It is not a secret: healthcare is both amazing and deadly. There are miracles. And, there are waste, inefficiency, and profound patient safety issues. In so many ways, case management has dramatically reduced these negatives. This editorial is a little reminder about some simple-to-complex ways we impact healthcare dollars-and patient lives.

Cause and Effect

Each of us knows of healthcare stories in which treatment for one issue led to a side effect. The symptoms (side effects) were treated with further treatment, usually medication, some of which may have caused more side effects, requiring other medications; and on and on we go (where it stops, nobody knows).

Here is a simple case of "cause and effect" averted!! One of your patients has the common problem of high cholesterol level. For years he took one statin with good results; however, slightly elevated liver tests could have been from this statin, so the medication was changed. The side effects from this new change were apparent, but not horrible enough to warrant another immediate change of formulary. In addition, the results were not good (cholesterol level elevated to more than 300) so the dose was doubled. There was only a slight improvement with the double dose, so the physician suggested adding a second cholesterol-lowering medication to mix-one that works on cholesterol differently.

But 6 months had taken place during this cholesterol-lowering experiment and the liver tests had not budged (thereby making it unlikely that the first statin caused the original concern). You could remain quiet and side effects could compound:

1. side effects of the relatively ineffective statin would remain;

2. side effects of the second drug could occur; and

3. side effects due to the interaction of the two cholesterol-lowering medications could further confuse the healthcare picture of the patient.

You did not remain silent. The patient was placed back on the first, effective medication and the slightly elevated liver tests were assessed further.

The Domino Effect

That was a simple, one-dimensional scenario. This one is more complex. Mr. Right is almost 90 years old and for several years has had a neurogenic bladder, necessitating self-catheterizing. More recently, a pacemaker was placed. Frequent bouts of atrial fibrillation (AF) had the cardiologist concerned. The standard treatment of warfarin was used, but the side effects included hemorrhagic bladder when self-cathing. After trying various dosages-and being hospitalized twice for evacuation of clots-warfarin was discontinued and anti-arrhythmics were tried instead.

However, the AF continued and a small stroke brought Mr. Right into the hospital. More medication was added to the mix without much success in stopping the AF. Then, almost overnight, classic signs of congestive heart failure (CHF) brought him to the emergency department. The emergency department physician began the CHF protocols and Mr. Right was admitted.

His astute cardiology of several years recognized that this elderly gentleman had no real reason for new onset CHF except that, in a small (1.9%) percentage of patients, one of the anti-arrhythmics causes acute CHF (in previously non-CHF patients). Instead of adding a new diagnosis (CHF) and all the medications and protocols associated with it, the cardiologist took him off the current new medications. In just a few weeks, all signs of CHF were gone. A different anti-arrhythmic was prescribed: both the atrial fibrillation and the congestive heart failure resolved.

But, suppose that the CHF was added to his list of diagnoses and the medication that caused the problem was not addressed and discontinued. The suffering from (drug-induced) CHF would have changed his quality of life forever. More medications for CHF would likely have been added: more side effects; further drug-drug interactions. And, this man, who also had a history of low sodium, would have been placed on a low sodium diet with further ramifications. Sometimes, less is more-and that is especially true with pharmaceuticals.

Effects of "Overkill" Healthcare

In another scenario, the domino effect is less apparent. Most healthcare providers have seen potentially unnecessary surgery done that (1) was not required to alleviate symptoms and/or (2) did not, in fact, relieve the intended symptoms. It seems that in every decade, there are reports about common surgeries that had been used unnecessarily or too frequently: from tonsillectomies to hysterectomies. More recently, back pain and subsequent surgeries have come into question.

Back pain and surgical back statistics are staggering, with over half a million of these surgeries performed annually in the United States alone. Although statistics differ on the number of Americans affected with back pain, it is clearly "many." More than 65 million Americans have back pain every year, with 30% of adults older than 30 years affected. Back problems are cited as the most common cause of disability in people younger than 45 and a leading contributor to missed work, with over 1 million workdays lost annually in the United States. Costs, too, boggle the imagination, with Americans spending an estimated $50 billion each year on low back pain ($50,000,000,000-i.e., 10 zeros).

So, when an article comes along that contains both evidence-based statistics and the capacity to decrease surgical interventions, I am intrigued. Anyone who has had, or knows of someone with, back pain will want to read this issue's "Is Your Client's Back Pain Rapidly Reversible? Improving Low Back Care at its Foundation" by Dr. R. Donelson. Dr. Donelson is a board-certified orthopedic surgeon whose passion for prevention of back surgeries is unique.

With relatively simple steps, using a paradigm called Mechanical Diagnosis and Therapy (a.k.a. McKenzie method), it is possible to identify a large subgroup of patients whose low back pain is rapidly reversible, meaning it can often be eliminated quickly, with return to full function, and without surgery, including many who were thought to be surgical candidates. The McKenzie method is not new; however, sometimes it takes many years, a body of scientific evidence, and a "champion" to bring an "important idea to light."

In the article, substantial evidence is cited and the "Case Management's Opportunity for Impact" section is crucial. However, although the single article is robust, it can only present an overview of this important topic and its implications. It does not permit the review of all the important studies, a thorough patient assessment discussion, or a discussion of the likely underlying biologic explanation for rapidly reversible low back pain (LBP). If you or your patients/family suffer from low back pain, Dr. Donelson's book, Rapidly Reversible Low Back Pain: An Evidence-Based Pathway to Widespread Recoveries and Savings (Donelson, 2007), may change the course of treatment and the quality of life.

They say that when you are a hammer, all the world looks like a nail. The major lesson here is to always take a step back in healthcare-critically look at what is going on with your patient, your father, your mother, your spouse, yourself, and so forth. What medications is the person on? Can the symptoms be treated without using a hammer (or surgery)? In fact, would pulling out a nail be more appropriate than hammering in another-and another? Just doing what we do best, case management is in a distinctive position to alter our healthcare system, and ultimately the lives of human beings.

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