Procedural Darwinism

New procedures in medicine do not always stay – they must survive.

I have been interested to see Procedural Darwinism at work in my daily practice. Charles Darwin introduced his theory of natural selection of species to the scientific community at the turn of the 20th century. But his work, I have found, is not limited to all creatures great and small – it is related to medical procedures as well. You see, some procedures that heath care professionals perform provide good value to the medical community and the doctors themselves, while other procedures are too time-consuming and too economically under-reimbursed to survive in the ever-frenetic pace of medicine today.

Take the stethoscope, for instance. It is rapidly succumbing to Procedural Darwinism. If it weren’t for the stethoscopes ability to hear breath sounds, it would have been extinct long ago. The echocardiogram is far superior to “hear” heart sounds, and adds procedural survival protection by providing additional size, structure, and functional information regarding the heart with little pain or toxicity to the patient. The echo also reimburses well. The echo will clearly and directly survive Procedural Darwinism.

Although it may be on the “Endangered Procedures” list because it reimburses nothing to the physician, the stethoscope still clings to Procedural Life by providing important value to the physician in a different venue: there is no faster way to detect the early onset of congestive heart failure or pneumonia. Stethoscopes survive, then, by providing indirect economic value to the physician (by making him improve outcomes and therefore referrals). Therefore, by indirect economics, the stethoscope is likely to survive Procedural Darwinism.

But some new procedures may not survive Procedural Darwinism. One such procedure is T-wave alternans testing for the evaluation of patient considered to be at risk for sudden death. For those not familiar with this test – it is like a treadmill test, but much more time-consuming to perform. It uses special (and relatively expensive) electrodes configured in a non-familiar way (to people who do these test for a living), and detects information that cannot be seen by the naked eye (therefore it’s hard to believe/understand/verify by those who do treadmills for a living). It also requires remarkable fortitude to assure reliable data are collected (have to hold the heart rate in a narrow range for a pre-specified amount of time). Worse still, the economics of reimbursement are poor: the “special” electrodes cost $74 a set while the entire inpatient reimbursement is under $150 for a test that takes at least 45-60 minutes per patient to perform in the inpatient setting. While the costs in the outpatient setting are a bit more favorable ($300 reimbursement), there are Medicare coding rules that are complicated to perfect, and therefore – at least in Illinois - difficult to assure collection of any reimbursement in the first place. This procedure, as it stands now, is destined for Procedural Extinction unless something changes.

St. Jude’s recent resuscitation of Cambridge Heart (the maker of the only approved T-wave alternans machine to date) flies against the forces of Procedural Darwinism. St Jude feels they have an answer to counteract their declining defibrillator sales: that the indirect value of T-wave alternans testing in terms of increased referrals for defibrillator implants will justify the hours spent performing the test (and revenues/time lost). If internists are to perform the test, unless they receive a kickback for such a referral to cardiac electrophysiologists, there will be little economic reason to perform this test due to its difficult procedural requirements in terms of time and reimbursement.

T-wave alternans testing will only survive if environmental conditions change: that is, a mandate by Medicare to require the testing for people with weak heart muscles and no prior arrhythmia or heart failure. Even then, the application of this test, when other better reimbursing tests exist (like EP testing), keeps this test likely for extinction.

-Wes