WhiteCoat

Unnecessary Care?

It isn’t much of a case, but it created questions in my mind.

A mom brings her 8 year old daughter to the hospital for a nonproductive cough. No fever. No runny nose. Just a cough. The patient had started school again this week, and so the microbiome in her nasal passages had thus begun mixing with all of the other microbiomes on school lunch tables, desks, and childrens’ shirt sleeves. The end result was that now she was coughing for a couple of days – like a majority of other children in the school.

The child looked fine. I told the mother that she likely had a “head cold” and that it would have to run its course.
The mother wasn’t convinced.
“How do you know she doesn’t have the flu”?
“Well, I don’t know for sure, but even if she did have the flu, it wouldn’t change the management right now. It would still have to run its course.”
“I want her tested for the flu.”
“Influenza testing really won’t help us much. The test itself has a high false negative rate, meaning that even if the test is negative, a large percentage of people still end up having influenza.”
“I want her tested for the flu.”
Fine, I thought. It’s your money.
Forty five minutes later, results from the influenza swab came back negative.
“So like I was saying before, this is something that will have to run its course.”
“You said that the test wasn’t accurate. There are a lot of kids in her school with influenza right now. I want her to get Tamiflu.”
“Tamiflu isn’t going to help. It is only effective within the first 48 hours. You said the cough started two days ago.”
“You know, I have always had good things to say about this hospital and I’ve never had this many problems with a doctor in the emergency department before. It hasn’t been 48 hours and I want her to get the Tamiflu.”
Nice threat.
So I gave the woman a prescription. Let her spend the $120 for a drug that won’t work.

Then I began thinking. Would some bean counting clipboard carrier claim I provided unnecessary care?

So what do you think? Knowing that rapid influenza testing has a significant false negative rate and knowing that influenza is widespread in the country, but also knowing that a patient has mild symptoms …

Is it unnecessary care to provide anti-influenza treatment to someone who tests negative for influenza?

  • Yes (76%, 185 Votes)
  • No (24%, 57 Votes)

Total Voters: 242

Loading ... Loading ...

By the way, after the visit, a pharmacist called and said that the patient was requesting a different medication since the patient was on state “insurance” and the “insurance” didn’t cover the cost of the medication.
Unfortunately, there isn’t anything else that works which was covered.

UPDATE 1/15/2012Thanks for the votes and comments.
When thinking about this situation, three issues came to my mind.
First, Tamiflu is approved by the FDA for acute uncomplicated influenza when symptoms have been present for not more than two days. It is also approved for prevention of influenza. From a technical perspective, a Tamiflu prescription was indicated if the child had influenza or if the child was being prophylaxed against influenza. The indications for use do not contain a description of any symptoms that must be present before Tamiflu is prescribed. If influenza is diagnosed or being prevented, Tamiflu is indicated.
Second, diagnosis of influenza in an inexact science. Rapid influenza testing is notoriously inaccurate. If the test is positive, there is a high likelihood that influenza is present (although about 1 in 50 patients with positive results do not have influenza). However, if the test is negative, one third of children and about one half of adults will still have influenza. A negative influenza test by no means excludes a diagnosis of influenza. Between 30 and 50 percent of influenza cases are asymptomatic and it is difficult to distinguish between a common cold and influenza early in the course of the disease.
Third, Tamiflu probably doesn’t work. A Cochrane review found that Roche funded all of the studies demonstrating Tamiflu’s efficacy, that Roche hid a majority of the data from studies about the effectiveness of Tamiflu (and still won’t disclose it), and that the study data that was released had significant bias. See also this article from Forbes.
Putting all of these facts together, then we need to consider why most people in this case thought that prescribing Tamiflu was “unnecessary”.
Was it unnecessary because Tamiflu doesn’t work? Then anyone who prescribes Tamiflu is providing unnecessary care.
Was it because the patient tested negative for influenza? How do we accurately diagnose influenza in order to prescribe the medications, then?
Was it because the patient’s symptoms weren’t severe enough? What symptoms are needed before Tamiflu can be appropriately prescribed?
In the end, when dealing with this patient’s mother, I decided that the prescription of Tamiflu ends up being an issue of medical discretion. Most people probably wouldn’t have given the medication to their children for those symptoms, but if she wanted it that bad, the medication was technically medically indicated and not prescribing the medication would have resulted in even lower patient satisfaction scores. So I gave her the prescription.

