Bending the Healthcare Cost Curve

Martin McKneally

Massey College Grand Rounds, an excellent annual symposium on healthcare issues, focused this year on “Sustaining Our Healthcare System: Challenges and Leadership”. Policy analysts Michael Rachlis and Will Falk emphasized corrections that have modified the misleading “straight line projections of relentlessly rising costs leading to bankruptcy of the healthcare system”. Telehealth is an important example. This conference was broadcast inexpensively to the Northern Ontario Medical School and included the participation of its Dean, Roger Strasser. Important developments in telemedicine have added value and reduced costs. When psychiatric consultations are conducted by telepresence, there is an immediate and highly efficient sorting out of diagnosis and management issues. Eliminating delay to the initial specialist consultation saves costs and eliminates frustrating impediments to efficient care. Similarly, video consultation on dermatology problems has been extremely effective, enabling highly accurate diagnosis of non-melanomatous diseases, and facilitating rapid referral for melanomas. Using telepresence, Toronto pathologists now provide diagnostic evaluations across borders. This effective and economical approach can prevent tragic errors like those recently reported in breast cancer diagnosis.

Wendy Levinson, Chair of Medicine at the University of Toronto, described and analyzed the overuse of diagnostic imaging, antibiotics and other expensive interventions. Working with Don Berwick - former director of American Medicare, Wendy has taken a leadership role in the “Choosing Wisely” project underway in the United States and now coming to Canada (http://www.deptmedicine.utoronto.ca/Medinews/
medi_newsletter/ April_2013/Chair_s_Article.htm). This program emphasizes education of patients and encouragement of doctors to avoid reflexly checking off or ordering the full spectrum of diagnostic laboratory tests. Complying with misdirected anxious requests from patients for a CT, MRI, or a course of antibiotics on the basis of incomplete information is a remediable cause of inappropriate expense that can be reduced by education.

An encouraging example of innovation with global impact is illustrated in our lead article about thoracic surgeon Marcelo Cypel and his colleagues. Using recently developed double lumen cannulas that deliver blood from the atrium to the extracorporeal perfusion system and return it to the heart, Marcelo was able to demonstrate the effectiveness of extracorporeal membrane oxygenation to colleagues in Brazil. He flew to Porto Alegre, where he had received his undergraduate and general surgical training, to bring the technology developed so well here in Toronto to help rescue victims of a tragic nightclub fire that killed many young people. He was able to continue telepresence oversight of this operation after returning to Toronto, working with personnel on site to manage the perfusion and weaning of victims of inhalation injury. He has conducted seminars locally and globally to diffuse the knowledge of this important technology.

Cardiac surgeon David Adams, our Harland Smith lecturer, showed how well video technology facilitates teaching surgical reconstruction of the mitral valve at Mount Sinai Hospital in New York. His intracardiac video illustrations of the precise coaptation of the mitral leaflets after careful anatomical restoration proved how effectively these techniques can be taught. Much of the development of this important technology of cardiac surgery had to be learned earlier by peeking over the shoulders of experts, such as Adams, Tirone David, and Alain Carpentier. Adams lecture demonstrated how important and valuable the Division of Anatomy is to the Department of Surgery.

The Surgical Ethics intensive course in Banff will be attended by many surgeons from across the country, including trainees from our own program, who will serve as course facilitators. Currently, George Ibrahim, Josh Mayich, Mark Camp, and Jennifer Guillemaud have been actively preparing themselves to serve as teachers and scholars in this field. Karen Devon has recently returned from the MacLean Center at the University of Chicago to broaden the scope of our Surgical Ethics Program. She has a focused current interest in ethical issues that arise through medical and surgical participation in social networks. At the Banff intensive course, we will report on the enabling innovation policy that has helped to speed adoption of surgical and medical innovations since it was introduced nearly a decade ago in many of our university hospitals. The understanding that surgical innovations are part of quality improvement rather than research has been a significant advance.

We will also report on an interesting project that has been underway for the past 2 years, recording pre-operative conversations about life sustaining treatments in patients who will undergo operations that carry significant risk. Vivek Rao is the Toronto Principal Investigator of this project, conducted in collaboration with surgeons at Harvard and the University of Wisconsin. We are finding that surgeons regularly bring up important complications and their treatments in order to be sure that patients understand and accept this aspect of their care. Remarkably, patients tend to derail these conversations by asking questions of a technical or social nature: “But will I have staples or sutures?” or “Will my husband be able to sleep in the room?”. As this research continues, we may find a way to help patients and doctors choose wisely among life sustaining technologies. Because of their unique position and decision – making skill, surgeons are well positioned to help bend this section of healthcare cost curve.

Finally, I want to underline the correct date for the Banff intensive Surgical Ethics course. I misinformed readers in the last issue, saying it would be conducted on May 28th. The correct date is May 29, to be followed by the Canadian Bioethics Society meeting on May 31st – June 2nd.

M.M.