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A trickle of anecdotes has become a flood of cautionary tales.
There’s one about the patient in intensive care who didn’t have a cardiac condition yet still had a troponin blood test on 26 consecutive days. Guidelines, of course, suggest that three tests in a 12- to 24-hour period are sufficient to diagnose or rule out a heart attack.
Here’s another: A schizophrenic patient complaining of abdominal pain was sent to the ED. After a normal CT scan, she was admitted to the hospital for further workup and pain control. Amid discussions over whether the doctors should order an MRI or surgery consultation, a review of her records revealed 40 CT scans over the previous five years. All had turned up nothing, and the patient’s family confirmed that her frequent bouts of abdominal pain went away on their own.
Then there’s the story about a middle-aged man with an asthma diagnosis from years before; he was scheduled for surgery to correct his painful umbilical hernia. As part of the patient’s evaluation in a pre-operative clinic, his surgeon ordered a chest X-ray (CXR), despite a lack of any respiratory symptoms. The results suggested a possible lung nodule, leading to a follow-up CT scan that revealed normal lungs but instead showed a potential adrenal gland nodule. A second CT scan showed only a benign lesion, but the series of false alarms effectively delayed his hernia surgery by six months.
In the subsequent report on the latter case, included in the “Teachable Moments” section of JAMA Internal Medicine, the co-authors concluded, “Despite the evidence that pre-operative CXR is unlikely to be beneficial, it continues to be used in daily practice. Exposing a patient to multiple, additional studies prolongs surgical delay, increases exposure to radiation, prolongs and exacerbates underlying anxiety, and increases the likelihood of additional incidentalomas.”1
Unnecessary overuse of medical care, in other words, can cause both waste and harm.
Some of the stories highlight egregious examples, while others meditate on more nuanced cases. All are zeroing in on needlessly wasteful healthcare that can negatively impact patients physically, emotionally, and financially.
“I think for a long time we thought, ‘Might help, can’t hurt,’ and we’re seeing time and time again that that is just totally false,” says Christopher Moriates, MD, assistant clinical professor in the division of hospital medicine at the University of California, San Francisco.
Increasingly, like-minded hospitalists and other physicians are launching groups and projects around the country with names like Caring Wisely, Providers for Responsible Ordering, Costs of Care, the Do No Harm Project, and I-CARE. Each group takes a slightly different approach toward reframing clinical decisions in a way that considers both the potential benefit and the accompanying risks and costs.
The Caring Wisely program, which Dr. Moriates leads, supports innovations that reduce healthcare costs while improving patient health. The nonprofit organization Costs of Care, meanwhile, is trying to change professional norms by pointing out the ethical downsides of overuse.
“I’ve never heard anybody get called unethical for wasting a healthcare resource, but that’s where we need to go,” says Neel Shah, MD, MPP, founder and executive director of Costs of Care and an assistant professor at Harvard Medical School in Boston.
This dogma-challenging, evidence-based, awareness-raising movement is building momentum at a critical time. Although the problem of wasteful healthcare isn’t unique to the United States, multiple experts have pointed out the big disconnect between the nation’s top ranking in per capita healthcare spending and only middling scores in a long list of healthcare outcomes.2
In their damning 2008 commentary, “The Perfect Storm of Overutilization,” National Institutes of Health bioethicist Ezekiel Emanuel, MD, PhD, and Stanford economist Victor Fuchs, PhD, laid out the argument that overutilization was the most important contributor to high healthcare costs in the U.S.3 A greater volume of interventions and unnecessary costs both contributed to this overuse, the authors suggested.
Subsequent reports by Thomson Reuters in 2010, an Institute of Medicine (IOM) roundtable on evidence-based medicine in 2011, and the RAND Corporation in 2012 largely agreed. Based on its report, “The Healthcare Imperative: Lowering Costs and Improving Outcomes,” the IOM laid out a particularly sobering analogy to the degree of waste found in medical care.2 If other prices had grown as quickly as healthcare since 1945, the report estimated, a gallon of milk would now cost $48. Yet, of the $2.5 trillion spent on healthcare in 2009, the report estimated that 30%, or $765 billion, was wasted. Of that number, the report suggested that unnecessary healthcare services accounted for $210 billion, or 27%.
A Culture of “More”
What contributes to so much unnecessary overuse? Drs. Emanuel and Fuchs cite multiple factors:
- Physician training and culture;
- The fee-for-service payment structure;
- Aggressive marketing by developers of tests, drugs, and procedures;
- Defensive medicine;
- A cultural preference for technological solutions; and
- A lack of transparency on the true costs of care.
The authors contend that each factor reinforces and amplifies the others, resulting in a “perfect storm of ‘more.’”
