December 16th, 2017
Last week, the New England Journal of Medicine (NEJM) published an editorial from cardiologist and NEJM correspondent Lisa Rosenbaum that quickly sparked a lot of discussion in the medical community. Rosenbaum asks, Are we oversimplifying the discussion when it comes to overuse? She concludes that the “crusade” to reduce overuse — including the Right Care Alliance and Choosing Wisely — leads to a slippery slope. In the “zeal” to avoid overuse medical professionals risk not providing necessary care to people who need it.
Rosenbaum is a skilled essayist, and makes some great points in this piece, but she also reinforces several misconceptions about the movement to reduce overuse. Here’s what we thought about it:
Rosenbaum’s argues that “less is more” is too simplistic to describe accurately how doctors and patients should approach medicine. This hardly needs saying. As Vikas Saini, Shannon Brownlee, and others write in the Lancet Right Care Series, the delivery of unnecessary care is happening right alongside the failure to deliver needed health care services. You would be hard-pressed to find a clinician who believes that all patients need less care, or that effective health care interventions should be limited because less is always more. The goal of the Right Care Alliance is not to promote less care for all patients, but to promote appropriate care – all the care patients need and none that they don’t.
Rosenbaum argues that building policy around reducing low-value care is based on the mistaken assumption “that we know what [value] means and can measure it, that the same things matter to all patients, and that the effect of any intervention can be understood in isolation from countless others.” It’s true that defining value is extremely complicated, and patients’ views are routinely not taken into account. The complexity involved in defining value can be seen in the difficulties pricing cancer drugs based on value or the pattern of women opting for more invasive breast cancer treatment.
We agree with Rosenbaum that many tests and procedures are in a “gray area” of value, where their effectiveness or appropriateness is uncertain, and whether or not it is recommended should depend on patient preferences or goals. However, we should also be able to agree that a procedure or medication that gives patients no clinical benefit and has a high risk of harm is a treatment of low value.
There are many health care services that fit this description — Arthroscopic surgery for knee osteoarthritis, prescribing benzodiazepines for sleep for seniors, vertebroplasties for low back pain, to name just a few. The Lown Institute and Right Care Alliance promote interventions that reduce truly unnecessary, ineffective services, which are much more likely to cause patients harm than good. We also encourage research and discussion on how to use health care services in the gray area appropriately.
Rosenbaum argues against what she perceives as a central claim by the “less is more” movement – that doctors being greedy is the main cause of overuse. The causes of overuse are complex and systemic, including volume-based payments, fear of malpractice, patient expectations for treatment, lack of time with patients, habits of normative practice, fear of uncertainty, overestimating the benefits of treatment, and flawed science. Nobody could argue that it is driven entirely by fee-for-service. (That’s why overuse exists even in countries without fee-for-service.)
Obviously, it’s not only clinicians who contribute to overuse – patients, drug and medical device companies, hospital administrators, insurers, and government all play a role. Indeed, doctors are leading the way to reducing overuse. The clinicians at the helm of the movement to reduce overuse, including the editors of JAMA IM, Providers for Responsible Ordering and Do No Harm, and the Right Care Alliance, were inspired to act because they see how overuse can harm patients unnecessarily. While Rosenbaum posits that doctors are under attack and being made to feel guilty by the “less is more” movement, many doctors are eager to change the system, for the benefit of both their patients and themselves.
A central theme throughout Rosenbaum’s piece is that “less is more” is taking over medicine. Rosenbaum contends that Right Care advocates dominate the policy discussion with their “missionary zeal.” It’s hard to ignore the tone she uses in this piece to describe the movement — crusade, mantra, missionary zeal. If you know nothing about the nature of overuse and efforts to combat it, you might conclude from reading her essay that the medical journals are filled with articles about unnecessary services, and that overuse police can be found lurking in every hospital corridor and doctor’s office, peering over clinician’s shoulders to make sure they didn’t order any extra blood tests or perform an unnecessary appendectomy.
Overuse is being covered in the journals and popular media more than ever before. But that’s all very recent. In 2007, when Brownlee came out with her book Overtreated (which Rosenbaum cites as the inspiration for her own interest in overuse), only a few dozen studies and papers had ever been published on the topic. Five years later, there were 478 articles written on overuse. In 2015, there were 821 and in 2016 there were 1,224. That’s progress, but it must be put into context: between 2000 and 2009, there were 52 systematic reviews done on medication adherence, which is only one form of underuse.
Although awareness of overuse is growing within medicine, it scarcely makes a ripple outside of the health professions. A 2013 public opinion poll (published in the New England Journal of Medicine) found only 1 in 6 Americans thought unnecessary testing and treatment contributed to rising Medicare expenses. Even the vast majority of physicians (75%) remain unaware of Choosing Wisely, the most prominent anti-overuse campaign. The idea that more care means higher-quality care still prevails among the American public; this goes especially for testing and screening.
Rosenbaum stretches credulity in arguing there is a “bias introduced by the less is more mindset” in journals and popular media. She decries the oversimplification of overuse research in the popular press, a problem that afflicts most of health news, not just the articles highlighting a treatment’s potential harms.
“Everyone knows that pharmaceutical companies are profit-driven and interprets company-sponsored trials accordingly. But when…a physician focused on mitigating overuse is quoted in support of withholding interventions, people reading the press coverage probably won’t weigh the relevant bias.”
Really? Not everyone knows to interpret company sponsored trials with a grain of salt (certainly not reporters, or they would not be criticized so regularly by Health News Review.) Often the connections to industry are hidden, making it difficult even for perceptive readers to effectively analyze trials.
Her claim that the “bias” held by clinicians who believe in reducing overuse is the same as the bias inherent in a financial conflict of interest is very misleading. There is a major difference between a clinician having an opinion about overuse based on their research and experience, and the promotion of products and services that companies and providers engage in. And let’s not forget the bias shown by academic medical centers, health care companies, and physician societies which hype this or that “breakthrough” treatment with no discussion of the lack of evidence or the potential risks.
Rosenbaum’s solution to the perceived oversimplification of overuse is to make sure we are not “pitting what’s best for the system against what’s best for our patients.” This is a false dichotomy, intended to stir worries about rationing. Rosenbaum is herself oversimplifying and overlooking the fact that reducing unnecessary care is not just about reducing cost, it’s about preventing real harm to patients.
For example, in commenting on the ORBITA trial, she warns against writing off stents for patients with stable angina because there are cases in which they are beneficial to patients. That is almost certainly true. Yet which patients? Wouldn’t it be important to figure that out before we deploy a medical technology across the entire world? If we know one thing about overuse, it is that it is often driven by therapeutic enthusiasm, and when the financial incentives align with it, that enthusiasm is turbocharged. The astonishing results of ORBITA point to the importance of careful clinical studies without preconceptions about what works.
Similarly Rosenbaum is worried that fewer tests and screening will expose patients to the “risks of not knowing.” She seems to forget the risks of knowing too much, of exposing patients to false positives, overtreatment, and other negative outcomes. Finding the balance forms the basis of determining appropriate care, or the right care for the right patient.
Despite what Rosenbaum gets wrong about the “less is more” movement, for those of us who are fighting for right care, her editorial is a good sign. It means that our progress in bringing awareness to overuse has not gone unnoticed. It means that we are making waves large enough to ruffle some feathers. As actor William Daniels as John Adams in the play 1776 said, “This is a revolution, dammit! We’re going to have to offend SOMEbody!”