Overtreated: More medical care isn't always better

[June 07, 2010]  WASHINGTON (AP) -- More medical care won't necessarily make you healthier -- it may make you sicker. It's an idea that technology-loving Americans find hard to believe.

Anywhere from one-fifth to nearly one-third of the tests and treatments we get are estimated to be unnecessary, and avoidable care is costly in more ways than the bill: It may lead to dangerous side effects.

It can start during birth, as some of the nation's increasing C-sections are triggered by controversial fetal monitors that signal a baby is in trouble when really everything's fine.

It extends to often futile intensive care at the end of the life.

In between:

• Americans get the most medical radiation in the world, much of it from repeated CT scans. Too many scans increase the risk of cancer.

• Thousands who get stents for blocked heart arteries should have tried medication first.

• Doctors prescribe antibiotics tens of millions of times for viruses such as colds that the drugs can't help.

• As major health groups warn of the limitations of prostate cancer screening, even in middle age, one-third of men over 75 get routine PSA tests despite guidelines that say most are too old to benefit. Millions of women at low risk of cervical cancer get more frequent Pap smears than recommended; millions more have been screened even after losing the cervix to a hysterectomy.

• Back pain stands out as the No. 1 overtreated condition, from repeated MRI scans that can't pinpoint the trouble to spine surgery on people who could have gotten better without it. About one in five who gets that first back operation will wind up having another in the next decade.

Overtreatment means someone could have fared as well or better with a lesser test or therapy, or maybe even none at all. Avoiding it is less about knowing when to say no, than knowing when to say, "Wait, doc, I need more information!"

The Associated Press combed hundreds of pages of studies and quizzed dozens of specialists to examine the nation's most overused practices. Medical groups are starting to get the message. Efforts are under way to help doctors ratchet back avoidable care and help patients take an unbiased look at the pros and cons of different options before choosing one.

"This is not, I repeat not, rationing," said Dr. Steven Weinberger of the American College of Physicians, which this summer begins publishing recommendations on overused tests, starting with low back pain.

It's trying to strike a balance, to provide appropriate care rather than the most care. Rare are patients who recognize they've crossed that line.

"Yet let me tell you, with additional tests and procedures comes significant harm," said Dr. Bernard Rosof, who heads projects by the nonprofit National Quality Forum and an American Medical Association panel to identify and decrease overuse.

"It's patient education that's going to be extremely important if we're going to make this happen, so people begin to understand less is often better," he said.

Not even doctors' families are immune.

A hospital appropriately did six CT scans to check Dr. Steven Birnbaum's 22-year-old daughter for injury after she was hit by a car. But the next day, Molly had an abdominal scan repeated as a precaution despite having no symptoms. When a doctor ordered still another, "I blew a gasket," said the New Hampshire radiologist, who put a stop to more.

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There are numerous reasons that one of three U.S. births now is by cesarean, but Dr. Alex Friedman blames some on an imprecise monitor strapped to laboring women. Too often, he has sliced open a mother's abdomen fearing the worst, only to pull out a pink, screaming bundle.

"Everyone knows it's a bad test," said Friedman of the Hospital of the University of Pennsylvania. "You haven't done the patient a big service by doing an unnecessary surgery."

Electronic fetal monitors record changes in the baby's heart rate, a possible sign of too little oxygen. They became a tradition -- now used in 85 percent of births -- years before research could prove how well they work.

Guidelines issued last summer, aiming to help doctors better interpret which tests are worrisome, acknowledge the monitors haven't reduced deaths or cerebral palsy. But they do increase the chances of a C-section. While they should be used in high-risk women, the guidelines say the low-risk could fare as well if a nurse regularly checked the baby's heart rate.

Later this year, the National Institutes of Health will begin a major study to see if adding a newer technology -- a type of fetal EKG already used in Europe -- to the heart-rate monitor would better identify which babies really are struggling and need rapid delivery.

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Undertreatment was in the headlines over the past year as the Obama administration and Congress wrestled with legislation to get better care to millions who lack it.

The flip side, overtreatment, is a big contributor to runaway health care costs. Yet it's one that lawmakers, wary of being accused of rationing, largely avoided in the new health care law. Included were modest steps -- studies to compare which treatments work best, some Medicare financial incentives -- to push higher-quality, lower-cost care.

"Physicians get up every day with the good intentions of wanting to do what's best for their patients," said Dr. David Goodman of the Dartmouth Institute for Health Policy. "We also live in environments where there are strong financial incentives to deliver certain types of care. We get well-paid for doing procedures. We get paid relatively poorly for spending time with patients and helping them make choices."

Where you live plays a role. Two decades of research from the respected Dartmouth Atlas of Health Care shows that in parts of the country, Medicare pays double or triple the price to treat people with the same illnesses. The differences are not fully explained by big cities' higher cost of living or populations that are poorer, older or sicker. How much care someone gets is a main reason, yet Dartmouth's data shows people in pricier areas don't necessarily fare better.

