Saturday, May 16, 2015


In 2010, the Institute of Medicine issued a report stating that waste accounted for thirty per cent of health-care spending, or some seven hundred and fifty billion dollars a year, which was more than our nation’s entire budget for K-12 education. The report found that higher prices, administrative expenses, and fraud accounted for almost half of this waste. Bigger than any of those, however, was the amount spent on unnecessary health-care services. Now a far more detailed study confirmed that such waste was pervasive...

Another powerful force toward unnecessary care emerged years after Arrow’s paper: the phenomenon of overtesting, which is a by-product of all the new technologies we have for peering into the human body. It has been hard for patients and doctors to recognize that tests and scans can be harmful. Why not take a look and see if anything is abnormal? People are discovering why not. The United States is a country of three hundred million people who annually undergo around fifteen million nuclear medicine scans, a hundred million CT and MRI scans, and almost ten billion laboratory tests. Often, these are fishing expeditions, and since no one is perfectly normal you tend to find a lot of fish. If you look closely and often enough, almost everyone will have a little nodule that can’t be completely explained, a lab result that is a bit off, a heart tracing that doesn’t look quite right...

What’s more, the value of any test depends on how likely you are to be having a significant problem in the first place.. .

Overtesting has also created a new, unanticipated problem: overdiagnosis. This isn’t misdiagnosis—the erroneous diagnosis of a disease. This is the correct diagnosis of a disease that is never going to bother you in your lifetime.


  1. When billionaire-entrepreneur-Dallas Mavericks owner Mark Cuban lobbed a Tweet in early April advising his followers to have their blood tested "for everything available" every 3 months, he probably didn't expect to unleash a Twitterspace debate on medical overuse.

    Scores of health journalists and clinicians jumped on this ill-advised tweet, explaining that such overtesting can result in false positives, further testing, unneeded treatment, patient stress, and considerable costs.Although it's unlikely that the furor swayed opinions on either side, it reflects a larger, thoughtful conversation within the healthcare community. That discussion is the "less is more" movement to reduce overuse of "low-value" services such as screening, diagnostic tests, or treatments that are unlikely to help patients and pose risk of harm.

    Proponents of less-is-more medicine stress that its focus is avoiding harm rather than mere cost-cutting, which consumers fear might reduce access to necessary care. But it's also clear that targeting tests and procedures that offer little or no value, involve unnecessary risks to patients, and result in avoidable downstream care will indeed reduce wasteful healthcare spending.

    Researchers have suggested the cost of wasted healthcare dollars, including from overuse of low-value services, makes up a third of the nation's $2.8 trillion healthcare bill. Despite this hefty price tag, U.S. healthcare ranks last overall compared with 10 high-income countries, as well for three other health indicators: infant mortality, mortality from conditions amenable to treatment, and healthy life expectancy at age 60.


  2. The patient was a healthy young man in his 40s, without any significant prior medical history, who experienced a popping sensation in his abdomen several days earlier after lifting a heavy object at work.

    When he developed some abdominal discomfort later that same day, he brought himself into our emergency room, where he was evaluated by the emergency room staff.

    The resident had reviewed the emergency room notes and data, and in the end the patient was discharged with a plan to follow up in our internal medicine practice for his ventral hernia.

    So he was sent here, instead of to the general surgery clinic, the place where they fix hernias?

    I looked quickly at the impressive amount of data, documentation, and testing that had been done on him, sent from the ED via uplink to our EHR.

    Well, at least they didn't send a troponin.

    I laughed a little. The resident smiled, but then I noticed that his smile seems somewhat nervous.

    Wait, really? They sent a troponin on him?

    Actually, two troponins, separated by several hours.

    Nothing in the history we saw recorded in the ED or that the resident had gotten from the patient suggested anything like an acute coronary syndrome in this healthy young man without any cardiac risk factors. It sounded he lifted something, and developed a hernia. It sounded like this is what they thought in the emergency room.

    But somehow we ended up with a massive collection of labs, an ultrasound to confirm the hernia they felt on exam, and then a CT of his abdomen and pelvis to reconfirm those same findings.

    And to top it off, instead of simply sending him on to surgery clinic, they referred him to the internal medicine practice, where our main intervention was likely simply going to be to refer him to a general surgeon.

    We see the same thing on the inpatient services, where patients get daily labs, phlebotomized to the point of anemia, x-rayed to the point where they glow-in-the-dark, tested until no mysteries remain, much of it is of little benefit.

    And we are not immune to this in the outpatient world. How many CBCs and TSHs have been sent in the name of fatigue, when all the patient really needed to be told was to stop eating so much junk and start exercising. How many scans have been done because patients hinted that someone they knew had the same symptoms and their doctor ignored them and they were dead a month later? How many antibiotics have been given to colds since it takes 30 seconds to prescribe and 30 minutes not to?


