Right Care Weekly

Welcome to the Right Care Weekly, a newsletter that will help you stay on top of all the important news in the ongoing quest to move the US health care system toward the right care. We’ll bring you the most important stories, news articles, and opinion pieces of the week, along with our interpretation of why they’re important and what they mean for patients, doctors, and communities.

• The New York Times reports growing concern among doctors about the treatment of toddlers for ADHD. A recent study suggests that over 10,000 two- and three-year-olds are prescribed ADHD medications such as Ritalin and Adderall, even though these drugs are not approved or recommended for children under 4 years old. While in rare cases the use of these medications may be appropriate, for the most part those prescriptions amount to “winging it,” according to one doctor quoted in the story. Behavioral pediatrician Dr. Doris Greenberg states that in many of these cases there are “overwhelmed parents who can’t cope and the doctor prescribes as a knee-jerk reaction. You have children with depression or anxiety who can present the same way, and these medications can just make those problems worse.” The overall picture is a deeply disturbing example of what happens what overdiagnosis becomes overmedication.

• As reported in the LA Times, a new JAMA study suggests that 7 out of 10 patients treated for acute bronchitis are being prescribed antibiotics, despite the fact that nearly 40 years of clinical research has shown that antibiotics are not effective in treating acute bronchitis. This is troublesome not only because patients are paying for prescription drugs that they do not need and that are not effective, but also because overuse of antibiotics is causing a rise in drug-resistant pathogens, possibly leading to what the World Health Organization describes as a “post-antibiotic era.”

• A USA Today story published this week explores the issue of prescription drug misuse among seniors. According to the Substance Abuse and Mental Heath Services Administration, an estimated 132,000 seniors are misusing or dependent on prescription pain relievers. Those addictions are fueled in part by what the article calls the “medicate-first” culture: doctors want to be able to help people, and often see patients as just wanting a prescription for their problems (even if that prescription is unlikely to help). Doctors also worry about stigma: “people don’t want to take away a 70-year-old’s medications.” However, in many cases of polypharmacy, where a patient is taking several drugs at the same time, it’s safer to stop some of them – taking fewer drugs can help patients avoid the risk for falls and other serious interactions and side effects.

• Finally, Lown Institute President Vikas Saini and Senior Vice President Shannon Brownlee spoke at the University Hospital of North Norway’s Leadership Conference yesterday. Check back soon for video and their thoughts on the conference!

The Right Care Weekly is made possible through the generous support of the Robert Wood Johnson Foundation.

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Right Care Weekly

Welcome to the Right Care Weekly, a newsletter that will help you stay on top of all the important news in the ongoing quest to move the US health care system toward the right care. We’ll bring you the most important stories, news articles, and opinion pieces of the week, along with our interpretation of why they’re important and what they mean for patients, doctors, and communities.

Big week in overuse news! Let’s get right to it.

• The top story this week: An article published this week in JAMA Internal Medicine estimates that over twenty-five percent of Medicare patients receive at least one unnecessary medical test or procedure each year. The study drew on lists of ineffective treatments from Choosing Wisely, the US Preventive Services Task Force, NICE, and others. The authors found that spending on just 26 ineffective procedures amounted to at least hundreds of millions of dollars, and more likely billions. It’s important to remember the procedures sampled amount to only a tiny fraction of the overuse in the system – much overuse isn’t on discrete procedures, so this exposes one limitation of focusing on specific procedures when trying to improve care. You can read more about the study at the Washington Post and Kaiser Health News.

• Breaking: as we were compiling the Weekly, the Obama administration announced its support for some use of “reference pricing” by insurance plans. The basic idea of reference pricing is that patients should be free to choose the treatment they want – but insurers and governments shouldn’t necessarily have to pay for more expensive options that are no more effective. For example, it’s been suggested as a way to deal with treatments like proton beam therapy for prostate cancer, which are far more expensive than standard treatment, but are no more effective. There are no specifics for the Obama administration’s proposal yet, but this could be an important first step toward reducing spending on invasive treatments that are no better than less-risky, less-expensive alternatives.