A major driver, several doctors agree, is a culture that has long embraced the “more is better” mantra. Brandon Combs, MD, assistant professor of medicine at the University of Colorado School of Medicine in Denver, puts it this way: “More information is better. More interventions are better. More scans are better. More surgery is better. More pills are better—this concept that if I’m getting more, if I’m spending more, if it costs more, then it must be kind of like a Mercedes. It must actually be better.” A collective “cultural blind spot,” he adds, leaves both doctors and patients unable to focus on anything beyond the upsides of care.
At the same time, medicine has reinforced the notion among trainees and attending physicians alike that doctors can never be wrong or miss a diagnosis.
“Diagnostic uncertainty really feeds into a system where we have ready access to lots of things,” Dr. Combs says. “We have such a supply of tests, whether that’s blood tests, whether that’s imaging tests, whether that’s access to consultations with subspecialists—we have a system that can supply whatever demand we seem to have.”
Dr. Shah calls it a “hidden curriculum” that imposes its will on doctors’ discretion. Case studies, for example, routinely focus on doctors ordering multiple tests in search of exceedingly rare causes of disease instead of being good stewards of limited resources.
“When you’re criticized by your colleagues or by your mentors, it’s always for things that you didn’t do but could’ve done, and it’s never about the things that you did do but didn’t have to,” he says.
Anthony Accurso, MD, instructor of medicine at the Johns Hopkins Bayview Medical Center in Baltimore, says the current system grew out of an apprenticeship model of medical training that dominated for much of the 20th century.
“You learn to do things the way they’ve always been done,” he says. About 20 years ago, however, healthcare providers began shifting toward evidence-based medicine. “That was a retreat from doing things the way they had always been done and a movement toward doing things that proved themselves to be effective though evidence and study,” he says.
High-value care is now emerging as a third outgrowth along the medical training pathway. “It says if there are two evidence-based treatments, both of which are effective but which have different costs, then it is rational and in fact prudent to do the one that costs less,” Dr. Accurso says.
The existing evidence base is far from complete, however, meaning that some decisions must be made without clear guidelines. And beyond the remaining uncertainties, doctors often struggle to keep up with evidence that’s constantly in flux.
“Things that are doctrine right now might be considered blasphemous in 10 or 15 years as we learn more,” says Robert Fogerty, MD, MPH, an academic hospitalist and assistant professor of medicine at Yale University School of Medicine in New Haven, Conn.
Those realities work against the natural desire to be right and safe, which can lead to redundant tests, extra therapeutics, and additional monitoring. “Because there’s so much that we don’t know, sometimes we like to ask more questions by ordering more tests to try and find the answer,” Dr. Fogerty says. “So it’s almost an endless quest for knowledge, an endless hope that the answer’s under some rock if we just turn over enough rocks.”
As reform advocates are finding, however, even ample evidence isn’t always enough. Dr. Shah points out that healthcare providers have known about the importance of hand washing, for example, for well over a century. And yet the field is still battling noncompliance.
“I feel very strongly, actually, that for physicians to improve the value of care we’re delivering, it doesn’t require a new set of knowledge,” he says. “It doesn’t require training in health policy or health economics; it’s stuff that we already know.”
It may require intervention before practice patterns become deeply engrained, however. According to Medscape’s Physician Compensation Report for 2012, two-thirds of the more than 24,000 respondents rejected the idea of cutting back on testing to contain costs. Roughly 43% responded, “No, because these guidelines are not in the patient’s best interest,” while 24% said, “No, because I am still going to practice defensive medicine.”
Medical students and residents receive great training on how to diagnose and treat diseases, says Stephanie Chen, MD, an internal medicine resident at Johns Hopkins Bayview Medical Center in Baltimore. “We don’t have good training on how to interpret tests and understand the sensitivity and specificity of the tests that we order—how those tests can influence our clinical management,” she says.
Dr. Accurso agrees. “My recollection of my training, which would have only been seven years ago, is that there wasn’t much discussion of when not to order,” he says.
Although defensive medicine and the fee-for-service payment structure clearly aren’t helping anti-waste efforts, Dr. Shah says they’re often used as excuses to mask other issues. Residents in an academic medical center, for example, don’t make any more money from over-ordering and are relatively protected from medical malpractice. And yet, he says, overutilization is rampant there too. Why?
After talking to residents around the country, he and his Costs of Care team tallied 10 contributing factors, most of which the group believes can be addressed more easily than either tort reform or payment reform. Among the factors, the group found that residents often use preemptive or prophylactic ordering to save time or minimize future workloads. In a busy ED, it’s often easier and faster to order five tests at once than to order each one sequentially after careful thought.
Vineet Arora, MD, MAPP, FHM, a hospitalist at the University of Chicago, has seen the prophylactic testing phenomenon at work when providers order an EKG or MRI ahead of time to hold their spot in line, just in case they might need the test before discharging a patient. That strategy can backfire, however, if everyone uses the same tactic and needlessly delays access for patients who really need it, or if the extra testing yields incidentalomas that require additional workup and extend the patient’s hospital stay.