  3. As I was flipping through the mail the other day, I noticed a flier from my medical clinic offering vascular screening. It warned me that “vascular disease often shows no symptoms or warning signs until it’s at an advanced stage and difficult to treat.” It encouraged me to call the clinic to schedule three tests — an ultrasound of the belly to look for a bulging aorta, another one for blockages in the carotid arteries to my brain and blood pressure readings to check for leg artery blockages — for an out-of pocket cost of only $150.

    The mailing did not encourage me to ask my doctor if I needed these tests. But since I am a primary care physician, I know that as a woman who has never smoked and who has no symptoms of any of these conditions, I should not get these tests.

    In fact, the only one of the three supported by evidence is the ultrasound for a bulging aorta — but only for men 65 to 75 years old who smoke or used to smoke.

    So what’s the harm in getting screened? Isn’t an ounce of prevention worth a pound of cure? In some situations, absolutely — for example, screening for colon cancer in older adults or for hypothyroidism in newborns. In these cases, evidence has shown that the benefit of screening a population outweighs the harm. But for many other screening tests, including the ones offered in the flier, the harm outweighs the benefits.

    You might wonder how a test like an ultrasound could cause harm. Here’s how: If that initial harmless test is abnormal, you may be told that you need another test for follow-up. And so begins the testing cascade, often culminating in an invasive confirmatory test like an angiogram. And if that is positive, surgery might be recommended to fix the problem. Angiograms and surgery can cause kidney failure, strokes, bleeding and even death.

    You might be willing to accept these risks if you knew that diagnosing the problem and getting it fixed while you are still feeling fine would lead to longer or improved quality of life. But in many situations, people do just as well or better if they don’t do anything until they become symptomatic, and many never become symptomatic.

    Let’s look at the carotid artery ultrasound as an example. The carotid arteries are the main blood vessels supplying the brain with oxygen and nutrients. Significant blockage of a carotid artery can cause a stroke, and these blockages can be seen on an ultrasound and fixed with surgery. And if you have experienced transient strokelike symptoms, known as TIAs, this surgery could prevent a stroke.

    But if you haven’t had those symptoms, there is good evidence that the surgery itself causes more complications — including strokes, deaths and heart attacks — than it prevents. There are safer ways to prevent strokes for people at risk that don’t require ultrasounds, angiograms or surgery, such as medications for high blood pressure and high cholesterol, smoking cessation and, in certain cases, daily aspirin.


  4. In the newspaper piece, she also challenged the health care clinic that sent the vascular screening promotion. Then she wrote to the clinic’s chief medical officer stating, “I’m disappointed in you.”

    After her Star Tribune article appeared, she got a letter from that same chief medical officer that basically said, “You’re right. This is contrary to our mission and values. I’m going to discontinue this campaign.”

    But her commentary didn’t sit well with Dr. Jay Cohn, director of the Rasmussen Center for Cardiovascular Disease Prevention at the University of Minnesota. Cohn wrote a letter to the editor of the Star Tribune, “Why cardiovascular screening matters, even without symptoms.” Excerpt:

    “Dr. Bloomfield needs to know that even “as a woman who never smoked and who has no symptoms,” for her atherosclerosis may be progressing and a future heart attack or stroke may be lurking.”

    Dr. Bloomfield thought that line about “lurking” was classic fear-mongering.

    That was my impression as well. It reminds me of an ad (below) from a Pfizer campaign years ago in Canada – an ad that also used that fear-mongering “lurking” term...

    We need to improve the public dialogue about health care – and specifically about the tradeoffs involved in any screening test. There’s usually an imbalance in such discussions: exaggerating or emphasizing benefits and minimizing or totally ignoring harms. (see illustration in article).

    We can do a better job. Kudos to Dr. Bloomfield for acting in her Howard Beale moment.


  5. Much of the aggressive and invasive health care we provide in the United States today, compared to time-tested, more conservative approaches, adds little value. And when independent scientific comparisons are done, the more complex approach often results not only in higher costs, but also in complications and adverse effects – all without significant benefit to the patient.

    Recent reviews of clinical outcomes have shown that many medical problems that we might have treated in the past with aggressive surgery would have avoided threatening patient health if managed instead by watchful waiting, with routine follow-up. But despite that information doctors continue to routinely recommend intervention, even in the absence of evidence suggesting a better outcome...

    Why do the recommendations by physicians to patients so often contradict the best science?

    The reasons for this preference to intervene are easy to identify. A medical culture attempting to maintain the status quo. A reimbursement system based on fee for service that creates perverse incentives. Direct-to-consumer advertising for the latest, most expensive drugs and invasive procedures. And physicians lacking the time to explain why a procedure or drug is unlikely to make a difference and can lead to even more problems...

    Many physicians, perhaps by nature or training have a hard time accepting that many of the treatments they perform have limited benefits. It is hard to tell a patient that little more can be done that will make a difference in outcome. For the physician, this can feel like failure. And this psychological reluctance is amplified by a fee-for-service system of reimbursement that encourages physicians to do more...

