Last week I read a review of an important article titled Surgery versus Physiotherapy for Stress Urinary Incontinence (NEJM. 2013;369(12):1124-1133) published in the New England Journal of Medicine this year. The review was titled with a question that every pelvic surgeon has asked……. Is Surgery a First-Line Option for Patients with SUI? I think the original title was going to be: ‘Is Obama Care Rolling-Out Smoothly?’ but they wanted to leave just a little more suspense to tempt the reader to dive into the article and see where it was going. But not much more…. only a little. I wonder if there is a Dental journal somewhere with an article titled: Is Root Canal Superior to Brushing?, or a Cardiology journal with an editorial on how: Bypass Surgery Found Superior to Diet and Exercise in Prevention of Cardiac Death. Help me I’m drowning. Here are the facts. The subjective cure rate for the physiotherapy group at one year was 53.4% and the objective cure rate for the physiotherapy group was 58% at one year. Although the subjective and objective cure rates were substantially greater for the patients that had surgery it should be noted that MOST of the physiotherapy patients were dry and happy without having surgery. It should also be noted that 10% of those that had surgery had some kind of complication.
Here is the bottom line (and I am speaking loudly now): SIMPLY SHOWING THAT A MORE INVASIVE TREATMENT WORKS BETTER THAN A NONINVASIVE TREATMENT DOES NOT MAKE THE MORE INVASIVE TREATMENT “FIRST LINE TREATMENT”.
Here’s the problem. The inmates are running the asylum. In a health care system where the providers of invasive services are still paid for the number of invasive services provided it would surprise no one to learn that there is a greater tendency to recommend (and of course justify) invasive services over noninvasive services. As the Affordable Care Act limps out into the spotlight we can agree that the intention to provide health insurance to all was a noble and good intention. While we may well provide inexpensive, high deductible, policies to those that can scarcely afford a high deductible, we have not (yet) done anything to change the inefficiency that makes health insurance so expensive in the first place. We have not done anything to change the incentives on the provider side. As long as providers are rewarded for doing more and punished (by a broken system of Torts) for not doing every test under the sun you can rest assured that the United States will continue to spend more on healthcare than any other nation. And yes the providers of services will continue to interpret important literature like the NEJM article above as an endorsement for taking patients straight to the OR.