Overtreated: Too Much Medical Care is Making Many Americans Sicker: More medical care won't necessarily make you healthier _ it may make you sicker. It's an idea that technology-loving Americans find hard to believe. Anywhere from one-fifth to nearly one-third of the tests and treatments we get are estimated to be unnecessary, and avoidable care is costly in more ways than the bill: It may lead to dangerous side effects.
Overtreated America History of Dangerous Treatments: Overtreated: Bleeding for colds, X-rays for shoes: WASHINGTON— Bloodletting for a cold? X-rays to see if your shoes fit? Medicines, tests or procedures that can be useful in the right situation, yet dangerous if overused _ it's been a recurring theme through history. From the 1930s to the 1950s, thousands of U.S. children getting new shoes would climb onto wooden contraptions, press a button and look at the bones in their toes, glowing in eerie green light. In the ritual, shoe stores had fluoroscopes, a sales tool that supposedly helped to make sure shoes fit correctly by X-raying them for five seconds to 45 seconds _ while they were on a kid's feet. The device fit into a "culture of artistic persuasion and scientific blather like Cinderella into her glass slipper," wrote Dr. Jacalyn Duffin of Queens University in Kingston, Ontario, in her study of the history of the machines. At first, people weren't worried about a possible hazard, but that changed after the first atomic bombs were detonated and the risks of radiation became more widely known, according to Duffin. The machine originally lured people into stores, but "once it stopped working as an advertisement, when it served to drive people away, the store owners got rid of them," she said. Reports of injuries from the devices are hard to pin down, Duffin said. No formal injury studies were done, though tests showed many machines produced unnecessarily high levels of X-rays. There was a report of a woman who had chronic skin problems on her feet after working several years demonstrating the safety of the machines. Pennsylvania banned the devices in 1957 and other states followed. And what about the idea that drugs sold in the U.S. actually work? Not until the early 1960s was there a law that required that. Before then, pharmaceutical products had to be safe, but there was no requirement for drugmakers to prove their products did what the companies claimed. That created a situation in which a company could market a product for all sorts of conditions and people took oodles of pills and potions they didn't need. What constitutes overuse? It may not have been known at the time that a product was being overused, "but you look back and say 'Wow,' we used too much of that,'" said John Swann, historian at the Food and Drug Administration. One example is Phenacetin. It was the "P" in once-popular A-P-C pills that also contained aspirin and caffeine. They served to ease pain and fever and give a boost. "It was a very effective fever reducer and had been around a long time," Swann said. "It was a pretty common medicine at the time." But after long-term use, it also turned out that women who used Phenacetin were subject to urinary and kidney disease, as well as high blood pressure. Phenacetin was banned in the U.S. in 1983. Another "drug" noted by Swann was Marmola, which was desiccated thyroid tablets sold early in the 20th century as a diet product. People took them like candy, Swann said, but it wasn't safe. It, too, was taken off the market. For many people, thinking about discredited medical care conjures up images of medieval bloodletting, a medical treatment popular for thousands of years for all sorts of illnesses.It's still used for some rare diseases. Duffin, a hematologist as well as medical historian, says she still uses it for diseases that cause an overloading of iron or red blood cells. But bloodletting was wildly overused throughout history and, in most cases, did more harm than good. George Washington, for example, caught a cold and suffered severe respiratory distress in the hours before he died. During that time, he was bled several times by a series of doctors _ a total estimated later at between five pints and seven pints in less than 12 hours. Even a big, sturdy man like Washington must have been weakened by losing that much blood.
Overtreated: More medical care isn't always better: WASHINGTON— More medical care won't necessarily make you healthier _ it may make you sicker. It's an idea that technology-loving Americans find hard to believe. Anywhere from one-fifth to nearly one-third of the tests and treatments we get are estimated to be unnecessary, and avoidable care is costly in more ways than the bill: It may lead to dangerous side effects. It can start during birth, as some of the nation's increasing C-sections are triggered by controversial fetal monitors that signal a baby is in trouble when really everything's fine. It extends to often futile intensive care at the end of the life.
