OVERTREATMENT
bmj.com News: Experts consider how to tackle overtreatment in US healthcare UNNECESSARY CARE (BMJ 2012;344:e3144) doc2doc Overdiagnosis: do we know when to stop? Discuss at doc2doc Is profit driven bmj.com/multimedia Jeanne Lenzer healthcare to blame? (pictured) investigates the harms of overtreatment A newly launched movement led by prominent doctors is challenging the basic assumption in US healthcare that more is better. Jeanne Lenzer reports
t 8 am on her first day as an Medicare recipients alone each year. Overall, Medicaid Services; and Harvey Fineberg, presi- intern, Diane Meier attended the unnecessary interventions are estimated to dent of the Institute of Medicine, which co-hosted resuscitation of an 89 year old man account for 10-30% of spending on healthcare the meeting. with end stage congestive heart in the US, or $250bn-$800bn (£154bn-£490bn; Participants poured out examples of ram- failure. The staff shocked the man’s €190bn-€610bn) annually.2 pant overtreatment, ranging from the overuse heartA repeatedly. They tried four times to place of screening tests and imaging technology to an a central line. They injected pressors directly Signs of change epidemic of questionable surgery (tonsillectomies into his heart, stuck his femoral artery for blood Earlier in the year, Meier, along with more than alone increased by 74% from 1996 to 2006). gases, and performed chest compressions for over 130 prominent doctors from the US, Canada, Rita Redberg, a cardiologist and editor of the an hour before finally pronouncing him dead. and the UK participated in a two day conference Archives of Internal Medicine, told the gathering Two decades later, after witnessing similar pre- on avoiding avoidable care, the first in the US to that many interventions need to be challenged, death rituals countless times, Meier published focus exclusively on overtreatment. The gathering such as cardiac computed tomography, cancer the story of a 73 year old man with metastatic in Cambridge, Massachusetts, was co-convened screening for people over 75, and elective car- lung cancer who told his doctors he didn’t want by the Lown Cardiovascular Research Foundation diac angioplasties. She cited a study that found invasive testing and treatment. His doctors in Brookline, Massachusetts, and the New Amer- nearly half of elective percutaneous coronary consulted a psychiatrist, who said the man was ica Foundation, a Washington DC think tank. interventions (PCI) were either inappropriate or “in denial” about his illness. After some pressure The impetus for the meeting arose two years of “uncertain” benefit.4 She said, “Most patients from his doctors, the man and his family agreed ago, when Vikas Saini, a Harvard cardiologist and who are getting a PCI think that they are getting to further diagnostic testing and treatment, president of the Lown foundation, read Shannon it to prevent a heart attack and that they are going including placement of a gastrostomy tube. He Brownlee’s book, Overtreated: How Too Much to live longer.”5 Yet the only established benefit of was ultimately subjected to 47 Physicians are trained Medicine is Making Us Sicker and angioplasty for stable coronary disease is possible days of painful and invasive Poorer.3 Saini contacted Brown- relief of symptoms. treatments before dying.1 to believe that staving lee, who is acting director of The group identified multiple reasons that For Meier, who went on to off death, even if health policy at the New Amer- clinicians and hospitals overtreat, including win a MacArthur “genius grant” only for days, is their ica Foundation, and together, malpractice fears, supply driven demand, knowl- for her work in palliative care, it over‑riding mission, and they hatched a plan to convene edge gaps, biased research, profit seeking, patient was not the patient who was in all available technology the conference. Saini says, “We demand, and financial conflicts of guideline denial, but his doctors. Physi- should be employed to wanted to bring together the writers. Other commonly cited problems included cians are trained to believe that achieve that goal many people we knew who felt the rapid uptake of unproved technology and the staving off death, even if only for that the system was out of con- failure to inform patients fully of the potential days, is their over-riding mission, and all available trol in order to find out if there was enough com- harms of elective treatments. technology should be employed to achieve that mon purpose and commitment among them to try Several speakers emphasised the way physi- goal. The cost of this self delusion in Meier’s eyes to do something about unnecessary care.” cians are paid and trained in the US as central can be measured in the patient’s suffering, inad- The pair conceived of the meeting as a “big factors. Meier told the BMJ, “Medical students are equate pain relief, and in time lost that could have tent,” Saini says. “We wanted to jumpstart a con- taught to do things, not how to know what not to been spent at home with family and loved ones. versation within the clinical community about do. Medicine is a very action based profession, On a national level, the problem is daunting: our ethical obligations to avoid the harm caused and that’s how physicians in the US are paid, annually, 65% of all deaths in the United States to patients by overtreatment.” perhaps not coincidentally. You don’t get paid for now occur in hospitals, multiplying the instances The meeting attracted a who’s who of Ameri- telling people that watching and waiting might when futile or unnecessary care is given. can medicine, including Bernard Lown, inven- be best, or that keeping someone comfortable The harms of overtreatment are not restricted tor of the cardiac defibrillator and winner of might be better.” The result is that overtreatment to dying patients. Overly aggressive treatment the Nobel Peace prize; Donald Berwick, former is woven through American medical culture—as is estimated to cause 30 000 deaths among administrator of the US Centers for Medicare and one participant said, “It’s in the air we breathe.”
