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Unnecessary genetic testing, examining the doctor shortage, and trauma center disparities

November 10, 2016

In order to bring you more of the news you want to read, RightCare Weekly summarizes and interprets three important articles and provides headlines linking to the many other articles and editorials you’ll find interesting. As always, RightCare Weekly presents articles related to moving our healthcare system toward the right care for all patients.

 

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Sometimes it may be better not to know. That’s what researchers at the University of Michigan conclude in their evaluation of an expensive genetic test. The test for inherited thrombophilia, a genetic characteristic that makes one more susceptible to dangerous blood clots, is commonly ordered for patients with severe blood clots. However, the test results are virtually useless, because patients who have already developed blood clots will benefit from anticoagulants whether or not they have the gene. The researchers found that doctors performed 280,000 thrombophilia tests on Medicare patients in 2014, costing taxpayers hundreds of millions in Medicare reimbursements. And that’s only Medicare; private insurers are also paying thousands of dollars per test. Not only does the test waste money, but unnecessary testing can cause increased anxiety and higher insurance premiums for patients. So why bother testing for thrombophilia? The researchers speculate that doctors order the test to “satisfy their curiosity” about the reason a patient developed a blood clot. This uncomfortableness with uncertainty is not limited to thrombophilia testing. As Arabella L. Simpkin, B.M., B.Ch., M.M.Sc, and Richard M. Schwartzstein, M.D, write in NEJM this week, “the culture of medicine evinces a deep-rooted unwillingness to acknowledge and embrace uncertainty.” Sometimes it’s better not to know, but to reduce unnecessary testing we must learn to be more comfortable not knowing.

There seems to be no shortage of dire warnings of physician shortages in the U.S. – shortages that (supposedly) are growing worse and will threaten access both to primary care and specialties. The reasoning goes that, as baby boomers age and the Affordable Care Act leaves fewer Americans uninsured, it’s imperative that we begin training and producing more physicians. But in this week’s New York Times, columnist Aaron E. Carroll offers a different spin on doctor shortages, highlighting efficiency – or the lack thereof – as the real culprit. By way of example, he writes, “We rely too heavily on physicians and not enough on midlevel practitioners, like physician assistants and nurse practitioners, especially because evidence supports they are just as effective in primary care settings.” Carroll also suggests that we may have all the doctors we need, but we simply have them in the wrong places. He cites Medicare’s higher reimbursement rates for providers in costlier communities as one driver behind this “geography gap.” Carroll concludes with calls for fixes such as a more plan-full distribution of our medical resources and a greater willingness to allow midlevel practitioners to help meet the demand for primary care. Lesson re-learned: more is not always better.

For people who have suffered a car accident, gunshot wound, or other traumatic injury, access to a trauma center can be the difference between life and death. A study published recently in the Journal of the American College of Surgeons found vast regional disparities in trauma center availability in the U.S. The five states with the greatest availability of high-capability trauma centers had eight times the number of surgeons compared to the five states with the lowest availability, despite having little variation in trauma center admittance. “Unfortunately, this study suggests that trauma services are not always located where the need is greatest,” said University of Oxford research fellow and coauthor David Metcalfe, as quoted in Reuters. Not only are some states drastically underserved, but other areas are oversaturated with trauma centers. Too many trauma centers can harm patients, because if each center treats only a small amount of patients, hospitals and specialists risk losing their expertise, says Metcalfe. In fact, a study published in Annals of Surgery found that diluting the volume of patients at trauma centers increased patient mortality rates. Part of the problem is that some states offer large financial incentives to trauma centers, creating the incentive to build new ones, even in areas where enough already exist. Development of trauma centers should be regulated so that access is based on medical need, not financial gain.

Announcement

On May 5-7, 2017, the Lown Institute is holding its 5th Annual Conference! We are continuing to call for abstracts for the research symposium that focus on enhancing our understanding of right care. We are also calling for proposals for skills-building workshops to engage health professionals, patients, patient advocates, and community leaders. Deadline for both submissions is December 18. Learn more about abstracts here. Learn more about workshops here.

Headlines

Overuse

Access

Clinician health

Conflicts of interest

Cost of care

Disparities

Doctor-patient relationship

Electronic health records

End of life

Evidence

FDA

Med ed

Model of care

Organizing

Palliative care

Pharma

Public health

Social determinants

 

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