Monday, 27 March 2017

DR. PARFREY'S REFRESHING FRANKNESS

Dr. Pat Parfrey
The number of people who turned out to hear well-known nephrologist (kidney specialist) and rugby coach, Dr. Pat Parfrey, kick off his lecture tour on behalf of a group called “Choosing Wisely NL” (CWNL) was far too small given that he had so many important things to say. 

CWNL, a program conducted by Memorial University's Faculty of Medicine in partnership with the Newfoundland and Labrador Medical Association, has been established to advance "the safe and appropriate use of health care resources," or what Parfey describes as the balance of benefits versus potential harms.

The small group of listeners belied the deepening concern over the financial crisis unfolding in our health care system, and its inescapable linkage with the even larger one facing the province. 

It is not often that the public, or even policy wonks, are treated to a blunt and politically unfettered chat about deep-seated problems and of an organized plan to fix some of them. But that is exactly what the long-practiced and straight-talking physician had on offer. Free of all the junk of professional ass-covering, the doctor’s frankness was refreshing.

Parfrey made it clear that his mission held less a financial objective than that of advancing CWNL’s goal of “improving the safe and appropriate use of health care resources…”  even though he notes "unsustainable spending" on health services is a concern of physicians. When broader fiscal matters in relation to spending on health care were raised by members of the audience he commented, simply, that these were issues for the politicians. His job was to advance improvements in health care practices.

The doctor spoke with clarity on the overuse of certain lab tests, x-rays, CT scans, and antibiotic prescriptions; both doctors and patients to blame. The problem was underscored by his assertion that many of the tests were driven not by knowledge but by unregulated demand and by numbers: 15,000 CT scans and 15,000 x-rays, all unnecessary.

With certainty, Parfrey knew that only the most disconnected audience would fail to see the symmetry between well-managed health care and issues of affordability.

The doctor’s examples of excess were compelling, and the statistics he used were current. Within a field of 600,000 tests Parfrey suggested that 80% were unnecessary. Three are especially worth noting.

One was that blood urea tests are often ordered along with serum creatinine and estimated GFR (eGFR) to measure kidney function. The first, he noted, “is unnecessary in stable patients” and creates “unnecessary diagnostic confusion” or false positives. This conclusion was based upon 217,916 tests conducted between April 1, 2015 and March 31, 2016.

I wanted to ask Parfrey about the math on all those tests what the largely unnecessary lab work had cost taxpayers. But he had already made clear his mission.

Another example cited was the overuse of imaging for low back pain. Parfrey noted that “less than 5% of patients with low back pain have a serious underlying spinal condition”.  Besides, the doctor warned that x-ray testing “may cause harm to patients due to unnecessary radiation exposure”. In this context, he emphasized the need for an “evidence-based” approach to such treatments. In part, the implication is that physicians have to stop caving in to patients’ demands for an x-ray at the first suggestion (my words, not his) of a case of a bad back. 

Overuse of antibiotics is rampant. You will appreciate the long-term risk to patients from excessive antibiotic consumption, but also the incredible cost (waste) associated with such over-prescription. Consider this statement by Dr. Parfrey: “In 2014, doctors in Newfoundland and Labrador prescribed more antibiotic than doctors in any other province in Canada a third more often than the province with the second-highest use rate.”

There are problems in other areas, too, including over-testing for peripheral vascular disease, for anemia, colonoscopies
Exhibit extracted from a presentation by Dr. Wade Locke to Chartered Professional Accounts, Feb. 2017

Likely it wasn’t Parfrey’s intention, but it was difficult not to come away from his lecture with the feeling that those were just a few examples of the problems that have arisen from decades during which the public believed health care was “free” and the players from physicians to the politicians felt no obligation to impose controls or wring out efficiencies.

Parfrey’s lecture held reminders that too much of a good thing can be bad for us. But even more, his analysis grounded in good statistics is proof that the health care system (providers and patients) needs a management model containing checks and balances.  

It is heresy even to hint at a model in which some part of the cost of service is assessed. But when Newfoundland and Labrador chalks up expenditures that exceed the national average by nearly 30% no one should think themselves safe from a fundamentally broken health care system.

Interestingly, Dr. Parfrey's talk followed the revelation, a few weeks earlier, by Eastern Health of 176,000 missed appointments in 2015-16. The announcement stated that “about 11 per cent of patients either did not show up for appointments, or did not cancel with the required 48 hours notice… in areas such as endoscopy, orthopedics, and diagnostic imaging.”

Undoubtedly, some percentage of the missed appointments are justified but, likely, most are not.

The Heath Care Corporation’s (HCC) release did not indicate the cost of the missed appointments. It is doubtful that they have such a tracking system. Now, HCC says patients will need a second referral letter from their physician if the appointment is still necessary.  Those visits aren’t free, but no estimate of the cost accompanied the release.

Now Eastern Health is setting up “a new automated notification system to remind people about appointments… patients will get a phone call seven days before their appointment…” “Eventually,” says Eastern Health, the reminders will “include text and email options for notification.” How novel!

