Memo to Dr. H. Gilbert Welch, professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice and co-author of “Overdiagnosed: Making People Sick in the Pursuit of Health:”
Dear Dr. Welch: I’ve just read your New York Times op-ed piece, Testing What We Think We Know, which discussed how much of current medical practice is based on shaky evidence. From P.S.A. testing for men to hormone replacement therapy for women, from breast cancer treatment to colonoscopies, medicine so often puts the cart before the horse (that awful cliche´ is mine, of course, not yours.) Procedures become standard medical practice before we have good data on whether they make sense. You ended with this proposal:
Dr. H. Gilbert Welch (Courtesy of HGW)
Here’s a simple idea to turn this around: devote 1 percent of health care expenditures to evaluating what the other 99 percent is buying. Distribute the research dollars to match the clinical dollars. Figure out what works and what doesn’t. The Patient-Centered Outcomes Research Institute (created as part of the Affordable Care Act to study the comparative effectiveness of different treatments) is supposed to tackle questions of direct relevance to patients and could take on this role, but its budget — less than 0.03 percent of total spending — is far from sufficient.
A call for more medical research might sound like pablum. Worse, coming from a medical researcher, it might sound like self-interest (cut me some slack, that’s another one of our standard practices). But I don’t need the money. The system does. Or if you prefer, we can continue to argue about who pays for what — without knowing what’s worth paying for.
Last I read in the JAMA Forum, even the modest federal money now devoted to patient-centered outcomes research was in jeopardy. I just wonder — merely idle thinking here, of course — what would happen if you posted your proposal to change.org, a popular grassroots Website that people use to launch petitions and gather popular support for all sorts of causes? Would it fly? Readers, would any of you sign it? And perhaps more importantly, would anyone in Washington care if you did?
Kaiser Health News unpacks
Complete blood cell counts are frequently requested, but often not needed, a study found
a study that analyzed the clinical importance of some common medical tests and procedures. The bottom line is that more than $6.8 billion a year is spent on care we could really do without.
The newest study, using data from federal medical surveys, estimated that 12 of those unnecessary treatments and screenings accounted for $6.8 billion in medical costs in 2009. The activity most frequently performed without need was a complete blood cell count at a routine physical exam. In 56 percent of routine physicals, doctors inappropriately ordered such tests, accounting for $32.7 million in unnecessary costs. In terms of dollars, the biggest-ticket item by far was physicians ordering brand-name statins before trying patients on a generic drug first: That accounted for a whopping $5.8 billion of the $6.8 billion total.
Minal Kale, an internist at Mount Sinai School of Medicine and lead author of the study, says $6.8 billion was a conservative estimate of the cost of the inappropriate care. Continue reading
Are older folks getting too many medical tests?
Don’t miss this superb story examining out-of-control medical testing for older folks
, some who are urged to get all sorts of pricey screenings even if they are over 80 or already suffering from a fatal illness, like late-stage lung cancer. The story reports on one woman who got her first mammogram at 100. Was that really necessary?
The piece, a collaboration between Kaiser Health News and The Washington Post, tracks the knee-jerk phenomenon that says all testing is wise, and finds a growing skepticism:
“An ounce of prevention can be a ton of trouble,” observed geriatrician Robert Jayes, an associate professor of medicine at George Washington University School of Medicine. “Screening can label someone with a disease they were blissfully unaware of.”
Dartmouth physician Lisa M. Schwartz cites one such case: a healthy 78-year-old man who was left incontinent and impotent by radiation treatments for prostate cancer, a disease that typically grows so slowly that many men die with — but not of — it. Continue reading