In healthcare, more is not always better
A version of this commentary appeared in iPolitics.ca, the Huffington Post and KevinMD
It is easy to assume that the real problem with our healthcare system is “not enough” — not enough physicians, not enough MRIs, not enough money.
But a growing number of studies show that more healthcare is not always better and the more expensive drug or treatment option is not necessarily the right choice. In fact, sometimes more care — specifically care that you don’t need — can be harmful for your health, and expose you to unnecessary risks.
So what is the “right amount” of care?
Getting the “right amount” of healthcare means you are getting as much care as you need, but not unnecessary, or too much, care.
Here are some examples: Getting antibiotics for an infection caused by bacteria that is helped by antibiotics is the “right amount” of care. Getting antibiotics for a viral infection that is not helped by antibiotics — such as the common cold — would be unnecessary care. Staying on schedule with preventive care and screening tests that are backed by evidence and recommended for your age and health condition is the “right amount” of care. Having preventive care and screening tests more often than recommended is unnecessary care.
Sounds common sense, except studies show that there is huge variation in the amount of healthcare that similar patients receive, depending largely on where they live.
For more than 20 years, the Dartmouth Atlas Project has tracked huge variations in the distribution and use of healthcare resources in the US. Studies consistently show that more care — specifically, more specialist visits, more diagnostic tests and more time in hospital, for similar patients — does not necessarily lead to better care; in fact, it could lead to harm.
By safely adopting more conservative practices, the evidence suggests that savings of about 30 percent of US Medicare costs or almost $40 billion, could be realized, with care that could be at least as good.
And in Canada? Large regional variations have been documented in the provision of healthcare for patients with conditions such as cardiac disease, stroke, arthritis, asthma and diabetes, despite the availability of evidence-based clinical guidelines.
Less is More
Last year the Good Stewardship Working Group published ‘Top 5’ lists for primary care providers in the Archives of Internal Medicine, under the heading: “Less is More”. They are, exactly as they sound — lists of the top five tests, medications or actions a doctor should refrain from doing unless special circumstances arise.
For example, in the ‘Top 5 List for Family Medicine,’ doctors are reminded not to order imaging tests for low back pain unless specific symptoms are present; not to routinely prescribe antibiotics for mild or moderate sinusitis unless it lasts longer than seven days or symptoms worsen after improvement; not to order annual ECGs or cardiac screening tests for low-risk patients with no symptoms of heart disease; not to perform Pap tests on patients younger than 21 years, and not to order DEXA screening for osteoporosis in women under age 65 years, and men under 70, with no risk factors.
Pediatricians are reminded not to prescribe antibiotics for pharyngitis unless a child tests positive for streptococcus; not to order diagnostic images for minor head injuries unless there is a loss of consciousness or other risk factors; to advise patients not to use cough and cold medications since there is little evidence they reduce symptoms yet have significant risks, including death.
The lists are handy references for doctors to ensure the right amount of care is being provided to the right patients. But this doesn’t always happen as it should.
Getting value for our health care dollars
A variety of factors, such as patient illness severity and physician clinical judgment, determine whether a patient receives more health services. But non-medical factors, including a medical culture that promotes testing and interventions regardless of necessity, fee-for-service physician payment structures that reward volume over quality, excess availability of health care resources, such as hospital beds, specialists, CT and MRI scanners, and to a more limited extent, patient demand, also play a critical role.
There are limits to the amount we can spend on health care, and there is a need to determine whether we are getting good value for our health care dollars.
We need to track, for example, whether physicians in some areas are prescribing antibiotics to children much more frequently than they are in other areas — and physician groups and regional health authorities need to be tasked with asking why such high rates exist.
The same question should be asked about high rates of X-rays, EKGs, CT and MRI scans, lab tests, PSA tests, Pap smears on young girls and high rates of C-sections, hysterectomies, and other common elective surgeries.
Too much health care isn’t just costly, it is all too often bad for your health.
Thérèse A. Stukel is an expert advisor with EvidenceNetwork.ca, Senior Scientist at the Institute for Clinical Evaluative Sciences and Professor of Health Policy, Management and Evaluation in the Faculty of Medicine at the University of Toronto. Noralou Roos is a Professor in the Department of Community Health Sciences, Faculty of Medicine, University of Manitoba and the co-founder of EvidenceNetwork.ca.
See the poster based on this commentary