Overutilization of health-care interventions has become a prime target of efforts to rein in health-care costs. Overtreatment of cancer patients is associated with a number of common harms to the patient—not just financial harm to the health-care system. At the recent ASCO Quality Care Symposium in Boston, Lisa K. Hicks, MD, MSc, a staff physician at St. Michael’s Hospital and Assistant Professor of Medicine at University of Toronto, discussed drivers of overtreatment, gave an example from her practice, and listed common harmful effects.1
In 2012, an Institute of Medicine report called for better care at lower cost.2 The report estimated that $750 billion were wasted each year and attributed $210 billion of these dollars to unnecessary care.
“The patient should be foremost in our thinking. Consider the harms and benefits of treatment, and if the harms outweigh the benefits, the treatment should not be prescribed,” Dr. Hicks told the audience.
Multiple Causative Factors
“Emanuel and Fuchs were the first to describe a ‘perfect storm’ that creates overutilization.3 The medical culture emphasizes data and thoroughness and is uncomfortable with uncertainty. Many physicians practice defensive medicine,” Dr. Hicks continued.
Overutilization is driven by cultural, medical, financial, and social factors. They include an emphasis on diligence and exhaustive testing, financial incentives that encourage doing over observing, rapid pace of science and sophisticated marketing, using high tech because reimbursement is higher, rapid pace of medical science and sophisticated marketing, and direct-to-consumer marketing.
Overtreatment occurs in four different settings: screening, investigations, treatment, and physician visits.
“Patients receive fragmented care delivery, and their needs are often misaligned with resources. Quality metrics are needed, as are guidelines, but most guidelines focus on what to do, not on what not to do,” she emphasized.
Dr. Hicks commended the Choosing Wisely campaign for getting the buy-in from various medical societies to list five tests or procedures each year that should not be routinely used. ASCO, the American Society of Hematology, the American Society for Radiation Oncology, and other medical societies are participating in this campaign, she said.
“Overutilization can cause patient harms,” she continued.
Cascade of Effects
Dr. Hicks gave listeners an example from her own practice. A 30-year-old male patient was treated for mediastinal diffuse large B-cell lymphoma and achieved remission. Two years later, he had a slight increase in residual mass on a surveillance computed tomography (CT) scan, but otherwise he was feeling well and his lab tests were all normal.
“I was worried so I ordered a [positron-emission tomography] scan and hoped for a normal result, but the findings were indeterminate. We elected to observe him, and he had a scan 6 weeks later with the same result. But he was so anxious and had chest pain, so we went on to biopsy. The good news is there was no cancer and he had reactive tissue. He is currently in remission, but he has a secondary diagnosis now of anxiety disorder with panic attacks. I think our testing may have worsened existing anxiety, and it may have precipitated panic attacks,” she acknowledged.
Other harms of additional imaging studies include increased risk of secondary cancers (estimated at 0.05% lifetime per CT scan for a 30-year-old man), risks of general anesthesia, discomfort, lost time, and worsened anxiety leading to financial hardship.
Types of harm from overtreatment include adverse events, direct and indirect financial harm, psychological distress, social stigma, lost time (not just work, but sitting in waiting rooms), and incidental findings that lead to further investigations, each of which carries a risk of adverse events.
Dr. Hicks cited a meta-analysis showing that 30% of CT scans pick up incidental findings,4 and this is likely to be higher among cancer patients, Dr. Hicks said.
“Doing unnecessary tests and giving unnecessary treatment create a cascade of effects,” she noted.
“I challenge you, when you go back home, to identify examples of overutilization in your own practice/hospital/provider community. Think about whether there is one test or procedure you could act on immediately. I suspect you will have no difficultly coming up with a long list. Try to change one thing that week, that day,” she encouraged listeners. ■
Disclosure: Dr. Hicks reported no potential conflicts of interest.
References
1. Hicks LK: Harms of care (overtreatment) and quality implications. ASCO Quality Care Symposium. Presented October 17, 2014.
2. Institute of Medicine: Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC, National Academies Press, September 6, 2012.
3. Emanuel EJ, Fuchs VR: The perfect storm of overutilization. JAMA 299:2789-2791, 2008.
4. Lumbreras B, Donat L, Hernández-Aguado I: Incidental findings in imaging diagnostic tests: A systematic review. Br J Radiol 83:276-289, 2010.
