Intended for healthcare professionals

Feature Essay

Overcoming overuse: the way forward is not standing still—an essay by Steven Woloshin and Lisa M Schwartz

BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k2035 (Published 22 May 2018) Cite this as: BMJ 2018;361:k2035
  1. Steven Woloshin, professor,
  2. Lisa M Schwartz, professor
  1. Center for Medicine in the Media, Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
  1. Correspondence to: Lisa M Schwartz lisa.schwartz{at}dartmouth.edu

Overdiagnosis and overtreatment are real, wasteful, and harmful, and doctors have an ethical duty to act, say Steven Woloshin and Lisa M Schwartz, responding to recent claims otherwise in the New England Medical Journal

In the old US television show Let’s Make a Deal the host, Monty Hall, awarded contestants a modest prize but then offered them a gamble: stick with that prize or exchange it for whatever was hidden behind a curtain. It might be a brand new car, but it could be a goat.

In her recent article, “The Less-Is-More Crusade—Are We Overmedicalizing or Oversimplifying?”1, the New England Journal of Medicine’s national correspondent, Lisa Rosenbaum, writes as if she were a risk averse contestant. Despite acknowledging that unnecessary tests and treatments in healthcare cause waste, she wants us to stick with the status quo—afraid that a goat lurks behind the curtain.

Rosenbaum’s article suggests that we don’t know how to eliminate wasteful care without inadvertently reducing beneficial care. And she criticises professionals concerned about reducing overuse as offering an oversimplified promise of “solutions without trade-offs.” But these assertions ignore a large and growing international body of research documenting that the status quo is itself sometimes a goat: patients get both too much and too little care, they have tests and treatments that provide more harm than benefit, and resources continue to be wasted on useless care such as preoperative testing for low risk surgery. It also overlooks the existence of evidence based approaches—not blind guesses—to mitigate overdiagnosis, overtreatment, and waste. To be deliberately provocative, Rosenbaum employs anecdote, selective examples, and caricature to dismiss a difficult but genuine science and to impugn the motives of, as she puts it, “less-is-more crusaders.”

Nevertheless, we should pause for thought. “Less is more” is much easier for policy makers to say than for doctors to do, and we need better measures of value and clarity about trade-offs to move forward wisely.

Sledgehammer versus Swiss Army knife

The goal of the less-is-more movement is not to mindlessly lower rates of medical use. Instead, it is to create a system that makes it easier for doctors and patients to understand their options and for patients to choose the most effective care that reflects personal values rather than commercial forces, ignorance, or fear.2 Furthermore, it emphasises the inextricable link between overuse and underuse: reducing wasteful care could enable resources to be redirected to counter the real problem of medical underuse, improving patient outcomes all round.

Rosenbaum worries that efforts to reduce low value care could eliminate appropriate care. She imagines an inexperienced cardiologist who refers all patients with chest pain for coronary angiography and is told to reduce his referral rates by the practice manager of an accountable care organisation. How do we know, she wonders, that this doctor won’t stop referring patients who genuinely need the test? Does this possibility mean that the health system should ignore what the cardiologist is doing? Of course not. Reducing needless angiography makes patients safer by reducing rare but serious complications that include bleeding, stroke, heart attack, and even death.

Rather than an indiscriminate sledgehammer, however, reform should resemble a flexible Swiss Army knife, with multiple approaches to reduce overuse, including tools to support clinical decision making, mechanisms to track unintended consequences, physician led guidelines, performance feedback from peers, and—most importantly—decisions shared among doctors and patients to influence care safely and appropriately. Although peer feedback is common, other approaches are inconsistent and remain aspirational.

Rosenbaum is certainly correct that richer measures of value, recognising clinical judgment and the social and economic realities that patients face, should guide these efforts. The current limits to how we measure value do not, however, justify a return to the era of authoritarian medicine. Many doctors, like her inexperienced cardiologist—do not “know best.” They make decisions ignorant of the evidence or patient preferences, unable to tolerate uncertainty, swayed by marketing and financial self interest, and reinforced by a legal system that punishes too little but not too much care.

Dartmouth and the science of overuse

According to Rosenbaum, “the missionary zeal of waste hunting [has begun] to obscure a complex evidence base, perpetuating an oversimplified narrative about waste’s magnitude, causes, and solutions.” In the interest of full disclosure, many of these zealots are our mentors, colleagues, and friends.

Over four decades ago, John Wennberg helped open the door to show that sometimes less is more. A pioneer in healthcare epidemiology, he founded the Dartmouth Atlas, which documents sometimes huge unwarranted variations in the use of medical resources in the United States. Patients received very different care simply because of where they lived rather than because of apparent medical need, he found.

