Getting Past Denial - The High Cost of Health Care in the United States

Dartmouth Institute for Health Policy and Clinical , Lebanon, NH, USA.
New England Journal of Medicine (Impact Factor: 54.42). 10/2009; 361(13):1227-30. DOI: 10.1056/NEJMp0907172
Source: PubMed
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    ABSTRACT: A recent international meeting was convened by two United Nations bodies to focus on international collaboration on clinical appropriateness/referral guidelines for use in medical imaging. This paper, the second of 4 from this technical meeting, addresses barriers to the successful development/deployment of clinical imaging guidelines and means of overcoming them. It reflects the discussions of the attendees, and the issues identified are treated under 7 headings: ■ Practical Strategy for Development and Deployment of Guidelines; ■ Governance Arrangements and Concerns with Deployment of Guidelines; ■ Finance, Sustainability, Reimbursement, and Related Issues; ■ Identifying Benefits and Radiation Risks from Radiological Examinations; ■ Information Given to Patients and the Public, and Consent Issues; ■ Special Concerns Related to Pregnancy; and ■ The Research Agenda. Examples of topics identified include the observation that guideline development is a global task and there is no case for continuing it as the project of the few professional organizations that have been brave enough to make the long-term commitment required. Advocacy for guidelines should include the expectations that they will facilitate: (1) better health care delivery; (2) lower cost of that delivery; with (3) reduced radiation dose and associated health risks. Radiation protection issues should not be isolated; rather, they should be integrated with the overall health care picture. The type of dose/radiation risk information to be provided with guidelines should include the uncertainty involved and advice on application of the precautionary principle with patients. This principle may be taken as an extension of the well-established medical principle of “first do no harm.”
    Journal of the American College of Radiology: JACR 02/2015; 12(2):158-165. DOI:10.1016/j.jacr.2014.07.024
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    Appropriatezza. Una guida pratica, Contributi per il governo clinico edited by Stafania Rodella, Davide Botturi, 01/2014: chapter 6: pages 93-101; Agenzia sanitaria e sociale regionale, Regione Emilia-Romagna.
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    ABSTRACT: As we have become more and more dependent upon the laboratory and special investigations in making our diagnosis, we have gradually lost the faculty of clinical observation which enabled these early clinicians to make an accurate diagnosis. William J Mayo, 1910 Experience is the great teacher; unfortunately experience leaves mental scars and scar tissue contracts. William J Mayo, 1921 The internist, the surgeon, and the specialist must join with the physiologists, the pathologists, and the laboratory workers to form the clinical group which must also include men learned in the abstract sciences. William J Mayo, 1921 Summary Atul Gawande and the case McAllen, Texas The Health reform promised by President Oba-ma has been extensively debated in the recent months not only in United States but also all around the world both in the scientific and pro-fessional journals and in general magazines. One of the authors present in the two fields is Atul Gawande, a young endocrine surgeon and asso-ciate director of the Center for Surgery and Pu-blic Health at Brigham and Women's Hospital in Boston, Massachusetts. He is also an associate professor at the Harvard School of Public Heal-th, an associate professor of surgery at Harvard Medical School and director of the World Health Organization's Global Challenge for Safer Surgi-cal Care. He has written for The New Yorker and Slate pieces on medicine and public health which have been collected in his books Complications and Better, published in over one hundred coun-tries. Born to two Indian immigrants, both doctors, Gawande grew up in Athens, Ohio. He was a Rhodes scholar (earning a P.P.E. degree from Balliol College, Oxford in 1989), and later graduated from Harvard Medical School. He was a volunteer for 1984 Gary Hart's campaign and for Al Gore's 1988 presidential campaign, served as Bill Clinton's health care lieutenant during the 1992 campaign and served as senior adviser in the Department of Health and Human Services in the earliest months of Clinton's administration. His research aims at areas ranging from surgical technique, US military care for the wounded, er-ror in medicine. In a very tantalizing article writ-ten for The New Yorker in June 2009 he reported the case of McAllen, a 100,000 inhabitants city in the Southern Texas, which is one of the most expensive health-care markets in the country; in 2006, Medicare spent there fifteen thousand dol-lars per enrollee, almost twice the national avera-ge. The author pointed out that cardiovascular-disease, asthma, HIV, infant mortality, cancer, and injury rates in the Hidalgo county are actually lower than the national average. Even if El Paso County, eight hundred miles up the border with Mexico, has essentially the same demographics, Medicare expenditures in 2006 at El Paso were $7,504 per enrollee-half as much as in McAllen. We summarize Gawande's comments and opi-nions; an important clue is that differences in de-cision-making emerged only in some cases. In si-tuations in which the right thing to do was well established, physicians in high-and low-cost are-as made the same decisions, while in cases in which the science was unclear, some physicians pursued the maximum possible amount of testing and procedures; some pursued the minimum.


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