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Health care in the United States is in a crisis. At present, rising costs account for 13% of the gross national product making health care the third largest industry in the country, and there is no end in sight as costs spiral out of control.1 For years we have been admonished as healthcare providers to control costs by improving productivity and flexibility, by adopting new appropriate technologies, and by using competitive market strategies to squeeze the fat out of the healthcare system. All of these innovations, it was assumed, would allow healthcare providers to continue to deliver high quality care while eventually cutting costs to the bone.2The promise of managed care as the big fix for US healthcare problems has not been realised. An analysis of managed care plan performance from 37 recently published peer reviewed studies reveals that on balance managed care has not improved the efficiency or quality of US health care and that some patients, specifically Medicare HMO enrollees with chronic health conditions, have received poor quality medical care as a result.3 By now it should be obvious to all of us that a big solution does not exist for our big problem.
It was, therefore, with great interest that I read the paper by Livingstone et al in this issue of the BJO (p473) in which the authors propose that eye drops used on hospital wards in the British National Health Service may be used for 2 weeks instead of the 1 week mandated by the Department of Health. Adoption of this practice would lead to an annual savings to the NHS of £500 000. The specific question is whether or not eye drops become increasingly contaminated with potential ocular pathogens by extending their hospital life by 1 week. There is real cause for concern. Microbial contamination of eye drop solutions and dropper tips has been implicated as a cause of severe ocular infection in a number of patients.4-7 In addition, the chance of contamination is much more likely on a hospital ward than in a domiciliary setting.8 To answer the question, Livingstone et al cultured eye drop residues for bacteria and fungi from 341 samples after 7 days and from 295 samples after 14 days in the setting of a hospital ward. Not surprisingly, the incidence of microbial contamination was not statistically different between the two groups. The authors also found that the contaminating micro-organisms were similar in both groups; they were mostly associated with the skin and none of the micro-organisms isolated was highly pathogenic. In view of those interesting research findings there appears to be no laboratory evidence to support the current practice of discarding eye drops on hospital wards after only 1 week because of the risk of contamination. As a result of this scientific study, an evidence based decision by the NHS may lead to a saving of £500 000 a year from the national healthcare budget.
This study by Livingstone et al should be used as a model for the evidence based rational decisions that need to be made regarding every aspect of the healthcare problem. The pressure to reduce burgeoning healthcare budgets in the United States and the UK has led to unpopular and at times irrational cost cutting measures. Healthcare “managers” with little understanding of the scientific approach to medical practice or the sanctity of the patient-physician relationship have been allowed to implement putative cost effective solutions in an attempt to solve the healthcare crisis. Since there is general agreement that this approach has not been effective, maybe it is time to try something else. The real need may be to implement many small painstaking solutions to fix the big seemingly insurmountable problem. Small evidence based solutions applied to every problem area of the healthcare system can result in cost savings and also in continued improvement in the quality of patient care. In implementing these small solutions physicians, researchers, nurses, and all healthcare workers should continue to be guided by the traditional principles: firstly, “do no harm” and secondly, “strive unceasingly to improve the quality of care”. Innovation, creativity, and dedication in solving the many small problems in the healthcare system will ultimately cure the big problem.