The classic example is tonsillectomy: rates varied 10-fold between two demographically similar towns just miles apart. Another finding: residents of Boston were 60% more likely to be admitted to hospital than similar patients in New Haven.34 Patterns were related to availability of care, such as the number of doctors or hospital beds. Since then, evidence generally has not found that people living in areas with greater use have better health outcomes, experience higher quality care, or are more satisfied. This raises concerns about waste and harm from overuse.5

The puzzle of variation generated questions challenging the status quo. Does variation reflect inadequate evidence (or knowledge) of which tests and treatments are best—or of when or how often they should be used? Is medical practice driven more by the availability of services (such as magnetic resonance imaging or intensive care beds), physician preferences, idiosyncratic local professional culture, or informed patient preferences? Variation also highlighted the importance of patients’ participation in medical decisions.4

With counterexamples and methodological questions, Rosenbaum casts doubt on Dartmouth’s work on the science of overuse as well as the size of the problem—that an estimated 30% of US healthcare dollars are wasted. Given the huge grey zone of what counts as waste, it is not surprising that published estimates vary from 6% to 47%.67 But even the lowest estimate represents trillions of wasted dollars. Substantial overuse of unnecessary tests and ineffective treatments has also been documented in low and middle income countries.6

The science of overuse continues to evolve. For example, the number of publications about overuse identified in systematic review nearly tripled from 440 in 2014 to 1200 in 2016.8 Action to mitigate the harms of overdiagnosis has also led to important changes, perhaps most notably in cancer treatment. Active surveillance is now the preferred option for men with low risk prostate cancers,9 major cancer centres offer this strategy for low risk papillary thyroid cancer,10 and trials are testing it for ductal carcinoma in situ.11

What drives overuse?

Rosenbaum asserts the “presumed primacy of greed seems to have shifted the debate away from evidence.” We agree that overuse is about more than money—at its core it is about physicians wanting to do their best for individual patients and the quality and safety of health care.23 A host of forces besides money tilt the system towards doing more: insufficient time for patient visits; quality measures that do not account for patient preferences, comorbidity, or frailty; physicians’ discomfort with uncertainty; and a public indoctrinated by the notion that more healthcare means better healthcare. Many past and current medical practices were adopted based on intuition, marketing, or tradition rather than evidence.

Nevertheless, the power of commercial interests is undeniable. The tragic example of the opioid epidemic shows industry’s harmful role in fuelling overuse through misleading marketing, biased medical education programmes, kickbacks, and manipulation of professional and patient organisations.12 These efforts transformed prescribing: opioids became drugs of choice for chronic non-cancer pain despite the lack of evidence of benefit. In the US between 1999 and 2008—the decade after oxycodone was approved for pain—prescriptions for opioids quadrupled, as did the opioid overdose death rate.

In less than a sentence Rosenbaum dismisses another driver of overuse, saying that overdiagnosis of cancers is “often invoked to suggest the harms of screening.” The concept of overdiagnosis— diagnoses that were never going to cause symptoms or death—is now widely recognised as a major harm of early detection for cancers of the prostate, breast, thyroid, and lung as well as melanoma.13

It is probably the rule rather than the exception for both organised and opportunistic screening, with the increased use of high resolution computed tomography and magnetic resonance imaging. Major organisations that make evidence based screening recommendations, such as the US Preventive Services Task Force, the American Cancer Society, and the UK National Screening Committee explicitly consider overdiagnosis when judging the net benefit of screening.

Similarly, the UK Royal College of General Practitioners’ overdiagnosis group has promulgated five criteria for policy making to ensure overdiagnosis is considered, to mitigate harms from testing.14 These practising physicians were motivated by the college’s screening or testing recommendations, such as dementia screening and inappropriately low haemoglobin A1c targets for diabetes, which evidence suggests are likely to consume resources without benefit to patients.

Rosenbaum also mischaracterises how overdiagnosis researchers approach expanded disease definitions, asserting that they only consider the harms. To refute their approach, she cites a before-after study that found using lower troponin thresholds to diagnose myocardial infarction was associated with better outcomes.15 The “new patients” diagnosed by the lower threshold had better outcomes when doctors were alerted to these values than when they were not. But Rosenbaum’s premise is incorrect. Overdiagnosis researchers do not uniformly oppose expanded disease definitions; they want to make sure changes are justified. The troponin study exemplifies—not refutes—a central tenet of the overdiagnosis agenda: the need for high quality evidence of net benefit before adoption.

