By Brian Schilling
In a remarkable essay that appeared recently in the Washington Post, an infectious disease specialist from Georgia wrote, "I believe I am guilty of overtesting my patients and overprescribing antibiotics to them." The disturbing part of the essay, however, is not that this particular physician has a tendency to overtreat patients, but that the practice is so very normal. Overtreatment—and the accompanying expense and risk—has become so routine in today's health care system that that it may account for one-third the nation's health care tab.
In April, nine leading medical societies took this issue head on, launching the highly publicized Choosing Wisely campaign to curb excess care. Led by the American Board of Internal Medicine (ABIM) Foundation, the medical societies identified a list of 45 medical tests and procedures that physicians shouldn't do without good reason. Each participating medical society was charged with identifying five common, potentially harmful tests or procedures for which the risks exceeded the benefits. The resulting "don't do" lists—one from each medical group—are remarkably clear: don't do expensive scans for lower back pain; don't do imaging for uncomplicated headaches; don't prescribe antibiotics for common colds; and so on. The full list of tests and procedures can be found here: http://choosingwisely.org/?page_id=13.
The roots of overtreatment are varied. Doctors often cite being apprehensive about medical malpractice and the need to practice defensive medicine. Others note that they may not even be aware of the issue since they are not routinely given data showing how their practice patterns may be in synch or out of line with their peers or with accepted guidelines. In many cases, it may also be in a physician's self-interest to overtest. About one-third of physicians, according to a 2008 study,1 have an ownership stake in a clinical lab. Patients play a role too, encouraging physicians to prescribe antibiotics when they are not indicated or pleading to arrange an expensive test, "just to be sure."
As an issue, overtreatment and overtesting may seem relatively innocuous. Consider the Pap test, a screen for cervical cancer. This routine, accurate, and simple test that costs approximately $50 is administered to millions of women every year. What's the harm? Unfortunately, the ranks of women routinely receiving Pap tests include millions of women who have had a hysterectomy and thus have no cervix and no risk for cervical cancer. According to a 2004 study, roughly 10 million women2 who had had a hysterectomy had a Pap smear in the previous three years. That's about half of all women who underwent a hysterectomy. Multiply that by hundreds of procedures and millions of patients and the costs add up. The net cost of overtreating and overtesting may be as much as $7003 billion added to the nation's health care tab annually.
To help spread the word on the new recommendations, the ABIM Foundation has enlisted the support of Consumer Reports, AARP, Wikipedia and hundreds of media outlets. NBCH and various business coalitions are also working to develop Choosing Wisely tool kits to help engage employers in the effort as well.
The campaign has generated hundreds of articles in the media; among physicians, it is a hot topic of conversation. Still, no one expects overtreatment to disappear as an issue any time soon. "This is a cultural shift that will take time," says Daniel Wolfson, executive vice president and chief operating officer of ABIM. "The important thing is that the campaign is provoking informed conversations between patients and physicians about unnecessary care and how it can lead to real harm."
References
1. http://www.hschange.com/CONTENT/1172/
2. http://blogcritics.org/culture/article/unnecessary-pap-smears/
3. Panel on Measuring Health Care Quality and Value (powerpoint presentation) Carolyn M. Clancy, MD, Director, Agency for Healthcare Research and Quality; Washington, DC – November 10, 2010
