Medical Overuse (8/12/13)
Three Trillion a Year
How did American health care come to cost nearly three trillion dollars a year?
One place to look is at procedures – diagnostic tests and therapeutic treatments. In terms of costs, “procedures” can be as simple as a red blood cell count or as complicated as a liver transplant. Hospitals, drug companies, device makers and many doctors are “incentivized” to order many tests and therapies.
But are they all necessary?
One simple question to ask is whether they are worth the money – the cost benefit ratio. But another question should be asked first – do they work?
Doctors themselves know many treatments and diagnostic tests are not worth doing.
In 2012 the American Board of Internal Medicine partnered with Consumer Reports to look at whether common procedures made sense. Some that didn’t:
-Allergy tests without obvious symptoms
– Inducing a caesarean section before the 39th week of pregnancy unless it was very clear it had to be done. Problems encountered with early caesareans: breathing and learning disabilities, plus many “unknown” risks.
-No CT scans of children for any but major head injuries. No one really knows how the high radiation dose of CT scanners will affect children’s future cancer rates and development.
-Routine opioid use for migraine headache sufferers. Some get worse headaches in time, others become addicted.
-Tight control of diabetes for those of Medicare age.
Medicine involves chance and many unknown factors. There are times in patient care where treatments not “generally” used are the only alternatives where benefit outplays risk.
But there are many reasons doctors order procedures they are told are often useless:
1. Tradition. I’ve seen it work – and it was how I was trained.
2. It won’t hurt the patient, gives me information I might need, and makes money.
3. If I don’t do this and something goes wrong I may very well get sued. Plus anything that violates my local community’s “standard of care” can get me in trouble.
4. The people who own my practice want me to do these tests.
5. It’s obvious – it just makes sense.
But procedures that “make sense” may not work.
The Standard of Care
Go into a courtroom for a medical malpractice case and you may soon hear legal jeremiads about “standard of care”. How could Dr. Smith have so wantonly “violated” the standard of care by not performing some necessary test or procedure.
But how good is the standard of care?
We get some idea – some – from a recent study in the New England Journal Of Medicine on “established treatments.”
The study was biased from the outset. Why? Proving an established treatment does not work is bigger news. Proving something “everyone” does is perfectly worthwhile doesn’t excite people much – even though it’s the lifeblood of medical practice. Prestigious journals like NEJM want noteworthy articles that maintain their “public profile.”
Here were the results:
40% of “established” tests were considered non-beneficial or harmful
38% were clearly beneficial
22% – the jury remains out.
Were all of these studies “foolproof”? No. As people found with hormonal replacement for post-menopausal women, touted by Harvard’s long running Nurse’s Study as cutting cardiovascular risk in half – there’s lots under the hood of even the most “prestigious” research. Many large clinical trials include complex statistical analyses that most doctors have never been taught and don’t understand. Plus the statistical models used in these analyses can be patently wrong.
Still, the overall numbers were perilously close to the old medical school dictum – stolen from many other sources – that “50% of what we’re teaching is right and 50% wrong – we just don’t know which 50%”.
Perhaps medical schools should explain to eager trainees that many of their recommendations may eventually prove both “wright and rong”.
Still, many procedures without evidence they work are done because they “make sense.” That’s been my experience over the past years, especially in dealing with surgeons of a certain vintage.
Alcoholism is very common. It’s certainly common among those treated surgically.
And some surgeons love to treat alcohol addiction post-operatively with – intravenous alcohol!
When I ask them how they came to this procedure they tell me the same story – you detox people from an addiction using the drug they use. Post-op patients have lots of IV lines anyway – so why not add some intravenous alcohol to prevent delirium tremens.
Why not? Because there’s at least 40 years of studies showing other medications – from benzodiazepines to anti-seizure drugs to alpha adrenergic blockers – work better. Are safer. Don’t intravenously push into a sick body the same toxin that may have led to the operation in the first place.
Some of them listen, but many don’t. It “makes sense” to do what they do.
Tradition trumps treatment.
Medical care is expensive for many reasons. One is that doctors are heavily “incentivized” to do tests and procedures that may not even work.
Programs like Britain’s National Institute of Clinical Effectiveness (NICE) can be looked to as models of how to get rid of tests and procedures that don’t work and sometimes provoke harm – medical and economic – to the country as a whole.
But culture is hard and slow to change.
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