Good intentions, false economy.

Abstract

Details of our clinical work continue to receive the focused attention of agents and resource managers. Because no work performed by humans can be always perfect, opportunities for outcome improvement can be found in every specialty. It is hardly a secret that much attention is given to cost reduction, surely one particular kind of improvement. The new buzzword expression picking the low-hanging fruit has not become part of modern healthcare reform argot accidentally. In my view, a valid definition of reform pairs the improvement or maintenance of care quality and responsible reduction of net care costs. Those of us involved in surgical care are particularly aware that numerous potential cost and quality issues await definition and resolution. As previously stated, frustration can accompany even sharply defined efforts to discover one incrementally improved care technique for a particular type of operation. Difficult challenges commonly arise from many directions. The list includes erroneous oversimplification in thinking about surgical-care steps, vexing semantic issues, term definition problems, the multifactorial relationships of a measured outcome to putative causal factors, the possible interference (s) introduced by various methodology problems, the differential fidelity of data gathered in surveillance work and in prospective scientific trials, and a looming concern to all but the naive that even carefully demonstrated, statistically significant improvement step (s) achieving publicity in some key journal may not, in fact, be generalizable to other healthcare institutions or patient types. One additional issue deserves separate commentary. When reducing care costs is the achieved goal of some logical care-plan change for a large or small series of patients, it is crucial (and maybe an ethical burden) to pose a reflexive question: For the demonstrated dollar-saving care plan change, were coincident outcome issues of other types examined or acknowledged? I regularly tell fellow surgeons to trust Nelson's instructive concept1 that every episode of care will have four interdependent outcome componentsAfinancial, clinical, patient satisfaction, and patient functional status. This scheme of component labeling is a useful abstraction that can powerfully organize process improvement thinking. Medical care could have used it decades ago! Curiously, if we accept the abstraction, its components exist for every case whether we measure them or not. A deliberate alteration of some care detail in a prospective series of casesA-even under pristine, clinical trial conditionsAthat seems to produce a change in one outcome component may or may not have a detectable effect on one or more of the other three, and it hardly needs emphasis that the post hoc fallacy always potentially lurks in the background when we begin contemplating what actually caused what. However, matters can be even stickier, because any single pairwise interaction of healthcare outcome components may become non-linear as some third component itself changes. An important principle can be found in pondering the mix of possibilities: Given that some demonstrated change in a care step reliably produces a better financial outcome (eg, savings in net cost per case by use of a less-expensive drug or procedure component) , the potential for concealed outcome component effects must be acknowledged by responsible workers, even if it is left to other groups to demonstrate later whether secondary outcome component changes are materially important, merely epiphenomenal, or nonexistent. It seems self-evident, as well, that cost savings are safely presumed only to be immediate in scope unless long-term economic consequences are tallied or modeled. It is an emerging truism that care-