    My elderly uncle suffered from heart failure and had a series of small strokes. From any realistic perspective, he was going to die in a matter of days. Yet when his kidneys started to fail, the consulting nephrologist ordered renal dialysis in an attempt to “reverse the abnormality.” But all the other physicians involved recognized that subjecting him to this procedure three times a week was unlikely to extend his life. Two weeks after treatments began, while hooked up to the machine, my uncle died. All the dialysis accomplished was to make his last days more uncomfortable...

    But surprisingly these same patients who received palliative care, rather than aggressive treatment, actually survived longer.

    And this type of futile care is not what patients want. A study from the California Health Care Foundation reported that although 70 percent of Americans want to die at home, only about 30 percent do.

  6. But a significant proportion of patients with advanced cancer receive intensive medical therapy in the last weeks or even days of life. Physicians play a large role in making decisions about end-of-life care, and several studies have recently examined that relationship.

    In one study that looked at over 1200 patients with stage IV lung or colorectal cancer who participated in the Cancer Care Outcomes Research and Surveillance Consortium, nearly half had received some type of aggressive end-of-life care. This included chemotherapy in the last 14 days of life (16%), care in the intensive care unit in the last 30 days of life (9%), and acute hospital-based care in the last 30 days of life (40%).

    In contrast, patients who had earlier discussions about end-of-life care were less likely to receive aggressive care, and the use of these interventions was much less frequent when discussions took place at any time before the last 30 days of life. The odds of entering hospice were nearly twice as high.

    Another paper recently published in Health Affairs found that physician characteristics were the strongest predictor of whether a patient will be referred to hospice care. This outweighed other known drivers such as geographic location, patient age, race, gender, and comorbidities.

    "We found that the physician a patient sees is the single most important predictor of whether that patient enrolls in hospice care," said lead author Ziad Obermeyer, MD, a physician-researcher in the department of emergency medicine at Brigham and Women's Hospital and an assistant professor of emergency medicine at Harvard Medical School, in Boston. "The take-home message is that doctors matter in their patients' choices regarding end-of-life care," he told Medscape. "Physicians need to take responsibility for asking patients about their preferences and informing them about options."

  7. Who’s driving up U.S. healthcare costs? A recent study by Harvard professors and colleagues revealed that the culprits may be “cowboy doctors”—physicians who provide intensive, unnecessary, and often ineffective patient care, resulting in wasteful spending costing as much as 2 percent of the nation’s Gross Domestic Product—hundreds of billions of dollars annually...

    Physicians treating a critically ill patient may decide either to provide intensive care beyond the indications of clinical guidelines (such as implanting a defibrillator to counter severe heart failure), or attempt to make the patient more comfortable by administering palliative care. The researchers called the former group “cowboys” and the latter “comforters,” and found that their respective concentrations in a region closely tracked end-of-life spending as a whole. “It was absolutely amazing how strong [the correlation] was,” Cutler said. The data indicate that cowboy doctors tend to congregate in southeastern states such as Florida. They are also more likely to be male, and less likely to be specialists.

    Though these cowboy doctors may be pushing the frontier of medicine by going above and beyond, said coauthor Jonathan Skinner, a professor of economics at Dartmouth, clinical evidence showed little or no marginal benefit derived from the extra procedures, resulting in wasteful spending. Cutler suggested that doctors’ beliefs in these ineffective treatments may spring from their self-perception as “interventionists”: “I think some doctors are saying: ‘I just can’t accept that this patient is dying and there’s absolutely nothing I can do. I’ve got to do something.’”

    The study noted that very few doctors wanted to discuss the option of palliative care with patients, prompting Cutler to draw an analogy to auto mechanics: “You want this engine fixed, I’ll fix it. I’m not going to talk to you about whether you should get a new car—that’s someone else’s’ job.” But as a result, he said, patients are “Ping-Ponged back and forth” between the primary-care physician, who recommends a specialist, and the specialist, who prefers to leave the question of whether certain treatments are necessary to the primary-care physician. Meanwhile, medical bills rise...

    The study also found that most doctors who recommended unnecessary procedures weren’t seeking extra income—suggesting to Cutler that the lack of financial penalty, rather than the presence of financial reward, accounts for “cowboy” doctors’ actions. The healthcare system’s current incentives, he said, often do not prompt doctors to ask the right questions, such as whether a proposed treatment truly benefits the patient. “If doctors restrict themselves to performing what is evidence-based,” Skinner pointed out, “we can save hundreds of billions of dollars a year.”...

    The new study, Fisher suggests, is important because it highlights a power imbalance in the physician-patient relationship: doctors tend to follow their own beliefs about the right treatment to use, leaving patients little say in the process. How to treat a patient is often a multiple-choice question without a straightforward, single “correct” answer. When making these decisions, Fisher said, doctors should pay more attention to the patient’s preferences, instead of relying on their own experience.

    The research suggests that it’s time for the cowboys to rein themselves in, and learn to listen.
    Courtesy of Doximity