Health care - administrative incompetence

[xjx388]

Is it in evidence that the reason for the different protocol in treating throat infections in the UK is cost-saving?

Not at all. It's just my suspicion that cost-saving might be a big reason for the difference in protocols. I could be wrong. But certainly, it's one of the big fears that doctors have when contemplating a Socialized Medical model.

 

[Uncayimmy]

I'm sure our doctor is well aware of when it is or is not appropriate to test for strep throat. I'm sure there are times when she just looks at a sore throat (along with all the other signs and symptoms) and determines that she should just treat it.

That's why I let her practice the medicine.

Then perhaps you shouldn't write things like, "We do a strep test for all sore throats." That's especially egregious since estimates are that only about 10% of sore throats are bacterial.

 

[Uncayimmy]

Not at all. It's just my suspicion that cost-saving might be a big reason for the difference in protocols. I could be wrong. But certainly, it's one of the big fears that doctors have when contemplating a Socialized Medical model.

Maybe before you make assumptions you could do a little research:

http://www.nhs.uk/Conditions/Sore-throat/Pages/Treatment.aspx
The use of antibiotics (medication to treat bacterial infection) is not usually recommended for the treatment of sore throats. This is because:
Most sore throats are not caused by bacteria.
Even if your sore throat is caused by bacteria, antibiotics have very little effect on the severity of the symptoms and how long they last, and may cause unpleasant side effects.
Overusing antibiotics to treat minor ailments can make them less effective in the treatment of life-threatening conditions.

Antibiotics are usually only prescribed if:
your sore throat is particularly severe
you are at increased risk of a severe infection, for example because you have a weakened immune system due to HIV or diabetes (a long-term condition caused by too much glucose in the blood)
you are at risk of having a weakened immune system, for example because you are taking a medication that can cause this, such as carbimazole (to treat an overactive thyroid gland)
you have a history of rheumatic fever (a condition that can cause widespread inflammation throughout the body)
you have valvular heart disease (a disease affecting the valves in your heart, which control blood flow)
you experience repeated infections caused by the group A streptococcus bacteria

 

[jimbob]

They can make an empirical diagnosis without a lab test for confirmation if most or all the symptoms are there. That's the Centor Score I referenced earlier. I suppose the UK uses the same thing or something similar.

Oh, yes it was pretty obvious to me what I had.

 

[cwalner]

I did find the comments about Strep Throat interesting. Throat infections caused by the strep bacteria can lead to serious, albeit somewhat rare, consequences. We do a strep test for all sore throats. If positive, antibiotics are given. This is just good medicine because it greatly reduces the possibility that complications will arise. Now, if the NHS doctors routinely do not treat Strep Throat with antibiotics, I think that's a real problem that has its roots in cost savings.

I'm not so sure about that. I have heard references to problems resulting from overperscription of anit-biotics. It is Natural Selection at work. Over time bacteria that are resistant or immune to the antibiotic flourish and the anti-biotics become less effective.

This could be as much behind the NHS reasoning for limiting use of anti-biotics as cost.

 

[xjx388]

I'm not going to further derail this topic regarding the diagnosis and treatment of strep throat. It is, however, an excellent illustration of how cost-savings might play a role. This is only speculation, but perhaps the NHS guidelines on treating Strep Throat (or any other condition) were drafted in order to spend the least amount of money.

This article certainly seems to support the idea that decisions are made based on cost-savings instead of what's best for the individual.

Trusts around the country are refusing to pay for operations ranging from hip replacements, to cataract removal and wisdom tooth extraction.
<snip>
NHS Portsmouth will not allow patient classed as overweight to have routine hip or knee replacements where as before they only said the obese could be refused and NHS West Kent are forcing smokers to go on quitting courses before they can join waiting lists for operations.
NHS Warwickshire is cutting 'low priority' treatments which include injections for back pain and any orthopaedic surgery must be first cleared by managers.
The NHS in Greater Manchester and Oldham are refusing surgery for mild varicose veins and strict criteria must be met before removal of warts or tonsils will be considered.
In nearby Warrington GPs have been asked to delay all non-urgent operations and treatments for eight weeks.
Katherine Murphy, chief executive, said: "I am really very concerned about trusts cutting back on diagnostics. What is the diagnosis comes too late? You cannot put a cost on someone's life.

 

[xjx388]

I'm not so sure about that. I have heard references to problems resulting from overperscription of anit-biotics. It is Natural Selection at work. Over time bacteria that are resistant or immune to the antibiotic flourish and the anti-biotics become less effective.

This could be as much behind the NHS reasoning for limiting use of anti-biotics as cost.

Yes, that's true. That's why we don't give antibiotics to patients with viral infections. But it's perfectly appropriate to give them to patients with bacterial infections. The focus in the US is 1)Reducing the risk of infection and 2)Reducing the risk of transmission -even if it doesn't reduce the actual symptoms of the infection any quicker.

