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Monday 27 March 2017


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.