Today’s clinical practice guidelines suggest a 79 year old woman with osteoporosis, osteoarthritis, diabetes, high blood pressure and chronic obstructive pulmonary disease could be taking 19 medications. Guidelines for osteoporosis suggest she should do weight bearing exercises, and guidelines for diabetes say she shouldn’t.
In 2000, some 125 million Americans suffered from chronic ill nesses. By 2020, that number is expected to be 157 million—32 million more people, in part because of an aging population. Right now, 75 million people in the U.S. suffer from multiple chronic diseases.
The new Institute of Medicine report Best Care at Lower Cost: The Path to Continuously Learning Health Care in America cites these figures to illustrate the many sets of circumstances that are increasing and exacerbating the challenges faced by clinicians and patients. It’s daunting enough that treatment guidelines may be contradictory when a patient has multiple conditions. The report also estimates that individual primary care physicians would have to spend 21 hours a day to provide all the care recommended for their patients’ acute, preventive, and chronic disease management needs. Further, the report quotes a study saying that during a single year, the average primary care physician coordinated with 229 other physicians in 117 different practices just for Medicare patients.
Complexity has increased exponentially. The U.S. healthcare system is characterized by more to know, do and manage than at any time in history, the IOM reports. There were, for instance, more than 200,000 research publications in 2000, and in 2010 new biomedical and clinical knowledge filled 750,000 such publications.
Patients may be beleaguered too. Healthcare costs have increased 76 percent during the last decade. For one of every 14 tests performed, patients weren’t told of abnormal results. The report cites a survey that found 25 percent of patients said tests had to be repeated because results hadn’t been shared among providers who cared for them.
Despite enormous increases in biomedical knowledge and therapeutic and procedural innovation, available knowledge is too rarely applied to patient care and information generated by patient care is too rarely gathered to improve existing knowledge, the report says. For instance, the report notes that in 1982 researchers found that the use of beta blockers after a heart attack reduced mortality by 25 percent. Researchers later found 40 percent reductions in mortality, and the practice was included in professional guidelines in the 1990s. But only in the last five years—a quarter century after the initial discovery—have most heart attack patients been receiving this treatment. The cost and quality of care vary enormously from one state to another, and high cost did not correlate with high quality. If the highest quality had been maintained in all states, 75,000 fewer people would have died in 2005.
While Americans spend $2.6 trillion a year in health care—18 percent of the gross domestic product—some $750 million is wasted. The IOM says that amount could pay salaries of all first responders, including police, fire fighters, and emergency medical technicians for 12 years.
Here is the IOM’s breakdown of estimated wasteful spending:
· Unnecessary services - $210 billion
· Inefficiently delivered services - $130 billion
· Excess administrative cost - $190 billion
· Prices that are too high - $105 billion
· Missed prevention opportunities - $55 billion
· Fraud - $75 billion
To address the complex issues of clinical care, individual and public health and overall cost, the IOM calls for a "continuously learning” health care system. Its characteristics would include:
· In science and informatics, real time access to best available knowledge, and the use of information technology to capture and analyze data from the patient experience
· Engaged, empowered patients and families to work with care providers to promote good health and treatment outcomes
· Incentives for continuous improvement and improved transparency
· Culture in which leaders foster and support continuous learning and supportive system competencies with feedback loops created for continuous analysis and improvement
The full report, a summary, and individual chapters, can be accessed here.