 

[Bob001]

This could be an example of how the legal system impacts U.S. health care. If a U.S. doctor failed to provide antibiotics to a patient with strep who had one of these conditions (possibly even unknown to himself) or who subsequently developed one of the rare but potential complications, he could find himself facing a malpractice suit (as well as a much sicker patient). Easier and safer (for both the patient and his doc) to say "Strep diagnosis = antibiotic prescription." It might be interesting to know whether there are statistics that compare the percentage of diagnosed strep infections that develop into something worse in the U.S. vs. the U.K. (As an aside, in the PBS special I referred to above, the correspondent asked doctors in several countries how they would treat his own old shoulder injury. An American doctor wanted to do a full-out surgical joint replacement. Doctors in some other countries recommended medication and physical therapy. The U.K. doc said, in effect, "Ah, it won't kill you. Just live with it." I guess every country has its own treatment philosophy.)

 

[Tatyana]

I appreciate everyone's comments here. I obviously have much to learn about how National Healthcare works. I plan to investigate it more fully.

I did find the comments about Strep Throat interesting. Throat infections caused by the strep bacteria can lead to serious, albeit somewhat rare, consequences. We do a strep test for all sore throats. If positive, antibiotics are given. This is just good medicine because it greatly reduces the possibility that complications will arise. Now, if the NHS doctors routinely do not treat Strep Throat with antibiotics, I think that's a real problem that has its roots in cost savings.

I guess this is my biggest concern with any form of National Health Care: How much is the practice of Medicine compromised in order to save taxpayer money?

Another minor note: Some of the comments seem to suggest that the US health care system is somehow out of date or overly wasteful. I think this is as big a myth as is the "two week wait" myth.

You strep test for all sore throats?

Is that tradition or evidence based medicine?

Micro is not my area of speciality, but this seems a bit ridiculous.

NICE is hailed in the NEJM as being quite revolutionary as it is focused on evidence based medicine rather than tradition or what doctors might think is best practice.

I commented that there are tests and practices in US pathology labs that are about twenty years out of date.

For example, if you are a doctor, are you using something like a Cockroft-Gault calculations are all of your creatinine results?

I am sure there are individual practitioners who do follow the latest evidence based medicine, but it isn't all of them.

The number of things like total T3 and reverse T3 results on lab reports indicates that the US is lagging behind in basic pathology.

 

[Tatyana]

I'm not going to further derail this topic regarding the diagnosis and treatment of strep throat. It is, however, an excellent illustration of how cost-savings might play a role. This is only speculation, but perhaps the NHS guidelines on treating Strep Throat (or any other condition) were drafted in order to spend the least amount of money.

This article certainly seems to support the idea that decisions are made based on cost-savings instead of what's best for the individual.

I think you may have heard people commenting that it is a national sport bashing the NHS.

It is a newspaper.

If you are a medical practitioner, you should realise that there are issues with replacing a hip or knee in an obese individual, they need to lose weight or the operation is for naught.

I can remember another 'scandalous, the NHS is RACIST' as ACE inhibitors were not being prescribed to people who had an African or Carribean heritage.

It isn't that the NHS is racist, it is that ACE inhibitors do not work on people from Africa or the Carribean.

I am relying on my memory, but I am fairly positive I ran across this argument demonstrating the evils of socialised medicine.

 

[Professor Yaffle]

My mother-in-law is obese, and has had a hip replacement (ETA in Scotland). The surgeon asked her to try to lose some weight before the operation (which she did) in order to minimise the risks of the operation/anaesthetic, but there was never a question of her being refused completely.

 

[Uncayimmy]

Suggestion: For those who don't list their actual location on their profile, it would be helpful to mention at some point at least your country. I'm familiar enough to know some, but I'm sure others reading this thread now or in the future may not know.

 

[jimbob]

Not at all. It's just my suspicion that cost-saving might be a big reason for the difference in protocols. I could be wrong. But certainly, it's one of the big fears that doctors have when contemplating a Socialized Medical model.

Previous American posters in this thread have given examples where needless bureaucracy due to different insurance companies approval processes has had a worse effect.

As for antibiotics, I thought that most generic antibiotics are fairly cheap, in which case the standard NHS prescription charge would cover most or all of the cost.

 

[xjx388]

Previous American posters in this thread have given examples where needless bureaucracy due to different insurance companies approval processes has had a worse effect.

Well, it certainly increases costs. That's why I said that if I didn't have to deal with the government and insurance companies I could charge a whole lot less for our clinic's services. In the case of strep throat, $40 would cover the visit and strep test easily. Unfortunately, I can't do that now because of all the costs I incur trying to wade through the multiple bureaucracies (among other things). It actually works out that I need to collect about $90 per average visit (at our current patient load) just to stay afloat. Think of this, it costs me an average of $8 just to send bills to each patient's insurance company. That doesn't even count the cost of dealing with denials, pre-authorizations, etc. Crazy stuff.

And we're just a Family Practice clinic. Specialists have much higher costs as do hospitals because they are subject to a whole lot more regulation. Deregulate and we can all charge less.

 

[Tatyana]

Previous American posters in this thread have given examples where needless bureaucracy due to different insurance companies approval processes has had a worse effect.

As for antibiotics, I thought that most generic antibiotics are fairly cheap, in which case the standard NHS prescription charge would cover most or all of the cost.

