When Advanced Care Is a Step Back

America is a country of newer! Better! Now! More! But in medical care, as readers of this blog know, more is not always better, and the point was driven home recently in a New York Times commentary.

“Doing More for Patients Often Does No Good,” by Dr. Aaron E. Carroll, a professor of pediatrics at Indiana University School of Medicine, explained how our desire to want the latest pharmaceuticals, medical devices and procedures “often does no good. Sometimes, it even leads to harm.”

Carroll understands that when you’re sick, it’s difficult to do nothing. An example of the inability, or unwillingness, to “do nothing,” we suggest, is the millions of healthy people who take vitamins when they’re already getting sufficient nutrition from the food they eat. An example is doctors who prescribe Tamiflu for patients who otherwise aren’t frail, elderly or at risk of complications.

According to meta research (review of many studies) published in the BMJ (British Medical Journal), there’s little evidence that antivirals like Tamiflu and Relenza reduce the risk of influenza complications or hospitalizations among the general population. And even when administered shortly after you start feeling ill, they usually shorten the time you feel the worst by hours, or maybe a day.

Antivirals are expensive, but they’re relatively new, and they’re promoted by the Centers for Disease Control and Prevention. The science is secondary to the popular pitch, and to Americans’ appetite for it.

Carroll cast an eye on emergency services. When someone seems to be in heart trouble, paramedics often proceed with advanced life support – they insert endotracheal breathing tubes, start intravenous lines, deliver sophisticated cardiac drugs and defibrillate patients manually.

“[B]ut steps taken out in the field can make a difference,” Carroll noted. “Basic life support, the kind you might be taught in a CPR class – involving the use of bag valve masks, cardiopulmonary resuscitation and automated external defibrillators – can absolutely save a life.”

Carroll said that usually we assume that advanced life support is superior to basic life support, and that where both options are available, advanced life support almost always wins out. But a recent study in JAMA Internal Medicine, calls that assumption into question. “Researchers examined Medicare patients who were billed for either advanced life support or basic life support before admission to the hospital …,” he wrote. “They looked at how often patients survived to hospital discharge, and then months later.”

They found that about 13 in 100 patients who received basic life support survived and were discharged; only 9 in 100 patients who received advanced life support had the same outcome. Ninety days after discharge, more of the patients who received basic life support were alive than those who got the advanced treatment. The basic life support patients also had better neurological outcomes.

Carroll pointed out the JAMA study’s limitations. It wasn’t a randomized, controlled trial, which is the gold standard for scientific inquiry. And it’s possible that sicker patients received advanced life support while people who didn’t appear as sick received basic life support. “But the authors called all of the state agencies,” he wrote, “and they reported that this can’t really happen. After all, a 911 dispatcher can’t tell if it’s a ‘mild’ or ‘severe’ heart attack from a third party on the phone with no medical training. Dispatchers send out advanced life support if it’s available, and basic life support if it’s not.”

And who knows if there were bystanders with CPR training, and if so, how good they were at the procedure. But the study factored that in, conducting what Carroll called “sensitivity analyses.” There, too, the advanced life support failed to outperform basic life support.

Carroll offered a long list of previous studies that show how less is often more:

  • A study in 2004 found that a cardiac arrest patient’s chances of survival significantly improved if the attack was witnessed by a bystander, and that CPR administered by bystanders improved survival, as did rapid defibrillation – all components of basic life support. The addition of advanced life support made no difference in survival.
  • A 2008 review showed that emergency intubation wasn’t effective.
  • Two studies, one in 2010 and one in 2013, found that inserting an airway tube instead of using a bag mask was associated with decreased survival compared with basic life support.
  • A 2012 study concluded that using epinephrine (which constricts blood vessels to raise blood pressure) was associated with worse outcomes, and a 2008 study found that adding vasopressin (for the same reason) did not improve things. A 2009 randomized, controlled trial of these drugs found no improvement in survival.

So, Carroll asked, why does advanced life support appear not to offer any benefit and is often associated with worse outcomes? Could it be that the advanced life support slows things down and distracts people from providing useful, basic life support measures, and delays a patient getting to the hospital?

Carroll also looked at the outcomes of women with unilateral breast cancer (one affected breast) who underwent breast-conserving surgery and radiation versus women who had a unilateral mastectomy and also those who had a bilateral (both breasts) prophylactic mastectomy – that is, removal of the breasts for preventive reasons, like Angelina Jolie.

“The 10-year survival differences between the groups were negligible,” Carroll reported. “Breast conservation therapy is more tolerable, is much less invasive and costs less.”

Our recent blog, “Bad Advice Abounds Regarding Surgery for DCIS” also addressed conservative versus radical treatment for a certain kind of breast cancer, with the same conclusion.

Despite the fact that breast conservation therapy has become a “standard of excellence” in breast cancer care, Carroll noted, a recent study showed that from 1998 through 2011, the chances that a woman eligible for breast conservation therapy would receive a mastectomy increased, as did rates of bilateral mastectomy.

And even though women with early breast cancer do better if they get less radiation, only 1 in 3 who qualified for a procedure that uses less radiation got it. Observed Carroll, “The rest got more, but not better, care.”

One reason why is money: In a fee-for-service system, which is how many insurance plans are structured, the more often you see a doctor and the more treatments you have, the more the doctor and facility get paid. “Research shows that twice as many women want hypofractionated radiation therapy as want conventional therapy,” Carroll said, “but only half of radiation oncologists offer it.

“But it’s not all money. It’s also probably fear. Many radiation oncologists are concerned that doing fewer treatments will lead to worse outcomes. That’s most likely the concern of women who choose much more invasive surgery than necessary as well.”

Often, fear is much harder to overcome than expense or any other quantifiable factor in medical care. In addition to our cultural lust for new and more, fear drives our choices. The advanced life support trial, according to Carroll, was supposed to be randomized and controlled, but paramedics apparently refused to follow that protocol because they believed that withholding advanced life support was unethical, in spite of evidence that it wasn’t effective.

“More is expensive. More sometimes does no good. Sometimes, more is even harmful,” Carroll concluded. “When our policies and care ignore these facts, we all suffer.”

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