The Latest Treatments : Updated Guidelines Would Help Busy Doctors Select Best Current Procedures
A RETIRED BUILDING contractor was hospitalized in Los Angeles with his second heart attack. After five days in the hospital, doctors reviewed the results of his exercise stress test and he was allowed to go home. His wife was concerned that he was being sent home too quickly. Just two years earlier, when the couple were living in Philadelphia, he had experienced a similar heart attack, but that time he stayed in the hospital for nearly two weeks.
The man’s experience was not unusual. In fact, studies have shown that a West Coast resident who suffers a heart attack generally will spend far less time in the hospital than an East Coast resident with identical symptoms. Research conducted during the past 20 years has shown that such geographic variations in medical care are remarkable for a number of illnesses.
Why do doctors in different places treat patients so dissimilarly when the medical problem is the same? For some problems, including heart attacks, there simply is no clear consensus among doctors about which treatments work best. For other conditions, such as heart bypass operations and hysterectomies, there is a consensus among physicians about when the operation should be performed--but not all doctors follow the suggestions. In general, doctors make decisions based on where they trained, where they practice and what their level of clinical experience is.
East-West differences in care are quite dramatic. Easterners spend considerably more time in the hospital than their Western relatives with similar illnesses. Yet there is no evidence of any differences in recovery rates.
Dr. Robert Brook, a health-policy expert at UCLA, says the major reason for the differences in medical care is the explosion in medical information: “Doctors do not have the time to read, learn and change the way they treat illnesses based on current research,” Brook says.
The problem of doctors not keeping current has spurred a movement to develop uniform treatment guidelines for many medical problems. The guidelines would function as a sort of national medical cookbook, ensuring that all patients receive the most up-to-date and appropriate care for a given problem. For example, when treating heart attacks, doctors in Los Angeles and Philadelphia would be encouraged to follow the same set of guidelines. The hope is that a person will receive good care no matter where he or she lives.
Sometimes, however, what’s important isn’t where you live but how you pay the medical bill. Research has shown that a patient’s ability to pay can significantly affect what the doctor decides to do. For example, researchers in Brooklyn, N.Y, found that pregnant women being cared for by their private physicians were much more likely to have their infants delivered by Cesarean section than women who could not afford a private doctor and went instead to a community clinic. The differences between private and clinic patients persisted even when the conditions of the pregnancy were similar. The researchers concluded that the private obstetricians were performing too many surgical deliveries, partly because their patients could afford to pay for them.
The notion of uniform treatment is not new. For many years, the National Institutes of Health in Bethesda, Md., and the Centers for Disease Control in Atlanta have issued “consensus statements” informing physicians about what experts think is the best treatment for a given disease. There are consensus statements about when to perform a Cesarean section, what chemotherapy or surgery to provide for various forms of cancer, how often to screen women for breast cancer and how to treat the common flu. Recently, an expert committee of the American Psychiatric Assn. issued a comprehensive manual on recommended treatments for almost all psychiatric and emotional disorders.
But these guidelines have not moved doctors to change their styles of practice. In many cases, doctors simply ignore the expert panel’s recommended treatment for a patient with a particular problem. Some doctors may disagree with the expert panel, while others resent the intrusion of guidelines into their practice of medicine.
“There are a million reasons not to follow a guideline,” Brook says. “But the fact remains that doctors need to know where they can turn for accurate, unbiased, up-to-date advice.”
Even doctors who agree with the premise of having guidelines may not practice in accordance with them. Physicians, like other people, often resist changing the way they do things. In the case of Cesarean sections, the National Institutes of Health in 1980 carefully outlined acceptable reasons for performing the operations. The recommendations were aimed at reducing the number of unnecessary C-sections, but after they were issued, the number of such procedures continued to rise.
Brook and others in the medical community believe that the time has come for groups of experts to develop and regularly update a treatment “cookbook.” But doctors probably won’t use it unless they are encouraged to. Some hospitals have used financial incentives to change doctors’ treatment practices: One Los Angeles hospital offered obstetricians a bonus for reducing the number of Cesarean sections they perform.
Federal agencies and the insurance industry also want to encourage the use of guidelines. They view it as a way of cutting the skyrocketing costs of health care. After all, if one week of hospitalization serves a heart-attack patient as well as two weeks, discharging most patients after a week would result in considerable savings. The problem is that the motivation to save money often is not consistent with the goal of providing high-quality medical care.
Organized medical groups and academic health centers, feeling that physicians will be subject to the whims of insurers, are racing to develop their own guidelines for quality care. With enormous status and influence at stake, the competition is understandably fierce.
