Column 95 - Choosing wisely..

Choosing wisely..

 

An article in the December issue of the Cleveland Clinic Journal of Medicine discusses headache treatment.   It states that "in the absence of red flag warning signals central nervous system imaging is unwarranted and can be harmful".  It goes further to state that the mneumonic POUND can be used to help in diagnosis.

Pulsatile

One day duration ( up to 72 hours)

Unilateral

Nausea or vomiting

Disabling

The article explains how to evaluate and score these factors to rate probabilty that the headache is a migraine. They site a story of a patient who presents with symptoms that certanly fit the POUND bill, but she insists that she wants an MRI because a friend was recently diagnosed with cancer.

Of course, no one wants to mess around with pain in the head and we are all fearful that it could be something much worse than a migraine. 

I have had clients make comments to the effect of " I am paying all this money, I want to get something for it, so I am going to insist on the highest level of testing."  At first blush this isn't so hard to reconcile.  But it isn't that simple, as the article explains.  

We need to be informed consumers who understand the costs;  both physical and financial of the treatment we are considering. It is important to have access to the tools that help us make informed decisions about health care.

An MRI of the brain or CT can easily cost thousands of dollars, even after the in-network discounts are applied.  The article also explains that that the effective radiation dose from a CT scan of the head is equivalent to 250 days of background radiation exposure or 100 chest radiographs.

I became acutely aware of the decisions that had to be made in 2010 when our daughter presented with severe headache.  In her case it did not fit the POUND criteria, even though multiple physicians insisted it was migraines.  The pain was debilitating, lasting consistently for more than two week.  She couldn't eat, was totally intolerant of light and noise.  She lost about 20 lbs in a short time. It escalated to include persistent vomiting.

After much frustration and insistence on her part that it was NOT a migraine, we insisted on a spinal tap.  At that point we were flying blind.  She was in San Diego, I was in Redding.  She was trying to keep from worrying us and I was going on instinct.  My exposure recently to another meningitis case, plus a long time understanding of my daughter's health history,  made me confident that meningitis was something to be ruled out.

After the spinal tap, the results were dangerously delayed several days due to Thanksgiving holiday and a lab mix up, which resulted in her being treated for viral meningitis.  Ultimately she had cryptococcal meningitis. This is a fungal infection that is typically found in AIDS patients or others with a weak immune system.  Had her diagnosis been delayed much longer she could have died. 

 

Her 7 day hospitalization and treatment cost well over $200,000- after network discounts!  Her excellent insurance covered most of it.

We are happy to report that she has had a complete recovery, altho she must be monitored regularly.  She is part of a clinical study at the National Institute of Health to help better understand this disease and immune competent people.

As much as she is anxious to know the status of these critters that live in her body, she is careful to avoid imaging as much as possible. She educated herself on the potential side effects and understands that it should not be taken lightly.

                The Cleveland Clinic article refers to an innovative program called Choosing Wisely. This is an initiative to encourage conversations between patients and providers about the appropriate care. They have created lists of "things providers and patients should question".   It includes evidence based recommendations that can help patients see their case more clearly. The website, www.choosingwisely.org asserts that 70 specialty societies have joined the campaign since it's inception in 2012.

One of the key provisions in the ACA (Affordable Care Act, also known as Obamacare) is outcomes research.  Like any research it takes time to develop the data before conclusions are made. But clearly the concept of health care transparency is taking hold and we have more resources to help us better understand the process and work in concert with our doctors. This is one worth checking out.

I believe it's imperative that we are informed about options.  No one knows your body as well as you do!  No one is going to care about your health as much as you do. So find and use all resources and work with your doctors to make informed choices.