Less Is More

The United States has the most technologically advanced health care system in the world. Although we spend far more on health care than any other country in the world, we perform poorly on many health measures, such as life expectancy and infant mortality, compared with countries spending much less. This leads one to wonder why the return on our $2.5 trillion investment in health care in the United States is not better. It is estimated that hundreds of billions to $1 trillion or more goes to waste annually—health care spending that does not contribute to the well-being of patients. [1]

The Less Is More series launched by the Archives of Internal Medicine in May 2010 is intended to educate physicians on how to identify and thus avoid such wasteful care. The series was inspired by a conversation between Deborah Grady, deputy editor, and me after the release of the U.S. Preventive Services Task Force (USPSTF) report concluding that mammography for women between the ages of 40 and 50 posed more harms than benefits. The negative reception to this evidence-based report made us realize that the medical profession needs to communicate the basis for its recommendations more effectively, particularly when these recommendations seem to reverse previous advice.

The Less Is More series highlights areas of health care for which there are no known benefits and definite harms. We have seen interest in and submissions to this series steadily increase as the nation grapples with the best way to promote evidence-based care while reducing care with no net benefit. Examples of such medical care abound, particularly in the areas broadly described as “early detection” of disease, such as cancer screening programs and subclinical cardiac disease screening. The negative response to the most recent USPSTF report on prostate-specific antigen screening illustrates how difficult it is for patients and physicians to accept that a test or program that has previously been touted as beneficial actually has been found to cause more harm than good. Such reception is understandable, as we have spent years telling the public that early detection is good; the much more complex message that it is not always good, and in fact can be bad, is hard to convey, especially in a sound bite.

A definition of this avoidable care was eloquently summarized by Institute of Medicine president Harvey V. Fineberg in his address to the Avoiding Avoidable Care Conference in April 2012. [2] He described avoidable care in the context of three key characteristics: 1) degree of benefit, 2) degree of risk, and 3) resources expended associated with the care. Dr. Fineberg went on to explain that avoidable care often is related to “magical thinking”—“convictions that individuals tend to hold despite evidence that should lead to contradictory or more nuanced beliefs.” Some examples of such thinking are the beliefs that technology is always good, that new technology is always better than  older technology, and that uncertainty is intolerable. These beliefs act as obstacles to improvement in the quality and value of health care and are addressed in the Less Is More series. [3]

Luckily, the medical profession is starting to take important actions to convey the message that sometimes less health care can result in better health. The National Physicians Alliance (NPA) did an evidence-based review on areas of avoidable care and compiled lists based on surveys of internal medicine, family practice, and pediatric physicians to determine the top five procedures their specialties could do less often that would result in better health and less waste. [4] These include procedures such as imaging in the first 6 weeks of back pain (since most symptoms resolve on their own in that time) and the use of antibiotics for uncomplicated sinusitis.

The Choosing Wisely campaign, launched by the American Board of Internal Medicine Foundation and Consumer Reports in April 2012, greatly expanded the NPA top five lists to include nine specialty societies, and the list is growing rapidly. This work, which showcases physician leadership in considering risks and benefits for each test or therapy, even commonly used ones, is groundbreaking in showing us a way out of our present pattern of spending billions of dollars on health care that does not improve health or well-being. The next steps for this campaign include development of a consistent, evidence-based methodology for composition of the top five lists, a methodology that considers which overused tests or procedures are associated with the most harms and focuses on those as the first five areas for improvement. Many professional societies now are eager to keep growing the lists, acknowledging that there are more than five overused procedures. There also are active discussions on how to operationalize the lists for actual practice, including incorporating them into quality measures, accreditation processes, reimbursement practices, and recognition programs.

There is increasing recognition among physicians that many of patients are receiving too much health care. In a recent survey of primary care physicians identified by the American Medical Association (AMA) masterfile, 42 percent said that patients in their own practices were getting too much care. [5] Physicians are interested in feedback about their own practices to help avoid wasteful care, which suggests receptiveness to change.

Nationally, increasing awareness of the need to avoid wasteful care while promoting beneficial care, so that both these goals are reflected in guidelines and performance measures, is already growing among physicians, patients, and the health care community. In addition to the NPA top five lists, [6] professional societies, including the American College of Cardiology, are compiling appropriate use criteria. The Joint Commission is starting to add overuse measures, and the AMA is beginning to include appropriateness criteria in its performance measures. The recent Supreme Court decision upholding the Affordable Care Act will help us to move forward with new plans for quality
improvement to reduce wasteful health care, which will in turn save lives and money.

 

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References

1. Fineberg, H. V. 2012. A Successful and Sustainable Health System – How to Get There from Here. Shattuck Lecture. New England Journal of Medicine 366:1020-1027. https://doi.org/10.1056/NEJMsa1114777
2. Fineberg, H. V. Avoidable Care: Magical Thinking and Modern Medicine. http://avoidablecare.org/the-healthcareimperative/.
3. Redberg, R. F. 2010. Less Is More. Archives of Internal Medicine 2010:170;7;583-4. https://doi.org/10.1001/archinternmed.2010.48
4. The Good Stewardship Working Group. The “Top 5” Lists in Primary Care; Meeting the Responsibility of Professionalism. Archives of Internal Medicine 2011:171;15; 1385. https://doi.org/10.1001/archinternmed.2011.231.
5. Sirovich, B. E., S. Woloshin, and L. M. Schwartz. 2011. Too Little? Too Much? Primary Care Physicians’ Views on US Health Care. Archives of Internal Medicine 2011:171;17,1582-4. https://doi.org/10.1001/archinternmed.2011.437.

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