Hospitals also contribute to the problem through duplicate ordering or repeating tests performed elsewhere.
“Instead of requesting outside films and outside studies, it’s easier to repeat it,” says Dr. Arora, who serves as director of educational initiatives for Costs of Care. “That just speaks to the fact that we don’t have good electronic systems that actually allow for those care transitions to take place.”
In a joint editorial entitled, “First, Do No (Financial) Harm,” Drs. Arora, Shah, and Moriates drive home the point that these lapses have very real—and avoidable—consequences for patients.4
Signs of Progress
Calming the “perfect storm” of overutilization will take time and multiple tactics, but hospitalists involved in the effort say they’re starting to see some blue sky. Among the reasons for optimism, Dr. Moriates cites increasingly strong engagement from medical students, residents, and young faculty members and a cultural shift in how providers are viewing care delivery and payment schemes.
Under the Caring Wisely program, established in 2012 at UCSF, he and his colleagues helped launch six projects designed to identify and reduce waste. One major initiative, dubbed Nebs No More After 24, began after the division’s finance administrator informed the group that it had spent more than $1 million in direct costs on nebulized bronchodilator therapies in 2011 for non-ICU patients.5
“We all kind of looked at each other and said, ‘Really? That’s crazy. I had no idea,’” Dr. Moriates recalls.
The medical center, they realized, was spending an inordinate sum despite good evidence that many of the patients could be safely switched from nebulizers to metered dose inhalers.
“That was one of those areas where we found a quick win-win,” he says. After an intervention that included an extensive education effort aimed at patients, physicians, respiratory therapists, and nurses, the division cut its nebulizer rate by more than half and saved roughly $250,000 annually on a single medical ward.
In 2011, Yale’s Dr. Fogerty and colleagues created a friendly competition called the Interactive Cost-Awareness Resident Exercise, or I-CARE, to emphasize the desirability of accounting for both accuracy and cost consideration when working up clinical cases.6 By design, the educational tool rewards medical residents and other providers who reach the correct diagnosis using the least amount of resources.
To help disseminate its own message, the Providers for Responsible Ordering (PRO) group at Johns Hopkins has handed out pocket cards summarizing best practice guidelines, compiled literature reviews, and other educational resources on its website. One recent PRO-backed project used a three-phase process to dramatically reduce unnecessary cardiac enzyme testing at the medical center.7
First, the group gave physicians informational pocket cards. Next, one of the group’s leaders, assistant professor of medicine Jeffrey Trost, MD, gave grand rounds and presented guidelines suggesting no creatine kinase (CK) or CK-MB tests for patients suspected of having acute coronary syndrome, and no more than three troponin tests except in rare circumstances. Finally, the medical center removed CK and CK-MB altogether from its standard physician order entry. As a result, the total orders fell by 66% in the first year, saving an estimated $1.25 million in patient charges.
Internal medicine resident Sonali Palchaudhuri, MD, another PRO member at Hopkins, says an evidence-based approach isn’t always simple. “But our goal with PRO is, 1) to make sure that the evidence is at everyone’s fingertips to at least tailor their decisions based on the evidence that’s out there, and 2) to encourage an environment where we are looking for the evidence more than remaining in the state of practice [that existed] before we knew some of the newer data,” she says.
Other efforts like the Do No Harm Project are helping both medical trainees and attending doctors “celebrate restraint” by emphasizing problem solving that focuses more on what is probable than on what is possible.
“On rounds, an attending might say, ‘Why didn’t you order that or do that?’” Dr. Combs says. “Sometimes, it’s the right thing to do. But not often enough do we say, ‘Good job. I’m glad that you didn’t get that, because that wasn’t necessary, and here’s why.’”
Researchers, meanwhile, are helping to sharpen the distinctions between low and high-value care. “The progression has been first to define what constitutes low-value care, then develop measures of low-value care, both to understand its prevalence and to what extent it’s a problem,” says William Schpero, a PhD student in health policy and management at Yale University. The next step, he says, will be using these measures to inform and evaluate quality improvement efforts at the hospital or clinic level and to provide feedback for physicians working to reduce low-value care within their practices.
Many physicians warn that diplomacy and good communication are essential for getting buy-in from providers. Instead of framing their projects as efforts to reduce unnecessary care, for example, Dr. Moriates and colleagues have described them as stewardship projects designed to ensure that providers are following the best guidelines and providing exceptional patient care.
“Suddenly, everybody can rally around that, because everybody wants to provide the best care,” he says. “And so you’re giving people an opportunity to give the best care rather than taking away something that they have, like transfusions.”
Likewise, framing an issue primarily in financial terms without emphasizing its toll on patients can put many physicians on the defensive.