The incentive to improve patient satisfaction favored prescribing Tamiflu and I had no disincentive for doing so. If the patient’s mother wants to pay for a useless medication that has many side effects in order to treat mild symptoms – after knowing these facts – why should she be prevented from doing so. This is just one example of how emphasizing patient satisfaction adversely affects medical judgment, encourages testing and treatment which is of questionable benefit, and drives up the cost of care.
“Unnecessary care” is going to be a catch phrase in the next few years as government and insurers try to decrease expenditures in medical care by refusing to pay for testing or treatment which is deemed “unnecessary.” When you hear this phrase, ask yourself who is making the determination, how the determination is being made, and who stands to benefit.

27 Responses to “Unnecessary Care?”

  1. SeaSpray says:

    Egads! This stuff must make you crazy sometimes. Not being a med person – I voted unnecessary based on facts you gave prior to giving her what she wanted. You said there can be false negatives and she has mild symptoms – but you also said she had been coughing for a couple of days. (more than 48 hrs?)

    Your first instinct was not to do any of that.

    Now …WC …I have this dry (ANNOYING)…unproductive cough, irritated throat and occasional sniffles …. ;)

    I wonder if she got the med?

  2. Dr. J says:

    Since Tamiflu really doesn’t do anything useful even when used in ideal conditions it is pretty much unnecessary care whenever it is Rx’d……That’s my 2 cents,
    Dr. J

  3. mdb says:

    What the pharmacist probably didn’t tell you was that they got an earful from the mother about why tamiflu isn’t covered and why is it so expensive. I know I seem to be getting alot of those from customers coming into my pharmacy. I also get at least one person a day it seems asking where is the tamiflu on the OTC shelves. I have to say I really hate the stupid tamiflu commercials blasted all over the TV.

  4. Ted says:

    Your question is too simple. If Tamiflu is otherwise indicated (clinical picture, right time of year, <48 hours of symptoms) then the test results don't matter. Just treating the test results isn't medicine, it's…pathetic.

  5. dee says:

    I’d say unnecessary but entirely understandable. I work in pharmacy and I’ve seen doctor-hopping for a zpak. There’s no reasoning with the folks who got their medical degrees from Dr Oz or the nightly news.

  6. elmo says:

    Really medicaid patients need to start paying copays like th rest of us to stop this stupiditiy. The blue states are typiclly the worst at this. They allow anything to be done for the medicaid patient, they just will not pay a reasonable rate for it. NY/NJ give payors less than 30 cents on the dollar cost, but god forbid they actually try to control costs with copay to limit idiotic and mass visits. Any reason why IMO these are some of the most entitled and rude patients I have ever delt with?

  7. throckmorton says:

    Just think, that kid blew his nose and wiped his hands all over the ED so the whole staff and all the other patients can catch his cold on top of the flu for which the vaccine is only partially effective.

  8. pat says:

    don’t you have a sepsis protocol??

  9. anymousie says:

    Tamiflu is not $120 -try $135. And that is if you are on the pills. 2 bottles of the liquid (because it almost always takes 2 bottles as he/she “can’t swallow”) is more like $225.

  10. Dave says:

    The worst is ordering a flu test for inpatients at the VA. For whatever reason the residents loved ordering them and they took forever to get back (in the labs defense these were much more accurate non-rapid tests but they still took a week). By the time they got back the patient usually was better/sent home or another cause found. Plus once that order is entered then you get the joy of dealing with airbourne precautions.

  11. Ryan says:

    The poll question is somewhat ambiguous as Ted mentioned above. You’re driving at two different questions – is Tamiflu unnecessary care, and should you treat people for clinical influenza even with a negative test. Given the right clinical scenario (as a hospitalist my patients are typically sicker since they are admitted), I will frequently treat even with a negative test – in fact, we’re not testing anymore in the right clinical scenario, since any negative is likely a false negative.

    Now whether the benefit of Tamiflu is greater than its cost is a different issue altogether. . .

  12. Xsurgerdoc says:

    Elmo is right on. EMTALA has turned the ER into the neighborhood free clinic and we are merely scribes giving out free meds to the masses whether they need it or not. A copayment of $5-10 should be deducted from one ‘s gov’t subsistence check the next month with exceptions only for really live threatening problems. That’s a pack of cigarettes or 2 beers. If nothing is done then this entitlement along MCare and SS will put us in a position worse than the EU

  13. Chris says:

    I’m not in the health care field, so I don’t understand this – YOU are the doctor. Why did you cave in to what the mother requested? YOU are supposed to be making the diagnosis. You said it wasn’t flu, and even if it was, tx wouldn’t be any different. Goodbye, have a good day, mom. That should have been the end of the visit. She demanded meds that weren’t necessary or indicated, and you gave them to her. I don’t mean this comment disrespectfully, I just don’t understand.

  14. Canuck ER MD says:

    It’s called Press-Ganey, Chris.

