Thursday, December 02, 2010

Co-Opting the History and Physical Examination

This week, new "performance" guidelines were published for adults with peripheral artery disease (or as one drug company brands it, "PAD.")

Interestingly, in explaining the rationale for these performance measures, these guidelines state:
Despite the overwhelming evidence that patients with PAD are at a markedly increased risk of myocardial infarction, stroke, and death, these patients are often undertreated, in that they do not receive antiplatelet therapy or statins with the same frequency as do patients with coronary artery disease (19).

Thus, these PAD performance measures are directed at strategies to improve diagnosis and treatment of patients with PAD with an overall goal of improving patients' walking distance and speed, improving their quality of life, and decreasing cardiovascular event rates.
And we should add, giving them appropriate pharmachologic and interventional therapy.

Fair enough.

But the guidelines push for the performance of an ankle brachial index, or ABI (a part of a thorough cardiovascular physical examination), in all patients determined on the basis of a questionnaire to be at risk for peripheral vascular disease. And they push hard, with statements simultaneously published the the Journal of the American College of Cardiology, Circulation, and reportedly also later in the Journal of Vascular Nursing, the Journal of Vascular Surgery and the Vascular Medicine Journal. The ABI is nothing more than a calculated ratio of blood pressures of the lower extremety systolic pressure divided by the upper extremity systolic blood pressure. A ratio of 0.9 or less is thought to suggest significant "PAD." To speed measurement of both arms and legs simultaneously, fancy new machines have been developed and costs about $75-110 to have performed by ancillary personnel.

Now don't get me wrong, I do think we can do a better job of detecting and treating peripheral vascular disease, but I have to ask several questions:

First, if "8 million persons in the United States are afflicted with PAD" and "the prevalence of PAD is approximately 12% of the adult population, with men being affected slightly more than women," how much will these screenings cost? Cost and the issues of dealing with false positive findings were part of the reason why screening EKG's were not recommended for all high school athletes in the American Heart Association's earlier guidelines. Should we not have a similar discussion for ABI screening?

Secondly, since when did we allow portions of the history and physical examination to be co-opted into billable procedures by professional organizations interested in promoting "quality care?"

How about a few more minutes in the exam room instead?

This is not just a rhetorical question any longer. Doctors are constantly being pushed by more and more "performance measures" to focus on things that might not have anything to do with the patient's chief complaint. Like bugs to a light, we are re-directed by these performance measures, soon-to-be mandated by Medicare, to direct our thinking away from patients toward the bureaucrats in the name of professional organizations' turf preservation.

Every screening measure amplified by millions of people has the potential to raise costs, not reduce them. And this era of a real need to significantly reduce costs of health care delivery, maybe we should have an honest discussion of the costs of these "performance measures."



Keith said...


Sounds like a job for comparitive effectiveness research. Compare the current method of screening for PAD vs this new fancy machine and then measure outcomes. Seems simple enough, but we rarely do this before unleashing these tests and procedures on our patients.

This seems like a reasonable role for the FDA to say before you utilize this device for a test that insurance would be willing to pay for, you need to perform the risk/bnenfit analysis much like you would do for any pharmaceutical agent. No proof that it is beneficial, no payment.

DrWes said...

Keith -

Interesting. Almost like we should do CER on every part of the physical exam to see if it's cost effective, right?

You're missing my point.

Is my job to prevent every known malady that could potentially walk into my office with each visit or address the patient's concerns? My beef is not with the machine that allows ABI's to be done faster to see if it improves "outcomes," however you might want to define that term. (By the way, depending on the definition I chose, I bet I could shape a prospective trial that would make nearly any technology I wanted to promote look beneficial, but I digress).

Rather, my beef is with the ever-growing list of bureaucratic intrusions that we're encountering in our examination rooms every day that steal precious time from the patient visit. As a result, we have less time to do our own examination and find that all this screening costs our patients a pretty penny.

Seriously. Who are we serving with all these measures - our patients or ourselves?

Keith said...




Anonymous said...

We have so much of this cr*p at the VA that I really think that pts should have a visit JUST to complete all the clinical reminders. Then have additional visits to address their health concerns/issues.