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Sunday, November 28, 2010

Science in reverse

When I was in RT school we discussed one day the ethics of how it is decided that a certain medicine or procedure becomes the treatment of choice, or one of the recommended options, for a particular patient diagnosis.

For example, based on the latest wisdom, based on best practice evidence, physicians that offer recommendations to the Centers for Medicaid and Medicare Services (CMS) have decided that a bronchodilator breathing treatment is beneficial for most pneumonia patients, and therefore this is one of the treatment options they look at when determining if the patient meets Intensity of Service in determining if or how much the hospital should be reimbursed for that patient.

A breathing treatment with Albuterol was included as a means of proving Intensity of Service because a study was completed a while back that showed the Beta Adrenergics, along with dilating bronchioles, also increase sputum secretion. Therefore, it is believed it will help the patient cough up the sputum.

Based on this wisdom, breathing treatments are now ordered on all pneumonia patients at Shoreline Medical. Yet there is no evidence that beta adrenergics like Albuterol do any good for pneumonia patients. There have never been studies in this regard. Therefore, someone came up with the theory that bronchodilators benefit pneumonia patients, and now all pneumonia patients get them.

The theory is that modern bronchodilators are safe, so why not just give them. Well, the reason why not is a cost measure. If you are giving a bronchodilator to a patient who technically doesn't need them, then you're wasting your money. Yet, to make sure the hospital meets Intensity of Service, it's wise to include Beta Adrenergics in the order set for pneumonia. Yes, this results in overkill, and loss of money for the hospital, yet in the long run it benefits the hospital because it assures reimbursement. Or at least it assures the hospital won't have to participate in a costly battle with CMS over payment for that particular patient.

So usually in the medical field we do science in reverse. Someone comes up with an idea, and we do it on everyone. Then we do it until it's proven not to do any good. Kind of like we did IPPB until it was finally decided all it did was overinflate good alveoli. We did that goofy thing for over 30 years until it was proven to be not necessary to improving outcomes. (although we do have one doc who still orders it from time to time).

We give bronchodilators on patients with congested heart failure, pneumonia, pneumothorax, pleural effusions, and even pulmonary embolisms (PE). There is actually science to prove that PEs do cause some localized bronchospasm, yet no evidence I've ever seen that shows conclusively that a beta adrenergic will even reach this localized region.

So I imagine doctors and RTs and nurses will continue to recommend continuous nebs on certain patients until -- perhaps in another 30 years -- more evidence comes along to show they don't do any good past an hour. That, perhaps, after three nebulized Albuterol treatments all the beta adrenergic receptor sites on the bronchioles are saturated.

Or, perhaps a study will come out showing that as soon as the steroids start working, and parts of the lungs open up, perhaps due to a patient coughing up a mucus plug, those beta adrenergics will be right there waiting to take up the spot and cause more bronchodilation.

So I suppose continuous nebs will be ordered on some patients for years to come. Or unless the patient refuses I suppose. Yet since most patient s who get treatment in the emergency room are in no condition to refuse, that job is left up to the physician.

And since most patients don't pay out of their pockets, they really have no incentive to refuse therapy.

Real science would have it that many studies be done to prove a certain therapy really benefits the patient. Then it's recommended based on best practice medicine. Yet in the real world, physicians don't want to wait 30 years. So, if the experts believe it might help, and it's deemed safe, they just do it.

So that's why we do chest physiotherapy as part of the pulmonary toilet. In theory the vibrations caused by clapping your hands on the chest help knock out secretions, yet in reality the evidence is mixed. Yet we still do CPT. What can it hurt? So the theory goes.

Yes, best practice evidence shows CPT benefits some patients. It may even be 2%. It may be 10%. Yet how do you know what 10% it will help? You don't. Therefore, you order it on every patient with a given diagnosis, or with a given lung sound, or whatever.

I think that order sets are great, as I wrote here. Yet I also believe since most of what we do is based on reverse science, this also results in overkill -- too many meds and too many procedures being ordered -- just to cover your bases results in loss of dollars for the hospital. Although CMS is assured to need to pay less, so the government will pay less.

And the fact that CMS gets to pay less is the bottom line.

So because we use science in reverse and order sets to help the patient meet Intensity of Service, this results in overkill. This ultimately results in increased cost to the hospital, decreased cost for the government, and a lot more work for RTs and RNs. This can lead to burnout and apathy.

Ideally, instead of doing the same things on every patient with a given diagnosis, some hospitals are going to protocols that allow RTs and RNs to do what works and not do what doesn't work. Some hospitals are ahead of the game in this regard. Yet some are still lagging behind. It's not easy getting a doctor champion.

Still, even with protocols, Intensity of Service still must be met. And in the world of HMOs and CMS, there will continue to be overkill, and procedures will continue to be ordered based on reverse science.

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