The NHS uses a lot of generic drugs, you can check the cost of any drug on the BNF website.

I am reading the treatment for adults for throat infections, it recommends phenoxymethylpenicillin (clarithromycin for penicillin allergic).

It states to consider antibiotic therapy if there is a history of valvular heart disease, systemic upset, peritonsillar cellulitis or abscess, or at increased risk from acute infection (immunosuppression or cystic fibrosis, and that it is required for beta-haemolytic sterptococcal pharyngitis.

It goes on with a few other bits, but I won't bore everyone.

It costs (net price for 28 tab packet) £ 1.35.

There is a seperate BNF for children, however, the advice is the same (except for a different antibiotic for those allergic to penicillin).

I think the issue with trying to grow a culture for EVERY sore throat is that:

1. It takes at least 24-48 hours to culture bacteria and in that time a bacterial infection could be quite nasty (which is why the doctor typically prescribes broad spectrum immediately if throat infection is suspected).

2. Most oral cultures (including sputum) are difficult as there is already such a phenomenal number of little beasties in our oral cavities.

3. Some of the really horrid bacteria do not grow readily in culture.

4. It is typically not necessary unless you do have some odd throat infection that does not respond to broad spectrum antibiotics. If so, it is likely that it may not even be a bacterial infection.

 

[xjx388]

I think you may have heard people commenting that it is a national sport bashing the NHS.

It is a newspaper.

Understood, but it reflects the fact that the NHS system isn't close to perfect either and that it might be just as "bad" as the US system but in different ways.

If you are a medical practitioner, you should realise that there are issues with replacing a hip or knee in an obese individual, they need to lose weight or the operation is for naught.

Absolutely. But I'm also aware how difficult it is for these people to actually lose the weight. I think it's wrong to make them wait for a surgery that can greatly relieve their suffering right now just because they are obese.

 

[jimbob]

Oh yes, there's plenty of room for improvement in the NHS. however, as far as cost-effectiveness, it is probably about the most efficient in the OECD.

 

[Tatyana]

Understood, but it reflects the fact that the NHS system isn't close to perfect either and that it might be just as "bad" as the US system but in different ways.

Absolutely. But I'm also aware how difficult it is for these people to actually lose the weight. I think it's wrong to make them wait for a surgery that can greatly relieve their suffering right now just because they are obese.

It isn't easy is it.

While the newspaper article states that procedures were denied, it doesn't mean that they are.

This is anecdotal, but I have found that there are issues with communication with clinician and patients.

I remember when I was studying haemotology and diagnosed with a homozygous mutation for MTHFR receptor. I could barely follow anything that she said, and afterwards, I had quite a few questions. My initial research on the internet only panicked me.

You have brought up a point that is true. When considering issues with diagnosis or treatment, in addition to the patient and practitioner, the issue of economics is considered.

If it benefits the patient and saves money running a simple lab test (macro enzymes and hormones are a fabulous example of this), rather than expensive imaging and/or biopsies, then the NHS is going to screen all patients with persistently elevated hormones or enzymes for macro-X first.

Discovering that you have macro-prolactin, rather that having to chop out your pituitary gland is one of the little diagnostic miracles in the laboratory, and now, common practice in the NHS.

It also saves a phenomenal amount of money in further testing and consultant time, as well as less stress to the patient as they only have to have a blood test.

 

[Professor Yaffle]

Absolutely. But I'm also aware how difficult it is for these people to actually lose the weight. I think it's wrong to make them wait for a surgery that can greatly relieve their suffering right now just because they are obese.

Even if it makes them more likely to die on the operating table?

 

[blutoski]

I'm not going to further derail this topic regarding the diagnosis and treatment of strep throat. It is, however, an excellent illustration of how cost-savings might play a role. This is only speculation, but perhaps the NHS guidelines on treating Strep Throat (or any other condition) were drafted in order to spend the least amount of money.

I think that's true, but if the MD is working for an HMO, he's already familiar with this.

My wife is an example: the HMO she worked in in the US decreed that schizophrenic patients recover in exactly 12 weekly sessions without exception. So: any more than 12 sessions are to be billed directly to the patient, as the HMO will reject them.

She did not have a choice with prescriptions either: the HMO had a "strategic alliance" with one pharmaceutical supplier (at the time, it was UpJohn/Pharmacia, but the landscape has changed a lot since then), and that limited the list of prescribeable meds for her patients. Usually only one choice of first-line antipsychotic or antidepressant, regardless of whether the patient had demonstrated prior refractory.

What I'm saying is that there are a few cases where cost reduction may interfere with patient satisfaction, but few where it will interfere with patient health - and the latter are often shortly reversed because it's the same payer and the administrators are intelligent enough to understand that there's no long-term benefit to a short-term cost reduction that does not produce positive net outcomes. If the patient shows up in emerg because of something that was untreated, there's no savings.

My point is to apply perspective: these hypothetical concerns are SOP in the US system. And in Canada... we get to vote on whether we like the administrative decisions or not, regardless of income. We're not just customers... we're owners.