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Tag: Elaine Schattner

Reducing Cancer Care Costs by Comparative and Cost-Effectiveness Research (CER)

Well, it’s time to resume our dis­cussion of Bending the Cost Curve in Cancer Care.

We’ve reached the end of the list, on ideas to reduce oncology costs put forth by Drs. Smith and Hillner in the May 25 issue of the NEJM. Really this 10th and final point intended for oncol­o­gists is two-​​in-​​one: “The need for cost-​​effectiveness analysis and for some limits of care must be accepted,” they chart. So doctors should embrace studies of com­par­ative effec­tiveness and cost effectiveness.

Hard to argue with reason — they’re correct, of course. They write:

… The national imper­ative is to empower a trans­parent, acceptable, equi­table, polit­i­cally inde­pendent agency for guidance in making tough choices in the public interest so that doctors do not have to make them at the bedside.60 Ulti­mately, we will have to make deci­sions based on some cri­teria, and comparative-​​effectiveness61 and cost-​​effectiveness62 analyses are good ways to align resource use with the greatest health benefit.

This sounds great, and is probably right, but I don’t think it’s realistic.

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How to Avoid Death in the ICU

Some­thing I learned as a medical intern is that there are worse things than dying.

As I recall, it was sometime in April, 1988. I was putting a line in an old man with end-​​stage kidney disease, cancer (maybe), heart failure, bac­teria in his blood and no con­sciousness. Prince was on the radio, loud, by his bedside. If you could call it that – the uncom­fortable, cur­tained com­partment didn’t seem like a good place for resting.

An attending physician, a smart guy I respected, approached me as I com­pleted the procedure.

“It’s kind of like Dante’s seventh circle,” he noted.

Indeed. A clear, flexible tube drained greenish fluid from the man’s stomach through his nose. Gauze covered his eyes, just par­tially. His head, hands and feet swelled with fluid. A semi-​​opaque hard-​​plastic instrument linked the man’s trachea, through his paper-​​taped mouth, to a noisy breathing machine. His skin, barely covered by a stained hos­pital gown, was pale but blotchy from bleeding beneath. An arterial catheter inserted by his wrist, just where I might have taken his pulse had he been healthier. A fresh adhesive covered the cotton gauze and brownish anti-​​bacterial solution I’d placed over his lower right neck.

“Yeah,” I said as we walked out of the room to review another patient’s chart.

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