 Editorial Modifying use of pathology services Participatory, non-punitive involvement of healthcare practitioners is needed
MJA 1999; 170: 8-9
| |
|
→ Other articles have cited this article Increasing use of pathology services is a worldwide phenomenon in countries with substantially different healthcare systems.1 In Australia, for almost a decade and a half the annual growth rates of Medicare-funded services have shown that the rates for pathology services have generally exceeded, and often been more than double, those of other medical services.2-4 In the financial year 1997-98, pathology, diagnostic imaging and general practitioner services grew by 4.28%, 3.86% and 0.59%, respectively, compared with the previous 12-month period. In the same period, the Medicare outlays (ie, "benefits") paid by the Health Insurance Commission for total medical services were $6.334 billion, of which 14.59% were for pathology services and 14.81% for diagnostic imaging services. Together with general practitioner services (37.39%), these account for two-thirds of Medicare outlays. By the turn of the century, the Medicare outlays for pathology and diagnostic imaging services will each exceed $1.0 billion per year.Pathology services in the public health sector, or for workers compensation and traffic accident insurance, are largely funded at State level by arrangements distinct from Medicare. The extent of pathology services and outlays in these sectors is largely unknown, but service growth rates at hospital level are not uncommonly of the order of 1%-3% per year. At the National Pathology Forum (Canberra, 1995) the annual public health sector pathology expenditure was estimated to be $450 million to $600 million. What is the explanation for the growth of pathology services? There is no consensus, but many real, speculative, anecdotal and even light-hearted reasons are given:2,5 among these are diagnosis, monitoring, screening and prognosis; availability and accuracy of prior result; pressure from patients, relatives and peers; reassurance; medicolegal issues; profit; fraud; research; insecurity; and habit. Given this list, some services would clearly be unnecessary and wasteful in the clinical setting,2 but these reasons do not obviously explain the increasing use of pathology services in Australia2-4 and similar trends in other countries.1 Other suggestions for consideration include improved technology allowing larger throughput with shorter turnaround of services, cost-shifting from publicly funded to Medicare-funded services, and altered clinical practice, such as the increasing need in general practice to exclude organic disease when faced with non-specific symptoms. The nature of Medicare data does not allow for conclusive evaluation of these possibilities. Do we really know whether the growth in use of pathology services is appropriate or inappropriate? In a recent review of 44 published studies of laboratory test use,1 11 studies used implicit criteria that were not provided, were very broad, or had not been adequately assessed for their reliability as criteria. In the other studies, explicit criteria were based on the appropriateness of test choice, frequency, timing, and the probability of a positive result. Estimates of inappropriate laboratory test use ranged from 4.5% to 95%! The review authors concluded that the criteria used in these studies did not meet methodological standards suggested for audits of therapeutic interventions, and suggested that researchers should develop alternative evidentiary standards for measuring inappropriateness of pathology service use. They also concluded that, while the evidence supporting the explicit criteria was weak by methodological standards, it was strong according to principles of physiology, pharmacology, and probability. Perhaps the real issue is how to modify the use of pathology services rather than to seek a definitive explanation for the growth in services. The Commonwealth government has sought to reduce Medicare outlays for these services by restructuring the relevant sections of the Commonwealth Medical Benefits Schedule, by informing those requesting these services of their patterns of use, by licensing and reducing the number of pathology collection centres, and by limiting the number of pathology services allowed per episode (ie, per patient each day) that attract benefits. A three-year agreement to cap outlays within predetermined limits was reached between the Commonwealth government and pathology services in 1996. At State level, many hospitals are applying the principles of competitive neutrality (which aims to ensure that government businesses do not enjoy competitive advantage simply because of their public ownership) and even market testing6 to their own pathology departments in an attempt to reduce expenditure, if not use. Such measures are effectively cost-cutting activities, and are seen to be imposed by the funders, often without effective incentives for the users or providers to change.7 Passive information and educational material accompanying these activities is usually prepared by the funders, and may be seen by the users as of little relevance or of poor quality. Moreover, such measures may not prevent the development of further distortions in use of services (through, for example, inappropriate use of other clinical procedures or marketing of other pathology services). Are there ways, other than externally imposed cuts in outlays, to modify use of pathology services? In this issue of the Journal, Isouard reports on the impact of a total quality management approach on the appropriateness of pathology service use in acute myocardial infarction.8 His study used a team which included doctors, nurses and pathologists to determine unnecessary variation in ordering of tests. The outcome was an increase from 77.5% to 88.2% in the proportion of clinically indicated tests that were ordered, and an 81.7% reduction in the use of non-clinically indicated tests. This is associated with the potential to reduce expenditure. It would be all too easy to criticise Isouard's article as being overly enthusiastic about total quality management, as research based around modification of human behaviour, and for the difficulty in rigidly controlling such experiments. Further criticisms might include the need to verify such major improvements independently, and the observed reduction in compliance with the guidelines once the interventions ceased. However, the importance of Isouard's report is that it provides an alternative, non-punitive way to modify pathology service use. It focuses on the processes of ordering and using services, it uses the knowledge and expertise of all the healthcare practitioners involved in the processes, it has the potential to eliminate inefficient and redundant process steps, and it is more likely to provide incentives to healthcare practitioners to reduce variation and hence costs. It also allows for re-engineering the processes to maintain or enhance quality. Favourable outcomes have been reported for similar studies with total hip replacement,7 elective surgery,9 and addressing adverse drug events.10 In these difficult times of rapid change, healthcare practitioners face increasing pressures to reduce costs while providing high quality patient care. Reductions in funding and the use of the traditional scientific method, accoutred with reductionism and concepts developed in "wet" laboratory experiments, may prove inadequate as tools to deal with situations such as the growth in use of pathology services. Healthcare practitioners now need to include in their armamentarium quality improvement techniques,7,9 critical pathways analysis,7 process re-engineering,7,9 and other methods such as qualitative research.11
Robert A J Conyers
©MJA 1998 |
|
| |
|
Contents | Home | Help | Archives
| |