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Monday, October 05, 2009

Health Care Rationality In America - Do More Ultrasound Scans!

Is it possible?

Try here at the NEJM for a calm chat.

Things are seriously wrong in American Health Care and something needs to be done.

The quality is killing people -

- Out of 19 industrialized countries, the U.S. ranked last on deaths amenable to health care, which are deaths that could have been prevented with timely and effective care.
- As many as 101,000 premature deaths a year would be averted if the U.S. was able to achieve the same mortality rate as other leading countries.


The cost is killing and hurting people -

- Economists have found that rising health care costs correlate with significant drops in health insurance coverage, and national surveys also show that the primary reason people are uninsured is due to the high and escalating cost of health insurance coverage.
- A recent study found that 62 percent of all bankruptcies filed in 2007 were linked to medical expenses. Of those who filed for bankruptcy, nearly 80 percent had health insurance.
- According to another published article, about 1.5 million families lose their homes to foreclosure every year due to unaffordable medical costs.


(Quotes are from The National Coalition on Health Care.)

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Personally, and being biased as a sonographer, I think US Health Care costs could be cut dramatically if instead of ordering a CT or an MRI as the first line diagnostic imaging test, Doctors ordered an ultrasound scan.

I don't have the breakdown on the financial stats but certainly the defensive use of imaging tools - doing a diagnostic study not because you believe there is anything wrong but just to cover your goddam ass in case of a malpractice suit! -and the widespread availability and advocacy of these expensive MRI and CT machines must means that diagnostic imaging is a much more significant part of health care costs than it is in other countries.

And certainly the number of articles published on diagnostic MRI and CT topics in both American and European journals that could sensibly be handled by competent ultrasound scans is stunning to an Australian. Sports medicine studies, peripheral nerve studies, a lot of vascular studies, the search for metastases in oncology patients, I believe in most of these cases and in many others, ultrasound should be the first line of diagnosis.

The main problem is the (often correct) perception of ultrasound as being unreliable primarily because it so operator dependant. The referring physician wonders if they can really trust the report. Ultrasound scans are considered so difficult to read by untrained eyes that the images themselves are pretty worthless to the referring physician. So here's a study in which he/she cannot confirm the finding for him/herself and which was performed by an anonymous somebody who could be the office cleaning lady for all the Doctor knows.

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I had a buddy in Australia who was about to proclaim at our annual sonographers' conference back in the early 90's that "70%" of ultrasound examinations in Australia were crap. He had made up that stat after completing an assessment during a training tour of some of the hospitals and clinics in Sydney. I pulled him up on using that exact number, but he certainly did have a point. Even in Australia, where we are proud of our advanced ultrasound standing, forced upon us by the strict control of MRI machines, the standards of many sonographers was indeed marginal at that time. In my own experience as an examiner for one of the Australian Societies, I had to fail some of these people for their sub-standard skills on several occasions.

Since that time, in Australia we have developed an Accreditation Board to oversee the development of courses available at the universities, and we maintain a Registry of suitably qualified sonographers (I was involved in the set-up of those boards) and I believe the relatively new imaging tool of ultrasound has advanced remarkably. Certainly many of those sub-standard wanna-be sonographers have now gained the experience to make them worthwhile scanners, even champions of ultrasound. Eventually, as a trainee you reach a point where the whole thing just clicks and from then on you really know what you are doing and what is expected of you. But that "click" takes time. That is why I favour longer periods of clinical training. It is not perfect in Australia yet, but it has come a long way.

In Australia, Sonography is a post-graduate degree (a Masters, for example), so we are already dealing with radiographers or Nuclear Medicine techs, or even nurses who generally already understand the anatomy, pathology and the science of imaging. We do have a more structured supervision for students and the universities all require tutor sonographers to supervise, and the students must present case-studies for assessment. At least one of the qualifications in Australia requires direct assessment by a third party during the clinical examination of real patients.

In comparison, the education and registration of American sonographers suffers in relation to Australia's in that it is an undergraduate degree, assessed by a standard exam for all applicants with no input from the students supervisor, no case studies, and no over-the-shoulder assessment.

It would be good if all American sonographers could also be educated in a similarly structured way to the Australian method (which is based on the British accreditation process). I personally would like to see something more like the Nursing registration schemes, where nurses are sort of mirco-accredited for specific skills. Each one of the ultrasound applications (abdominal, Sports MSK, Neuro-MSK, OB-Gyn, vascular) requires relatively huge amount of knowledge, skill and experience.

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However, what I have said doesn't mean that ALL American sonographers are bad and that is why MRI is winning, but I do believe that as they are coming from a lower level of education, American sonographers (as a whole, not specific songraphers, who may be exceptional if they have already had the "click") can only achieve what must be a lower level of INITIAL competency during their shorter training period. This might be one of the explanations for referrers sending their patients directly to MRI or to CT.

Another of the ways to gain the trust of American referrers is to standardize the examination to ensure a certain minimum standard is met. Improved technology is being placed in most high-end and even mid-range ultrasound scanners to help achieve this aim: such as recording short video loops instead of still frames, of taking 3D volumes and processing them like CT scans (not just for babies but for the upper abdominal and the pelvic organs), of programmed protocol guides that ensure the sonographer does a complete study and doesn't miss anything. These sorts of innovations might make the exam easier to read and review by a referring physician (so long as he has the software to read them).

There is an accreditation system for hospitals and medical clinics in the USA, but it doesn't really go far enough and compare the outcomes of the actual sonographers who do the scans, because that is the critical interface: where the patient meets the machine that goes "ping". Neither does the Australian system, but it is something that was being looked at.

So it comes down to education, the processing of accreditation and the continuing appraisal of a sonographer's continuing education.

So maybe this is another path on the road achieving lower costs of health-care in America. It would of course require the skills of experienced sonographers to give that advanced training and make these assessments. It would also require funding from the socieites to provide this service and pay the costs. Hopefully, the vast amount of money that could saved woudl more than cover the costs.

I wonder if there is anyone I know who could fit that bill?

Waddabout

E@L

2 comments:

Mark said...

Hmmm, no comments here?, but it certainly deserves a word or two (yeah, me .... again...)

You make a very valid point, the newest, sexiest, most expensive and totally overkill technology gets favored in these situations, for all the reasons you've stated, and often for economic reasons (someone is making more money... somewhere, somehow). In this case training (AND accreditation) are certainly the answer.

It all reminds me that generally, Oz does these sort of things pretty well. If you hire a plumber (or a sonographer) in Australia, you can be reasonably confidant he knows his job.

expat@large said...

Mark: thanks for the support on this very specialised topic. It's sort of a no-brainer to me, but the issue about education is genuine.

Sonographers as a rule are the most highly motivated of the MI Techs (cough, cough) because there is so much to learn and so much responsibility devolves onto you. The MRI and CT just presses a button (selection of technical settings is crucial of course) and then bang bang bang the machine does it all. The ultrasound scan is more of pre-death autopsy and you have to hunting for the all the problems manually using only sound waves - it's CSI for dolphins.

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