Low-Value Treatments, Prescriptions Common, Survey Finds

Tara Haelle

December 06, 2016

Overuse of antibiotics, aggressive nonpalliative end-of-life care, chronic pain medications, and dietary supplements offer patients the least value despite widespread use, according to a research letter published in the December 6 issue of the Annals of Internal Medicine.

The letter reports findings from a survey conducted by the American College of Physicians, which defines "high-value" interventions as those whose potential benefits outweigh the potential harms and costs.

"This concept hinges on net benefit: A low-cost intervention is not necessarily high-value if the harms outweigh the benefits," writes lead author Amir Qaseem, MD, PhD, MHA, vice president for ACP clinical policy and chair of ACP's High Value Care Task Force. "Conversely, an expensive intervention may be high value if the benefits outweigh the harms."

Dr Qaseem and colleagues conclude that the survey's responses "can offer valuable insight from an on-the-ground perspective" and reflect a willingness on the part of providers to critically assess clinical practice.

That said, the authors note that "[m]any respondents struggled to identify therapies, instead naming diagnostics, which may reflect a challenge that a broader set of stakeholders face — the intrinsic motivations to err on the side of treatment and the fear of 'doing nothing.' "

The researchers sent the email survey to 5000 randomly selected ACP member physicians and received 1582 (32.3%) responses. The survey asked the physicians to "list two treatment interventions that you believe clinicians in internal medicine frequently use that are unlikely to provide value to patients." The authors ranked the 1130 answers from the initial sample of 1829 answers (some physicians provided only one answer instead of two) after excluding those cited by less than 1% of physicians.

The use of antibiotics, primarily for upper respiratory infections, topped the list, with 27.3% of physicians identifying it as not providing value to patients.

The authors grouped together the 8.6% of responses that listed aggressive, nonpalliative treatment in patients with a limited life expectancy. This category, which ranked second highest in not providing value, "mostly included life-support measures near the end-of-life, such as feeding tubes, intubation, and resuscitation; treatments to prevent long-term complications in patients with limited life expectancy, such as hemodialysis or invasive cardiac procedures; and chemotherapy in patients with advanced or metastatic cancer."

Pharmacologic treatments for chronic pain management, which primarily included references to opioids and narcotics, came in third, cited by 8.6% of respondents, and was followed in fourth place, with 4.9% of respondents, by dietary supplements, including vitamin D, niacin, fish oil, calcium, multivitamins and folic acid.

Just behind dietary supplements, 4.8% of physicians cited use of statins and lipid-lowering therapy as primary prevention in the elderly, and 4.5% listed routine or long-term use of proton-pump inhibitors as prophylaxis.

The remaining seven interventions were each cited by fewer than 2% of the physicians: nonpharmacologic pain management, particularly for back pain; diabetes treatments other than metformin; osteopenia and osteoporosis treatment (primarily bisphosphonates); medications for dementia; overmanaged or inappropriate blood pressure control; prescribing of newer or brand-name drugs instead of generics; and steroids, especially for respiratory illness.

"The goal of this observation is to promote thoughtful discussion among clinicians, patients, and policymakers about the value of care by balancing benefits, harms, and costs," the authors write. They acknowledge that the cross-sectional and self-reported nature of the data means it may not represent which interventions are actually overused or misused.

"A framework built on value of care is a rational approach, not a rationing approach, and provides an opportunity for appropriate clinical decision making that considers resource use without pointing fingers," they write.

Just under a third (29%) of the physicians who answered were internal medicine subspecialists, and 70% reported that they spent more than 74% of their time in direct patient care. More than half (57.1%) primarily worked in outpatient care, and 13.2% worked primarily in inpatient care, with the remainder exclusively working in one or the other.

Just 10.3% of respondents were under 40 years old, with 40- to 55-year-olds comprising 47.8% of respondents and the remaining respondents aged 56 years or older. The vast majority of respondents were male (70.9%), and 72.7% were white. The races/ethnicities of other respondents included black, Asian, Arab, Hispanic, Indian, Pakistani, Native American/Alaskan, Pacific Islander, and others.

The research was funded by the American College of Physicians. The authors have disclosed no relevant financial relationships.

Ann Intern Med. 2016;165;831-832. Extract

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