Finding Value in Medicine

Abstract

The medical care system in the United States is being restructured, with the goal of containing rising health care expenditures. Cost-containment strategies…have as their major purpose restraining the use of high-cost medical services. Yet little attention has been paid to how patients' health and level of functioning in everyday activities are affected by these and other strategies." 1(p925) Twenty-five years ago, Tarlov and colleagues 1 so opened a landmark series of articles describing the rationale and results of the Medical Outcomes Study, a massive undertaking meant to reverse what they saw as a corrosive trend in health services research: the disappearing patient.The Medical Outcomes Study gave us the SF-36, the first well-validated patient-centered metric, built to measure outcomes of diverse patient populations across system of care, variation in practice style, and diverse disease and health states. The hope of these pioneers was that future innovations in care could be measured by simply asking patients a set of standardized and validated questions about their lives rather than by annual echocardiograms, positron-emission tomographic scans, or other technologically intensive and expensive means. The study ushered in a new era of functional outcomes research, and 1000 similar instruments bloomed.And then faded. Functional status is still used commonly as an outcome, but the real money in health services research today is still in…money.For this reason, it is refreshing to read the article in this issue of JAMA Internal Medicine by Krieger and colleagues 2 describing their experience with a community health worker (CHW) program for low-income patients with asthma. The program, HomeBASE, trained high school graduates from the target communities to work with a majority-minority cohort of working-poor patients living with moderate to severe asthma. Such patients have symptoms notoriously difficult to control; in the study cohort, participants had fewer than 4 symptom-free days per 2 weeks. Using a combination of motivational interviewing, home-based education, environmental modification, and social support, the intervention succeeded in increasing symptom-free days, asthma-related quality of life scores, general physical function, and other patient-centered outcomes, when compared with like controls. What the intervention did not show was a comparative decrease in urgent medical care use, including emergency department visits, unscheduled physician visits, and hospitalizations, which declined among both intervention and control participants, or use of steroid pulses. Doubtless, many readers will view this as a negative trial result; each intervention participant cost the program approximately $1800, with no return to be found in concomitant medi-