Greater engagement needed to achieve meaningful health care reform

It almost seems overly redundant to have to say that there is an international need to bend the curve on the rapidly rising cost of health care. Many jurisdictions, organizations, institutions and professional organizations have worked, written and commented extensively on the issue in the past 25 years. Uncountable working hours and careers have been committed to the issue with relatively little real impact. Costs are still rising and health outcomes are still variable and in many areas not improving. The province of Alberta now spends in excess of 40% of its provincial budget on health care. This figure is matched in most other Canadian provinces.

While many individual physicians have contributed to the discussions and made supreme efforts towards creating a changed health care culture, the profession as a whole has been largely missing and the practice of medicine and health care delivery has remained unchanged for decades.

In his 2008 report on the state of Acute Care services in New South Wales, Justice Garling mused why it takes 15-18 years to train someone to change a hip? Why indeed?

Vast amounts of money are spent training specialist physicians who then spend the majority of their time on procedures that could and should be conducted by other professionals. Why not create a “nurse-surgeon” for example? This person could be trained to perform a procedure such as a hip replacement just as capably as an orthopedic surgery resident. This would free up the specialists to use their training to the full scope in assessing and advising patients on treatment options. The focus of the “nurse-surgeon” on a particular procedure would provide greater experience and at a lower cost.

One hundred years ago, a nurse wasn’t permitted to take a patient’s blood pressure. It would have been unthinkable for a nurse to attempt such a “complicated” procedure. We must continue to challenge the status quo or the requisite change will never occur.

The delegation of authority for procedures works in other specialist area. The role of the Nurse-Anesthetist is well established and exists in over 35 countries. There are presently more than 50,000 nurse anesthetists in the U.S., administering more than 43 million anesthetics annually. One could easily argue that the practice of modern anesthesia is a great deal more complex than many standardized surgical procedures. In Oncology, for example, treatment recommendations in radiation oncology and medical oncology are made by the oncologists but delivery of the therapy is by radiation therapists and nurses.

Oncology needs to go further though. I often wonder why oncologists with 20 or 30 years experience are spending time examining well patient’s years after treatment when there are waiting lists for newly diagnosed patients who urgently need the expertise and advice of these experienced professionals. These “well follow-up” patients would be much better served by oncology nurses who are well trained in examining post treatment prostates and breasts as well as interpreting various lab results. Costs could be lowered by focusing expertise where it is most needed and permitting professionals to practice the full scope of their enhanced training.

Additional focus needs to be placed on determining more appropriate outcomes from various procedures. Health care organizations report their “surgical mortality rates”, their “30-day re-admission rates” and various other safety parameters. These are really surrogate indicators used to measure outcomes. Nowhere, other than perhaps in the published literature, can be found the outcome of the intervention relative to the reason for its performance. If the reason for a hip replacement is to relieve pain or improve mobility, what proportion of patients are pain free 30, 60, 90 and 365 days post op, or what proportion of patients have regained their mobility?

In oncology, take a simple example. Spinal cord compression is one of the commonest oncologic emergencies. In this situation, nerve function is compromised because a tumour is pressing on the spinal cord causing pain, weakness and varying degrees of paralysis. In many case, treatment is by radiation therapy to relieve the compression. Patients are treated with a series of daily exposures to radiation. This clinical presentation the one clinical situation that really sends radiation oncology departments into overdrive and patients are treated on an emergency basis often in the evenings and over weekends. Oncologists will quote various literature reports in providing information about outcomes, but nowhere can we see the results of the emergency in terms of recovery or prevention of worsening of neurological functioning. Do patients have relief of pain? Do patients recover from their paralysis or spend the remainder of their lives paralyzed? We should be able to see these outcome measure by department, by treating oncologist and by pathological diagnosis. If the treatment is working, then refine and further improve it, but if it’s not working, why continue do it? We need to measure outcomes in many more situations and measure relative to the reason for the intervention.

These are not easily answered questions and the medical profession needs to be fully engaged in the discussion on the way forward. Ongoing reluctance to fully engaged will not endear the profession to the community and they may risk losing some of their self regulation autonomy. The paying public will demand it.