The Compounding Risk of Inappropriate Treatment
By Miles Varn, M.D., Chief Medical Officer of PinnacleCare
The Compounding Risk of Inappropriate Treatment
In medical treatment, more is not always better. Several studies have found that a patient’s risk of being over treated or receiving inappropriate treatment continues to rise. This trend can have a significant negative impact on the outcome of treatment, in some cases leading to serious harm or even death. It also contributes to increased medical costs.
Risks and Costs of Over Treatment and Inappropriate Treatment
In the U.S., patients receive inappropriate treatment for a range of health problems, including some types of cancer, back pain, heart disease and knee pain. Inappropriate care can cause serious health complications and sometimes permanent disability or death. It also hinders employee productivity, can result in significant legal costs and malpractice payouts, and can lead to considerable spending on unnecessary or misguided care. The Institute of Medicine puts the cost of over treatment at more than $210 billion per year.
There are three elements that define over treatment and inappropriate treatment:
1. Inadequate treatment despite clinical evidence or guidelines that support specific treatment benefit to the patient
2. Inappropriate treatment that has no clinical evidence or proven benefit and which can pose potential harm to the patient
3. Unnecessary treatment for a stable condition that does not pose a serious threat to the patient’s health
For a number of conditions, patients may not be receiving appropriate standards of care or may risk treatment that is not supported by clinical evidence:
Ovarian cancer: Only 37 percent of women diagnosed with ovarian cancer receive care that adheres to guidelines developed by the National Comprehensive Cancer Network. Women with advanced ovarian cancer who did not receive the recommended care had a 10 percent lower survival rate than those who did.
Heart disease: Nearly 12 percent of patients with stable cardiovascular disease undergo inappropriate angioplasty and stent placement. These unnecessary stents can put patients at risk for blood clots, post-operative bleeding from anti-clotting medications, and artery blockages caused by scarring. In addition, unnecessary stents cost the U.S. healthcare system $2.4 billion a year.
Back pain: Patients are prescribed narcotics and referred for surgery rather than receiving anti-inflammatory medications and physical therapy, the treatments most often supported by clinical research.
Patients also undergo unnecessary surgical procedures that do not yield the desired results and come with a high risk of serious complications:
Spinal surgery: Complex fusion procedures are performed when less complex surgery would be equally effective. The use of these complex procedures is linked to an increase in known complications as well as life-threatening complications such as heart attack, stroke and pneumonia and post-surgical disability.
Knee replacement: One-third of knee replacements are inappropriate because arthritis is not advanced enough to warrant surgery. In these cases, joint replacement often does not significantly reduce pain or increase function.
Hysterectomy, cardiac bypass, and other common surgeries: Approximately 30 percent of common surgical procedures are provided for reasons not supported by clinical research and may be harmful to patients who undergo these procedures.
Early stage prostate cancer and papillary thyroid cancer are examples of conditions where patients often receive invasive treatment for a problem that does not pose a serious threat to the patient’s health. One of the recommended treatments for older men with early stage, low risk prostate cancer is active surveillance, but in a study, only one-fifth of treating physicians followed this approach. The remaining patients received radiation and/or surgical treatment, which can cause incontinence and/or erectile dysfunction.
A similar situation can be found with papillary thyroid cancer. The number of thyroid cancer cases has doubled in the last two decades while the death rate remained very low and virtually unchanged.
These statistics suggest that an increase in ultrasound screening of patients with no symptoms may be leading to the discovery and treatment of small tumors that may never grow, spread, or pose a serious health risk.
Strategies to Lower Risk
There are a number of proactive strategies that can be used to reduce a patient’s risk of over treatment or inappropriate treatment:
Second opinions: When a patient receives a serious diagnosis, such as cancer, or a recommendation for surgery, the first step should be to consider a second opinion from a top specialist. A qualified second opinion can help to confirm or refute the diagnosis and treatment plan or suggest a more appropriate approach.
Educational resources: It is important that patients educate themselves about the potential treatment options and related risks and benefits. Information should come from objective and reliable sources that are up-to-date on the published clinical evidence.
Physician access: Patients should be able to access physicians who are highly experienced with the specific condition and appropriate research and range of treatments, not just physicians who may be closest geographically or part of a narrowing insurance network.
A trusted advocate: It can be helpful to have a professional health advisor or advocate to support the patient through this process. Patients and their families often need a healthcare professional they can trust who can dedicate the time and resources to represent their best interests and guide them to an appropriate and effective treatment plan.
Data supports the importance of proactive strategies to reduce the risk of inappropriate treatment. PinnacleCare reviewed data from a sampling of 1373 cases with known outcomes from 2012–2015. In nearly 77 percent of the total outcomes reported, PinnacleCare interventions led to changes in diagnosis, treatment, and/or treating physician. As a result, 30 patients avoided unnecessary or inappropriate surgery.
With specialized advisors to bridge the knowledge gap and coordinate access to top specialists, patients are more likely to engage in the process and follow through on treatment recommendations. In the end, results show that professional support can lead to a better outcome for the patient and help avoid the potential harm and costs of unnecessary surgeries or procedures.
The ultimate goal is to enhance a patient’s understanding of what sound clinical evidence shows and to provide ongoing decision support for their most critical healthcare decisions. With the right strategies and resources in place, patients can feel confident in their decision-making process and empowered to choose the most appropriate treatment plan for their needs and specific situation.
This content has been excerpted from a more comprehensive white paper on the topic, which can be found here.