Arrest of Doctors
September 1, 2017
Ethics in Emergency Care
October 25, 2017

Wasteful Spending on Patient Care

Need for health ministry to be run as a mission to preserve health

Dr. R. Kumar

It is a common knowledge that doctors routinely order tests on patients that are unnecessary and wasteful. Costly, and possibly harmful. Indian estimates are difficult to make. However some experts estimate that over $200 billion is wasted annually in USA on excessive testing and treatment. This aggressive care also can harm patients, generating mistakes and injuries believed to cause 30,000 deaths each year. They estimate that up to 30 percent of the costs of medical care delivered in the U.S. is for unnecessary tests, procedures, doctor visits, hospital stays, and other services that may not actually improve patient health—and in some cases may cause harm. In India where the accountability is much lower the wasteful/avoidable percent may be 70%. There is a great need for evaluating waste, implementing waste-reduction strategies, and reducing the burden of unnecessary patient care spending. SPEAK has focused on cutting the number of elective cesarean sections, knee replacements, stent insertion, cataract removal, reducing opioid use and avoiding overtreatment for patients suffering low-back pain. Many patients and their families expect antibiotics to be prescribed for a sore throat or a CT scan for a bump on the head, besides avoidable surgeries. Wasteful medical treatment is patient- initiated as well.

Truth of US Healthcare

  • Every year, nearly half a million Americans have knee replacement surgery meant to relieve pain. The total national annual expenditure is around $4 billion, but studies show that physical therapy alone can relieve symptoms just as well as the surgery. This is catching up in India as well.
  • Lacs of brain scans are performed each year on headache sufferers. But unless a patient has specific risk factors, a CT scan is very unlikely to affect how the headache is treated.
  • For people with no family history of colon cancer, clinical guidelines don’t recommend getting a colonoscopy. Yet annually, more than 14 million of them are performed, often unnecessarily.

The decision to undergo many discretionary medical treatments should be based on informed patient choice.  Many patients who consult their doctor, present with physical symptoms that he thinks are not explained by physical disease.  Nevertheless, these patients often receive extensive investigation and treatment, which is usually attributed to pressure from patients for medicinal treatment and cure.  This is not due to doctors’ unethical greed to earn more money. The community needs to be educated on that.

Unnecessary medication

Tests that don’t reveal the problem, or uncover a “problem” that isn’t really there can be called un-necessary. A new study by researchers at the University Of Maryland School of Medicine highlights some of the most egregious examples of medical overuse in America. “Too often, health care practitioners do not rely on the latest evidence and their patients don’t get the best care,” said Daniel Morgan, associate professor of epidemiology & public health and infectious diseases at UM SOM. The paper appears in the most recent issue of JAMA Internal Medicine. The study examined more than 2200 journal articles and observed the following 10 overused tests and treatments.

Transesophageal Echocardiography: TEE is an invasive test that is used to diagnose heart issues that could lead to stroke. Although the test has a reputation for being more sensitive, a recent study found that it does not improve outcomes over a simpler test. Because it is an invasive procedure that requires sedation, it poses increased risks for patients compared to other alternatives.

Computed Tomography Pulmonary Angiography (CTPA): the use of this test in emergency departments has increased markedly in recent years. It is used to help diagnose pulmonary embolism, the blockage of a blood vessel in the lung. Researchers found that the test is overused compared to less risky tests. Overuse of CTPA is likely to result in delays, higher costs, and patient harm from unnecessary exposure to radiation and contrast dye.

Computed Tomography in Patients with Respiratory Symptoms: computed tomography, a high-tech scanning technology, is increasingly used in patients with respiratory symptoms. The study found that it was over used in patients who had non-life-threatening respiratory symptoms. In these cases, CT does not improve patient outcomes and could lead to false positive results. It also poses risks for patients, exposing them to radiation, with between 1.5 and 2 percent of all cancers in the U.S. attributable to radiation from CT.

Carotid Artery Ultrasonography and Stenting: this study found that more than 90 percent of carotid ultrasonography for patients without symptoms, who end up having stents or surgery, is performed for uncertain or inappropriate indications. This suggests that many of these procedures may be unnecessary. Given the risk of stenting or surgery, this indicates that the test and the procedure are likely both overused.

Aggressive Management of Prostate Cancer: a study of men who had prostate cancer surgery after being diagnosed through a blood test found that the rate of cancer -related death was 1 percent, with no difference between the groups who had been treated and those who had not been treated. Given that prostate cancer treatments can significantly increase erectile dysfunction and other problems, this suggests that the risks of treatment may outweigh the benefits in many men. The researchers argue that blood tests for prostate cancer should generally be avoided because they are more harmful than beneficial.

Supplemental Oxygen Does Not Help Patients with COPD and Moderate Lack of Oxygen: this study found that giving extra oxygen to patients with the lung illness chronic obstructive pulmonary disease, who had only mild oxygen deficit, did not improve quality of life or lung function.

No Benefit of Surgery for knee replacement: this research found that having surgery for a meniscus tear did not improve symptoms, even for patients who had clicking in the knee. Because of fewer risks and lower costs, conservative management and rehabilitation are a more effective strategy, the researchers argued.

Little Benefit to Nutritional Support in Medical Inpatients: Malnutrition may be associated with worse outcomes for hospital patients. But this study found that giving critically ill patients nutritional intervention, generally oral feeding, made no difference in overall death rate or length of stay in the hospital. The researchers concluded that nutritional support should not be routinely used because it did not have a benefit for patients.

Strategies to Reduce Overuse of Antibiotics: Up to half of all antibiotic use is inappropriate, exposing patients to the risk of adverse drug events, and increasing the overall risk of resistant bacteria. This study examined several methods to reduce the rate of antibiotic prescriptions by doctors. The most effective approach was to show doctors comparisons to their peers who prescribed correctly. In this group, inappropriate prescriptions dropped from nearly 20 percent to less than 4 percent. In this context, peer pressure can be effective, it appears.

Reducing the Use of Unnecessary Cardiac Imaging: Advanced cardiac imaging for patients with chest pain has more than tripled over the past decade. Many low-risk patients may receive noninvasive testing that could lead to unnecessary hospitalization and intervention. A study in which doctors and patients shared decision-making over whether or not to test found that this approach reduced the number of tests.

Indian Scenario

Ministry of health needs to shift its focus from patient care to health preservation and promotion through simple measures like regular exercise for all, clean air, plenty of water, adequate sleep, contentment and peace of mind, besides good governance. 70-80% people can be saved from hospitals and medicines in this manner. This also entails reducing the role of hospitals and doctors by 70-to 80%. Setting of a large number of AIIMS at huge costs but poor outcome for those admitted there may help in patient care to small percentage but is not the solution for the health of the teaming millions. Those who do fall sick must be treated with ethical and affordable treatment with fewer investigations and less medicines. It has to work like a missionary and not impersonal bureaucrat.

Our society where a large percentage of population is BPL, cannot afford the luxury of American style of over-exploitation of resources.

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