QUALITY OF CARE = ACCESS TO CARE

The most important issue for health care consumers is the quality of medical care.  One aspect of quality care is access to care.  All insurers and HMOs claim that they do not "ration" or limit access to care.   Kaiser, for example, advertises that health care decisions are made by its physicians solely on the basis of patient need.  But even if that statement is true, policies driven by economic considerations can be implemented to limit access to care.  For example, staffing levels may determine how easy or difficult it is for a Kaiser subscriber to get an appointment with a physician or with a specialist.  A policy may determine whether a patient will receive a certain type of diagnostic test.  Here are a few examples.

IN THE BAY AREA KAISER ONLY OFFERS NEUROSURGERY

AT KAISER HOSPITAL IN REDWOOD CITY

In the Bay Area, Kaiser only maintains a Department of Neurosurgery at its medical facility.   In the case of a Kaiser patient who arrives with a neurosurgical emergency, that patient is either transferred to the hospital, or to a local hospital, depending on the urgency of the problem.

A transfer from one hospital to another can be, and usually is, time-consuming.   A patient with a neurosurgical emergency will usually require a critical-care ambulance for transfer.  These types of ambulances are not always readily available.  It can also take several hours to transfer a Kaiser patient from Kaiser Oakland hospital. While waiting for transfer to Redwood City, a Kaiser patient with an urgent neurosurgical emergency will be treated by an emergency room physician, possibly by a neurologist if there is one available.  Emergency room physicians generally do not have the same knowledge and experience as a neurosurgeon in treating neurosurgical emergencies.  Usually emergency room physicians are busy treating several patients at once, and an emergency room physician may not have enough time to provide the focused care that a neurosurgical emergency may require.

This lawyer knows of one case which involved a patient with a brain hemorrhage who was brought promptly to Kaiser Oakland hospital after being stricken.  She also remained in the Kaiser emergency room for about 5 hours before an ambulance could take her.  It took another hour to get her from Oakland into a bed on the neurosurgery service at Kaiser Redwood City.   By the time the patient arrived in Redwood City, her brain hemorrhage had become a fatal brain injury.  It would have been difficult to know whether the patient would have survived if the services of an experienced neurosurgeon had been available at the Oakland facility.  But if an experienced neurosurgeon had been available in Oakland and had provided focused care, the patient's life might have been saved.

The absence of neurosurgery departments at Kaiser hospitals in the Bay Area except is most probably related to economic considerations.   Kaiser probably saves a considerable amount of money by having a neurosurgery department at only one of its Bay Area hospitals.  This economic decision may, in some instances, result in some patients receiving less than optimum care.

CAROTID ARTERY ULTRASOUND - IS THIS TEST RATIONED?

One of the leading causes of stroke is atherosclerosis of the carotid arteries, large blood vessels that provide blood to the front  half of the brain.  The pulse that can be felt on either side of the throat is the pulse from the common carotid arteries.

People who have smoked a pack of cigarettes per day for 20 years or more, who have high cholesterol, who have a family history of cardiovascular disease, and who are older, are at risk for clogged carotid arteries caused by plaque buildup.   When carotid arteries are narrowed 70% or more, that increases the chances that  blood clots will form at the narrowed location. These clots may then travel to the brain and lodge in smaller blood vessels.  When this happens, the clot stops blood flow to brain tissues which are served by the blocked blood vessel.  The absence of blood to these tissues may cause them to die.  When there is brain tissue death, the function that the tissue had controlled dies with it. For example, brain tissue in the left front half of the brain controls the ability to speak.  If that brain tissue dies from lack of blood because of a blocked blood vessel,  the patient will be unable to speak.

Sometimes when carotid arteries are becoming narrowed (it is frequently a progressive disease), there will be some signs or symptoms that one of the patient's carotid arteries is becoming blocked.   One sign of plaque buildup is a "whistling" noise which is made by the artery and that can be heard through a stethoscope.  The artery sometimes makes a "whistling" noise -  because the narrowing increases the velocity of the blood flow in the narrowed part of the artery - just like the water flowing through a garden hose will make more noise if you make the hose more narrow by pinching the hose.    A noisy carotid artery tells the doctor that the patient has some degree of narrowing of the artery, but it does not tell the doctor how much the artery is narrowed.

Apart from a "whistling" sound, a patient may have other symptoms or signs of a clogged carotid artery, for example, "transient ischemic attacks" ("TIAs").  Transient ischemic attacks result from blood clots which block blood flow temporarily to a part of the brain.  During the temporary blockage, the patient experiences stroke-like symptoms in parts of his or her body controlled by the front half of his brain, for example, slurred speech or loss of speech, loss of muscle control or sensation in the right or left hand, right or left foot, or even loss of eyesight in the right or left eye.   These temporary blockages are typically caused by small clots which quickly break up and dissolve.  Because blood flow is quickly restored, brain tissue is not permanently injured (hopefully) and neurological function becomes normal again.   TIAs are a sign that a major stroke may be imminent.

There is an imaging test which can tell the doctor and the patient whether the patient has a partially obstructed carotid artery and how great the obstruction is.   The test is called "carotid ultrasound."   Using only sound signals - non-intrusively - you can check the carotid arteries.  The cost to a provider like Kaiser for a carotid ultrasound test is estimated to be about $150 to $200 per test.

