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The elephant in the room: the rising cost of health care in America
LETTERS TO THE EDITOR
The elephant in the room: the rising cost of health care in America To the Editor: As a pediatrician from Africa, I was fortunate to spend a sabbatical in the United States during the time of the historic 2008 elections. It was heartening to witness the debates around improving access to health care for all Americans. I also was impressed by a new sense of environmental awareness; clearly, our environmental legacy will have a profound influence on the future health of children. Both presidential candidates suggested new funding mechanisms to improve access to health care; however, neither addressed the desperate need to contain spiraling health care costs. Finding ways to reduce the cost of health care is never a popular topic, but it seems like a critical area in which the medical profession should be taking the lead. Clearly, it is our moral obligation to be part of the solution and not contribute to the barriers that make health care inaccessible to so many. In some respects, the US health care system can pride itself on providing the best health care in the world, and I am truly thankful for the experience that I gained while on sabbatical. The one proviso is that this exceptional level of health care is being provided to a smaller and smaller percentage of the general population. As an outsider, I observed the near-complete disregard for the costs of care provided. Physicians feel uncomfortable discussing cost issues because it seems unethical to even consider compromising the quality of care. In reality, however, we cannot escape these uncomfortable compromises. This issue should be part of the ethical debate, because the flip-side of the coin is reduced access to care for those who cannot afford it. A limited focus on providing optimal care to each individual patient regardless of financial consequences often implies that promoting disease prevention and limiting longterm negative impacts receive less attention. The overuse of antibiotics leading to increased microbial resistance and sophisticated imaging that may expose the patient to high-dose irradiation without influencing patient management serve as examples of this. The issues at stake are complex, including fears of medical litigation, the desire to protect professional reputations, and the need to maintain the image and profitability of hospitals. But at this time of economic crisis, exceptional leadership is required from the medical profession in developing strategies aimed at reducing costs and improving access to health care for all Americans. Ben J. Marais, MD, PhD Department of Paediatrics and Child Health Faculty of Health Sciences, Stellenbosch University Tygerberg, South Africa 10.1016/j.jpeds.2009.01.046
Letters to the Editor
How to assess the aEEG background To the Editor: With interest, we read the article by Shellhaas et al concerning the assessment of neonatal EEG background activity using conventional and two different aEEG classification systems.1 As can be seen in the Acknowledgments, we were involved in scoring the traces, but unfortunately, we were not asked to assist with data interpretation or data presentation. Once we had scored one-third of the traces, we contacted the authors and questioned the value of performing the analysis of the traces, without having access to either the impedance or the raw EEG. Many traces were of poor quality with many artifacts, which made it difficult to interpret them correctly. We therefore considered the study “out of date” and no longer relevant because all new digital machines now have access to both the impedance as well as the raw EEG, and some even have a seizure detection algorithm. For the sake of the study, we were encouraged to continue the analysis of the traces. There are other issues concerning this report that need to be addressed. Many of the tracings were in our opinion of too poor quality to be analyzed reliably, but they have been included in the results section as it is stated that “the number of aEEGs reviewed by the neonatologists ranged from 127 to 144.” The reason the number was different for the different reviewers was because the other tracings were of too poor quality or were too much affected by ictal discharges to assess the background activity. Absolute numbers are mentioned in the methods section of the 3 different categories (normal/slightly abnormal, moderately abnormal, and severely abnormal). It is stated that 58 tracings were normal, but we have now looked at the traces again and found that the number of normal/slightly abnormal recordings could not be more than 25 to 30 of all cases, using the specific guidelines provided. It is not completely clear from the methods section of the paper in which category a “DC-pattern” belongs: In our previous studies, we have always taken this group together with the CV group,2 with a normal outcome in the majority of these children, but it seems that in this study they were taken as moderately abnormal tracings, although this is not stated in the methods. It is concluded that the simple scoring system for the background activity (looking at voltage) was more reliable than the scoring system that looked at patterns. This conclusion should be interpreted with caution. The phenomenon “drift of the baseline” was not seen in their cases, and this may be due to how they were able to convert the EEG to an aEEG. On other available machines, this artifact, usually due to an ECG artifact, is unfortunately not uncommon.3 This has been reported to lead to incorrect interpretations4 (J.D. 625