BMJ | 6 OCTOBER 2012 | VOLUME 345 19 OVERTREATMENT
There was general agreement on some solu- Inevitable opposition insured under the Aff ordable Care Act, interest tions: use guideline writers free of confl icts of While many of the Cambridge conference partici- in cutting costs has become a central topic in US interest, implement shared decision making, pants have been warning for decades about the politics, and overtreatment is increasingly a focus reduce excess hospital capacity, and reform tort harms of overtreatment, it is only now, with glo- in the clinical community. law. There was some disagreement about whether bal fi nancial downturns and growing awareness A fl urry of books, articles, international initia- the provisions in the recent Aff ordable Care Act of the unsustainability of healthcare spending, tives, and conferences focused on various aspects would reduce overtreatment. The majority that the issue is receiving signifi cant attention of overtreatment has appeared in the past few endorsed global payment schemes in a primary from the American media and politicians. With years. The American Board of Internal Medicine care driven system. some 30 million Americans expected to be newly announced its Choosing Wisely campaign in Is the USA’s problem ours too? The United Kingdom is fortunate in randomised controlled trials. investigating people who are that it is insulated against some Faced with the contract, GPs are unlikely to bene t. of the needless overtesting, made to ask themselves why a These campaigns are o en overtreating, and overdiagnosing patient is not taking a drug, rather pivotal to publicity by patient that doctors in the United States than why they should be. groups and charities. However, are rising up against. Instead, we A long campaign for fairer, nancial relations between these have the National Institute for better information on NHS groups and the drug industry— Health and Clinical Excellence screening—which was supported with its agendas for the uptake (NICE), which o ers evidence by one of the instigators of breast of new interventions and its PR based appraisals of healthcare screening in the UK, Professor expertise—are o en unclear. And interventions and screening and Michael Baum—looks like it may despite the continuing problems which protects against treatments have, at least in part, succeeded. of opaque data from clinical Did this UK campaign (above) lead to unnecessary chest x rays? of little or no e cacy being o ered The current review of information trials, earlier this year doctors
on the NHS. We also have the UK given about screening tests in were told not to “accept the decide which treatments to fund. National Screening Committee, the UK is likely to recommend negative myths about cooperating Will this result in political whim, which provides critical reviews balanced information on the with industry” in guidance rather than evidence based, and recommendations of what pros and cons of screening and supported by numerous colleges, decision making? The Health screening is e ective and useful. promote informed choice. There medical journals, the BMA, and and Social Care Act has given Does this mean that we can is no doubt that screening causes the Association of the British permission for the dissolution of relax? Unfortunately not. The overdiagnosis and overtreatment. Pharmaceutical Industry. the NHS into a mere brand, and general practice contract has However, private screening clinics, Shopping last month, I was with competition companies who improved the quanti cation of of which there are many, thrive. handed leaflets from a stall are likely to fragment care despite what we do, but the price of this is Similar problems are created demanding “awareness” about evidence that continuity results that more patients are exposed to by non-evidenced awareness restless legs, suggesting I could in less intervention and better guidelines rich in pharmaceutical campaigns. For example, the get treatment from my GP. The ¢ satisfaction. Our iatrogenic recommendations. Some may be UK government’s recent “Three same week a drug representative harms may be slightly less obvious bene cial. However, most lack week cough campaign” to tried to gain access to my practice than those in the US, but they are guidance about when prescribing promote awareness of lung cancer to “educate” me on treatments. politically engrained. should end or is no longer likely increased the number of chest We can hardly avoid harm when Margaret McCartney is a general to be useful; we lack data about x rays performed but did not we allow this to perpetuate. practitioner , Glasgow, UK the risks of the polypharmacy signi cantly increase diagnoses But politics threatens most. Competing interests: None declared. that the contract generates. It of lung cancer. Charities also The coalition government intends Provenance and peer review: Commissioned; is common for patients to be use awareness campaigns, but to begin “value based pricing” not externally peer reviewed. taking or more medications; the bene ts of earlier diagnosis in ; this will mean that References are in the version on bmj.com yet such patients are rarely seen are rarely proved and they risk government rather than NICE will Cite this as: BMJ ;:e
20 BMJ | 6 OCTOBER 2012 | VOLUME 345 OVERTREATMENT DR P MARAZZI/SPLPDR MARAZZI/SPLPDR
Left from opposite page: Diane Meier, Shannon Brownlee, David Himmelstein, Vikas Saini, and Bernard Lown, all part of a movement committed to tackling overtreatment, such as overuse of tonsillectomies, cardiac computed tomography, and elective cardiac angioplasties
