A 57-year-old low risk healthcare worker went into his physician office recently for a completely routine check-up.  He had no complaints and the internist proceeded to probing the chronic problem list with questions.  The blood pressure was under excellent control on Lisinopril.  A 2008 lipid profile showed the cholesterol under excellent control with Simvastatin.  The last hearing evaluation was from 2006 and the patient had no sense of worsening high frequency hearing loss.  The sleep apnea appeared under good control and there had been no weight gain since a CPAP machine was started in 2006.  A colonoscopy done in 2000, at age 47, for occasional blood noted on the toilet tissue, was negative. There were no new GI symptoms and the hemocult exam was negative.  A review of past immunizations disclosed the absence of a hepatitis A or B vaccine. The physical was normal except for a small mole on the back that was “probably normal.

The physician recommended and scheduled the patient for a complete battery of blood tests, including a lipid panel and PSA. A new EKG was ordered since the last on file was in 2000 and an updated one was thought recommended every 10 years. A repeat hearing evaluation was scheduled with Audiology. A repeat colonoscopy was scheduled because it had been 10 years and “why wait until you’re 60 when insurance will cover it now.” The Twinrix hepatitis AB vaccine was ordered with the first dose received before leaving the office. A dermatologist was consulted, pictures taken, and a follow-up visit arranged in six months.  The cost to the patient and health plan was approximately $5,250. No changes in medication were recommended.

To you the reader, is this good and appropriate care, or excessive care?  More importantly, does evidence support the recommendations?  Starting with the most expensive recommendation, colonoscopy, should we have waited another three years before considering this test given the lack of symptoms, no high risk considerations, and a negative colonoscopy at age 47?  At approximately $3,000, a three year, deferral would have saved almost $1,000.  And what about repeating a hearing evaluation in a patient with a documented high frequency hearing loss with no new troubling symptoms? Is there evidence to suggest we need to document the problem isn’t worsening, or maybe re-evaluate if now a hearing aide could help?  Should vaccination against hepatitis B be offered to all healthcare workers even when they are rarely engaged in patient contact and never involved in contact with blood or blood products? Do you consult a dermatologist the first time you see a mole or do you follow it and consider referral if there are obvious malignant changes? Is another EKG really warranted?

Today there is rationing of care in the United States based on one’s ability to get third party payment or ability and willingness to pay out-of-pocket.  Healthcare reform seeks to change the rationing model by increasing the availability of third-party coverage for all Americans but only covering services that are shown by evidence to be beneficial.  So, is there evidence to suggest this patient should have received these services, many of which the new legislation guarantees no out-of-pocket cost because the services are preventative in scope? What should this 57-year-old expect from a check-up in the future?

This 57-year-old is quite typical of the many thousands of doctor-patient interactions that occur every day.  The literature and evidence-based research simply cannot answer these and many similar questions that arise today regarding if, when, and how best to proceed.  We speak freely about evidence based practice but often there is little evidence to address specific situations.  As one can readily see, a lot of money can be either placed at risk or appropriately deployed based on how one interprets what quality healthcare really means.

Quality Quest seeks to raise the level of awareness around what healthcare quality and value can really mean to a community, focusing on specific measures and outcomes.  Realizing evidence may not always clearly address specific situations, data should help clarify trends, help engage debate, and help push us all toward a better understanding of what value can mean to each of us.  Join us on our quest and help us move the debate forward.