As we move into a post- health reform environment, the first priority is implementing the reform provisions that reduce the number of uninsured. The second, and much harder priority, is to improve care while reducing costs. Why is this so much harder? One reason is that many members of the public, patient advocates, and providers have a firm belief that all medical treatment available – either drugs or medical procedures – for a particular condition should be used until that condition is cured. Even if a particular treatment has just a small chance (or maybe not much chance at all) of working, it’s still worth trying because it might just work for that one person.
The problem with this belief is it ignores the fact that medical treatment can and does often have serious unintended consequences or side effects. Some treatments may not work to treat illness and otherwise be benign. Others may be effective, but have such debilitating side effects that are either known or unknown that the cure is worse than the disease. The additional problem is that medical care has become so specialized and high pressure – especially for those primary care doctors who we somehow expect to see 35 or more patients a day – that it’s hard even for the most dedicated physicians to keep up with even all the independent research on available drugs and treatments.
As a result we have situations like Sarah Avery reports about today in the News and Observer. Avery has a story about serious side effects from a drug called metoclopramide. Metoclopramide has been in use for over thirty years to treat severe nausea, primarily in chemotherapy patients and for people with diabetes also suffering from nausea. Like many drugs however, drug company marketing and related activity along with the general trend toward more use of medical treatment for everyone has resulted in much wider and longer-term use of the drug.
Unfortunately, as Avery reports today, it turns out that use of metoclopramide causes the majority of cases in the US of tardive dyskinesia, or lifelong involuntary tics and movements that can be severe and debilitating. The risk is higher for people who use the drug longer than 12 weeks or use high doses of the drug. Indeed, the dangers of long-term use of metoclopramide have been reported in the national media as much as a year ago already, making it all the more amazing that this drug would still be prescribed for long-term use or in any case but the limited ones where the benefits of the drug truly outweigh the serious risks.
Health reform gives us the opportunity to address the issue that Avery writes about today. Providing more information and studies about drugs like metoclopramide can help physicians make the tough decisions when to provide a drug like this. Better electronic medical record systems combined with better coordination of care can also provide an early warning system to identify patients who might be harmed by inappropriate prescribing of drugs like metoclopramide and recommend more appropriate treatments. Not only does this improve care, but it also saves money, and that’s one side effect that should be welcomed by everyone.