Eyeworld

EW NEWS & OPINION 20 February 2017 Insights by J.C. Noreika, MD, MBA quality and cost. Surely the govern- ment, insurance companies, and the insured in the U.S. incurred higher costs for a more aggressive approach to triple-A repairs than in England. The population-adjusted rate of surgical repair over 8 years was half as high in England as in the U.S. Benefit accrued to Britain's economic ledger. Furthermore, the 3-year survival of about 80% among patients undergoing repair before rupture was the same in both coun- tries. From an outcome standpoint, Britain's NHS produces equivalent results. The lifeblood of trial lawyers, avoidable death is a flagrant, self- evident miscarriage of health care delivery: In 2012, the incidence of aneurysm-related deaths in England was 34.43 per 100,000 compared to 9.03 per 100,000 in the U.S. This extraordinary disparity—a magni- tude of almost four times—can be measured in terms of millimeters, exactly 5.4, the difference between the diameter of aneurysms under ob- servation in the U.K. and repaired in the U.S. Karthikesalingam's import- ant study suggests that operating earlier with advanced technology on aneurysms of smaller diameter saved many American lives. Can the cost-quality dialectic be reconciled? For those additional 25 per 100,000 people who died in the U.K. from an abdominal aortic aneurysm, their uncounted family members and friends, neither cost nor quality, but in Porter's words, results are all that mattered. EW References 1. Dale SB, et al. Two-year costs and quality in the comprehensive primary care initiative. N Engl J Med. 2016;374:2345–56. 2. Porter ME, et al. Standardizing patient outcomes measurement. N Engl J Med. 2016;374:504–6. 3. Karthikesalingam A, et al. Thresholds for abdominal aortic aneurysm repair in England and the United States. N Engl J Med. 2016;375:2051–2059. Editors' note: Dr. Noreika has practiced ophthalmology since 1981. He has been a member of ASCRS for more than 35 years. Contact information Noreika: JCNMD@aol.com patients survive a triple-A rupture. Between 2005 and 2012, 29,300 patients in England and 278,921 pa- tients in the U.S. underwent surgery for an unruptured abdominal aortic aneurysm. The study revealed that repair of triple-A was less common and aneurysm-related hospitalization and death due to rupture more fre- quent in England. Previous studies had shown definitively that the diameter of an aneurysm is the best predictor of rupture; risk is non-lin- ear, exponentially increasing with diameter. "Across all study years and after standardization for popula- tion, age, and sex, repair of intact aortic aneurysms was significantly less common per 100,000 popula- tion in England than in the United States." The diameter of aneurysms at the time of repair was 58.3 mm in the U.S. and 63.7 mm in England, a difference of 5.4 mm. In 2012, the incidence of hospitalization for aneurysm rupture was 7.29 and 16.3 per 100,000, respectively. More aggressive repair of aneurysms in the U.S. was not associated with greater peri- or postoperative risk. England's national health system tolerates a rate of aneurysm rupture more than twice that of the U.S. During the study, patients were more likely to undergo a technolog- ically advanced endovascular repair, 67.0% vs. 45.5%, in the U.S. than in the U.K.; in-hospital mortality from the technique was the same in both countries. In comparison, mortality for an open repair was four times greater than endovascular repair. So what? The answer goes to the heart of the dynamic between the quality of care or patient experi- ence—including the ability to obtain timely appointments, care, and in- formation—plus how well providers communicate with patients, pro- viders' knowledge of care patients received from other providers, and the overall rating of providers by patients proved illusive. Analysis indicted the usual suspects: The time frame for study was too short, the incentives not financially sufficient, the program's requirements too burdensome, prompting physicians to avoid buy in. Might the program's underlying premise be misguided? Quality of care is generally defined by adherence to evidence- based practice guidelines. The International Consortium for Health Outcomes Measurements Standard- ized Outcome Sets endeavors to normalize guidelines globally. Its first 3 years of work covered 45% of the world's burden of disease. Cataracts were one of the first of four conditions studied in 2013, and macular degeneration was one of eight in 2014. But as Porter et al. imply, 2 patients don't give a hoot about guidelines. They want results and, skeptics might observe, results delivered magically at little pain and minimal cost. Patients deem outcomes acceptable when function is restored, pain alleviated, or death averted. Everything else is window dressing. And that injects millimeters into the narrative. In the New England Journal of Medicine, Karthikesalingam et al. 3 published a study retrospec- tively investigating the repair of abdominal aortic aneurysms in the U.S. and the U.K. Only 50% of Physicians are coerced to square the circle when it comes to decreasing cost and improving quality of patient care. If possible, is it advisable? I t is a cliché that baseball, foot- ball, and other sports are games of inches. Visual science con- ducts its business in microns, even angstroms. Is it not then intriguing when comparison be- tween health care outcomes of two first-world systems can be distilled to a handful of millimeters? Two drivers that defy pro- portionality create dissonance in medicine: attempts to slow costs and efforts to improve care. Quality, value directives, quality-adjusted life years, effectiveness, coordination of care, patient centered medical homes, and accountable care organi- zations are current memes specifying sociopolitical initiatives devised to correlate the two forces. Previous attempts to bend the cost curve, e.g., RBRVS, bundling, and capitation, failed to yield the desired result. Current acronymic responses— MACRA, MIPS, and APMs—repre- sent the latest attempt to resolve the cost-quality conundrum. The Comprehensive Primary Care Initiative began in October 2012. This 4-year program was con- ceived to reduce costs and improve care delivery at nearly 500 primary care practices across the country. Incentives included payment of fees for care management, apportioning realized savings and data feedback to improve processes by sharing best practices. Stipends included payment for phone calls, emails, and other interactions related to care management. Two years of data have been analyzed and published. 1 Participating practices have demon- strated no savings for Medicare Parts A and B after accounting for care management fees. Improvements in Cost and quality in 5.4 millimeters J.C. Noreika, MD, MBA

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