Overtested, Overtreated, Overcharged

Here’s more evidence for the charge that the health-care industry overscreens, overdiagnoses, overtreats and often overcharges.

A recent study by the University of Michigan published in the Archives of Internal Medicine found that expensive tests like MRIs are used more often than more effective screenings that cost less.

The study concerned peripheral neuropathy, a disorder in which the nerves relaying information to and from the brain don’t work properly. Symptoms include tingling, burning and numbness in the arms and/or legs. Diabetes is the most common cause of peripheral neuropathy.

Nearly 1 in 4 patients receiving neuropathy diagnoses undergo high-cost, low-yield MRIs while very few receive low-cost, high-yield glucose tolerance tests. Patients diagnosed with peripheral neuropathy typically are given many tests. As one of the researchers said, “We spend a lot of money to work up a diagnosis of neuropathy. The question is whether that money is well spent.”

The answer: no.

The researchers looked at 15 different peripheral neuropathy diagnostic tests, analyzing their frequency six months before and after the initial diagnosis. They concluded: “Currently no standard approach to the evaluation of peripheral neuropathy exists. We need more research to determine an optimal approach. We do a lot of tests that cost a lot of money, and there’s no agreement on what we’re doing.”

A more practical light on the subject was shone recently by Dr. Joe Kosterich writing on the KevinMD blog. Much of what he expressed echoed a couple of recent posts of ours. One was about practitioners being overly in love with technology, another about cost considerations in prescribing care.

“As the world speeds up we tend to assume that newer must be better,” Kosterich wrote. “In some instances it is but when it comes to health, less so than one might expect. The other tendency is to overlook simple solutions and go to complicated, and often expensive ones.

“In medical practice there is one step even before considering what to do with a given problem and that is whether there is a need to ‘do’ anything. The great untold story of health and medicine is that much of what ails us will actually resolve by itself and much will resolve by actions of the individual rather than what the doctor does.”

He revisited the truism that all medical interventions have potential side effects, that caregivers and patients must consider the benefit-harm balance in deciding on a course of care.

“Someone who has pneumonia caused by a bacteria will need an antibiotic and notwithstanding that they may experience side effects, the benefits outweigh the harm,” he explained. “The same side effects are not as acceptable if an antibiotic is taken to treat a viral sore throat where there will be no benefit at all.” This scenario, as we’ve noted, has a greater social harm of making microbes more resistant to pharmaceutical intervention.

“The notion of a simple blood test has appeal but no blood test is simple,” Kosterich wrote. “A false result can lead to more tests and unnecessary treatments as well as needless anxiety. An unnecessary scan adds to cumulative radiation exposure.”

He reminded us about the overuse of screening tests, such as PSA for prostate health and mammograms for breast health. The list of “too much, too often” seems endless.

Relentless government and academic pressure, Kosterich said, has promoted the idea that treating numbers is more important than treating people. The financial incentives that
sometimes reward doctors who achieve certain “targets” can lead to conflicts of interest.
The knee-jerk clinical response to perform tests “just in case” ignores the fact that sometimes they yield inaccurate results.

“[H]arm can come from any medical intervention. This does not mean they should not be done but in every case there is a trade off of risk versus benefit. Protocols can never allow for this individual variability,” Kosterich stated.

Gary Schwitzer of HealthNewsReview recently alluded to a story in the Salt Lake Tribune that perfectly captured the test-now, analyze-later response of the medical community to new technology. He lauds the story, which describes how a bunch of independent radiologists promoted a scanning device that takes 360-degree CT images, never mind that it isn’t new technology, isn’t new to Salt Lake and it isn’t clear that the brand is superior to other systems. The reporter does a good job, Schwitzer said, of calling out the project’s hype and for championing informed decision-making on the part of patients.

Last on our list of inquiring minds that want to know why we can’t seem to strike the right balance for testing and treating illness comes in the form of a book review published in the Patient Safety America Newsletter. “Over-Diagnosed: Making People Sick in the Pursuit of Health” was written primarily by a practicing physician H. Gilbert Welch who surveyed the conditions under which Americans are subjected to questionable screening and overtreatment of “diseases” that will never have an adverse effect on their health. He explained the creep of illnesses “discovered” by lowering numerical diagnostic thresholds-it’s not that more people contract a disease, he said, it’s that we now identify a disease by more relaxed standards. “His point,” the review says, “is not that screening is worthless, but that the medical care industry has sold us some of this screening and we potentially ‘sick’ patients must be wary of how we understand and respond to the findings.”

Before medical school Welch majored in economics, and his book helps laypeople understand the notion of “loss leader.” In the medical realm, that translates as offering the public some sort of screening at below the actual cost in order to gin up the customer base for someone’s diagnostic and treatment facility.

This is a big topic that will require a social movement to fully address. But individual patients can flex some muscle to ensure they’re not the subjects of overtesting, overdiagnosing and overtreating. Patients, Kosterich suggested, should be mindful that:

  • Most symptoms are not due to disease. A cough might be a symptom of lung cancer but hardly anyone who coughs has lung cancer. Likewise with a headache and brain tumors.
  • Most conditions are not acute emergencies; they can be given time to resolve themselves. You do not always have to run to the doctor at the first sign of any symptom. Listen to your body.
  • Tests and treatments play important roles but are not free from potential harm. Ask whatever questions you need to be able to weigh the benefits against the risks.

Kosterich’s prescription for the medical industrial complex is:

  • Get back to treating people and not numbers so as to please governments and academics.
  • Clean up the process of setting treatment and performance guidelines.

To avoid becoming a victim of what the Welch book review calls a “frenzy of blind screening,” examine your tolerance for “a slightly higher chance of death from little screening vs. your desire to avoid overdiagnosis with its anxiety, and troublesome medical interventions.” If you don’t have symptoms but a test turns up an “abnormality,” be skeptical; additional testing is likely to lead to overdiagnosis. So unless you enjoy medical interventions, you might decline further examination.

It’s difficult to make these calls when you feel the medical “experts” are better trained, better informed and smarter than you are. Sometimes they are. Sometimes they’re not.

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