• Charles Ornstein, Lena Groeger, and Ryan Grochowski Jones at ProPublica have pulled together an incredible app for exploring the Medicare physician payment data released earlier this year. There aren’t any clear conclusions to draw from the data yet, but it’s a major step forward for health care transparency.

• We missed an important story last week: Dr. Peter Bach’s heart-rending story of his wife’s death from lung cancer. The long piece in New York Magazine explores the difficulty he faced as a doctor, knowing in detail how his wife’s illness would most likely progress, but feeling too scared to share that knowledge – not wanting to take away their hope. The story includes a powerful acknowledgement of how patients and families can feel compelled to try additional treatment, because “why not?” – even knowing that it was unlikely to help and would cause additional suffering.

“As he wrote out the prescription for her to start the next treatment, what doctors call “second-line treatment,” I recalled a colleague of mine explaining the progression from first-line to second-line to third-line treatment. Each successive change brings more side effects with less chance of benefit. As my colleague put it, the cancer gets smarter, the treatments get dumber. Somewhere in this progression the trade-off no longer makes sense. Where that is may differ for each patient, but I’ve often thought that cancer doctors go well past that point.

“None of that mattered to me, the medical professional to whom all these nuances and trade-offs should. All I could think about was the blood test telling us the tumor marker was too high. With that, any dreamy conceit—that patients should be given enough knowledge that they can weigh the risks and benefits for themselves, then come to the choice that best suits them—flew out the window. Our choice wasn’t a choice. Take the chemo.”

• Rosemary Gibson, author of several important books on health care and panelist at the 2013 Lown Conference, has this piece in the BMJ on “The Human Cost of Overuse.” It draws on the example of the small town of China, Maine, to show how high medical spending – driven in part by overuse – causes serious problems for local communities, and the struggles those communities face in making up the shortfall.

• Vox covered the importance of understanding health care news stories, and linked to Gary Schwitzer’s guide in JAMA Internal Medicine. Schwitzer’s Health News Review site has done important work over the last several years in exposing flaws in health reporting. The guide is worth saving – and avoiding misinformation is important for clinicians, as well as the public!

• NPR Health News posted a column from a physician on the anxiety over cholesterol that permeates American medical culture. Although high cholesterol is a risk factor for heart disease, it has been so blown out of proportion in popular culture that healthy patients see cholesterol testing – and aggressive attempts to lower cholesterol – as an essential part of getting good health care. The author sees conversations that start with cholesterol as a way to open up conversations about other, more important issues. But the concern over cholesterol also illustrates how media and pharmaceutical messaging can interfere with the doctor-patient relationship. If patients see cholesterol testing as central to “good medical virtue,” and are skeptical of a doctor who rightly suggests that  healthy patients don’t need to be overly concerned, it’s not a conversation-starter – it just makes it that much harder for those other important conversations to happen.

• A new study conducted by researchers at UCLA suggests that treating early-stage prostate cancer in older men with other health problems does more harm than good. Medical News Today writes that aggressive treatments often do not help older patients live longer ,and instead can make other unrelated health problems worse. Instead, the focus for these patients should be on preserving and enhancing quality of life.

• Finally, we have a couple new videos from Shannon Brownlee’s participation in the “Reform to Transform” event hosted by the Universal Healthcare Foundation of Connecticut. The videos of her talk address the three interrelated issues of overuse, underuse, and misuse of health care. Check them out!

The Right Care Weekly is made possible through the generous support of the Robert Wood Johnson Foundation.

Right Care Weekly

Welcome to the Right Care Weekly, a newsletter that will help you stay on top of all the important news in the ongoing quest to move the US health care system toward the right care. We’ll bring you the most important stories, news articles, and opinion pieces of the week, along with our interpretation of why they’re important and what they mean for patients, doctors, and communities.

UPDATE: Our post on the Health Affairs blog, When Less Is More: Issues Of Overuse In Health Care, was the blog’s most-read post for April! If you haven’t had a chance to read it yet, go check it out.