Still, guideline panels often expand definitions without assessing net benefit. Between 2000 and 2013, 10 of 14 major US panels did so. To help policy makers, a Guidelines International Network working group, which included overdiagnosis researchers, developed a checklist for making evidence based determinations of the net benefit of a disease definition.16 Recently, the working group applied the checklist to controversial new recommendations from the American College of Cardiology and the American Heart Association on high blood pressure. The group concluded no net benefit for the lowered diagnostic threshold—systolic blood pressure <130 mm Hg rather than <140 mm Hg—for the 25 million low risk new “hypertensive” patients recommended diet and exercise. However, the evidence did support drug treatment to the lower systolic target of <130 mm Hg for the three million people with higher cardiovascular risk.17

Hype is hype: for more or for less

The ORBITA trial19 found no difference in exercise time among patients with symptomatic angina and severe single vessel stenosis who had been randomised to percutaneous coronary intervention or optimal medical therapy. Rosenbaum uses reporting of this study to claim that the media are wrongly biased towards less is more. Yet the two news stories she cites1 undermine her contention.

Health News Review, an independent media watchdog, gave the New York Times’s story on ORBITA 4 out of 5 stars for the quality of its reporting, specifically praising the newspaper’s discussion of the study’s limitations. The principal investigator was quoted as saying that the trial’s results may not apply to patients with worse disease or over a longer period of observation and that stents might be appropriate for patients who do not want drugs or do not respond to them.20

In Rosenbaum’s second example, a report in the Atlantic, experts explained ORBITA’s limitations, and even an expert who did not believe the study results acknowledged that percutaneous coronary intervention is overused in stable patients.21

Exaggerated news coverage of health is not unusual: academics may exaggerate their findings, and journalists sometimes overstate benefits, minimise or omit harms, or fail to mention important limitations or conflicts of interest of quoted study authors, experts, or patients.22 We are not aware of any systematic investigation, however, that shows that media coverage of less-is-more research is more exaggerated, or less sceptical, than coverage of studies that show that more is more. Indeed, enthusiastic coverage that stimulates greater uptake of new tests, treatments, and services is no doubt more common than enthusiastic news about less is more. Regardless, exaggeration in the media should be avoided in either direction. Hype is hype, whether for more or for less care.

Researchers speaking to the media have a responsibility to avoid exaggeration. They do a disservice to the public when they overstate the magnitude, meaning, or certainty of research findings. Extreme statements may make an attention grabbing pull-out quote, but they harm the public by generating unfounded fear, hope, or cynicism.

Overdiagnosis of bias

Are medical journals biased towards less is more? Rosenbaum worries—without presenting any evidence—that publications by “journals that decry overmedicalization” are as biased as drug company publications.

Medical journals, however, are not in business to sell medical treatments or devices but to be honest brokers of information. Journals that run series about overuse, such as The BMJ and JAMA Internal Medicine, routinely publish studies of beneficial interventions or studies showing that more care is better (such as The BMJ article showing higher mortality for patients discharged from emergency departments with lower admission rates18).

Less can be more, but it can also be less. Developing and implementing evidence based strategies to recognise and safely reduce wasteful, ineffective, and harmful practices can lead to good for our patients and society. And it can free up resources to tackle the similarly prevalent problem of underuse of effective care. Rather than making assertions, asking, “Is less more?” has resulted in a profound shift in the ethos of medicine: a recognition that healthcare truly is a double edged sword that can harm as well as benefit patients. The nuances in, and possible unintended consequences of, the less-is-more movement cannot justify maintaining the status quo: it is unethical for doctors to knowingly cause harm. We will not get to better healthcare by standing still.

Biography

Lisa Schwartz and Steven Woloshin are general internists, professors of medicine, and codirectors of the Center for Medicine in the Media at the Dartmouth Institute for Health Policy and Clinical Practice. Their careers have focused on improving the communication of medical evidence to physicians, journalists, policy makers, and the public, with particular interest in overdiagnosis, prescription drugs, and statistics. They are founding organisers of the international preventing overdiagnosis conference, run in collaboration with The BMJ and others; coauthors of two books, Know Your Chances and Overdiagnosed; and recipients of the American Medical Writers Association’s John P McGovern award for pre-eminent contribution to medical communication.

Acknowledgments

We thank Robert Drake, Iona Heath, Deborah Korenstein, and Margaret McCartney for helpful feedback.

Footnotes

  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare that we are members of the preventing overdiagnosis conference board and cochairs of the scientific committee. We have both served as medical experts for the plaintiffs in testosterone litigation. We were the cofounders of Informulary, a company providing data about prescription drug benefits and harms, which ceased operations in December 2016.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References

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