The elephant in the room: the rising cost of health care in America To the Editor: As a pediatrician from Africa, I was fortunate to spend a sabbatical in the United States during the time of the historic 2008 elections. It was heartening to witness the debates around improving access to health care for all Americans. I also was impressed by a new sense of environmental awareness; clearly, our environmental legacy will have a profound influence on the future health of children. Both presidential candidates suggested new funding mechanisms to improve access to health care; however, neither addressed the desperate need to contain spiraling health care costs. Finding ways to reduce the cost of health care is never a popular topic, but it seems like a critical area in which the medical profession should be taking the lead. Clearly, it is our moral obligation to be part of the solution and not contribute to the barriers that make health care inaccessible to so many. In some respects, the US health care system can pride itself on providing the best health care in the world, and I am truly thankful for the experience that I gained while on sabbatical. The one proviso is that this exceptional level of health care is being provided to a smaller and smaller percentage of the general population. As an outsider, I observed the near-complete disregard for the costs of care provided. Physicians feel uncomfortable discussing cost issues because it seems unethical to even consider compromising the quality of care. In reality, however, we cannot escape these uncomfortable compromises. This issue should be part of the ethical debate, because the flip-side of the coin is reduced access to care for those who cannot afford it. A limited focus on providing optimal care to each individual patient regardless of financial consequences often implies that promoting disease prevention and limiting longterm negative impacts receive less attention. The overuse of antibiotics leading to increased microbial resistance and sophisticated imaging that may expose the patient to high-dose irradiation without influencing patient management serve as examples of this. The issues at stake are complex, including fears of medical litigation, the desire to protect professional reputations, and the need to maintain the image and profitability of hospitals. But at this time of economic crisis, exceptional leadership is required from the medical profession in developing strategies aimed at reducing costs and improving access to health care for all Americans. Ben J. Marais, MD, PhD Department of Paediatrics and Child Health Faculty of Health Sciences, Stellenbosch University Tygerberg, South Africa 10.1016/j.jpeds.2009.01.046
Letters to the Editor
How to assess the aEEG background To the Editor: With interest, we read the article by Shellhaas et al concerning the assessment of neonatal EEG background activity using conventional and two different aEEG classification systems.1 As can be seen in the Acknowledgments, we were involved in scoring the traces, but unfortunately, we were not asked to assist with data interpretation or data presentation. Once we had scored one-third of the traces, we contacted the authors and questioned the value of performing the analysis of the traces, without having access to either the impedance or the raw EEG. Many traces were of poor quality with many artifacts, which made it difficult to interpret them correctly. We therefore considered the study “out of date” and no longer relevant because all new digital machines now have access to both the impedance as well as the raw EEG, and some even have a seizure detection algorithm. For the sake of the study, we were encouraged to continue the analysis of the traces. There are other issues concerning this report that need to be addressed. Many of the tracings were in our opinion of too poor quality to be analyzed reliably, but they have been included in the results section as it is stated that “the number of aEEGs reviewed by the neonatologists ranged from 127 to 144.” The reason the number was different for the different reviewers was because the other tracings were of too poor quality or were too much affected by ictal discharges to assess the background activity. Absolute numbers are mentioned in the methods section of the 3 different categories (normal/slightly abnormal, moderately abnormal, and severely abnormal). It is stated that 58 tracings were normal, but we have now looked at the traces again and found that the number of normal/slightly abnormal recordings could not be more than 25 to 30 of all cases, using the specific guidelines provided. It is not completely clear from the methods section of the paper in which category a “DC-pattern” belongs: In our previous studies, we have always taken this group together with the CV group,2 with a normal outcome in the majority of these children, but it seems that in this study they were taken as moderately abnormal tracings, although this is not stated in the methods. It is concluded that the simple scoring system for the background activity (looking at voltage) was more reliable than the scoring system that looked at patterns. This conclusion should be interpreted with caution. The phenomenon “drift of the baseline” was not seen in their cases, and this may be due to how they were able to convert the EEG to an aEEG. On other available machines, this artifact, usually due to an ECG artifact, is unfortunately not uncommon.3 This has been reported to lead to incorrect interpretations4 (J.D. 625