Dartmouth's check of 2005 Medicare data found that during their last six months of life, older adults in Boise, Idaho, spent 5.3 days in the hospital compared with 17 days in Miami.

Fee-for-service care and local habits aren't the only drivers.

Fear of malpractice lawsuits "has everything to do with it," said Dr. Angela Gardner, president of the American College of Emergency Physicians, whose members face intense pressure to overtest in the life-and-death chaos of the ER.

Nor is there always clear evidence for one therapy choice over another. It can be faster to give in to a patient's demand for medicine than to explain why, for example, a child doesn't need antibiotics for ear pain.

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Care for the dying is often a powerful illustration of treatment going too far.

Texas author Liza Ely had lined up hospice care for her 93-year-old mother, Verna Burnett, as she lived her last days with Alzheimer's and heart failure. Yet when Burnett developed an irregular heartbeat, the care provider at her Tyler, Texas, nursing home recommended seeing a cardiologist, to have a tube threaded through blood vessels to her heart to check it out.

"We were speechless," Ely said. "We asked what could be done if something showed up on the test."

The response: "Nothing, really."

Ely said the family refused the "painful, expensive and unnecessary test."

Congress' health care overhaul initially included a provision that would have authorized Medicare to pay doctors for counseling patients interested in end-of-life options. The provision died in the hue and cry after Sarah Palin dubbed the effort "death panels," a charge named 2009 political "Lie of the Year" by the nonpartisan fact-checking organization PolitiFact.

Rep. Earl Blumenauer, D-Ore., said he plans to reintroduce his idea.

"Today there is no guarantee that people will get the care they want when they are incapacitated or in those final stages of life. The default is sometimes the most painful, the most intrusive, the most frightening treatment -- whether or not that is what people want," he told the AP.

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New efforts are beginning to push back against overtreatment:

• In Minnesota, the influential health cooperative HealthPartners saw use of MRIs and radiation-heavy CTs growing between 15 percent and 18 percent a year. So the insurer began a new program: National radiology guidelines pop up on each patient's electronic medical record whenever a doctor orders a scan. It's not a requirement, but a gentle reminder of when such tests are recommended.
  
  In two years and counting, HealthPartners estimates it avoided 20,000 unnecessary tests, preventing dangerous radiation exposure and saving $14 million.
  
  Providing the guidelines helps doctors deal with patients who demand a scan, says medical director Dr. Pat Courneya. He recently examined a young man who wanted a brain CT because of dizziness. Courneya's physical exam turned up no neurologic red flags like weakness or eye problems, but seeing the guidelines helped reassure the man.

• An American Medical Association journal, Archives of Internal Medicine, just began a "Less is More" series to educate doctors about the risks of overused treatments.
  
  First up: Studies saying more than half of the 100 million-plus prescriptions for the strongest stomach acid suppressors -- proton pump inhibitors such as Nexium -- go to people who don't need something that powerful. That puts them at unnecessary risk of side effects, including bone fractures and infections.

• This summer, the journal Annals of Internal Medicine begins publishing American College of Physicians' guidelines for "high-value, cost-conscious care."

• To increase patients' savvy, about a dozen health centers around the country are testing "shared decision-making." That process uses plain-English guides, often DVDs, to explain the advantages and disadvantages of test and treatment options. Given full information, patients choose a less aggressive approach than doctors initially recommend about 20 percent of the time, says Dr. Michael Barry of the nonprofit Foundation for Informed Medical Decision-Making.
  
  "Where I think no one in the Consumer Reports age would go to the car lot and say, 'I'm going to let the dealer figure out what car I want or need,' now we are taking a little of that spirit to the doctor's office," he said.

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Online:

American College of Physicians:
http://www.acponline.org/

National Quality Forum:
http://www.qualityforum.org/

American Medical Association:
http://www.ama-assn.org/

National Institutes of Health:
http://www.nih.gov/

Dartmouth Institute for Health Policy:
http://tdi.dartmouth.edu/

Dartmouth Atlas of Health Care:
http://www.dartmouthatlas.org/

American College of Emergency Physicians:
http://www.acep.org/

HealthPartners:
http://www.healthpartners.com/public/

Archives of Internal Medicine:
http://archinte.ama-assn.org/

Foundation for Informed Medical Decision-Making:
http://www.informedmedicaldecisions.org/

Annals of Internal Medicine:
http://www.annals.org/

[Associated Press; By LAURAN NEERGAARD]

Associated Press writer Ricardo Alonso-Zaldivar in Washington and Medical Writers Lindsey Tanner in Chicago and Marilynn Marchione in Milwaukee contributed to this report.

Copyright 2010 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.