August 14, 2015

Dr. Atul's Gawande's Excellent Commentary on "Less is More" in Healthcare

 I've posted about Gawande before. Several friends and blog readers have thanked me for recommending Gawande's book Being Mortal in which this surgeon/author, after dealing with the final illness of his father, meditates on how we can better deal with age-related frailty, serious illness, and approaching death. He is a wonderful writer and thinker.

The Less-is-More Movement
Last week I talked about this trend. It aims to reduce the use of practices that offer little or no value and instead put patients at unnecessary risk. Researchers estimate that these practices account for a large part of the hundreds of billions of healthcare dollars wasted every year.

Six years ago, Dr. Gawande wrote about the problems of unnecessary health care in McAllen, Texas, where Medicare costs were among the highest in the country. Since then, Medicare costs have flattened across the country, but he found that they've dropped dramatically in McAllen. Many health outcomes have improved there, too.

Gawande's earlier article apparently helped spur the changes in McAllen. So has the Affordable Care Act, which encourages doctors to form "accountable-care organizations," and rewards them for providing higher-value services, thus improving outcomes and saving money.

That's the title of Gawande's latest article, Here is the subtitle:
An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it?
According to Gawande, research indicates that virtually every family in the country has been subjected to overtesting and overtreatment in one form or another. The costs appear to take thousands of dollars out of the paychecks of every household each year. Millions of people are receiving drugs that aren't helping them, operations that aren't going to make them better, and scans and tests that do nothing beneficial for them, and often cause harm.

Doctors are in a powerful position. They can recommend treatments of little or no value because doing so enhances their incomes, because it's their habit, or because they genuinely -- but incorrectly -- believe in those treatments. Handicapped by lack of knowledge, patients tend to follow their doctors' recommendations.

Excessive Testing
Excessive testing is a problem, and some diagnostic studies are harmful in themselves. Doctors are ordering so many CT scans and other imaging procedures that some experts suggest these tests are causing increased cancer rates.

What's more, he says, the value of any test depends on the likelihood that the patient has a significant problem in the first place. For example, although experts recommend against doing electrocardiograms on healthy people, millions of those procedures are performed each year.

Overtesting has also created a new unanticipated problem: overdiagnosis. For example, Gawande notes that cancer screening with mammography, ultrasound, and blood testing has dramatically increased the detection of breast, thyroid, and prostate cancer during the past quarter century. He says:
We're treating hundreds of thousands more people each year for these diseases than we ever have. Yet only a tiny reduction in death, if any has resulted.
This strikes home with me. When blood tests and a biopsy indicated I had prostate cancer, I had a prostatectomy in 1995. Postoperative blood tests showed that some cancer remained. It has been a very slow-growing cancer. I get checked every six months and the results to date have not signaled any need for additional treatment. Meanwhile I have been dealing with issues of incontinence and impotence that have negatively affected the quality of my life over the 20 years since the operation.

The Hidden Harm of Overtreatment
It isn't enough to eliminate unnecessary care, Gawande says. It has to be replaced with necessary care. And that is the hidden harm: unnecessary care often crowds out necessary care, particularly when the necessary care is less remunerative.

And the Risk of Undertreatment
It is possible the less-is-more movement will bring the unintended consequence of undertreatment. But right now, Gawande says, "we are so wildly over the boundary line in the other direction that it is hard to see how we could accept leaving healthcare the way it is. Waste is not just consuming a third of healthcare spending. it's costing people's lives."

Hope for the Future
After describing yet another case of overkill, Gawande ends his article on an optimistic note:
The medical system had done when it so often does: perform tests, unnecessarily, to reveal problems that aren't quite problems to then be fixed, unnecessarily, at great expense and no little risk. Meanwhile we avoid taking adequate care of the biggest problems that people face – – problems like diabetes, high blood pressure, or any number of less technologically intensive conditions. An entire health care system has been devoted to this game.
Yet we are finally seeing evidence that the system can change – – even in the most expensive places for healthcare in the country.
If you want to read the article in full, which I recommend, click here.

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