by Tom Liu
This past weekend, I had the opportunity to attend the 2013 Lown Institute conference in Boston. The Lown Institute is an organization founded by Dr. Bernard Lown in 1973 that promotes a humanistic, patient-centered practice of medicine. A major topic covered during this conference, as well as during last year’s inaugural conference, was that of overuse in health care.
Just How Much Overuse Is There in the U.S.?
Dr. Don Berwick, who gave the keynote address, estimated the cost of overuse in the U.S. to be $158-$226 billion in 2011. Interestingly, the methods of the four studies cited for the $158-226 billion figure were primarily based on macro-level economic approximations (e.g. comparison of DRG intensity between U.S. and Canada)—not on micro-level analyses of overuse in violation of widely-accepted standards.
Which makes sense, given that for many questions of what constitutes overuse, the science may simply not be clear. In 2012, Dr. Deborah Korenstein and colleagues published a review of the literature on overuse in the U.S. The study’s subtitle (“An Understudied Problem”) reveals the punch line. While they were able to document overuse rates for specific treatments that have clear standards (e.g. antibiotics for upper respiratory infection), they concluded that “the overuse literature includes relatively few procedures and diagnostic tests.” And they attributed that to the uncertainty of our science:
“The limited overuse literature is understandable given the challenges of developing standards to measure overuse. […] the process of defining appropriateness for many services remains incomplete owing to both gaps in the evidence and failure to translate evidence into appropriateness criteria.” –Korenstein et al., 2012
Which puts us as (aspiring) providers in a bit of a quandary.
Eliminating Overuse May Take More Than a Checklist
For providers (especially in a profession susceptible to paternalism), the most straightforward solution might seem to be to direct patients away from those wasteful, inappropriate treatments, shaving 7-8% off of our $2.7 trillion and growing health care expenditures. But for the majority of cases, there may not be enough evidence to clearly support a treat or don’t treat decision. And even when evidence-based recommendations exist, they are likely based on population-level analyses, which may conflict with the desires of the individual patient.
As Jessie Gruman argues, there is a coming conflict between clinicians pressured to adhere to a burgeoning number of quality measures and patients who are becoming increasingly engaged in their treatment decisions. Dr. Gruman was at the Lown conference, and she described her experience choosing a new doctor when her old one refused to give her a treatment that he deemed was “not worth it” (despite a 20% success rate). Dr. Gruman belongs to a growing chorus of advocates calling for increased patient engagement in their care decisions. Have the provider lay out the treatment options, with each option’s risk and chance of success, and let the patient decide.
At the same time, I kept hearing my former Swarthmore professor Dr. Barry Swartz whispering three words in my ear: “paradox of choice”. Presenting people with 24 varieties of jam was enough to confuse them into inaction. Present patients with too many treatment options under actual life-or-death situations, and you could create a lot of (unwarranted?) stress and anxiety.
It seems to me that while some patients may be ready to be empowered consumers choosing from among a menu of options their provider lays out, others may not be there (yet). As Dr. Ranjana Srivastava, another panelist, aptly described, “Even with a menu of options, patients expect their doctor to take charge of their treatment.”
Overcoming the Culture of Overuse
Therefore, I believe the role of providers in reducing overuse will be much more complex than simply adhering to evidence-based recommendations to root out overuse. It will require engaging with each individual patient, intuiting that patient’s preferences for autonomy vs. provider advice, and having a conversation about the value of each treatment option (see Teaching Value Project)—including being willing to argue that the most aggressive option may not always be the best (though it certainly might be for that patient).
P.S. If you are interested in the issue of overuse, I strongly encourage you to check out the Lown Institute’s Right Care Declaration and sign if you so choose.