Saturday, September 23, 2017

Life with Chronic Conditions: How to Avoid Unnecessary Care

Virtually every family in the country, the research indicates, has been subject to overtesting and overtreatment in one form or another. The costs appear to take thousands of dollars out of the paychecks of every household each year. Researchers have come to refer to financial as well as physical “toxicities” of inappropriate care—including reduced spending on food, clothing, education, and shelter. Millions of people are receiving drugs that aren’t helping them, operations that aren’t going to make them better, and scans and tests that do nothing beneficial for them, and often cause harm.

Doctors generally know more about the value of a given medical treatment than patients, who have little ability to determine the quality of the advice they are getting. Doctors, therefore, are in a powerful position. We can recommend care of little or no value because it enhances our incomes, because it’s our habit, or because we genuinely but incorrectly believe in it, and patients will tend to follow our recommendations. Overkill

The studies just continue to pile up about the high costs and negative impacts of being over tested and treated, with the most recent one published in PLoS One, confirming what’s been known for a long time, doctors practice defensive medicine. In other words, they don’t want to be sued so they over test and over treat “just in case.”

Economics is also an issue. Paying physicians a fee every time they provide a service encourages them to order more tests and procedures. Equally important are patient expectations of more tests, treatments, pills etc. One of the best examples of the latter was the backlash when the US Prevention Task Force came out with its recommendations on mammography. Women continue to follow old standards in the belief they were doing something to prevent breast cancer.

We’ve long assumed that if we screen a healthy population for diseases like cancer or coronary-artery disease, and catch those diseases early, we’ll be able to treat them before they get dangerously advanced, and save lives in large numbers. But it hasn’t turned out that way. For instance, cancer screening with mammography, ultrasound, and blood testing has dramatically increased the detection of breast, thyroid, and prostate cancer during the past quarter century. We’re treating hundreds of thousands more people each year for these diseases than we ever have. Yet only a tiny reduction in death, if any, has resulted.

Called “low value care,” it could easily become “harmful care.” For those with chronic conditions, where both provider and patient are looking for answers, it’s possible that they may be the most vulnerable. The least impact is that nothing happens but your still out the cost of extra testing and/or treatment as well as your time. The worse is that it can actually make you a lot sicker as well as create unnecessary anxiety over something that wasn’t a problem in the first place. Excessive testing just isn’t financially costly, but the more tests ordered the greater the risk of a false positive. In the case of CT scans and other forms of imaging, the more you receive, the more radiation you are exposed to.

The article Overkill by Dr. Atul Gawande is an excellent overview of unnecessary care and would recommend taking the time to read it. 

To avoid unnecessary care, Consider the following:

1. Be a willing partner to “shared-decision making.” Recognize that while your provider knows a lot about their field, you know yourself better than they do. If they prescribe medication you know you’ll never take or wont take as prescribed, this is important information to discuss. Fortunately, many hospitals and even condition specific organizations offer shared decision making tools to help both you and your provider. Your provider should explain your condition; take time to understand your goals and concerns; explain the latest medical evidence as well as benefits and risks of options, including doing nothing; explain things in a language you understand; listens to you; and helps you make decisions after considering all the options. Ultimately, you have to live with the choices made, so learn to become a good medical decision maker.


2. Check current recommendations for testing and treatment. There are several groups/panels of medical providers that make recommendations based on evidence. Check these out for recommendations regarding testing, treatment etc. Also contact your condition specific organization (e.g. American Diabetic Association) to discuss their recommendations. As each patient situation is unique, providers and patients should use the recommendations as guidelines to determine an appropriate treatment plan together.


US PreventiveServices Task Force (USPSTF) created in 1984, is an independent, volunteer panel of national experts in prevention and evidence-based medicine. The Task Force works to improve the health of all Americans by making evidence-based recommendations. 
ChoosingWisely is an initiative of the ABIM Foundation in partnership with Consumer Reports that seeks to advance a national dialogue on avoiding wasteful or unnecessary medical tests, treatments and procedures. They offer a variety of lists that were created by national medical specialty societies and represent specific, evidence-based recommendations clinicians and patients should discuss. Each list provides information on when tests and procedures may be appropriate, as well as the methodology used in its creation. Choosing Wisely has an App that you can use on your phone at your medical appointments. 

3. Question “lets get some lab tests.” Ask how many, why, what information will they provide and what are the costs? The more tests ordered the greater the risk of a false positive, which can ultimately lead to a care plan that isn’t right for you. In cases where there are unusual circumstances, such as you’ve been having strange symptoms that no one can seem to figure out, a scatter shot approach to testing may be appropriate. However, if this is just a normal situation, don’t settle for vague answers to why tests are needed.

4. Be wary of generalizations about medications. You need to know how a medication will directly impact your health situation. What are potential side effects? Costs? Are there generics for the medication? Is there an alternative approach that can be taken?

5. Are you continually being referred to a specialist for one reason or another? This could be an indication that your primary care provider is overwhelmed and it’s time to look for a new one.

6. Technology such as CT scans and MRIs should only be done when medically necessary.  The better the technology, the more likely it is to find something that may not be dangerous. CT scans and MRIs while very helpful in diagnosing a problem, can pick up normal imperfections, that wouldn’t cause harm, but can precipitate additional testing and treatment.

Additional Reading

Overkill by Atul Gawande An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it?

• How to Get Patients to Take More Control of Their Medical Decisions

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