No one should be impressed that Eastern Health is only now getting around to the problem. You can bet your booties last year was not the first when tens of thousands of missed appointments were recorded.

There is plenty of context and analysis that could be applied to this problem and to the issues cited by Dr. Parfrey. I will make only two points.

While the issue of excessive and unnecessary testing has cultural roots and embodies a physician’s willingness to let the patient self-prescribe (cost being no issue), the matter of missed appointments displays a serious deficiency in basic management practices.

Secondly, when NL health care costs 27.3% higher than the Canadian average are raised in public discourse, the standard knee-jerk invocation from Union heads and politicians is the “rural” card: the euphemism for “inherently inefficient”. Of course, that is codswallop. None of those issues are strictly rural. The excessive use of health care resources is pervasive across North America. Here we have simply figured out how to do things worse than elsewhere. 

Indeed, to issues of waste and inefficiency we can add the cost to the health care system of beds occupied by patients who should be housed in a long term care facility, archaic MCP billing practices, and the absence of basic dental coverage to prevent more serious and intractable heath issues.

Undoubtedly, rural health care will suffer when the fiscal ax eventually drops. The truth is, however, our health care system could likely be dramatically improved with less money. Removing just one-half of the unnecessary testing and other appointments from the system would dramatically shorten wait times for medically necessary procedures.

In short, we have administered health care. We don’t have managed health care. In a system lacking checks and balances, no incentive exists to curb waste.

And the problem is not unique to health care.

The public needs more straight-talking advocates like Dr. Pat Parfrey.

19 comments:

  1. Physicians are knowledgeable about medicine but we too often assume this extends to the business of health care. It does not. Dr Parfrey is one who does have such knowledge and understanding. The problem is not just needless tests.
    It also extends to services and health care facilities. An example is the radiation treatment unit planned for the new acute care facility in Corner Brook. The review done by the previous Government was simply a method to endorse a political decision to place such services in Corner Brook. Whether it was the right decision is open to no end of debate and in the end of little value as it will happen. However it is a new service , one that does not currently exist and one that will cost money when we cannot afford current health services. It is also one that will keep on costing. Never mind the construction cost, the operating cost for physicians and staff will be significant to say the least and likely match the construction cost in the first 2 to 3 years of operation. Bear in mind it wasn't Ed Martin that was in the top three income earners on the The Telegram's sunshine list , it was radiation oncologists. If we want to know why are health care costs are high then at least some of it comes from that face in the mirror.

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  3. Excellent article Des!

    While everyone gets excited about Government increasing the dollars spent on health care, this is a great reminder that their are massive savings hidden in better management of what we already have.

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  4. My comment on the grid peak load has been removed. OK, it was off the topic for today, and may get re-posted later, it sometimes happens, and I do at times go off on a tangent, and get concerned about power warnings......Liberty warned there would be days like this.
    On Dr Parfrey, I was surprised to see this subject on UG, but an important subject, as to the cost of medical case and waste in the system. I had seen this doctor with Debbie Cooper on Here and Now a couple of months ago, and was taken back by some of his statements, which give me concern.
    Winston

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    1. Off topic. But interested in your comments on this

      https://thetyee.ca/Opinion/2017/03/29/BC-Liberals-BC-Hydro-Playing-Politics/

      Maybe when Des does an update on Speech from Throne.

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  5. Uncle Whiney has all the answers. Everything will be just fine when he is co-premier along with Greg Malone

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  6. A timely piece. At 8 am in the morning I have an appointment for an MRI on my brain. I have had chronic issues. This scan is a follow up one. A brain MRI scan in Jan 2016 showed what appears to be a cyst about the size of a large marble, 0.75 inch. I think it is benign, but a follow up was recommended for July 2016. To get the scan and find the cyst I had to travel out of the country for assessment. The follow up here in St John's is 8 months later than recommended.
    It may be that the first scan and this one are both unnecessary. I have 3 risk factors that discourages radiation, and wonder if this scan is prudent, but will go.
    Contrary to this piece, I did not receive a reminder call 7 days before, but got a written reminder sent 21 days before. And I almost forgot......a 7 day advance call would be better. What if I had been away on vacation say, and did not appear tomorrow........just another missed appointment, and MRIs ....state side, these cost $3000.00 , US funds. Yet here, not worth a call to confirm I will appear. Perhaps UG can have the good doctor explain why prudence in health care spending, in this case, is not being followed as planned.
    Winston Adams

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    1. MRI does not expose you to radiation

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    2. Victoria, You are pretty sharp, maybe work in the field with MRIs? Or a health care worker, or are you even from Nfld?
      Of course you are technically correct. And I wondered if someone would pick up on that, which you have. But it still reasonable to have concern about radiation with MRI scans, is it not? I am not trying to be cute in asking this question. I have CDK issues as well.
      Winston

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  7. Excellent....and while we're trying to save health care dollars, review the Methadone Program. It is not working

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  8. Finally.....I would like to see a Choosing Widely program for every province in Canada......get citizens involved(not politicians)!!!

