Tuesday, May 03, 2005

Is Evidence-Based Medicine Cruel????
From The New York Times, For a Hospital Stay, Only a Select Few Qualify:
The first time Mrs. Harris got a blood clot in her leg, back in 1998, she spent almost three weeks in the hospital. So when the other leg swelled up and began to throb last month, she came to the emergency room with a good-size suitcase, ready to stay.

As it happens, she never even got to unpack. She was riding back home in an ambulette barely 24 hours later with a sore leg, a bag of medicines to dissolve her new clot, and a vague sense of unease.
Is it because the outpatient treatment of DVT is advantageous? The author seems to imply that hospitals are "cruel":
Hospitals in this country have become cruelly selective institutions of higher healing. Only the most qualified applicants are admitted (and then only a fraction of them get to unpack). The underlying financial principles are simple enough: most admissions generate a lump sum compensation. The simpler the illness, the smaller the sum. The longer the stay, the further it must stretch. The hospital thrums to a simple bottom line: get 'em in, get 'em out.
The evolution of DVT therapy is examined:
Until a few years ago, a clot in the leg got you in and kept you there. In view of the worst possible outcome - that the clot would move to the lungs and cause respiratory collapse - observation and bed rest seemed essential. To dissolve the clot, one blood thinner had to be given by vein until a second oral one began to take effect, and levels of both needed frequent monitoring, lest spontaneous bleeding occur.

Then the technology changed. The intravenous medication was reformulated so that patients could inject it themselves, like insulin. The new drug did not need such careful monitoring. Studies showed that bouncing around at home with a clot in the leg was not particularly dangerous. Frequent blood tests were still necessary, but patients could get them as outpatients, and watch for bleeding themselves.
Isn't this better? Most patients want to be at home and keeping them out of the hospital helps them avoid nosocomial infections. Early ambulation avoids deconditioning. The author seems to take issue with the economic aspects of EBM, that is how it is used to reduce the costs of treating an illness. This can be accomplished, as it has with thromboembolism therapy, by converting an illness previously handled on an inpatient basis to one handled as an outpatient. And cost is no small thing with DVT therapy as a Medline search of "outpatient dvt therapy" reveals many articles examining the cost benefits of outpatient therapy. There are some circumstances that may make Mrs. Harris a less than ideal candidate for outpatient therapy.
Unlike her disease, though, not too much about Mrs. Harris herself has changed since 1998. She still weighs close to 300 pounds, has a bad heart and stiff lungs, and lives a good hour from the hospital. She is still not very good at reading medication bottles or remembering drug doses.
She still cannot stand giving herself injections. She still hates having strangers (like visiting nurses) in her home. She is still the person who began to bleed from some unidentified site in her intestine while she was taking blood thinners the first time.
As the Retired Doc reminded us not all patients will fit nicely into the results of a randomized controlled trial. But none of the complaints offered up have much, if anything, to do with geography, obesity, or poor vision. The most concerning one, the GI bleed, is more often seen in treatment with unfractionated heparin (UH) than with the low-molecular weight version (LMWH). Often times LMWH is used in the inpatient setting because of improved safety and yes, less cost than intravenous UH, because of the decreased lab requirements.
Most of the problems the author has with the situation has to do with the inconvenience of it all:
And so, it has been a hectic month for Mrs. Harris and her outpatient caretakers, of whom I am one, what with the missed injections, confused prescriptions, frantic phone calls, specially dispatched ambulettes and blood tests that are consistently off the mark. So far, she is doing fine despite it all. The rest of us are a little fatigued.
(emphasis mine).
So despite the evil, money-grubbing hospital treating this patient as an outpatient, she is doing just fine, without the complications she had before.
The real gem comes at the end:
It is a cliché that once patients remove their street clothes and slip on hospital johnnies, they become invisible to medical staff, morphing from stockbroker, carpenter, musician into just one more generic body to process.

Exactly the same holds true, of course, when they slip on a disease. All their individuality tends to vanish behind its skimpy folds.

Would that someone had examined the lady with the blood clot in Room 9B24, discovered Mrs. Harris instead, overrode that inexorable get 'em in, get 'em out, and kept her right there.
Why? For what reason? To have her "outpatient caretakers" avoid a hectic month? Did this patient expect to go to the hospital for a vacation? EBM requires us to examine the patterns of our practice and ask ourselves why we do what we do. Can we do it better? Can we do it as well, or better at, perish the thought, a lower cost?
The utilization of EBM will not only require a shift in the thought patterns of physicians, but in patients as well. Which will be harder to do? Stay tuned.
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