My Newest Incentive Spirometer, Physical Therapy, and Magic
This magical device may or may not confer Healing unto those who take it home and lose it immediately
I was recently treated to some surgery to get some (probably vat-grown) replacement parts, hooray for biomedical technology! One of the parting gifts from the experience (besides the bruises and extra hole in my body) was the ever-popular “incentive spirometer”. Due to an above-average degree of contact with health care providers the last few years (family members and self in and out of hospitals), I have seen this thing many times now, because (evidently) Everyone Gets One. My cursory review of the literature suggests that it does what it is supposed to do, and is widely recommended. I am not going to weigh in on the thing’s functionality, instead I see it as a symptom of a disconnected healthcare system.
The incentive spirometer (glamor shot, see above) is a device which is intended to help post-op and other patients gain strength with their lungs and avoid infections like pneumonia. It is handed out to people along with training on how to use it. Basically, you inhale through a tube and it gives a numeric estimate of how much air volume you are moving around. It’s low-cost, effective, and safe to use with minimal training! (See, I can write ad copy, please email me to write your next brochure).
My bet is that 99.99% of patients who get one of these prizes never use it more than a couple of times, and/or lose it more or less immediately. Someone somewhere went to a lot of trouble to show that this is an effective therapeutic tool, but I suspect that the original research included subjects using the device more than once while a discharge nurse was watching. This leads to my hangup about it: if we can pretty much guarantee that a therapeutic tool is not used, we might also conclude that its clinical advantages are rarely realized. Ha! A pox on that last sentence, I should write for academia too! Rewrite: if people used it as directed, it could help them, but they don't use it.
Applying results of science in the real world is typically a lossy process. The phd-docs who ran the studies can shrug and say “well, we can’t control compliance” and of course they can’t, but it’s absurd that we’re all going along with it. Nowhere in the whole twisted system is there an incentive for anyone to pull the cord and reconsider - it is unlikely that the companies that build and ship these things by the bazillions are going to raise their responsible corporate hands to say “gosh, you hospitals should stop ordering these because there is no demonstrated compliance or effectiveness in practice! We will shut down our business now for the good of humanity and to save Medicare a few million per year”.
A few million per year is a rounding error for insurance payouts and Medicare so what’s the big deal? It would cost more to reconfigure the protocols and quit sending the dang things home with people than it would save. But if you consider every other medical procedure where there is pre- and after-care for a given procedure or treatment, you might get into real money.
The very existence of my lovely souvenir spirometer is thanks to having had a new hip installed. Last year I got a less fancy spirometer for a different surgery, hmph. (Note to surgery team: missed branding opportunity, need to attach a scrolling LED display reminding patients of what team did the surgery).
Two surgeries, two years, and both ortho docs focused on the surgery, and then delegated aftercare to another provider (physical therapy, PT). There was a little bit of (subjective) baseline assessment and a little bit of post-op assessment (again, subjective, e.g., “feels better now, right?”) but nothing rigorous. That’s ok, maybe it’s enough, but if you are going to always prescribe PT for post-operative recovery, then shouldn't patient compliance and the quality of the PT provider have a significant impact on the final outcome of the surgery? The most I will get is “how did PT go?” from the orthopedic surgeons. If I were the surgeon and surgery plus PT was the essential combination, then I would want to track specific metrics for a patient at 3, 6, 12, AND 18 months (most wouldn't even have to be in-person! Just a dumb web form!)
A healthcare product like joint replacement ideally yields long-term positive results for the patient. Inputs to evaluate results should span the whole process, starting with a patient eating well and moving around as much as possible leading up to a surgery (for example), skilled surgeon kicking ass, and then cooperating with PT to get an optimal result. The basic shape of an end-to-end process is notionally in place: nutritional and prep advice is given to the patient, surgery happens, PT is prescribed -- so it's all there, but it's all disjoint activities. There is no follow up to see if the real world process (PT recipe x as recovery plan for surgery y) bears any resemblance to the controlled environment lab version. Just like taking home the incentive spirometer - we all Just Believe that making a gesture will result in a positive outcome. For all we know, actual magic might be taking place, but we will never know because we don't even check.
For sake of argument, assume that it is less magic and more science. Let's say that Dr. Someone showed that people who did exercise y after procedure z got better 30% of the time - a clear and actionable finding. Alas, when a protocol derived from such a finding is applied to actual people, real-world compliance is ignored. Magic happens: The PT protocol was assigned, therefore success. But wait! Did the patient go to PT? Did it help? How much? In what way? You might get confirmation that a patient actually went to the prescribed PT sessions, but there is no interest or attempt to collect data to confirm or deny the magic spell being invoked here. Given how my quads feel 10 days post-op, I sincerely hope that waving my wand and invoking the sana me vastus lateralis spell will make a difference.
A good PT team will instruct you in how to do specific exercises on your own, and provide in-person guidance to ensure you're doing the things correctly, and this guidance plays a significant role in the recovery arc of a patient. But anyone who's done PT will tell you it is all about the homework -- your own self-discipline and pain tolerance. Most people are not diligent this way (modulo trained athletes and similarly obsessed people) but we still consider the mere existence of PT sessions to be effective. The current standard to measure effectiveness is to count visits to the PT provider -- even though a body count doesn't provide any useful information as to the effectiveness of a PT program.
I do not knock PTs, these are well-trained and knowledgeable people who do good work. The part I am trying to focus on is the system that simply ignores real-world outcomes. Obviously, "body count" is not a good metric for effectiveness but that's all that is required to get paid. If reporting outcomes were linked to getting paid, I will go out on a limb and say that there’s a good chance that everyone (miraculously!) would make great progress in their assessments. Indeed, with a little bit of searching on the net, I found a document by PT providers which described a promising, well-intentioned system by which they could publish metrics-based outcomes for patients. Surprise! The program is being abandoned, because the PT industry is just fine reporting on volume only, thank you very much. This makes perfect sense, because as ably demonstrated by McDonalds, if you do a lot of something, it must be good.
Whether it’s the take-home device or a PT prescription, it seems like all parties (providers and patients) are playing along and pretending that what they are doing yields results because it's protocol and the protocol was developed with…science! We would do well to realize that there is a lot of daylight between a lab experiment and how people behave in the wild. At the moment, the incentives are all wrong so nothing will change, but we the victims, erm, participants can be thoughtful about what the current gestures were intended to do. If we can grasp the intent, then we can take personal responsibility to employ known protocols that deliver positive clinical outcomes.
PS: Turns out there is a Health and Human Services division called the Agency for Healthcare Research and Quality whose charter seems to be focused on these topics. See the work published at https://www.ahrq.gov
-- at least there is a gesture toward improving the current gestures.
Thanks for reading. Comments, corrections, etc. enlighten me! via @srehorn on twitter and threads.net, Substack notes, whatever.
Nice observations on a classic, deeply ingrained problem across all of health care & interventions. Humans are busy being humans and for a variety of (often good) reasons don’t follow protocols. This in turn has a large impact on the real world effectiveness on treatments. This is true even for something as “simple” as taking medication. The results from randomized clinical trials are far higher than what is seen when the medication is approved and used by free range humans.