    She has him (and the sodding Hospital CEO) by the balls…

    The US has to get rid of Press – Ganey : it’s a barrier to sane / logical care in a “customer is king” environment.

    And you need to help.

  15. Anon ER MD says:

    I give my big scary “side effects are bad plus benefit plus it’s expensive and not usually covered” lecture to these folks – because when you look at the side effects (particularly in kids) and the potential benefit (12 hours earlier improvement, maybe) and in my area, not covered by state insurance. So far, it’s worked on all but one family…and they then complained how expensive it was for their 3 sniffly kids.

    That being said – the hospitalized patient, the immunocompromised patient, the very bad lung disease patient – gets the same warnings but not as scary – because they probably do benefit more than healthy people looking to avoid symptoms in general.

  16. Essay says:

    I voted no just because the question was presented in black and white. While I think it’s unnecessary *most* of the time, I do think it’s prudent in high risk patients (elderly with minor symptoms, especially if they’ve been known to be exposed to a flu patient, people on immunosuppressants, other high risk categories). There are times it does make sense.

  17. Emergencyfltdoc says:

    An 8 year old, healthy, afebrile child with a cough? 1. Shouldn’t be in the ED in the first place and 2. Doesn’t meet CDC guidelines for treatment. Tell the patient’s mother to kindly sod off, that the only way her daughter gets an influenza test or Tamiflu is if the mother has a medical license.

  18. GruntDoc says:

    a busy ED weakens your willingness to have “at length” discussions with the “deserving/demanding “…order the damn test…go see more pts…report the good news… discuss meds, if any needed… go see more pts…write the script…go see more pts…never discuss test probability prior to testing (on the BS stuff)… not mentioning high false neg rates would have saved oxygen and a pain in the ass!

  19. Dorothy says:

    The disincentive for ordering an unnecessary test and prescribing an unnecessary drug is that it is the wrong thing to do.

    • WhiteCoat says:

      That’s a nice news byte. Now give me a good way to determine what constitutes an “unnecessary test” and what is an “unnecessary drug” and I’ll figure out some solutions to keep it from happening again.

      • Dorothy says:

        An unnecessary test is one that is not clinically indicated, such as an influenza test for an afebrile patient. Especially when the results of the test, since the patient is 2 days out from onset of symptoms, will not change the course of treatment. Why not X-ray her feet, too? Regarding what constitutes an unnecessary drug: Then cast her feet.

      • WhiteCoat says:

        No afebrile patient should ever have influenza testing done? Even though 30-50% of the cases are asymptomatic? Think you’re over reaching a little here.

        Who gets to judge when something is “clinically indicated”? You? Popular vote? Some old curmudgeon at the FDA who hasn’t practiced medicine since the Civil War?
        24% of people responding to the poll stated that they believed the care was not unnecessary in this case. Do we just disregard the opinions that we don’t like?

        I’m not disagreeing with you that I wouldn’t have wanted testing or treatment for my own kids in this situation. My point is that once we start down this slippery slope, it will be difficult to keep from sliding further down.

        Telling people that they can’t have things they want is OK when it applies to other people, but not so nice when it applies to you.

        Simple solution is to deregulate and make the testing and medications over the counter. If people want to do 20 flu tests on themselves, they should be able to do so … at their expense.

      • Dorothy says:

        Would a positive influenza test have affected the treatment regimen at this time? Fluids, rest, NSAIDs.

        Who gets to judge when something is “clinically indicated”? You, the doctor. Not I (your faithful but long-suffering ER nurse) and not the patient.

        I think instant gratification is the most American of human desires.

        I like the idea of selling influenza tests over-the-counter, but I’m sure you know that accessibility won’t keep people from presenting at the ER and demanding for “free” what they can buy at the dollar store.

      • CJL says:

        If the benefit of Tamiflu is that it decreases the length of symptoms by half a day, then why would you ever test someone who was asymptomatic? They have no symptoms to get rid of, so who cares if they have the flu? You shouldn’t be doing anything for them anyway.

        I fully understand why you did what you did in this scenario. I saw the exact same patient a few months ago, except swap out “flu” for “strep.” Screw the CENTOR criteria, mom saw a “pus pocket” on her tonsils. Lucky for me, the rapid Strep test was negative, and I got to leave it at that.

Leave a Reply


eight − 4 =

Popular Authors

  • Greg Henry
  • Rick Bukata
  • Mark Plaster
  • Kevin Klauer
  • Jesse Pines
  • David Newman
  • Rich Levitan
  • Ghazala Sharieff
  • Nicholas Genes
  • Jeannette Wolfe
  • William Sullivan
  • Michael Silverman

Subscribe to EPM