|Dr. Pat Parfrey|
of people who turned out to hear well-known nephrologist (kidney specialist) and rugby coach, Dr.
Pat Parfrey, kick off his lecture tour on behalf of a group called “Choosing
Wisely NL” (CWNL) was far too small given that he had so many important things
CWNL, a program conducted by Memorial University’s Faculty of Medicine in partnership with the Newfoundland and Labrador Medical Association, has been established to advance “the safe and appropriate use of health care resources,” or what Parfey describes as the balance of benefits versus potential harms.
group of listeners belied the deepening concern over the financial crisis
unfolding in our health care system, and its inescapable linkage with the even larger
one facing the province.
often that the public, or even policy wonks, are treated to a blunt and
politically unfettered chat about deep-seated problems and of an organized plan
to fix some of them. But that is exactly what the long–practiced and straight–talking physician had on offer. Free of all the junk of professional
ass-covering, the doctor’s frankness was refreshing.
advancing CWNL’s goal of “improving the safe and appropriate use of health care
resources…” even though he notes “unsustainable spending” on health services is a concern of physicians. When broader fiscal matters — in relation to spending on health care — were
raised by members of the audience he commented, simply, that these were issues for
the politicians. His job was to advance improvements in health care practices.
spoke with clarity on the overuse of certain lab tests, x-rays, CT scans, and antibiotic
prescriptions; both doctors and patients to blame. The problem was underscored by his assertion that many of the tests were driven not by knowledge but by unregulated demand and by numbers: 15,000 CT scans and 15,000 x–rays, all unnecessary.
With certainty, Parfrey knew that only the most disconnected audience would fail to see the symmetry between well-managed health care and issues of affordability.
examples of excess were compelling, and the statistics he used were current. Within a field of 600,000 tests Parfrey suggested that 80% were unnecessary. Three are especially worth noting.
blood urea tests are often ordered along with serum creatinine and estimated
GFR (eGFR) to measure kidney function. The first, he noted, “is unnecessary in
stable patients” and creates “unnecessary diagnostic confusion” or false
positives. This conclusion was based upon 217,916 tests conducted between April
1, 2015 and March 31, 2016.
ask Parfrey about the math on all those tests — what the largely
unnecessary lab work had cost taxpayers. But he had already made clear his
cited was the overuse of imaging for low back pain. Parfrey noted that “less
than 5% of patients with low back pain have a serious underlying spinal
condition”. Besides, the doctor warned
that x-ray testing “may cause harm to patients due to unnecessary radiation
exposure”. In this context, he emphasized the need for an “evidence-based”
approach to such treatments. In part, the implication is that physicians have
to stop caving in to patients’ demands for an x-ray at the first suggestion (my
words, not his) of a case of a bad back.
antibiotics is rampant. You will appreciate the long–term risk to patients from
excessive antibiotic consumption, but also the incredible cost (waste)
associated with such over-prescription. Consider this statement by Dr. Parfrey:
“In 2014, doctors in Newfoundland and Labrador prescribed more antibiotic than
doctors in any other province in Canada — a third more often than the province
with the second–highest use rate.”
problems in other areas, too, including over–testing for peripheral vascular
disease, for anemia, colonoscopies…
|Exhibit extracted from a presentation by Dr. Wade Locke to Chartered Professional Accounts, Feb. 2017|
wasn’t Parfrey’s intention, but it was difficult not to come away from his
lecture with the feeling that those were just a few examples of the problems
that have arisen from decades during which the public believed health care was
“free” and the players — from physicians to the politicians — felt no obligation to impose
controls or wring out efficiencies.
lecture held reminders that too much of a good thing can be bad for us. But even
more, his analysis — grounded in good statistics — is proof that the health
care system (providers and patients) needs a management model containing
checks and balances.
even to hint at a model in which some part of the cost of service is assessed.
But when Newfoundland and Labrador chalks up expenditures that exceed the
national average by nearly 30% no one should think themselves safe from a fundamentally
broken health care system.
Dr. Parfrey’s talk followed the revelation, a few weeks earlier, by Eastern
Health of 176,000 missed appointments in 2015-16. The announcement stated that
“about 11 per cent of patients either did not show up for appointments, or did
not cancel with the required 48 hours notice… in areas such as endoscopy,
orthopedics, and diagnostic imaging.”
some percentage of the missed appointments are justified — but, likely, most are
Care Corporation’s (HCC) release did not indicate the cost of the missed appointments.
It is doubtful that they have such a tracking system. Now, HCC says patients will need a second
referral letter from their physician if the appointment is still necessary. Those visits aren’t free, but no estimate of the cost accompanied the release.
Health is setting up “a new automated notification system to remind people
about appointments… patients will get a phone call seven days before their
appointment…” “Eventually,” says Eastern Health, the reminders will “include
text and email options for notification.” How novel!
should be impressed that Eastern Health is only now getting around to the
problem. You can bet your booties last year was not the first when tens of
thousands of missed appointments were recorded.
plenty of context and analysis that could be applied to this problem and to the
issues cited by Dr. Parfrey. I will make only two points.
issue of excessive and unnecessary testing has cultural roots and embodies a
physician’s willingness to let the patient self-prescribe (cost being no issue),
the matter of missed appointments displays a serious deficiency in basic
when NL health care costs — 27.3% higher than the Canadian average — are raised
in public discourse, the standard knee-jerk invocation from Union heads and
politicians is the “rural” card: the euphemism for “inherently inefficient”.
Of course, that is codswallop. None of those issues are strictly rural. The excessive use of health care resources is pervasive across North America. Here we have simply figured out how to do things worse than elsewhere.
of waste and inefficiency we can add the cost to the health care system of beds
occupied by patients who should be housed in a long term care facility, archaic
MCP billing practices, and the absence of basic dental coverage — to prevent
more serious and intractable heath issues.
rural health care will suffer when the fiscal ax eventually drops. The truth
is, however, our health care system could likely be dramatically improved with
less money. Removing just one-half of the unnecessary testing and other
appointments from the system would dramatically shorten wait times for medically
have administered health care. We don’t have managed health care. In a system lacking checks and balances, no incentive exists to curb waste.
problem is not unique to health care.