Should we Change the Diagnostic and Treatment Thresholds for Illness?

Everyone who cares about the USA wants Americans to be healthier. Would we not therefore embrace a method of improving health which involves no cost; which actually creates tremendous savings in healthcare, and which can be instantly implemented without delay?

Dr. H. Gilbert Welch, Professor of Medicine at the Dartmouth Institute for Health Policy and clinical Practice, has “the way.” His solution is to change the “diagnostic and treatment thresholds” for illness, thus making fewer people ill by definition. He further argues in a newspaper column for the Los Angeles Times and the McClatchy-Tribune news service, “To have any hope of controlling healthcare costs, ‘doctors will have to raise their diagnostic and treatment thresholds.’ And higher thresholds would be good for more than the bottom line. Less diagnosis and treatment of disease would return millions of Americans to normal, healthy lives. That’s right: Higher thresholds could well improve health.”

The philosophical question at the root of Dr. Welch’s idea is, “Do definitions create reality, or only describe or define an objective reality?” And secondly, “Would simply changing the definition of health affect objective change in the state of an individual’s health?” Dr. Gilbert would have us think it does. He asserts that, “Diagnostic thresholds that are set too low lead in turn to a bigger problem: treatment thresholds that are too low. Diagnosis is the critical entry step into medical care–getting one tends to beget treatment. That’s a big reason why we are treating millions more people for high blood pressure, diabetes, osteoporosis, glaucoma, depression, heart disease–and even cancer.” He believes, if we tell you you are not sick; if we tell you you are not at risk of getting sick; you no longer have to be concerned about your health. Problem solved.

The pesky problem with this is science and facts. Have the scientifically-based thresholds for establishing the presence of diabetes, aggravated the problem? Would people be healthier if we did not tell them they have diabetes? Would those people who are not being treated for diabetes because we raise the threshold for its diagnosis, thus telling them that by definition they don’t have diabetes, truly be healthy, or would they just be unaware of their illness and deteriorating health? Would their lives be better because they are unaware that untreated, diabetes will result in serious, irreversible consequences, which will cause their death?

When Dr. Elliott Joslin founded the Joslin Diabetes Center in 1898, the life expectancy of a patient with Type 1 diabetes after diagnosis was four months. Did he create the avalanche of cost which in 2007 resulted in $174 billion in costs of diagnosed diabetes in the United States? Has the refinement of the definition of diabetes–the diagnostic threshold–aggravated this problem?

Dr. Welch’s proposals for changing healthcare have much more to do with his political and social philosophy than with science and evidence-based medicine. His assertion that the standards of quality metrics come from the quality metrics themselves is to ignore science. The standard of seven percent for hemoglobin A1C to judge the quality of diabetes care was not established by the defining of a quality metric; it was defined by science.

Advancement in healthcare, particularly in preventive care, screening care and disease management will, in the short run, increase cost. In the long run it will decrease cost. But, none of this addresses the value of the individual, who in our value system is paramount, as it is not the collective which only has value, but each individual, no matter how poor, no matter how old, no matter how powerless–you name the “no matter…” –has absolute value as a human being.