Evidence-based medicine and rising healthcare costs

IT ALL STARTED when I read an article on a man who rebuilt his house along modern lines which was not in accordance with its Tudor-themed estate. This had so upset his neighbours that they wanted the character of the estate restored in the facade of the house.

However, it was the response of the Urban Redevelopment Authority spokesman that caused the most consternation. And I quote: "While we understand that some people prefer to retain uniformity within their estate, there are others who may want to redevelop their property to meet their changing lifestyle needs. It would not be reasonable to insist that all landed housing estates keep to their original design, height or size."

My first reaction was surely this could not be so. My wife added that the original developer may have inserted a private treaty to the sale and purchase document, to bind all owners to maintain a certain facade to the estate possibly for a period of time.

But she also added that the response of the URA spokesman would actually be dependent on what was the question that was asked. This set me thinking, that the spokesman may not have been given all the information pertinent to the article, and his answer would depend on the question asked.

In many ways, this incident reflected the issue of overcharging in the private medical sector. Of course, there are black sheep in the profession with the issue of overcharging, but in truth, what is charged is dependent on what is done.

I recently managed a young woman who was admitted for severe abdominal muscle wall pain after she pulled a muscle on an adventure in Laos, possibly when handling her luggage. I had expected her to get better with some rest and analgesic/anti-inflammatory drugs. However, she insisted on some form of imaging and I was sceptical that I would find a problem. That is usually one of my greatest fears when asking for a scan: would it show the problem?

Precision in treatment

She did eventually have an MRI of the abdominal wall and I found something wrong: she had torn the rectus sheath, a fibrous covering of the muscle that gives us the six packs, or the one barrel in the tummy, depending on your body shape.

Once the diagnosis was made, treatment could be directed very precisely. We could direct medication into the injured portion to relieve pain and reduce inflammation, and a binder could be applied to aid the sitting up movement from a lying position.

This is what I call evidenced-based medicine, where a patient's disease is demonstrated in no uncertain terms and cannot be refuted by anyone else. That is why when sports personalities are injured, they are immediately scanned to assess the nature and severity of injury and effect therapy.

I was running a medical clinic during reservist training to prepare servicemen for medical boards to have them downgraded. They came with various letters from specialists, and my advice was to get a scan done, so that one can have irrefutable proof of the injury, and the case would be watertight. Otherwise, the claim can be challenged and no conclusion can be made. And this was important as the medical board of the Singapore Armed Forces has a large volume of cases to clear and waiting time for appointments is long, and one doesn't really want to waste any opportunities, because the next may be long in coming.

It used to be that when one gets admitted to the hospital for severe right lower abdominal pain, if the conditions are right, a clinical diagnosis of acute appendicitis is made and the appendix is removed. Then, a negative appendicetomy rate of 30 per cent was the norm.

In today's context, one would get a CT to have irrefutable proof of appendicitis before surgery is performed.

Of course, not every study is diagnostic and not every right-sided lower abdominal pain needs surgery. One could have an inflamed colon that is also residing in the vicinity of the appendix which presents similar signs and symptoms, or a stone in the ureter or even a gynaecological problem if you were a lady. And these may be differentiated on the CT.

And not all negative studies are without value. There was a lady who came to see me recently, who complained of a lump in the thigh when her hips and knees were flexed, and this was giving her some discomfort.

She was an active tennis player and this problem had prevented her from playing for some months and she had been quite vexed by the problem for the past six weeks. An ultrasound was requested initially and I managed to convince her to get an MRI instead as this would be the definitive evaluation of choice.

As in, if the injury is not evident on ultrasound, it may not mean that there is no problem, but just that the ultrasound does not show it. However, if there was no abnormality seen on the MRI, it would mean that there is no series organic injury and she could go on to physio and actively work the muscles to get the tone and function back again. She agreed to the advice, and the scan was unremarkable and she has gone back to rehab to get fit again.

Improving outcomes

Practice has indeed changed, and I think for the better. With more safeguards in the system, one can make better clinical decisions and have improved outcomes. One would get a CT angiogram before coronary artery stenting, to determine if the catheter angiogram is even necessary. And although a clinical scan can diagnose acute appendicitis accurately, I would prefer a CT before I am operated on.

In a recent symposium, the head of a busy A&E department in the US was asked what was the indication of an urgent head scan for headache. His response was that it was for those who have a neurological abnormality, and also for those without. In other words, everybody would be scanned.

Therefore, in this day and age, "evidenced-based medicine" can be costly, but can you do without it? Would you want to be operated upon without irrefutable proof?

With a better educated population, the demand for bigger, better and faster is inevitable. So the next time you see an expensive bill, ask what has been done. However, don't ask if it was necessary for the scan to be obtained to reach the conclusion. That would require an even longer response

This series is produced on alternate Saturdays in collaboration with Singapore Medical Specialists Centre.