Apply standards of care equitably

Two patients in a hospital's emergency department exhibit similar symptoms, including white blood count results, that suggest appendicitis. The patient with health insurance is sent for a computed tomography scan, but a surgeon is called for consultation on the patient without insurance. Is the latter patient being treated fairly?

Reply:

This scenario touches on many ethical and decision-making issues, including the utility of imaging for appendicitis diagnosis, how standards of care are developed, assessment of risk in medical decision-making, equitable distribution of care, and physicians' attitudes regarding patient input and socioeconomic status.

The use of CT scans in the diagnosis of suspected appendicitis has become fairly common in the past 10 years. The test has very high sensitivity and specificity when properly performed; yet in practice, its value is less clear.

Research studies have yielded conflicting results for the impact of CT scanning on undesirable outcomes. Some studies have linked "liberal" use of scanning to dramatic reductions in both unnecessary operations and appendiceal rupture rates due to improved speed and accuracy of diagnosis. Other studies have shown no significant reductions in undesirable outcomes to justify the added expense and risk of additional radiation exposure. Nevertheless, many physicians and hospitals have embraced the promise of the test and recommend its use, either judiciously or liberally, as a matter of standard care. A significant drop in rates of negative appendectomy (unnecessary surgery) has been noted during the period of adoption of scanning, although a cause-and-effect link between the two trends is uncertain.

This scenario prompts us to ask how standards for ordering diagnostic tests are set. Similarly, in the absence of a set standard, how should individual physicians decide whether or not to use a test? These are basic questions of medical decision-making and should be emphasized in all medical education curricula to ensure that only necessary tests are performed, to keep costs and risks as low as possible.

Yet in this highly technological era it is all too easy for physicians to order unnecessary or redundant tests. They do this for a number of reasons, including fear of litigation (defensive medicine), lack of confidence in their clinical abilities, desire to maximize patient confidence or encouragement to use billable institutional resources.

Thus, a tenet of medical decision-making bears repeating here -- a test should be done only if its results could change the course of treatment. The underlying theory of decision-making and efforts to quantify a test's role in decision-making can be complicated. But it boils down to how certain the physician is about the diagnosis based on pretest clinical observations. For very high and very low clinical suspicion, the test should not be ordered. The test should be ordered only if clinical suspicion is in the gray area and the risks of the test itself are relatively low. Because the research on CT scans is inconclusive, physicians, hospitals and payers are independently setting their own standards of care.

Determining the best care

In this scenario, the two patients have identical histories and symptoms. One receives a CT scan; one does not. The only reason we can see for this difference is that the first had insurance coverage and the second did not.

There is inequality of treatment, but it is uncertain which patient received the "better" treatment. If the standard of care had been to use CT scans even when clinical suspicion of appendicitis is high, then the first patient received more proper care, while the second patient was denied it. If the fictional hospital in the scenario has not adopted CT scanning as a protocol when clinical suspicion is high, we could argue that the first patient incurred unnecessary risk and charges.

The most obvious unnecessary direct charges to the patient probably come in the form of a co-payment, but physicians tend to forget that patients also pay indirectly for tests through insurance premiums.

The risks of an unnecessary CT scan are small, but real. Radiation exposure is potentially harmful, but an inconclusive scan on a high-suspicion patient could dissuade the physician from promptly recommending a necessary appendectomy. The risk of delay and the consequences of rupture are well known and severe.

In the absence of conclusive science, the best way to avoid the ethical dilemma depicted in this scenario would be always to follow the standard of care for all patients, regardless of ability to pay, while continually monitoring the developing science to determine if, and when, the standard should be changed.

One of the reasons the ED physician did not request a CT scan for the uninsured patient well might have been a concern for his ability to pay. The physician may not have wanted to burden the patient with a bill or cause an uncompensated loss for the hospital. This is a common undocumented consideration that goes through the mind of many health care professionals. But the lack of insurance, in and of itself, does not necessarily indicate a patient's socioeconomic status or ability to pay. It is not out of the question that a patient from a middle-class or wealthy family would be without health insurance. Uninsured rates are actually quite high for this demographic.

The point is that sensitivity and specificity of indicators is as important for social judgments as it is for medical judgments. More important, this entire ethical muddle could have been avoided by an equitable and objective application of the hospital's standard of care.

Mark F. Guagliardo, PhD, assistant professor of pediatrics and of prevention and community health, Children's National Medical Center and George Washington University, Washington, D.C.

Kurt D. Newman, MD, director, Joseph E. Robert Jr. Center for Surgical Care, Children's National Medical Center; professor of pediatrics and surgery, George Washington University, Washington, D.C.