• “I don’t want Jenny to think I’m abandoning her.” Attendees of our last two conferences will recognize this story: Diane Meier, a palliative care physician, writes of her experience treating Jenny, a terminal cancer patient, and of the struggle Jenny’s oncologist faced in caring for her without over-treating her. Meier notes that many physicians find it difficult to express their caring for patients without ordering intense, and sometimes unnecessary, medical procedures. That emotional disconnect reflects the technical emphasis of physicians’ training, and the limited time available for developing personal relationships with patients and their families.  The oncologist’s fear that Jenny would think he was “abandoning her” by stopping curative treatment – and the unnecessary, invasive treatment that almost resulted – shows the importance of relationships and communication for both patients and clinicians.

• A panel of cancer experts argued this week in The Lancet for renaming some types of slow-growing conditions that are unlikely to cause harm if untreated. Melinda Beck of the Wall Street Journal writes that the proposed new name, “IDLE” (indolent lesions of epithelial origin), is important because for many patients and physicians, it’s difficult to even consider not treating something called “cancer.” Changing the way we talk about these conditions could help reduce overdiagnosis, make it easier for patients to understand the risks they face (and compare that with the possible harms of treatment), and reduce the anxiety that can lead to unnecessary follow-up testing and treatment.

• In 2003, the large drugmaker Bayer asked the FDA to approve aspirin as a drug for primary prevention of heart attacks, arguing that studies suggested that a daily aspirin regimen could save lives even in people without heart disease. This week the FDA denied their request, based on evidence showing that while aspirin is useful in preventing second heart attacks in those who had already had them, for people without preexisting heart disease, the risk of harm from bleeding in the brain or stomach outweighs any benefit from heart attacks that are prevented.

• The idea that statins are overused is not new, but this week, Roni Caryn Rabin on the NYT Well blog suggested that this problem may be even more serious for women. While studies of statins have enrolled far more male patients than female patients, women tend to develop heart disease later in life than men and stand to benefit less from reduced risk of heart attack. The story goes on to note that the side-effects of statin use can be serious and for young, healthy women those side-effects are not worth it for a treatment that offers almost no benefit.

• Finally, we’ve written before about the evidence that screening mammograms have no proven mortality benefit, and could actually do more harm than good. Dr. Janice Boughton has written a good overview of that literature, incorporating two new articles, and shows once again that the benefits of screening for women at low risk are small, while the harms for those overdiagnosed can be substantial.

The Right Care Weekly is made possible through the generous support of the Robert Wood Johnson Foundation.

Welcome to the Right Care Weekly, a newsletter that will help you stay on top of all the important news in the ongoing quest to move the US health care system toward the right care. We’ll bring you the most important stories, news articles, and opinion pieces of the week, along with our interpretation of why they’re important and what they mean for patients, doctors, and communities.

• First up, Vikas Saini and Shannon Brownlee of the Lown Institute have coauthored a blog post with Christine Cassel, over at the Health Affairs blog: When Less Is More: Issues Of Overuse In Health Care. The post gives a broad overview of the state of overuse in the US health care system, and is a great resource to suggest to friends or colleagues who are interested in learning a little more about the issue!

• Andrew Pollack’s provocative New York Times story on doctors considering the cost of treatments when creating clinical guidelines is the latest in a long-standing debate: what role should costs play in guiding medical practice? While it’s important to control spending in the health care system as a whole, making guidelines based on cost-effectiveness – or worse, pressing individual doctors to make ad-hoc decisions about whether society’s needs should override their patient’s – isn’t the right answer. The best way to reduce health care spending is to stop wasting money on things that don’t work, or cause harm. But in addition to reducing overuse, we need to create places in civil society to make decisions about what treatments are worth while – and those conversations need to make clear what we’re giving up in exchange for low-value medical spending.

