Too Much Healthcare?

Industry grapples with overdiagnosis, overtreatment

For materials executives, the Holy Grail of cost reduction is utilization. If clinicians would use less stuff and perform fewer procedures, costs would go down. But, lacking clinical training, materials executives have been hampered in their efforts to influence utilization. Now, it seems, they’re getting a little help from clinicians themselves.

In 2010, the Institute of Medicine reported that approximately 30 percent of healthcare costs – more than $750 billion annually – is spent on wasted care, care that is potentially avoidable and would not negatively affect the quality of care if eliminated.

A number of professional organizations, including the American College of Physicians, American Medical Association and Alliance for Academic Internal Medicine, are taking steps to address the problem head-on.
According to published studies, it’s about time.

Overdiagnosis
Last fall, the Dartmouth Institute for Health Policy & Clinical Practice published three studies that point to potential overuse of certain medical procedures. In a study published in the Nov. 21, 2012, New England Journal of Medicine, researchers reported that more than a million women have been overdiagnosed with breast cancer, and that despite all the screenings with mammograms, there has been no change in the incidence of metastatic breast cancer and little decrease in the rate that late-stage cancer is found. Fewer women are dying from breast cancer, but the researchers concluded that this is due largely to better treatment, not screening.

“[A]lthough no one can say with certainty which women are overdiagnosed, there is certainty about what happens to them,” the researchers wrote. “[T]hey undergo surgery, radiation therapy, hormonal therapy for five years or more, chemotherapy, or (usually) a combination of these treatments for abnormalities that otherwise would not have caused illness.”

“Women should recognize that our study does not answer the question ‘Should I be screened for breast cancer?’” the researchers wrote. “However, they can rest assured that the question has more than one right answer.”

In a second study, published in the Archives of Internal Medicine, researchers found that diagnostic tests are frequently repeated among Medicare beneficiaries. The study results indicate that among Medicare beneficiaries undergoing echocardiography (examination of the heart), 55 percent had a second test within three years. Repeat testing for the other examinations also was common: 44 percent of imaging stress tests were repeated within three years, as were 49 percent of pulmonary function tests, 46 percent of chest computed tomography, 41 percent of cystoscopies (an examination of the bladder), and 35 percent of upper endoscopies (examination of the digestive tract).

“Although we expected a certain fraction of examinations to be repeated, we were struck by the magnitude of that fraction,” wrote the researchers.

End-of-life care
A third report from the Dartmouth Atlas Project found that the way academic medical centers deliver healthcare – particularly, end-of-life care – differs dramatically from one institution to the next. These differences affect the training that medical students receive, and may affect the way they practice medicine in the future. The Dartmouth Atlas Project uses Medicare data to analyze and compare national, regional and local healthcare practices. Some examples:

  • In 2010, about half of chronically ill patients (49.4 percent) treated at Johns Hopkins Hospital in Baltimore were enrolled in hospice in their last six months of life, compared to only 23.1 percent of patients treated at Mount Sinai Medical Center in New York City.
  • In 2010, 66.6 percent of chronically ill patients at NYU Langone Medical Center in New York City saw 10 or more different physicians during their last six months of life, compared to only 42.5 percent of patients at Scott & White Memorial Hospital in Temple, Texas. Hence, a patient’s care will likely be more influenced by specialists’ opinions at NYU.
  • In 2010, patients were twice as likely to get knee replacement surgery in Salt Lake City (11.9 per 1,000 discharges) than in Manhattan (4.5 per 1,000 discharges). As a result, a resident trained in Salt Lake City may be more likely to learn a treatment style involving surgery than in New York City, where a resident might more readily prescribe physical therapy.

“These findings challenge the assumption that clinical science alone drives medical practice at these prestigious institutions and thus raise a serious issue for academic medicine,” said David C. Goodman, M.D., MS, co-principal investigator for the Dartmouth Atlas Project, and director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy & Clinical Practice.

High-value, cost-conscious care
In July 2012, the American College of Physicians and the Alliance for Academic Internal Medicine developed a
curriculum to help train internal medicine residents about how to avoid overuse and misuse of tests and treatments that do not improve outcomes and may cause harm. The curriculum is part of the ACP’s “High Value, Cost-Conscious Care” initiative, launched in 2010, to help physicians and patients understand the benefits, harms and costs of tests and treatment options for common clinical issues.

The free curriculum (available at www.highvaluecarecurriculum.org) is designed to engage internal medicine residents and faculty in small group activities organized around actual patient cases. It consists of 10 one-hour interactive sessions, which can be incorporated into the existing conference structure of a program.

“Physicians receive little specific training about identifying and eliminating wasteful diagnostic and treatment options,” said Cynthia D. Smith, M.D., FACP, ACP’s senior medical associate for content development and the lead author of “Teaching High-Value Cost-Conscious Care to Residents: The AAIM-ACP Curriculum,” published online in Annals of Internal Medicine.

“Residency training is an excellent time to introduce the concept of high-value, cost-conscious care, because the habits that residents learn during training have been shown to stay with them throughout their professional careers.”

For each of the modules, residents will be directed to use a five-step framework to develop the skills of practicing high value, cost-conscious care:

  • Step 1: Understand the benefits, harms, and relative costs of the interventions they are considering.
  • Step 2: Decrease or eliminate the use of interventions that provide no benefits and/or may be harmful.
  • Step 3: Choose interventions and care settings that maximize benefits, minimize harms, and reduce costs. Use comparative effectiveness and cost effectiveness data where available.
  • Step 4: Customize a care plan with each patient that incorporates the patient’s values and addresses patient and family concerns.
  • Step 5: Identify system level opportunities to improve outcomes, minimize harms, and reduce healthcare waste.

National Summit on Overuse
Meanwhile, the American Medical Association-convened Physician Consortium for Performance Improvement (PCPI) and The Joint Commission co-sponsored the National Summit on Overuse in September 2012 to discuss strategies to improve the quality and safety of patient care. A variety of key stakeholders, including representatives from physician organizations, medical specialties, government agencies, research institutions and patient groups, came together to discuss the appropriate use of the following five treatments and procedures:

  • Heart vessel stents.
  • Blood transfusions.
  • Ear tubes for brief periods of fluid behind the ear drum.
  • Antibiotics for the common cold.
  • Early scheduled births without medical need.

At the summit, participants considered the existing evidence surrounding the appropriate use of these five treatments and procedures and discussed ways to raise awareness among healthcare professionals and patients, and provide ways to reduce overuse.

“Overuse of medical tests, treatments and procedures is a serious quality and patient safety concern that needs urgent attention,” said The Joint Commission President Mark R. Chassin, M.D., FACP, M.P.P., M.P.H. “Our aim is to help improve safety for patients by raising awareness about the inappropriate indications for these procedures and treatments. Widespread and effective dissemination of this important information will help physicians and patients make informed decisions and avoid overuse.”

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