Letter to the Editor
Dr Menkin points out that methods used to constrain health care costs can have unintended and harmful consequences for patients. In England, the National Institute for Clinical Excellence (NICE) uses a health utility, which he cites and which intends to standardize comparisons between therapies. NICE estimates the cost of the additional quality of life provided for a year (QALY) for any therapy. Although in theory, this approach helps to determine which medical approaches are of greatest value, the analyses are time consuming and there is considerable disagreement about the methods used. Only a small number of medical decisions will ever have the benefit of that kind of formal analysis.
There are less time-consuming and more practical approaches that physicians can use beyond formal cost-effectiveness analysis to eliminate wasteful care. As a starting point, neurologists need to understand the relative value of their recommendations. Most would agree that an accountant with longstanding diabetes mellitus who develops a new peripheral neuropathy is unlikely to have lead toxicity or systemic lupus erythematosus. Yet many routinely order a panoply of tests to exclude all diagnostic possibilities.
One reader who prefers anonymity wrote to tell me that he was accused of malpractice for not ordering a neuroimaging study in a patient with headache. Although the case was dismissed, he points out that if we spend fewer resources looking for a needle in a haystack, meaningful medical malpractice reform can provide added assurance to physicians that they need not practice defensive medicine.
Steven P. Ringel, MD
University of Colorado-Denver