Needed: Standards for Rehabilitation

Last week, Secretary Sebelius was urged to expand insurance coverage for patients with traumatic brain injury (TBI).

This expansion in many ways is similar to a greater mandated coverage for autism. Both conditions can require prolonged, intensive rehabilitative services designed to improve function and outcome. While there clearly is substantial need for assisting those afflicted with these conditions, it is unclear what constitutes progress and reasonable expectations. What is the correct formula for length and intensity of treatment? When does improvement plateau and continued intensive therapy provide diminishing returns? TBI and autism are heartbreaking personal and family challenges that often do not resolve to a normal functional status. Clinicians and policy makers are in great need of tools to assess progress and outcomes in order to match resource needs with expected patient outcomes. As health resources become increasingly restricted, intensive rehabilitation services represent another expensive technology that calls for careful assessment and application just like interventional procedures and biologic pharmaceuticals.

PSA = Please Stop in the Aged?

Few topics create more angst in clinical medicine than prostate cancer screening. The test is not particularly sensitive or specific, the therapy for early disease is not well defined, and some interventions inflict substantial morbidity for a condition that requires at least 10-15 years to demonstrate a change in mortality in some populations. Because of this constellation of findings, most prostate cancer experts advise against screening patients with a limited life expectancy or in healthier men over age 75 years. Nevertheless, patients in their 80’s apparently still receive PSA testing as frequently as younger men, according to reports in the Journal of Clinical Oncology and the New York Times.

Some of this demand reflects boomers who aspire to immortality or at least centegenarian status. I find that by explaining the usual cascade of testing that accompanies vaguely elevated PSAs, and that it takes nearly 50 radical prostatectomies to save one life among the average population of 68-year-old men, most of my younger patients opt out of screening.