• Next, a Kaiser Health News story by Jordan Rau pointed out that, while the Choosing Wisely campaign has drawn a lot of attention to overuse, it hasn’t focused on the lucrative procedures that waste huge amounts of money in the medical system – and feed some doctors’ large paychecks. The story is important not least because it demonstrates how broad the problem of overuse is. The Choosing Wisely lists now cover hundreds of distinct procedures that aren’t evidence-based, but there are still many more that the health care system has been less willing to give up. That doesn’t even start to address how the culture of overuse encourages unnecessary hospitalizations and other behaviors that are much harder to call out than individual procedures.ABIM Foundation Vice President Daniel Wolfson has responded to the story, and rightly points out, “the usefulness of a medical test or procedure should be gauged by the outcomes it achieves for patients, not the income it generates for the health system.”

• We read a while ago about a surgeon who said, when an uninsured patient asked about treating his appendicitis with antibiotics (cheap) instead of surgery (expensive), “This is America, not Sweden. We operate.” Leaving aside the jingoistic assumption that choosing more intense treatment is a badge of honor for the US health care system, the surgeon’s indifference was a striking example of easily our health care system misses the huge number of other circumstances in a patient’s life that determine what it means for them to get good care.We were reminded of that story this week, because the drug treatment option got a bit of a boost: in a new study of a small group of children, most of the kids with appendicitis were treated successfully with antibiotics. While costs shouldn’t force parents to accept less-effective treatment options for their kids, clinicians should be open to the possibility that sometimes, avoiding surgery (and the recovery time, lost time in school, and other costs that come with it) might be the right choice. Medical orthodoxy shouldn’t be used to overrule reasonable patient preferences.

• Finally, Shannon Brownlee spoke a few weeks ago at the Universal Health Care Foundation of Connecticut’s Reform to Transform event. You can see some of the video from the event here.

• EDIT: Yesterday, the Choosing Wisely campaign released the results of a survey which found that 1 in 5 doctors in the US knows about the campaign, and most of those docs  said they’re less likely to order tests and treatments that are on the lists of things to avoid. Jordan Rau has complete coverage for NPR.

The Right Care Weekly is made possible through the generous support of the Robert Wood Johnson Foundation.

Right Care News

Lots of news on overuse in the last week or so! Here’s a quick roundup of the important stories you should read:

• Mount Sinai directing elective stent patients through the emergency department: Three reporters for Bloomberg News wrote an in-depth story on several questionable practices reported at Mount Sinai Medical Center in New York City. The most troubling allegation is that patients scheduled for cardiac catheterizations (a kind of heart surgery) were told to come in through the emergency departments. Some patients said they had been coached to say they had the symptoms of acute coronary syndrome. Directing patients through the ER could have induced insurers to pay for some procedures that they wouldn’t have covered otherwise; it could also have increased the hospital’s payment for the procedure, by allowing them to charge the “emergency” cath rate as opposed to the charge for the elective procedure.

The article also notes that Mount Sinai does far more caths than any other hospital in the New York area. Catheterization and stenting are commonly overused – one researcher commented in the article, “It seems unlikely any cath lab could do that many procedures that are all appropriately indicated.

• Surgical checklist produces disappointing results in Ontario: A recent study of the implementation of a surgical checklist in Ontario, Canada found that the checklist mandate had no effect on rates of harmful medical errors or deaths from surgical complications. That’s a huge disappointment, since many previous studies have suggested that the simple act of going through a checklist at a few crucial points in an operation can prevent potentially disastrous errors and complications.

To us, the checklist’s apparent failure in Ontario doesn’t doom it forever, and it doesn’t outweigh the evidence showing that checklists can reduce mortality. Rather, it’s an important reminder that the checklist is just a tool, not a patient safety strategy in itself. To use the tool successfully, surgeons and others have to understand why it’s important – the culture of that particular hospital has to take patient safety seriously. Simply mandating that checklists get used, as Ontario did, doesn’t create the cultural shif that will really protect patients.

• The Incidental Economist has a series of posts on the study that address many of these issues – read this from from Bill Gardner, Aaron Carroll, a response from Atul Gawande (who helped popularize the checklist), and Carroll again.

