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An Epidemic of Overtreatment and Inappropriate Care? The Treatment: Physician Collaboration and Second Opinion

  • 10th September 201310/09/13
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Reading about healthcare in newspapers this summer, I was struck by how often the news was about overtreatment and inappropriate care. It started to sound like an epidemic, with alarming rates of unnecessary surgeries and overmedication, as well as delayed diagnoses and other medical malpractice and mistakes.

The reality is not as bleak as the headlines. Americans still get remarkably high-quality healthcare, in general. Despite the alarmist nature of these media stories, they do point to some important areas that need improvement. Today, we are on the verge of significant changes with the potential to bring improvements.

Here is information from four recent reports that caught my attention:

Problem #1: Unnecessary Surgeries

“Tens of thousands” of unnecessary surgeries were performed, according to a USA Today review of medical databases and government records. They also found that “Since 2005, more than 1,000 doctors have made payments to settle or close malpractice claims in surgical cases that involved allegations of unnecessary or inappropriate procedures.”

A few specifics they cited:

  • Spinal fusion: About 10% of surgeries covered by Medicare in 2011 were not necessary.
  • Back and neck pain: More than 17% of patients were told they needed surgery when they did not, according to another 2011 study.
  • Implantable cardiverter-defibrillators: 22.5% of the patients in a 2011 study did not need the one they got.
  • Angioplasty: A 2011 review of cardiac patients who were not having heart-attack symptoms found that 12% who had angioplasty did not need it. Many also had stents inserted.
  • Hysterectomy: A 2000 study of women in nine southern California managed care organizations found that 70% of the procedures were inappropriate; non-surgical treatments were not tried first.

Problem #2: Overtreating Back Pain

Earlier this month, The New York Times reported that doctors were not following guidelines when caring for patients with back pain, according to a new study from the Journal of the American Medical Association. Rather than starting treatment as recommended—with NSAIDs or acetaminophen and physical therapy—many physicians ordered pricey scans, prescribed strong painkillers and sent patients to specialists. The study discovered that this overtreatment has become increasingly common, even though it is rarely necessary or helpful. Back pain usually gets better within a few weeks with little or no treatment .

Problem #3: Mistreating Ovarian Cancer

Earlier this year, a disturbing study was presented showing that just slightly more than one-third of ovarian cancer patients receive the right care. In their coverage of the study, The New York Times reported: “Most women with ovarian cancer receive inadequate care and miss out on treatments that could add a year or more to their lives.”

The report blames much of the mistreatment on doctors’ lack of experience and suggests that women fare better seeking treatment at major cancer centers. There, they are more likely to be treated by a gynecological oncologist who has experience with the lengthy, complicated surgery necessary to remove as much of the cancer as possible, giving chemo drugs a good chance at getting rid of the rest.

Problem #4: Outdated Procedures

Just a few weeks ago, The New York Times reported that many patients are receiving the wrong medical care in general. “More than 40 percent of established practices studied were found to be ineffective or harmful, 38 percent beneficial, and the remaining 22 percent unknown,” they cited, from a study in the August issue of Mayo Clinic Proceedings. On the list: hormone therapy in postmenopausal women, high-dose chemotherapy and stem cell transplant for breast cancer, and intensive glucose lowering in Type 2 diabetes patients in intensive care. At the same time, outdated ideas persist that prevent patients from appropriate care, such as the fear that oral contraception will harm lupus patients, that vaccines might harm people with multiple sclerosis, or that epidurals increase rates of C-sections. The study author, Dr. Vinay Prasad, said old treatment beliefs take about 10 years to die out after they are proven wrong.

The Causes and Cures

The causes of inappropriate care are complex, but often the root is simply lack of knowledge, an honest mistake, or a healthcare provider who simply wants to help a patient when treatment isn’t working. Sometimes, profit-driven decision-making or fear of malpractice claims lead to over-testing and overtreatment.

Thankfully, a few forces are driving medicine in the direction of increasingly appropriate care. To name a few: Healthcare reform (The Affordable Care Act) and Accountable Care Organizations emphasize adherence to evidence-based medicine and approved protocols. Insurance companies often join in; ultimately, appropriate care should be less costly and more effective than unproven, outdated or unnecessary treatments. The push toward electronic medical records and e-prescribing should enhance continuity of care and reduce errors due to missing charts or illegible handwriting. Using EMRs generates a wealth of patient data, which could provide more evidence upon which to create and update appropriate care protocols.

But if Dr. Prasad is right, it could still take 10 years for new medical evidence to become broadly followed. In the near term, the best approach may be a combination of well-informed patients asking the right questions and seeking top doctors who stay abreast of the latest research, and rigor in using second opinions. The last point may be the most useful. Consider this evidence from the USA Today report:

A 1982 study in the journal Medical Care found that a mandatory second opinion program for Massachusetts Medicaid patients led to a 20% drop in certain surgeries, such as hysterectomies, that were considered more likely to be done unnecessarily. A 1997 study in the Journal of the American College of Surgeons looked at 5,601 patients recommended for surgery and found that second opinions found no need for the operation in 9% of the cases. Among those who got the countervailing second opinion, 62% opted not to have the operation.

These numbers provide the strongest hope for rapidly improving the rates of appropriate care. Insurers often insist on a second opinion prior to surgery. Patients and doctors should, too.

Additional Sources:

http://www.niams.nih.gov/Health_Info/back_Pain

http://www.aans.org/en/Patient%20Information/Conditions%20and%20Treatments/Low%20Back%20Pain.aspx

http://www.aafp.org/afp/2000/0315/p1779.html

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