In between:
1. Americans get the most medical radiation in the world, much of it from repeated CT scans. Too many scans increase the risk of cancer.
2. Thousands who get stents for blocked heart arteries should have tried medication first.
3. Doctors prescribe antibiotics tens of millions of times for viruses such as colds that the drugs can't help.
4. As major health groups warn of the limitations of prostate cancer screening, even in middle age, one-third of men over 75 get routine PSA tests despite guidelines that say most are too old to benefit. Millions of women at low risk of cervical cancer get more frequent Pap smears than recommended; millions more have been screened even after losing the cervix to a hysterectomy.
5. Back pain stands out as the No. 1 overtreated condition, from repeated MRI scans that can't pinpoint the trouble to spine surgery on people who could have gotten better without it. About one in five who gets that first back operation will wind up having another in the next decade.
Overtreatment means: someone could have fared as well or better with a lesser test or therapy, or maybe even none at all. Avoiding it is less about knowing when to say no, than knowing when to say, "Wait, doc, I need more information!"
The Associated Press combed hundreds of pages of studies and quizzed dozens of specialists to examine the nation's most overused practices. Medical groups are starting to get the message. Efforts are under way to help doctors ratchet back avoidable care and help patients take an unbiased look at the pros and cons of different options before choosing one.
"This is not, I repeat not, rationing," said Dr. Steven Weinberger of the American College of Physicians, which this summer begins publishing recommendations on overused tests, starting with low back pain.
It's trying to strike a balance, to provide appropriate care rather than the most care. Rare are patients who recognize they've crossed that line.
"Yet let me tell you, with additional tests and procedures comes significant harm," said Dr. Bernard Rosof, who heads projects by the nonprofit National Quality Forum and an American Medical Association panel to identify and decrease overuse.
"It's patient education that's going to be extremely important if we're going to make this happen, so people begin to understand less is often better," he said.
Not even doctors' families are immune: A hospital appropriately did six CT scans to check Dr. Steven Birnbaum's 22-year-old daughter for injury after she was hit by a car. But the next day, Molly had an abdominal scan repeated as a precaution despite having no symptoms. When a doctor ordered still another, "I blew a gasket," said the New Hampshire radiologist, who put a stop to more.
_There are numerous reasons that one of three U.S. births now is by cesarean, but Dr. Alex Friedman blames some on an imprecise monitor strapped to laboring women. Too often, he has sliced open a mother's abdomen fearing the worst, only to pull out a pink, screaming bundle. "Everyone knows it's a bad test," said Friedman of the Hospital of the University of Pennsylvania. "You haven't done the patient a big service by doing an unnecessary surgery." Electronic fetal monitors record changes in the baby's heart rate, a possible sign of too little oxygen. They became a tradition _ now used in 85 percent of births _ years before research could prove how well they work. Guidelines issued last summer, aiming to help doctors better interpret which tests are worrisome, acknowledge the monitors haven't reduced deaths or cerebral palsy. But they do increase the chances of a C-section. While they should be used in high-risk women, the guidelines say the low-risk could fare as well if a nurse regularly checked the baby's heart rate. Later this year, the National Institutes of Health will begin a major study to see if adding a newer technology _ a type of fetal EKG already used in Europe _ to the heart-rate monitor would better identify which babies really are struggling and need rapid delivery.