December 2011, enlisting nine specialty societies California, Los Angeles, suggests no amount of with just the right amount of technology that to each identify fi ve tests, treatments, or services denying will prevent the message from being improves health and wellbeing, but not an ounce “that should be re-evaluated.” The Archives of distorted by those whose interests it threatens. more. If we do that, cost containment follows as Internal Medicine launched its section, “Less is He told the BMJ , “Advocates shouldn’t be afraid a result, not as the deliberate goal.” Hoff man More,” in April 2010, to examine “unnecessary when opponents try to demonise making wise comments, “At some point, the movement will harms of treatment and testing, with no expected choices by labelling it ‘the R-word.’ Of course we have to address the elephant in the room. Physi- benefi t.” Other initiatives include PharmedOut, should budget resources—as we do everywhere cians and nurses have a fi duciary responsibility a Georgetown University Medical Center project in our lives. In addition, there’s already lots of to put the needs of patients fi rst. But the fi duciary that “advances evidence-based prescribing”; rationing in healthcare; wouldn’t it be better for responsibility of companies selling healthcare the international “selling sickness” conferences; us to decide what should be available, based on services is very diff erent; it’s to the bottom line of a 2013 conference on preventing overdiagnosis 6 ; what’s best for our health, rather than having shareholders. Whenever there is tension between and the international Healthy Skepticism project. insurance companies decide, based on what’s what’s best for the public health and what’s most Participants in the Cambridge conference hope most profi table for them?” profi table, these companies must choose the lat- to forge a coalition of groups from these initiatives. ter. Ultimately, aft er we agree on which interven- But as these initiatives begin to move forward and Is there an elephant in the room? tions are useless and wasteful, we’re still going join forces, they will face formidable challenges Proponents of reducing overtreatment will also to have to tackle the more diffi cult question, as from the healthcare industry and the general pub- have to contend with disparate views on who Bernard Lown so eloquently put it, of whether lic. Certainly this has been the case in the past. should pay for healthcare: government, private or not profi t driven healthcare is an oxymoron.” In 2000, Citizens for Better Medicare spent over insurers, or a mix of the two. David Himmelstein, Brownlee and Saini contend that the only $65m on a television advertisement opposing professor at the City University of New York way to move forward is by growing a move- President Clinton’s proposed Medicare prescrip- School of Public Health, cofounder of Physi- ment, and they hope to develop the resources tion drug benefi t plan. The ad featured “Flo,” an cians for a National Health Program, and a pro- for a national, coordinated eff ort. They report arthritic bowler who claimed she wanted “big gov- ponent of a “single payer,” or government funded strong interest from the Cambridge participants ernment out of my medicine cabinet.” Citizens for system, says that as a young physician he saw in another meeting next year, and would like to Better Medicare turned out to be a front group for “murderous undertreatment” at a public hospi- see it be more international in scope. They say the drug industry, which opposed price controls. 7 tal where he worked, while patients at a nearby that engaging clinicians will be a central focus More recently, patient groups, many of which are private hospital were subjected to the dangers of of their eff orts, a strategy that Lown supports. He heavily funded by industry, have denounced inde- overtreatment. “We have a problem of malap- says that doctors are accorded special credibility pendent evidence based screening guidelines, portionment,” says Himmelstein. By adopting a by the public because “we speak from within the suggesting that they constitute “rationing” and single payer health system, he says, the US could belly of the beast” of the healthcare system. the work of government “death panels.” 8 save 45 000 lives lost because of undertreatment “The intense debate about how to move Some specialty professional societies and each year and save enough money to cover the forward is a sign that overtreatment matters, ” doctors’ groups also claim that rationing is just 50 million currently underinsured or uninsured. Brownlee says. “We want everyone involved around the corner. AmericanDoctors4Truth spon- Himmelstein says that tackling undertreat- and sharing their expertise on potential solu- sored a television advertisement in which Presi- ment could go a long way toward reassuring a tions. There is room for many political ideologies dent Obama pushes an elderly grandmother in a sceptical public that the overtreatment move- and beliefs about how to pay for healthcare. The wheelchair off a cliff rather than allow her to have ment is not a dressed-up scheme to ration care crucial step right now is to get the medical com- a pacemaker. . with a real goal of boosting profi ts. In Lown’s munity mobilized around the idea that overtreat- The overtreatment movement will have to view “undertreatment is the Siamese twin” of ment harms patients.” respond to inevitable charges of rationing, but overtreatment, and both are bound together by Jeanne Lenzer is a journalist , New York [email protected] Meier vigorously opposes the use of the word. the drive for money. “When it’s more profi table Competing interests: JL has written articles with Shannon “Rationing means that you are limiting nec- not to treat because someone is uninsured, they Brownlee and has close collegial relationships with several essary care. What we are proposing is limit- are left untreated, and when it’s profi table to treat of the people interviewed. Provenance and peer review: Commissioned; not ing unnecessary care—harmful care.” Jerome the insured, they are overtreated,” he says. externally peer reviewed. R Hoffman, emeritus professor of medicine Saini says , “We can take care of our patients References are in the version on bmj.com. and emergency medicine at the University of in the way we all want to be treated— humanely, Cite this as: BMJ ;:e
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