Choosing Wisely and Delivering Value in Obstetrics and Gynecology
The pressure on physicians to provide better care at lower costs is coming from all directions — top down from policymakers who want more accountability in how healthcare resources are being used, and bottom up from patients who want more transparency in how their money is being spent.
Obstetricians and gynecologists have not been spared any scrutiny. As primary care providers for many women, we are in thick of the debate on appropriate use of pap and mammography screening. As surgeons we also find ourselves increasingly answering for the expense and morbidity of unacceptably high C-section rates.
While our clinical breadth provides ample fodder for scrutiny, it also may uniquely position us to help patients choose wisely among the growing panoply of diagnostic and therapeutic options. One of the most commonly encountered and difficult decisions that patients encounter is, “Should I pursue medical management or surgery?” Like other specialties, Ob/Gyn's are seeing surgical indications shrink as medical therapies become increasingly available and effective. Unlike other specialties, we often continue managing the patient's condition whether she chooses surgery or not.
In a brave new world of increased healthcare scrutiny, the value of each option is only clear in comparison to the alternatives. Generally speaking, a trial of medical management is almost always preferable to surgery, even when the medicine is expensive.
Take tranexemic acid (Lysteda), recently approved by the FDA to treat menorrhagia: the retail price is generally more than $170 per month. However, for the correctly selected patient for whom there are limited safe medical alternatives, it is well worth trialing over the potential pain, inconvenience and several thousand-dollar price tag of surgery. Leuprolide acetate (Lupron), most often used for endometriosis-related pelvic pain, is another example of a very expensive medication (close to $1000 for a three month dose) that could be a good value for the correctly selected patient who does not want to commit to an operation.