Medical Overtreatment: It's Not Always a Case of Bad Financial Incentives
It has been well-established that 30 to 40 percent of healthcare provided in the U.S. is wasted because it's either redundant or unnecessary. While much of the overtreatment and over-testing of patients springs from the financial incentives of our system to do more, there are other categories of overtreatment that can't be eliminated by changing how doctors and hospitals are paid.
Two examples. The first concerns the use of blood transfusions in coronary artery bypass graft (CABG) surgery. A study of over 100,000 operations reveals that the frequency of these costly and sometimes dangerous interventions varies widely among various hospitals. Adjustment for patient risk factors, geographic location, and whether the hospital is an academic medical center explains only about 11 percent of the variations. However, blood usage was more than twice as low in the Mountain and New England regions as in the West South Central region.
The transfusions are given to address anemia, which is a risk factor for death and complications after CABG surgery. But there's apparently no consensus on what constitutes the right indication for transfusing patients. Another study shows that transfusing patients when their red blood cell count hits two different points produces no difference in outcomes.
What this reveals is how much remains unknown in medicine. But the research on variations in care shows something else: Two decades after the frequency of transfusions during heart operations was first questioned, hospitals and surgeons have not changed their procedures.
Once again, the overuse of transfusions illustrates the clannishness of medicine: Doctors practice in clusters -- often within the same area as the medical school they attended or the residency program they trained in -- and pay more attention to their colleagues than to the latest journal studies. They call it the community standard of care; but really, it's safety in numbers. The only way to overcome it is to do more solid research on what works best and require doctors to follow evidence-based guidelines, unless there's a reason not to.
The other example of overtreatment displays a certain mindlessness. Research shows that many Medicare patients who have advanced, incurable forms of cancer continue to be screened... for cancer! Among women in this category, 9 percent received mammograms and 6 percent had a Pap test, compared to 22 percent and 13 percent, respectively, of women who didn't have cancer. Among men with an advanced malignancy, 15 percent were screened for prostate cancer, compared to 27 percent of those who didn't have cancer.
Since the survival time of the cancer patients ranged from 4 months to 16 months, they clearly didn't benefit from being screened. In fact, the authors noted, eliminating these unnecessary tests would avoid biopsies and spare patients additional distress. It would also save money.
So why did doctors order screening tests for these patients? "What we think we see here is the manifestation of cancer screening on auto pilot," lead researcher Cecilia Sims of Memorial Sloan-Kettering Cancer Center told Bloomberg.
This bit of understatement points to a problem that may have nothing to do with financial incentives. Ironically, it might be related to the very kind of guidelines that doctors should follow to avoid unnecessary transfusions during CABG operations. Doctors may be over-conscientious, or they may be influenced by institutional directives to make sure that every patient of a certain age receives mammography or a PSA test. It's easier to just do it for everybody than to discriminate.
As these examples show, it will be much harder to eradicate waste from our system than many people think. But there are also solutions to these problems, if we have the will to find them.
Image supplied courtesy of Flickr.
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