Waste: Unnecessary Overuse of Medical Care Causes Both Waste and Harm

Bryn Nelson, PhD

Disclosures

The Hospitalist. 2015;19(6):1, 23-27. 

In This Article

Introduction

A trickle of anecdotes has become a flood of cautionary tales.

There's one about the patient in intensive care who didn't have a cardiac condition yet still had a troponin blood test on 26 consecutive days. Guidelines, of course, suggest that three tests in a 12- to 24-hour period are sufficient to diagnose or rule out a heart attack.

Here's another: A schizophrenic patient complaining of abdominal pain was sent to the ED. After a normal CT scan, she was admitted to the hospital for further workup and pain control. Amid discussions over whether the doctors should order an MRI or surgery consultation, a review of her records revealed 40 CT scans over the previous five years. All had turned up nothing, and the patient's family confirmed that her frequent bouts of abdominal pain went away on their own.

Then there's the story about a middle-aged man with an asthma diagnosis from years before; he was scheduled for surgery to correct his painful umbilical hernia. As part of the patient's evaluation in a pre-operative clinic, his surgeon ordered a chest X-ray (CXR), despite a lack of any respiratory symptoms. The results suggested a possible lung nodule, leading to a follow-up CT scan that revealed normal lungs but instead showed a potential adrenal gland nodule. A second CT scan showed only a benign lesion, but the series of false alarms effectively delayed his hernia surgery by six months.

In the subsequent report on the latter case, included in the "Teachable Moments" section of JAMA Internal Medicine, the co-authors concluded, "Despite the evidence that preoperative CXR is unlikely to be beneficial, it continues to be used in daily practice. Exposing a patient to multiple, additional studies prolongs surgical delay, increases exposure to radiation, prolongs and exacerbates underlying anxiety, and increases the likelihood of additional incidentalomas."[1]

Unnecessary overuse of medical care, in other words, can cause both waste and harm.

Some of the stories highlight egregious examples, while others meditate on more nuanced cases. All are zeroing in on needlessly wasteful healthcare that can negatively impact patients physically, emotionally, and financially.

"I think for a long time we thought, 'Might help, can't hurt,' and we're seeing time and time again that that is just totally false," says Christopher Moriates, MD, assistant clinical professor in the division of hospital medicine at the University of California, San Francisco.

Increasingly, like-minded hospitalists and other physicians are launching groups and projects around the country with names like Caring Wisely, Providers for Responsible Ordering, Costs of Care, the Do No Harm Project, and I-CARE. Each group takes a slightly different approach toward reframing clinical decisions in a way that considers both the potential benefit and the accompanying risks and costs.

The Caring Wisely program, which Dr. Moriates leads, supports innovations that reduce healthcare costs while improving patient health. The nonprofit organization Costs of Care, meanwhile, is trying to change professional norms by pointing out the ethical downsides of overuse.

"I've never heard anybody get called unethical for wasting a healthcare resource, but that's where we need to go," says Neel Shah, MD, MPP, founder and executive director of Costs of Care and an assistant professor at Harvard Medical School in Boston.

This dogma-challenging, evidence-based, awareness-raising movement is building momentum at a critical time. Although the problem of wasteful healthcare isn't unique to the United States, multiple experts have pointed out the big disconnect between the nation's top ranking in per capita healthcare spending and only middling scores in a long list of healthcare outcomes.[2]

In their damning 2008 commentary, "The Perfect Storm of Overutilization," National Institutes of Health bioethicist Ezekiel Emanuel, MD, PhD, and Stanford economist Victor Fuchs, PhD, laid out the argument that overutilization was the most important contributor to high healthcare costs in the U.S.[3] A greater volume of interventions and unnecessary costs both contributed to this overuse, the authors suggested.

Subsequent reports by Thomson Reuters in 2010, an Institute of Medicine (IOM) roundtable on evidence-based medicine in 2011, and the RAND Corporation in 2012 largely agreed. Based on its report, "The Healthcare Imperative: Lowering Costs and Improving Outcomes," the IOM laid out a particularly sobering analogy to the degree of waste found in medical care.[2] If other prices had grown as quickly as healthcare since 1945, the report estimated, a gallon of milk would now cost $48. Yet, of the $2.5 trillion spent on healthcare in 2009, the report estimated that 30%, or $765 billion, was wasted. Of that number, the report suggested that unnecessary healthcare services accounted for $210 billion, or 27%.

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