Unnecessary Medical Treatments and Tests
Written by Faith Anderson on April 4, 2012
Doctors Fear Unnecessary Tests Raise Costs
The 45 items on the comprehensive list include most repeat colonoscopies within ten years of the first, brain scans for patients who fainted but didn’t have seizures, early imaging for most back pain, and antibiotics for mild-to-moderate sinus issues. Also on the list is heart imaging stress tests for patients without coronary symptoms and tumor treatment in end-stage patients who have not responded to multiple therapies and are not eligible for experimental treatments.
According to Dr. Christine Cassel, president of the American Board of Internal Medicine, the goal is to minimize wasteful spending without harming patients. She indicated that some patients may also benefit from avoiding known risks associated with certain tests, such as exposure to radiation. “We all know there is overuse and waste in the system, so let’s have the doctors take responsibility for that and look at the things that are overused,” said Cassel. “We’re doing this because we think we don’t need to ration health care if we can get rid of waste.”
Call to End Cancer Treatment that Doesn’t Extend Lives
Perhaps the most controversial recommendation is to not use chemotherapy and other treatments in patients with advanced solid-tumor cancers, such as lung and colorectal, who are in poor health and did not benefit from previous chemo treatments. Such treatment is widespread, and at one large health maintenance organization, 49% of patients with a common form of lung cancer but with poor “performance status” received chemo. However, research shows that this treatment is unlikely to extend life or improve its quality. Similarly, some cancer patients receive three or four kinds of chemo after not responding to earlier rounds. In the largest study of its kind, however, only 2% of lung cancer patients responded to a third form of chemo and 0% responded to a fourth form.
Because of this research, ASCO recommends that such very ill and non-responsive patients receive only palliative and other end-of-life care. “In no way do we want to deprive a desperately-ill patient of something that might be helpful,” said another doctor. “But if nature is telling us that something will not help, it is our obligation to do no harm.” The challenge for doctors and insurers will be to balance the needs of the vast majority of patients against the rare cases. Research has shown that when very ill lung cancer patients were given a common chemotherapy, the average rate of survival was half that of stronger patients – 3 to 4 months.
Fear of Malpractice Lawsuits Prompts Unnecessary Testing and Treatment
The recommendation that physicians not perform bone scans or advanced imaging in patients with early-stage breast or low-grade prostate cancer that is unlikely to spread also reflects research that goes against what many patients believe. In these patients, imaging like CT and PET to search for metastasis does not extend survival or improve detection of metastases. But the expensive imaging does misdiagnose some harmless changes as cancer, sometimes leading to unnecessary invasive medical procedures or treatments that can actually shorten lives.
So, the question is, why do doctors keep doing these tests since “most of them are aware of the evidence that these tests don’t benefit patients?” asks one physician. Dr. James Fasules of the American College of Cardiology says the goal is to begin changing attitudes among doctors and patients. “We kind of have a general feeling that if you don’t get a test, you haven’t been cared for well,” said Fasules. The new advice isn’t meant to override a doctor’s judgment, of course, but to inform and support decisions. Unfortunately, the medical societies don’t have any power of enforcement, and fear of medical malpractice lawsuits may prompt many doctors to keep ordering as many tests as ever.