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  9. They can save a lot of money by doctors who has this 10 minutes 1 thing appointments .Its like getting in line up Mcdonalds Dont bring up 2 problems with you doctot because he will just ingnore you ,1 issue and come back for the next issue

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    1. Yes there is a major waste of money on one item doctors....You can get your ears checked but make another appointment to check the rash on your legs or sore throat.... Make that 3 appointment that would take about 10 minutes to diagnose...Now if they play the game for minor stuff like that what the hell about major problems...Speaking about mri and other test I was in the hospital for 10 day back in feb because of my heart problem...The specialist came into my room and said to me I hear you have an alberta health care card.I responded yes..The next morning I was set up for an MRI...a CT Cat Scan and a ultra sound on my neck....I lucked out my alberta health card got me same day service...Now a few months ago I went with a kidney stone problem and the doc said no cat scan at the night time and sent me home with pain killers....Theres is a major problem with health care service in newfoundland no doubt I know lots of people who wait months for that service.....

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  10. These are great initiatives but someone should look into the amount of surgeries that are done on people who are elderly and have so many co-morbidities that they very often don't survive the surgeries and spend weeks or months in our ICU,S being tortured until they finally succumb.There is a time for all of us to die but because of modern medicine and we may be able to do something nobody is allowed to pass away of natural causes anymore. Imagine putting a pacemaker in a 99 yr old.If that person was at home they have passed gently and with dignity in their sleep.There are a lot of things that are done in health care that you would question the ethics.We all have to remember that there are a lot of things that are worse than dying and many nurses see it every day.

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    1. Recently there have been several shows on W5 etc. in regards to Long-term Care Homes in Canada. Makes one wonder what is ahead.....I am a Senior and know my options!

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    2. With provinces like BC, Long Term Care Homes are left in the private sector, and are out of reach to most middle to low income seniors. Government is avoiding like the plague the ownership and operation of Long Term care. Oh well, the GIS kicks in and everything is good again. My wife and I are able to rent a century old miner's cottage, which is on grade, and still able to live somewhat modestly, and independently. Stay healthy and independent Kathleen.

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  11. The term "Health Care" is largely a political one. What we have is a for-profit, sickness extending system. Through drugs, few if any patients ever get cured, or even "better". Successful surgeries on the other hand, fixes many conditions. Both Des and Dr. Parfrey are noble in intent, and in action, for revealing these truths. Truly effective management is so lacking throughout that system that everyone (including single-issue Dr.s and no-show patients) have become complacent in their wealth and unlimited resource circumstances. We all pay fr this in spades. A stronger statistic from that chart is the comparison between NL's and ON's use per capita, (mind boggling). ... In terms of solutions???? .... everyone on planet earth needs to witness the facts and corruption behind the sickness industry and save their own families and loved ones from a system that kills more humans than has been ever imagined by most folks. Vimeo is currently hosting a documentary called "WHAT THE HEALTH". It exposes the facts that many don't know and need to. Your sickness is a pre-determined outcome funded by billions in marketing, lobbying and lies to the general public. Two other great health Doc.s are "Cowspiracy" and "Fat, Sick and Nearly Dead" on Youtube. Watch these after your meal is settled though, because they contain some harsh realities.... that just might save your life. Cheers!!

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  12. Thank you Des for highlighting this subject. Choosing Wisely (I recommend readers go to the web site for information) is a self admission by the Canadian Medical Association that they have largely failed in cost effective good heath care.
    Go to the topics there, whether mental health, heart or kidney disease, or imaging and you will find what is BEST PRACTICES and it is largely what NOT to do, and is usually opposite of what is being done, especially here in NL.
    With our power system, Liberty in their reports often uses the word Prudent, and we find our power companies are largely IMPRUDENT.
    The word WISE and PRUDENT mean much the same. Choosing wisely could be stated Choosing PRUDENTLY. After DARKNL, it took Liberty to confirm the large scale imprudence of our power companies.
    The medical association is self admitting imprudence.
    Liberty continuously advises that a Change of CULTURE is needed at Nfld Hydro, and I suggest also Nfld Power and especially Nalcor. Likewise a change of CULTURE is needed for our health care. Acknowledging this and making the change is two different things. With our power companies there has been NO meaningful, or very little, culture change, despite the many citations by Liberty. For Conservation and Efficiency measures our power companies are second worst in Canada, and are proud to be in that position.
    Is our health care any better........
    Our provincial debt problems are largely caused by Muskrat and health care........... there is no change of direction with Muskrat, but prices will double. It is likely we will see no change with health care chosing wisely, but that care will be even worse, if that is possible.
    I just got a phone call from Urban Salon, a reminder that my wife has an appointment for tomorrow. That is typically a 50 or 60 dollar cost and they can call a day in advance. That is private business efficiency. I got no reminder call for my MRI yesterday, a procedure costing thousands. Let me know when they have implemented the reminders calls for expensive scans, a most simple thing to implement, and maybe that will be the first evidence of health care efficiency, and confirmation of our throne speech promise of doing better with less.

    Winston Adams

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  13. So what do you all think of the mismanagement of your Health Care model now?

    http://www.cbc.ca/news/canada/newfoundland-labrador/flatter-leaner-nl-health-cuts-93-positions-1.4045492

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