Archimedes knew that with a long enough lever, he could move the Earth. For our new administration taking office this month, fixing the mess that is the American health-care system will be only slightly less challenging. But it, too, will come down to tools.
Among the findings in a study by health-care reform expert Dr. Marc Nuwer, reported in Neurology last month, two statistics jump out: 31 percent of U.S. health-care funds go toward administrative costs; another 10 percent goes to defensive medicine, costly tests to rule out rare conditions ordered by physicians simply to protect against malpractice.
Against that backdrop is the widely acknowledged trend that, as our soaring costs rise, the individual patient will assume a greater burden. A December article in the Journal of General Internal Medicine details an unforeseen outcome of that trend: As patients assume a greater out-of-pocket liability for medical costs, trust in their physicians "to put their needs above all else" goes down. "Exposing patients to more of the costs could lead to greater skepticism and less trust of physicians' decision-making, thereby making health-care delivery less effective," the author concludes.
One long-awaited potential pathway out of this mess has been evidence-based medicine. But the gap between what is known scientifically and what is implemented clinically continues to confound researchers. A few years back there was much attention given to the arrival in ophthalmology of a risk calculator for ocular hypertension. Similar calculators had been successfully integrated into general practice for cardiovascular disease.
It may not make headlines, but last month the Journal of Glaucoma reported one of the earliest studies of the impact of risk calculators. Its conclusion: Use of a risk calculator in cases of ocular hypertension "changed recommendations, increasing the measure of confidence and decreasing the measure of inconsistency." The results were more consistent with the findings of the pivotal OHTS study when a calculator was used.
There's an awful long way to go to remedy our health-care mess but it's encouraging to see that science and evidence combined with clinical utility may actually be recognized as tools that can get us there.