• New York Times op-ed calls out the importance of social care in improving health: Elizabeth Bradley and Lauren Taylor of Yale’s Global Health Leadership Institute point out that while many other countries spend less than the US on “health care,” they spend proportionately far more on social care, including pensions, housing support, and unemployment benefits. The importance of that spending is borne out in international comparisons of health outcomes, where the US doesn’t seem to be getting much benefit from all the money we dump into medicine.

• Dr. Sandeep Jauhar wonders if we’ve reached the point of diminishing (or vanishing) returns to high-intensity medical interventions like cardiac arrest care. He notes that while medicine advanced rapidly for much of the twentieth century, recent years haven’t yielded the same levels of rapid progress. If he’s right and we’re seeing a long-term slowdown in meaningful innovation, it may be more important to focus on using the treatments we already have the best we can – and not using the new “innovations” that don’t offer any benefits.

• The US spends around $1 billion each year on CT and MRI scans for patients with headaches – even though those scans are usually unnecessary.

• Finally, an industry-funded trial will be looking into whether chocolate can reduce heart attacks, strokes, and heart disease deaths.

What does it take to believe a treatment works?

A lot less than it takes to believe that it doesn’t work, apparently.

Once again, Aaron Carroll of The Incidental Economist has a quick but incredibly important point on how people interpret evidence in medicine.

Following on last week’s publication of the 25-year follow-up of an RCT of screening mammography, he links to the new JAMA paper showing just how little evidence it takes for the FDA to approve a new treatment. You should read the whole post, but the immediate take-away is that the majority of treatments were approved based on only one or two trials. More than half of approvals were based on studies that included fewer than a thousand patients.

That probably has something to do with why the BMJ’s Clinical Evidence site has categorized only 35% of the more than 3,000 treatments they’ve reviewed as “beneficial” or “likely to be beneficial,” while half are of “unknown effectiveness.”

 

Shannon Brownlee on Broadside with Jim Braude

Last night, Shannon Brownlee appeared on NECN’s Broadside with Jim Braude to discuss the recent study finding no benefit to screening mammography. It’s a great segment that gets into what the study should mean for doctors and patients.

If you missed it last night (or if you don’t live in the Boston area), the whole segment is available to watch online!

Bloomberg op-ed: Keep doctors, not hospitals, in charge of patient care

Shannon Brownlee and Vikas Saini of the Lown Institute have an op-ed posted at Bloomberg View today. It points out that when hospitals purchase large physician groups, they usually raise prices – but there’s not much evidence that care gets any better. Collaboration between clinicians is important, but it requires leadership and a desire to organize care to benefit patients – not just the formal structure of an integrated practice.

The key quote:

“If we want better care and less waste, the balance of control over what happens to patients should be in the hands of physicians, not hospitals.”

Check it out!

Quick follow-up on mammography

This morning, Shannon Brownlee went on the Diane Rehm Show to discuss the RCT published in the BMJ showing no mortality benefit to screening mammography. If you weren’t able to catch the show this morning, you can listen to the show here.

Also, Dr. Aaron Carroll, blogger at The Incidental Economist, has a fantastic post that responds to a lot of the arguments against the study that came up on the radio show. His last paragraph sums up the debate perfectly:

“I leave you with one final thought. If you’re not going to be swayed at all by a randomized controlled trial of 90,000 women with 25 year follow up, excellent compliance, and damn good methods , it might be time to consider that there’s really no study at all that will make you change your mind.”

 

Long-term study shows screening mammography doesn’t reduce mortality.

Yesterday, a Canadian study group published the final follow-up results of a long-term randomized controlled trial in the BMJ, showing that screening mammography had no mortality benefit for middle-aged women, and that screening has the potential to cause substantial harm.

The study, which shows that mammography offered no more benefit than physical breast examinations, but overdiagnosed breast cancer in a number of women, is in line with other studies showing that screening mammography does not reduce mortality, and that breast cancer is commonly overdiagnosed and overtreated.

Women who are considering getting screened need to understand the possibility of overdiagnosis, and the potential harm from being treated unnecessarily, especially in a medical environment that heavily promotes such tests as the only responsible way to manage one’s health.

Read more at the New York Times and The Incidental Economist.

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