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Thursday, April 8, 2010

More indications of positive change from the Journal of the AMA

Who would have thought that the Journal of the AMA would be an agent of positive social change? The AMA has, for me, symbolized the most frighteningly powerful aspects of organized medicine, and its trade journal, the JAMA has been one of the big 3 (with the New England Journal and the Annals of Internal Medicine) vehicles for presentation of relevant cutting edge clinical research. But since health care reform has been in the news the JAMA has offered many well considered opinion articles about how best to make American medicine serve the people.

The lead article this week presented research in the area of surgical treatment for spinal stenosis.  Spinal stenosis is a common and disabling subset of what people think of as "a nerve pinched in my back".  Patients with spinal stenosis have bony growth or disc protrusion into their spinal canal in such a way that the spinal cord is crowded, leading to pain down a leg, or both legs, with exertion or in certain postures.  It has been pretty successfully treated for many years with decompression and sometimes fusion of the vertebrae involved.  In recent years there have been advances in the field of spine surgery and now the vertebral column is sometimes stabilized with complex and expensive hardware, and sometimes the bone growth is enhanced with the use of bone growth proteins.  This has allowed surgery to be successful in very complex cases, including cases in which there is spinal deformity such as severe scoliosis.  Use of these new technologies, however, is extremely expensive, and cases in which the new technologies are used have a higher complication rate.  This would be acceptable if the new technologies were only used for the complex cases, but now the new technologies are very commonly used, resulting in an increase in cost for surgical treatment of spinal stenosis from about $23,000 for the standard procedure and hospitalization to over $80,000 for the complicated version, with a relative risk for complications, including death, that is nearly 2 and a half times that of the less complicated surgery.  The factors that lead to increase in use of the more complex surgeries include the fact that medical device manufacturers advertise the superiority of these procedures (which involve the use of hardware that can cost upwards of $50,000 per case) as well as fact that a surgeon may be reimbursed $600-$800 dollars for the simpler surgery and up to 10 times that for the more complex surgery.

What, you might ask, is positive about that story? What is positive is that it is the lead article in the JAMA and that there is an editorial by Jay Lemery which neither apologizes for or rationalizes the findings. The conclusions, in fact, of the editorial are that patients and surgeons and payors need to carefully assess the value and risks of new technologies, and that market forces, such as they are, do not favor careful assessment. Tell it, brother!

Only 4 pages away from this editorial is another opinion piece with the title "Moving Reform to the Bedside." The authors, Drs. Erica Spatz and Cary Gross, say that doctors should start reforming health care themselves, without waiting for legislators to do it for them.  They suggest that doctors use the tools we have to provide good quality care that is based on evidence of what works, when there is such evidence, and that we consider costs when deciding which tests and medications to use. They suggest involving patients in making decisions, and even talking to them about why health care reform is necessary and how these changes might occur. They suggest that we become involved with creative ways to allow access to health care in our communities, and that we avoid being seduced into free lunches and other goodies by representatives of drug and device companies.  None of this is new, in fact most of these pieces of advice can be found somewhere in the archives of this blog, but it is INCREDIBLY GRATIFYING to see them in an editorial in the Journal of that bastion of organized medicine, the American Medical Association.

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