Cleaveland: Dealing with the 'death panel' nonsense

photo Dr. Clif Cleaveland

Since the Affordable Care Act (ACA) was signed into law in 2010, many critics have raised the specter of "death panels." These imagined boards would have unlimited power in granting or denying vital care for sick people. This is patently untrue, yet the deception endures.

Establishment of a nonprofit Patient-Centered Outcomes Research Institute in 2010 was one of the early achievements of the ACA. The purpose of the institute is to systematically evaluate in terms of effectiveness and cost the countless preventive, diagnostic and therapeutic tools available to health care providers. It seeks broad engagement of clinicians, researchers, administrators and policy-makers to define what works and what doesn't in U.S. health care.

The task is daunting. Uncertainty exists around almost every disease as to the best means to prevent, diagnose and treat.

Effectiveness research depends upon carefully structured projects to address specific questions in health and disease. Competitive grants are awarded to institutions and newly assembled networks of providers. One recent focus is the prevention of falls in elderly people. Another goal is management of severe asthma.

In addition to evaluating clinical services, the institute's agenda includes improving health care systems, timely dissemination of clinical information, addressing disparities in health care minorities and creating better mechanisms for gathering and analyzing data. The institute will not dictate what is done; rather, it will provide patients and caregivers with information for making informed decisions.

In response, professional societies have recently developed lists of five low-value health services based on rigorous analysis of data from medical specialists. The lists represent a beginning for identifying procedures of little value.

For example, the American College of Physicians lists cardiac stress-testing in patients with no symptoms and no risk factors for cardiac disease. Heading the list for the American Academy of Pediatricians is the use of antibiotics in viral upper respiratory illnesses. The American College of Radiology advises against routine chest X-rays on admission or prior to operations unless abnormalities are suggested by history and physical examination.

Effectiveness studies can also determine if established tests or treatments are actually worth the money. For years, the U.S. Preventive Services Task Force has produced guidelines for clinicians based upon reviews of studies published in peer-reviewed scientific journals. A recent task force report on the timing of mammography triggered controversy among professional groups that advocated different ages for initiating the procedure. Effectiveness studies are subject to revision based on new clinical studies.

Another recent study, this directed by the National Cancer Institute, enrolled more than 50,000 heavy smokers to assess the value of a diagnostic test. Annual low-dose CT scans of the chest were obtained for persons with 30 or more pack-years of smoking - a pack-year equals 20 cigarettes daily for one year.

For years, uncertainty existed as to the usefulness of this technology in identifying lung cancers that could be cured by surgical removal. Testing was stopped once a person had achieved 15 years of non-smoking or had become too frail from other illnesses to be a candidate for surgery. The study, conducted over years, validated this approach to diagnostic scanning. A lot of money and expertise in experimental design are required for such studies.

Guidelines allow a patient and a physician to have up-to-date information regarding safety, reliability and cost of a test or treatment. Often, this is information that an individual clinic or physician simply do not have time or resources to gather. Guidelines inform rather than dictate the decision that they make in consultation with their patients.

Death panels? Hardly. Informational panels? Certainly.

Contact Clif Cleaveland at