Authors of a recent study published in PLoS ONE questioned the use of two commonly prescribed presurgical tests in the US. They somewhat predictably found that while prothrombin time (PT) was ordered unnecessarily in 94.3 per cent of the cases, activated partial thromboplastin time (aPTT) was unnecessary in 99.9 per cent of cases. The authors, Capoor et al., point out that these tests were intended primarily to be diagnostic and there is no rationale to indicate their use in routine screens.
The sample was quite extensive, as it included 1,053,472 consecutive patients from 27 medical facilities enrolled from 2009 to 2012, with complete data gathered for 65 per cent of those patients. Thus, these findings have significant weight, considering that the US, and for that matter, all governments are striving to rationalise healthcare costs.
The authors of the PLoS ONE study conclude that over-diagnosis of disease seems to be a modern epidemic in high-income countries. But there is clear evidence of symptoms of this epidemic in India as well, spanning not just over-diagnosis but for instance, medical implants like heart stents.
Timed with World Heart Day on September 29, our lead story in the Cardiac Care special examines this controversial topic (See story, The Stent Saga, pages 42-45). While stent manufacturers tend to refute this allegation, cardiac surgeons weigh in on both sides of the debate.
There are already signs of regulation. For instance, cardiologists from AIIMS formed the Society for Less Investigative Medicine (SLIM) last year, and with growing support, the initiative went national this May.
Globally too there is a move towards relooking practices and procedures, evolving towards a more rational healthcare model. Medical practitioners will feel that to ‘test is best’, simply to avoid medico-legal consequences but there has to be a balance between evidence and experience-driven clinical practice.
The man on our cover in this issue, Dr Naresh Trehan, too has very strong views on achieving this fine balance. Sample this quote, a more colourful one back from the days when he was still at Escorts Heart Institute: “There is a difference between medicine and commerce. It’s the difference between a wife and a whore.”
A decade later, as Chairman of his brainchild, Medanta-The Medicity, he still doesn’t believe in mincing his words. Driven by a dream to “create a distinct identity of healthcare delivery that India provides”, the good doctor has often courted controversy, like his unceremonious exit from Escorts to being slapped with a medical negligence charge when former Chief Justice of India JS Verma died of multiple organ failure at Medanta.
But I believe history will be kinder to this US-returned Lucknow boy than his peers. In the final analysis, his larger than life personality will have done more good than harm for India Healthcare Inc. Our cover story details not just Medanta’s rise as the Mecca of cutting edge high end cardiac care, but his efforts as the health sector lead in various industry associations and as advisor to the policy makers. His detractors say he is moulding policy to suit his agenda, while others say that healthcare needs a rockstar personality to get ‘government babus’ to listen. (See story, The Sapient Surgeon, pages 26-32)
One policy maker who does seem to listen is Satyendar Jain, Minister of Home, Health, Power, PWD and Industries, in Arvind Kejriwal’s Aam Aadmi Party. His vision to transform Delhi’s healthcare system could be driven by politics but one year from now, if Delhi’s mohalla clinics can truly form an ATM-like network to serve the basic healthcare needs of the population, will the means justify the ends? Juggling media queries on the death/ alleged murder of an inmate in the Tihar Jail to fielding queries on Delhi’s plans for the homeless aged, Jain appeared more than capable of talking into the night to me on his party’s vision to correct past mistakes. (See interview: ‘Our govt’s focus is first on quality healthcare’; pages 33-36)
In the coming issues, we hope to feature the views of more state governments on their plans to implement healthcare schemes. Some states have announced schemes which prove that at least they are not afraid of trying out new models. For instance, take Rajasthan’s announcement that it would run its primary health centres in a public-private-partnership mode. Such initiatives may have teething problems like the Chhattisgarh government’s move to outsource diagnostic services in health facilities in 2013 which was put on hold pending a ‘fresh look’ at the gaps but today, we have some guidelines in place for the free diagnostics initiative under the National Health Mission as well as operational guidelines for mobile medical units. As policy evolves, there is also the sense that health is finally on the political agenda. Thanks no doubt to rockstars like Dr Trehan who take it upon themselves to champion the cause. More power to them.