs are safe to take, even those that expired years ago. A rare exception to this may be tetracycline, but the report on this is controversial among researchers. It's true the effectiveness of a drug may decrease over time, but much of the original potency still remains even a decade after the expiration date. Excluding nitroglycerin, insulin, and liquid antibiotics, most medications are as long-lasting as the ones tested by the military. Placing a medication in a cool place, such as a refrigerator, will help a drug remain potent for many years."

"Drug Expiration Dates — Do They Mean Anything?"   Havard Health Publications, Updated by them 9/2/2015