Should a patient with risk factors for carotid artery disease be screened with carotid ultrasound?  Should a patient with a "whistling" noise in a carotid artery receive a carotid ultrasound? Should a patient with TIAs receive carotid ultrasound?  There is a debate in the medical community about using diagnostic tests like carotid ultrasound.  This debate concerns other tests as well, for example, mammography.  The reason for the debate about screening is cost.  Screening large populations is an expensive proposition.

This lawyer has attempted to estimate the cost of carotid artery ultrasound screening for the population of Kaiser patients who are likely to have the risk factors for carotid artery disease.  While this estimate is just a GUESS,  it is a conservative guess.   (This lawyer invites the comments of more knowledgeable persons.)

The estimate is this:  Kaiser has 8.4 million subscribers.    If 25% of those subscribers are 50 years old or older, that population is approximately 2 million patients.   If 10% of those patients have three risk factors for carotid artery disease, e.g. smoking for 20 years, high cholesterol and older than 50 years, that population would be approximately 200,000 people.  The cost of carotid artery ultrasound to screen 200,000 patients would be 30 to 40 million dollars.   Because atherosclerosis is a progressive disease, re-screening of some of those patients annually or semiannually would be necessary.  If such screening resulted in finding hundreds or thousands of patients with significant carotid artery disease, i.e., 70% or greater blockage, there is effective surgical treatment to correct the problem.  That surgery is, however, expensive.

Given this estimated cost of screening and given the cost of surgery or medical care for the disease, what policy, if any, should a physician who needs to decide whether or not to order carotid ultrasound for a patient follow?  Should carotid artery ultrasound be ordered when the patient has 1, 2 or 3  risk factors for the disease, but does not have either a "whistling" sound or TIAs? What if the patient has a "whistling" sound" but no risk factors and no TIAs? What if the patient has a "whistling" sound and one or more risk factors? What if the patient has TIA's but no whistling sound and no risk factors? What if the patient has TIA's and a whistling sound and one or more risk factors?

The medical community is in unanimous agreement that patients with TIAs should have carotid ultrasound.  They are called "symptomatic" patients, i.e., they have clinical symptoms which suggest that carotid artery disease is causing blood clots to form and temporarily block blood vessels.  But there is disagreement about whether "asymptomatic patients," i.e. patients without TIA's, should have carotid ultrasound.   Some studies by medical centers have suggested that it is not cost-effective to screen asymptomatic patients with carotid ultrasound to look for disease.  The problem with waiting until a patient has a TIA before doing carotid ultrasound is that a number of patients will suffer major strokes from carotid artery disease without first having a recognized TIA.  Physicians who are not economically constrained will usually order carotid ultrasound if they hear a "whistling" noise in that artery, with or without risk factors.   Or if a patient is known to have significant cardiovascular disease of the heart or legs, a physician may order carotid ultrasound to check the carotid vessels, particularly if the patient has been a heavy smoker.

Does Kaiser have a policy which limits carotid ultrasound to symptomatic patients so that a physician would feel constrained about whether to prescribe carotid ultrasound in instances when a patient is asymptomatic?  I do not know the answer to this question. However, my experience has made me question whether Kaiser had such a policy.

In addition, there are some specific differences between Kaiser facilities with regard to whether carotid ultrasound is available on the premises or whether carotid ultrasound must be ordered through a third party.  At Oakland Kaiser, a family practitioner must get the permission of the Chief of Medicine or his designee to send a patient to a third-party  for ultrasound, unless the patient has been admitted to the hospital.   At Redwood City Kaiser, the hospital has ultrasound available on the premises.

Because a decision to order carotid ultrasound most frequently depends on recognition of symptoms that suggest TIA in the carotid distribution, a general practitioner may or may not seek the aid of a neurologist in deciding whether a symptom is a TIA in the carotid distribution and whether an ultrasound is warranted.  Neurologists have more experience than any other branch of medicine in treating and caring for strokes.  At Kaiser San Rafael, a published protocol requires a family practitioner - in cases of suspected TIA’s -  to consult with a neurologist.  I have not been able to find a similar protocol for Kaiser Oakland.   Variability in practice guidelines between Kaisers can result in significant differences in outcome - a patient treated with surgery to prevent stroke versus another patient who does not get the surgery and suffers a severe, debilitating stroke.

Lastly, a retrospective analysis of about 1800 Kaiser patients who presented at Kaiser emergency rooms in the Bay Area in the late 1990's with symptoms of TIAs was preformed by a group of researchers.  The findings of that study were reported in the December 2000 Journal of the American Medical Association.  The study showed that 11% of persons with three risk factors for stroke, including certain types of TIAs, would suffer a stroke within 90 days of being seen in the ER, and of that 11%, half of them would suffer a stroke within 2 days of presenting at ER.   In other words, 5 or 6 people out of 100 people with TIAs will suffer stroke within 2 days.

These findings showed that when certain symptoms and risks factors are present, carotid ultrasound must be performed urgently, meaning as soon as possible within 24 hours. If carotid ultrasound shows 70% or greater obstruction, urgent surgery to remove carotid plaque is indicated, i.e., surgery within one or two days, at most.  Until surgery is performed a patient is admitted to the hospital and placed on a blood thinner.