Appropriate or Inappropriate – That is the Question…

As pressure continues to mount across the country for the health care system to deliver better and safer care in a faster and cheaper way, many are turning to the question of appropriateness – particularly of diagnostic testing – in the hope that addressing this issue will help to improve the efficiency of the system. Unnecessary and duplicate testing undoubtedly contributes to additional waits for patients, additional costs for payers, and a high degree of clinical practice variation – a phenomenon well known to contribute to suboptimal outcomes and poor efficiency.

Governments are beginning to apply blunt instruments. In Ontario recently, an attempt to deal with what has been perceived as an overuse of echocardiography (echo) saw the MOHLTC propose an end to the practice of self-referral. Doctors are in a conflict, goes the thinking, when they refer to themselves. Consequently, self-referral must necessarily be bad.

As cooler heads prevailed, thoughtful contributors to the debate began to propose alternatives. How can we increase appropriateness without such a drastic measure – a measure sure to lead to the unintended consequence of reduced access for many patients?

The Cardiac Care Network (CCN) – together with physician leaders and in partnership with the MOHLTC – has developed a position statement on the appropriate use of echo and on the need for accreditation of echo labs and echo readers. The new standards positively define appropriate indications for echo, but specifically state that a 10% deviation is acceptable (10% of tests ordered by a doctor, or done by an institution can be done “outside” guidelines). This is intended to recognize all the many hundreds of unusual but legitimate situations that cannot be envisioned in a boardroom but which we all know are present in the clinical, “real” world. Thus, the objectives of reduction in clinical variation, cost control, and preserving the value that clinical judgment provides are all preserved.

The importance of this very positive engagement cannot be overstated. A solution has been proposed that satisfies the needs of the MOHLTC, the physicians, and most importantly, patients.

Just as important is the implicit acknowledgement that “appropriateness” cannot be dichotomized. That which is not “appropriate” is not necessarily “inappropriate”. We live in a world where appropriateness is going to be increasingly adjudicated by third parties who are responsible for remuneration, evaluation of performance, and resource allocation. Accordingly, the working definition of “appropriateness” should reflect the presence of this grey zone.

It is a very important distinction, since it is nearly impossible to positively define every conceivable “appropriate” circumstance for a medical intervention in a complex environment like the practice of medicine. Clinical medicine is inevitably a human endeavor conducted by professionals who use judgment to recognize and respond to the profound complexity of the world, the context of situations and circumstances, and the unique particularity of the persons they strive to help. Clinicians must have some degree of leeway to practice clinical judgment, otherwise, we have reduced the practice of medicine to a simple application of practice standards. This is not science, but scientism because it would deny the necessity of clinical judgment in that application.

Appropriateness criteria – yes! But there are three criteria – appropriate, inappropriate, and may be appropriate.

Doctors as solutions-providers. Keep up the great work!

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