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ANDRÉ PICARD

When health care becomes unnecessary care Add to ...

Sir Bruce Keogh, head of England’s National Health Service, said on the weekend that a “substantial proportion” of health spending in Western health care systems is wasted on ineffective and unnecessary care.

He estimated that 10 to 15 per cent of all medical and surgical treatments offer little or no benefit and, in many cases, do more harm than good.

“The waste is profligate,” Sir Bruce told The Telegraph. “I don’t think we should be ashamed of pointing that out and certainly we shouldn’t be ashamed of dealing with it.”

The candour is refreshing but, if anything, he is underestimating the scope of the problem.

Research done in the United States shows that 30 to 40 per cent of care is unnecessary, driven by the foolish consumerist philosophy that more is necessarily better.

In Canada, there is, unfortunately, little research on the topic but, on the profligate waste scale, we probably lie somewhere between Britain’s 15 per cent and the United States’ 40 per cent.

In this country, there is not the same temptation to overtreat in the quest for profit as in the U.S., but there is also little accountability and cost control the way there is in the National Health Service (NHS).

In analyzing our health spending, we seem to prefer blissful ignorance to the uncomfortable truth that we are probably wasting somewhere between $32-billion and $86-billion in health spending annually.

Regardless of dollar value, the reality is that the challenges of delivering appropriate, effective and cost-efficient care are similar in most Western countries.

Sir Bruce was driving home the message in a new report from The King’s Fund, entitled Better Value for the NHS, which makes several good points on our volume-driven (rather than quality-driven) approach to clinical practice:

There are a lot of “low value” treatments done like cataract and hernia operations, and tonsillectomies;

There is a lot of unnecessary and excessive testing, ranging from routine blood tests that provide little useful information, to large-scale cancer screening programs that need to be rethought;

There is significant overprescription of some drugs, and many prescriptions go unfilled or unused. Costly brand name drugs are too often used when equally effective and cheaper generics will do;

Too many patients with terminal illnesses still die in hospital, rather than in hospice or with palliative home care;

About one in every 20 hospital admissions provide no benefit to the patient and are a waste of money.

The principal manner in which policy researchers identify waste is by looking at outcomes and in variations. For example, about half of patients who undergo hernia operations report no benefit from the operation, and one in seven women who undergo hysterectomy don’t need the operation.

Regional variations in care among similar populations also suggest that some patients are getting unnecessary interventions. For example, in Canada, the proportion of cesarean deliveries varies wildly between regions, from about one in four births to one in 20.

The difficulty in these analyses is knowing what the “right” number is. Increasingly, physicians (and other health professionals) have the benefit of clinical guidelines that recommend a standard of care, and initiatives like Choosing Wisely Canada to promote appropriate care.

The greater difficulty is knowing when to deviate from the rules to benefit an individual patient. Algorithm-based guidelines are important, but medicine is as much an art as a science, especially when you are making highly personal trade-offs like opting between greater life expectancy and improved quality of life. Knowing when to deviate from the rules – and not – is key to delivering good care.

All this to say that it is relatively easy to identify unnecessary and wasteful care on a systems level, but it is much more difficult to do so at an individual level.

Take the hernia example: The surgery doesn’t work half the time but there is no simple way of identifying ahead of time who will benefit. So what do you do? Treat no one and deny benefits to many, or treat many and waste precious health dollars?

Identifying the problem, as Sir Bruce of the NHS has done, is important, but it’s not sufficient.

If unnecessary care and over-treatment are sicknesses plaguing our system, then we need appropriate treatments.

If we are to cut, then the cuts must not be made blindly, but with surgical precision, and guided by evidence – and recognizing there will be benefits and risks.

 

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