We must ensure that patients get all the care they need, and none that they do not.
In health care, more is not always better. Unnecessary or ineffective procedures, tests, scans, and medications cause substantial physical harm to patients and waste money and resources. Such “low-value care” ranges from useless CT scans and repeated lab tests, to unnecessary prescriptions, major surgeries, and the implantation of poorly tested medical devices.
As much as one-third of health care spending in the U.S. each year is wasted, which drives out-of-pocket costs and threatens the sustainability of our health care system. Low-value care is a significant portion of this waste; estimates of spending on low-value care range from $100 billion to $700 billion each year. All patients are at risk of being subjected to low-value care, regardless of their income, race, class, or insurance status. By reducing overuse, overtreatment, and overdiagnosis, we not only reduce financial waste, but we ensure that patients get all the care they need, and avoid the preventable harm from care they do not need.
The scope of low-value care
As much as 30% of health care spending in the US is wasted on low-value care, administrative complexity, and other inefficiencies. Low-value care is a significant portion of this waste; estimates of spending on low-value care range from $100 billion to $700 billion each year. Up to 40% of Medicare beneficiaries receive a low-value service each year, while 15% of Medicaid patients and 11% of commercially insured patients receive a low-value service every year.
Harms of low-value care
Overuse of medications, including over-the-counter drugs and supplements, has created an epidemic of serious side effects that are entirely preventable at a great financial cost. Drug reactions range from relatively mild symptoms such as drowsiness, nausea, or incontinence to more debilitating symptoms such as delirium (and the persistent cognitive changes often associated with it), falls, serious bleeding (including in the brain), or death. Overuse of certain medications has been especially problematic in leading to adverse drug events for older adults, including opioids, benzodiazepines (anti-anxiety medications), anti-cholinergic drugs, antipsychotics, diabetes medications, and antibiotics.
This epidemic of multiple medication use is particularly prevalent among older Americans. Over the past decade, the proportion of older people (age 65 and over) taking five or more medications has tripled, and the rate of ADEs in this population nearly doubled.
Overuse of medications happens for many reasons—our society favors the “quick fix” of taking a pill to solve medical problems over lifestyle changes; our fragmented health care system makes it difficult to know exactly what medications patients are taking; and pharmaceutical company marketing leads both clinicians and patients to overestimate the benefits of medications and underestimate the harms.
Americans believe that “cancer screening saves lives.” Unfortunately, it’s not that simple. While some cancers are detectable early, before symptoms arise, and can be treated effectively, others advance much too quickly for detection. Many cancers that are detected would never have caused symptoms and are treated needless—often with powerful and potentially harmful chemotherapeutic drugs and radiation. Screening itself comes with high rates of side effects, such as false alarms, unnecessary biopsies, and unnecessary surgeries and other procedures. This is why cancer screening decisions should be made as a shared decision between patients and clinicians, with informed consent around the potential consequences.
Cancer screening tests aren’t perfect. Tests such as mammograms, lung cancer CTs, and PSAs (prostate-specific antigen test) have high rates of false positives and risk of overdiagnosis and overtreatment. For example, for every 10,000 women in their 40s who get annual mammograms, three fewer will die of breast cancer in ten years, but 6,130 will have a false positive test, 700 will receive an unnecessary biopsy, 28 will undergo needless treatment, and there will be no reduction in all-cause mortality.
Routine PSA testing of 1,000 men ages 55 to 69 will prevent one prostate cancer death, but will lead to 40 other men experiencing serious side effects from a biopsy or from procedures to treat slow-growing cancers that never would have caused symptoms.
Lung cancer screening for high-risk, asymptomatic patients results in about 3 in 1,000 people saved from lung cancer over five years. At the same time, 250 people will have an abnormal scan result and will undergo further testing, which can be dangerous, stressful and costly. While a CT generally costs about $300, follow-up procedures such as lung biopsies, PET scans, and lung surgeries can cost thousands of dollars.
When we come to the clinic or hospital with a medical problem, we want our clinicians to “do something” to help. Similarly, clinicians often feel better taking action, even when doing nothing would be better for the patient’s health. Many new medical devices and procedures have not been adequately tested for effectiveness before they become the standard of care.
For example, putting in stents to relieve pain from stable angina is a widely-used procedure. In 2017, the ORBITA trial tested this procedure against a “sham” stent procedure for the first time, to find out how much of the benefit of stents was due to the placebo effect. They found that compared to the placebo procedure, stents had no greater effect on angina pain or exercise time. Drugs and changes in lifestyle and behavior alone accounted for the vast majority of improvement in patients’ symptoms. Other procedures such as vertebroplasty, shoulder arthroscopy, knee arthroscopy, and more have not passed muster compared to sham procedures. There is a real need to test more surgeries and procedures against placebo procedures, to determine their real effectiveness.
There are other surgeries and procedures that have shown to be effective when necessary, but are often used in cases where they are not necessary, which can only lead to harm. For example, women over childbearing age frequently undergo unnecessary hysterectomy when ovarian cancer is suspected, even though there are far less invasive procedures that could be done instead. Similarly, the c-section rate for low-risk births is extremely high in many areas of the US, which exposes patients to unnecessary risk and cost.
Proton Beam Therapy for cancer is another widely overused procedure, at an exorbitant cost. Proton beam therapy (PBT) is a relatively new cancer treatment that uses protons instead of photons to target cancerous tumors, avoiding radiation of surrounding tissue. Proton beam therapy is useful for treating cancers in sensitive areas like the brain stem, eye, or spinal cord, and for treating pediatric cancer patients without exposing children to unnecessary radiation. However, there is little evidence that PBT is more effective than conventional radiation treatment for more common adult cancers like lung, breast, or prostate cancer. Despite this lack of evidence, the popularity of PBT to treat certain cancers has grown substantially in the past decade, as more and more health systems are building proton beam machines and centers for treatment.
Every day, 750 older people living in the United States (age 65 and older) are hospitalized due to serious side effects from one or more medications. The Lown Institute is bringing attention to the epidemic of harm from the excessive prescribing of medications. Read our report, Medication Overload: America’s Other Drug Problem, to learn more about the scope, harms and major drivers of medication overload. The Lown Institute will be releasing a comprehensive action plan in January 2020 with recommendations from a working group of expert clinicians, patient advocates, and researchers on how to eliminate medication overload.
“Right Care Series” in the American Family Physician
The Lown Institute and the American Family Physician are collaborating on a new series of commentary articles called the “Lown Right Care” series. This series applies the framework of right care — evidence-based, patient-focused, high value care — to common clinical situations. Each article provides an example of a common clinical situation where there there are opportunities to avoid overuse by not doing things, and to improve underuse by incorporating things into routine practice. Read the latest in the series at American Family Physician!