_Undertreatment was in the headlines over the past year as the Obama administration and Congress wrestled with legislation to get better care to millions who lack it. The flip side, overtreatment, is a big contributor to runaway health care costs. Yet it's one that lawmakers, wary of being accused of rationing, largely avoided in the new health care law. Included were modest steps _ studies to compare which treatments work best, some Medicare financial incentives _ to push higher-quality, lower-cost care. "Physicians get up every day with the good intentions of wanting to do what's best for their patients," said Dr. David Goodman of the Dartmouth Institute for Health Policy. "We also live in environments where there are strong financial incentives to deliver certain types of care. We get well-paid for doing procedures. We get paid relatively poorly for spending time with patients and helping them make choices." Where you live plays a role. Two decades of research from the respected Dartmouth Atlas of Health Care shows that in parts of the country, Medicare pays double or triple the price to treat people with the same illnesses. The differences are not fully explained by big cities' higher cost of living or populations that are poorer, older or sicker. How much care someone gets is a main reason, yet Dartmouth's data shows people in pricier areas don't necessarily fare better. Dartmouth's check of 2005 Medicare data found that during their last six months of life, older adults in Boise, Idaho, spent 5.3 days in the hospital compared with 17 days in Miami. Fee-for-service care and local habits aren't the only drivers. Fear of malpractice lawsuits "has everything to do with it," said Dr. Angela Gardner, president of the American College of Emergency Physicians, whose members face intense pressure to overtest in the life-and-death chaos of the ER. Nor is there always clear evidence for one therapy choice over another. It can be faster to give in to a patient's demand for medicine than to explain why, for example, a child doesn't need antibiotics for ear pain.
_Care for the dying is often a powerful illustration of treatment going too far. Texas author Liza Ely had lined up hospice care for her 93-year-old mother, Verna Burnett, as she lived her last days with Alzheimer's and heart failure. Yet when Burnett developed an irregular heartbeat, the care provider at her Tyler, Texas, nursing home recommended seeing a cardiologist, to have a tube threaded through blood vessels to her heart to check it out. "We were speechless," Ely said. "We asked what could be done if something showed up on the test." The response: "Nothing, really." Ely said the family refused the "painful, expensive and unnecessary test." Congress' health care overhaul initially included a provision that would have authorized Medicare to pay doctors for counseling patients interested in end-of-life options. The provision died in the hue and cry after Sarah Palin dubbed the effort "death panels," a charge named 2009 political "Lie of the Year" by the nonpartisan fact-checking organization PolitiFact. Rep. Earl Blumenauer, D-Ore., said he plans to reintroduce his idea. "Today there is no guarantee that people will get the care they want when they are incapacitated or in those final stages of life. The default is sometimes the most painful, the most intrusive, the most frightening treatment _ whether or not that is what people want,"
New efforts are beginning to push back against overtreatment:
1. In Minnesota, the influential health cooperative HealthPartners saw use of MRIs and radiation-heavy CTs growing between 15 percent and 18 percent a year. So the insurer began a new program: National radiology guidelines pop up on each patient's electronic medical record whenever a doctor orders a scan. It's not a requirement, but a gentle reminder of when such tests are recommended. In two years and counting, HealthPartners estimates it avoided 20,000 unnecessary tests, preventing dangerous radiation exposure and saving $14 million. Providing the guidelines helps doctors deal with patients who demand a scan, says medical director Dr. Pat Courneya. He recently examined a young man who wanted a brain CT because of dizziness. Courneya's physical exam turned up no neurologic red flags like weakness or eye problems, but seeing the guidelines helped reassure the man.
2. An American Medical Association journal, Archives of Internal Medicine, just began a "Less is More" series to educate doctors about the risks of overused treatments. First up: Studies saying more than half of the 100 million-plus prescriptions for the strongest stomach acid suppressors _ proton pump inhibitors such as Nexium _ go to people who don't need something that powerful. That puts them at unnecessary risk of side effects, including bone fractures and infections.
3. This summer, the journal Annals of Internal Medicine begins publishing American College of Physicians' guidelines for "high-value, cost-conscious care."
4. To increase patients' savvy, about a dozen health centers around the country are testing "shared decision-making." That process uses plain-English guides, often DVDs, to explain the advantages and disadvantages of test and treatment options. Given full information, patients choose a less aggressive approach than doctors initially recommend about 20 percent of the time, says Dr. Michael Barry of the nonprofit Foundation for Informed Medical Decision-Making.
"Where I think no one in the Consumer Reports age would go to the car lot and say, 'I'm going to let the dealer figure out what car I want or need,' now we are taking a little of that spirit to the doctor's office," he said. More Isn't Always Better.
No comments:
Post a Comment