Are We Failing When It Comes to Complicated Care?

Comorbidity: Are we prepared to care for people with chronic or complex conditions?

In their article “The Challenge of Multiple Comorbidity for the US Health Care System,” Parekh and Barton found that the more chronic conditions, the greater the likelihood of the following: “unnecessary hospitalizations; adverse drug events; duplicative tests; conflicting medical advice; and, most important, poor functional status and death. Approximately 65% of total health care spending is directed at the approximately 25% of US population who have multiple chronic conditions. Individuals with multiple chronic conditions also face financial challenges related to the out-of-pocket costs of their care, including higher prescription drug costs and total out-of-pocket health care spending."

Fee-for-service (FFS) medicine hardly incentivizes care coordination, and in some cases, actually does the opposite: “duplication of services, rehospitalizations, and additional unnecessary care.” We now see Congress proposing legislation that “includes experimental and pilot approaches to realigning such incentives and payments.” Nevertheless, is the complex patient going to be compliant, especially if there is poor care coordination and no “medical home?” It is not clear whether “the potential benefits of chronic disease self-care management; personal health records; and other health information exchange platforms, such as secure messaging, are being fully realized to maximize patient participation and health.” However, there is hope in “evidence-based clinical decision making in the care for patients with comorbidities.”

Now, evidence-based medicine sometimes will reveal abuses of the healthcare system. Let's take one poignant example: in “Trends, Major Medical Complications, and Charges Associated with Surgery for Lumbar Spinal Stenosis in Older Adults,” Deyo, et al. note that clinically risky and unnecessarily expensive substitute practices that could not be justified by the clinical evidence are at work in spinal surgery: "Overall, surgical rates declined slightly from 2002-2007, but the rate of complex fusion procedures increased 15-fold, from 1.3 to 19.9 per 100,000 beneficiaries. Life-threatening complications increased with increasing surgical invasiveness, from 2.3% among patients having decompression alone to 5.6% among those having complex fusions. After adjustment for age, comorbidity, previous spine surgery, and other features, the odds ratio (OR) of life-threatening complications for complex fusion compared with decompression alone was 2.95 (95% confidence interval [CI], 2.50-3.49). A similar pattern was observed for rehospitalization within 30 days, which occurred for 7.8% of patients undergoing decompression and 13.0% having a complex fusion (adjusted OR, 1.94; 95% CI, 1.74-2.17). Adjusted mean hospital charges for complex fusion procedures were US $80,888 compared with US $23,724 for decompression alone.”

In “The Increasing Morbidity of Elective Spinal Stenosis Surgery: Is It Necessary?” Eugene Carragee notes that “Consumer Reports has rated spinal surgery as number 1 on its list of overused tests and treatments. This was a harsh rebuke given the benefit associated with many common spinal surgeries. However, the findings from the study by Deyo, et al. should not only remind patients, surgeons, and payers that the efficacy of basic spinal techniques must be assessed carefully against the plethora of unproven but financially attractive alternatives, but also should serve as an important reminder that as currently configured, financial incentives and market forces do not favor this careful assessment before technologies are widely adopted. When applied broadly across medical care in the United States, the result is a formidable economic and social problem.”