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ROBIN ABCARIAN

What's the Price Tag on Peace of Mind?

September 22, 1993|ROBIN ABCARIAN

The first picture of our baby occupies a place of honor in the bedroom. It sits in a frame of honor, too--a small but fancy thing, gold matte, with spiky rays spiraling from the sides, evoking the sun. And so the baby has become, sun to our planets, the being around whom we revolve.

It is not really a high-quality print, mostly a sea of black and white dots, with a little . . . sea horse in the middle, unrecognizable as the blue-eyed, strawberry-blond child she will become, but very beautiful anyway. The baby at seven weeks. Seven weeks after conception .

The photographer was our obstetrician; the camera an ultrasound machine.

Ultrasound gave me such peace of mind. Early on, it showed a beating heart, a normal fetus, a child-to-be. Later, it showed that the baby had all her fingers, toes, a brain.

I imagine a lot of parents have such photographs of their babies nowadays.

Ultrasonography has, in the words of one physician, "revolutionized the care of obstetrical patients. Before the procedure became available, the uterus of a pregnant woman was a closed space that effectively hid most of its secrets."

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Last week, a group of doctors reported in the New England Journal of Medicine the results of a study on prenatal ultrasound. They were trying to determine if routine ultrasound exams improve the outcome of low-risk pregnancies. In other words: Does this screening procedure save babies' lives?

The answer was no.

The study involved 15,151 pregnant women randomly assigned to two groups. The first received scheduled ultrasound screening twice during pregnancy; the others were scanned only if doctors felt it was necessary. The bottom line: There was no difference in the outcome of pregnancy between the two groups.

"We did not set out to prove that ultrasound wasn't helpful," said lead investigator Dr. Bernard Ewigman of the University of Missouri at Columbia. In fact, he said, he was somewhat surprised by the results.

There is no standard American practice regarding ultrasound, Ewigman said. In some big cities, ultrasound is routinely ordered by doctors in private practice. It is a way of determining gestational age, whether a fetus is growing properly and the location of the placenta, as well as a way to screen for abnormalities.

In terms of garnering attention, the study's timing could not have been better. Tonight, President Clinton is scheduled to unveil his health-care reform plan to the public. The whole purpose of revamping the health-care system is to save money. Ewigman and his colleagues estimated--very loosely--that about a billion dollars a year is spent on ultrasound exams (at about $200 per exam), and that if the exams were limited to women who are truly at risk of complication, the savings could amount to $500 million a year.

"I thought there would be some subgroups--twins and so on--where there might be a better outcome (with ultrasound), but there was zilch, no difference at all," Ewigman said.

What about peace of mind, I ventured. Can you put a price on that?

"I had a patient who was a special ed teacher," he replied. "She dealt with kids with disabilities and birth defects. She wanted to know if her baby had a birth defect. I ordered an ultrasound for her, and I think that is appropriate.

"I am not anti-ultrasound, I simply distinguish between making a judgment and doing it . . . on every patient."

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The obstetrician's office is one of the many places where the hard decisions will be made about health care, where the issue of peace of mind will collide squarely with the desire to save money.

To test or not to test? That is the $500-million question.

Insurance companies, you can bet, are paying extraordinary attention to studies such as these. After all, why should they pay for tests proven to have no beneficial effects?

Despite the syrupy, solicitous advertisements and commercials that are all over the billboards and airwaves these days, health insurance companies are not really in the business of peace of mind. (Otherwise, they would all pay for immunizations and well-baby visits.)

It comes down to dollars. Would patients who are low risk for complications be willing to pay for ultrasound out of their own pockets?

"You see fingers and toes, and that is reassuring," Ewigman said. "The value is real, but highly overestimated."

I don't know. I often look at that picture of my daughter with wonder and joy. And remember the fears it allayed.

Can you really put a price tag on that?

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