Dear Marjorie

MOST Important issue is ETHICS... It is not only specific to one country, but there are reports across global poles... One example is below

http://www.indiamedicaltimes.com/2013/01/30/cardiologist-arrested-for-taking-bribe-from-stent-supplier/

Great question. If one starts with the premise that [value] = [quality] / [cost] and believes that we should focus on maximizing value, then the question can be re-focused as "when do we see incremental quality result from optimizing diagnostic accuracy?"  This relates to the patient population (diagnosing pre-malingnant colon polyps has a very different meaning for an 88 year old than for a 52 year-old), the illness (missing a diagnosis of iron deficiency is not as important as missing a diagnosis of HIV because of the seriousness of the illness and the public health implications), and the operating characteristics of the tests (over-screening for colon cancer with fecal occult blood testing might lead to unneccessary, expensive, and not-risk-free colonoscopies because there are a lot of false-positives). I believe, anecdotally, that the biggest errors we make in assessing the value of diagnostic tests are (1) focusing on sensitivity and specificity instead of likelihood ratios; after all, Bayes' theorem works with likelihood ratios, and (2) assuming that tests have similar operating characteristics in all patient populations. Using a ferritin value to detect iron deficiency makes sense in young healthy women, but not in hospitalized patients, but this type of issue has not been well characterized for many diagnostic tests that we assume work well in all populations but may not.

You provide an excellent example of one of the most challenging dilemmas facing mankind today.  How do you provide healthcare to patients.  Healthcare costs are increasing rapidly.  Advances in medical technology are far outstripping the ability of organizations and patients to pay for such treatments.

I have attached below a PPT file of an evaporating cloud (this thinking process tool was developed by Eli Goldratt as part of his Theory of Constraints management philosophy.  Its purpose is to precisely define a problem so one can surface its assumptions to find a win-win solution.) of a similar dilemma constructed by Alex Knight, a healthcare consultant in the UK.  The objective in solving the problem is to A. Be an ever-flourishing hospital (in your case whatever the organization you are describing that provides/ uses the technology).  The Requirements for achieving the Objective A are Requirement B Provide high quality and timely care for all patients and Requirement C Be financially stable.  Both B and C requirements must be achieved to achieve the objective A.  BUT in order to achieve requirement B Provide high quality and timely care for all patients, you must take the Pre-requisite action: D Add more (front line) resources.  BUT to meet the requirement C Be financially stable you must take the Pre-requisite action D’ Reduce (front-line) resources.  In this cloud Alex is looking at the trade-off of adding resources versus reducing resources (staff0.  Note that if you take one action it jeopardizes the other (diagonal) requirement so most people teeter between Pre-requisite D and D’.  In your case they try to figure out what they can afford or just buy the technology and increase prices significantly to cover the cost.

Note for your specific problem you can change the prerequisites to purchase new technology versus don’t purchase new technology OR preform a more expensive test (and more precise) or don’t perform a more expensive test (maybe perform a less precise test). One responder indicates that one should use ethics to make a decision of who to perform a test on:  age as the criterion.  What if the 88 year old is a scientist contributing to mankind versus a 50 year old who is a convict?  So we keep adding to what ethics mean in applying the concept. Some might ask “What of money as the criterion?”. Give the treatment to those that can afford it.) In both cases, we are teetering between the prerequisites.  This is where everyone looks to solve the problem: what is the best compromise to resolve the DD’ conflict.  BUT what you want is a win-win solution that allows you to achieve the two requirements: B Provide high-quality and timely care to all patients and C Be financially stable.  This is done by surfacing and challenging the assumptions related to each relationship.  BD arrow, CD’ arrow, and DD’ arrow. 

You might like to read Alex Knight’s Pride and Joy, a novel describing the use of TOC in healthcare in the UK.  Alex has implemented these concepts in over 50 hospitals worldwide.  As you read the book you can easily see the VA hospital dilemma (described as it exists in the UK healthcare system) and its solution.  Alex has made several presentations to the TOCICO (Theory of Constraints International Certification Organization) over the years.  Some are available for viewing by anyone on their website.  Look under Success Stories then Healthcare portal.  If you are interested in learning more about Goldratt’s thinking processes there is a portal under Success Stories which teaches the basics of the thinking processes. 

Dr. Brotman’s response is excellent in that he is providing specific situations where one test might be appropriate for one patient population verses useless useful (or even give false results) for another patient population.  His logic is easily diagrammed in a Current Reality tree and Future Reality tree to determine causes and effects for different population sets and given this situation what might be appropriate for use with a specific patient in making medical decisions based on the assumptions and background of that patient.  It is what he would do in his mind in making such a decision, the tools just forces him to verbalize his underlying thoughts in making the decision. 

Hope this is helpful.