“We don’t like to think of ourselves as being motivated by cost,” Dr. Combs says. He also urges caution when discussing high-value care. “When a person, especially a lay person, hears ‘value,’ I think it’s very easy to construe that as cost savings or reducing costs or doing it on the cheap,” he says. Instead, when talking to medical trainees, he likes to define high-value care by quoting Bernard Lown, MD, founder of the Brookline, Mass.-based Lown Institute: “As much as possible for the patient, as little as possible to the patient.”
Perhaps the biggest sign of success in getting that message to stick will come when the flood of cautionary tales becomes a trickle once again.
Bryn Nelson is a freelance medical writer in Seattle.
References
- Niess MA, Prochazka A. Preoperative chest x-rays: a teachable moment. JAMA Intern Med. 2014;174(1):12.
- Institute of Medicine (US) Roundtable on Evidence-Based Medicine; Yong PL, Saunders RS, Olsen LA, editors. The healthcare imperative: Lowering costs and improving outcomes: workshop series summary. National Academies Press (US); 2010. Available at: http://www.ncbi.nlm.nih.gov/books/NBK53920/. Accessed May 14, 2015.
- Emanuel EJ, Fuchs VR. The perfect storm of overutilization. JAMA. 2008;299(23):2789-2791.
- Moriates C, Shah NT, Arora VM. First, do no (financial) harm. JAMA. 2013;310(6):577-578.
- Moriates C, Mourad M, Novelero M, Wachter RM. Development of a hospital-based program focused on improving healthcare value. J Hosp Med. 2014; 9(10):671-677.
- Fogerty RL, Heavner JJ, Moriarty JP, Sofair AN, Jenq G. Novel integration of systems-based practice into internal medicine residency programs: the Interactive Cost-Awareness Resident Exercise (I-CARE). Teach Learn Med. 2014;26(1):90-94.
- Larochelle MR, Knight AM, Pantle H, Riedel S, Trost JC. Reducing excess cardiac biomarker testing at an academic medical center. J Gen Intern Med. 2014;29(11):1468-1474.
A trickle of anecdotes has become a flood of cautionary tales.
There’s one about the patient in intensive care who didn’t have a cardiac condition yet still had a troponin blood test on 26 consecutive days. Guidelines, of course, suggest that three tests in a 12- to 24-hour period are sufficient to diagnose or rule out a heart attack.
Here’s another: A schizophrenic patient complaining of abdominal pain was sent to the ED. After a normal CT scan, she was admitted to the hospital for further workup and pain control. Amid discussions over whether the doctors should order an MRI or surgery consultation, a review of her records revealed 40 CT scans over the previous five years. All had turned up nothing, and the patient’s family confirmed that her frequent bouts of abdominal pain went away on their own.
Then there’s the story about a middle-aged man with an asthma diagnosis from years before; he was scheduled for surgery to correct his painful umbilical hernia. As part of the patient’s evaluation in a pre-operative clinic, his surgeon ordered a chest X-ray (CXR), despite a lack of any respiratory symptoms. The results suggested a possible lung nodule, leading to a follow-up CT scan that revealed normal lungs but instead showed a potential adrenal gland nodule. A second CT scan showed only a benign lesion, but the series of false alarms effectively delayed his hernia surgery by six months.
In the subsequent report on the latter case, included in the “Teachable Moments” section of JAMA Internal Medicine, the co-authors concluded, “Despite the evidence that pre-operative CXR is unlikely to be beneficial, it continues to be used in daily practice. Exposing a patient to multiple, additional studies prolongs surgical delay, increases exposure to radiation, prolongs and exacerbates underlying anxiety, and increases the likelihood of additional incidentalomas.”1
Unnecessary overuse of medical care, in other words, can cause both waste and harm.
Some of the stories highlight egregious examples, while others meditate on more nuanced cases. All are zeroing in on needlessly wasteful healthcare that can negatively impact patients physically, emotionally, and financially.
“I think for a long time we thought, ‘Might help, can’t hurt,’ and we’re seeing time and time again that that is just totally false,” says Christopher Moriates, MD, assistant clinical professor in the division of hospital medicine at the University of California, San Francisco.
Increasingly, like-minded hospitalists and other physicians are launching groups and projects around the country with names like Caring Wisely, Providers for Responsible Ordering, Costs of Care, the Do No Harm Project, and I-CARE. Each group takes a slightly different approach toward reframing clinical decisions in a way that considers both the potential benefit and the accompanying risks and costs.
The Caring Wisely program, which Dr. Moriates leads, supports innovations that reduce healthcare costs while improving patient health. The nonprofit organization Costs of Care, meanwhile, is trying to change professional norms by pointing out the ethical downsides of overuse.
“I’ve never heard anybody get called unethical for wasting a healthcare resource, but that’s where we need to go,” says Neel Shah, MD, MPP, founder and executive director of Costs of Care and an assistant professor at Harvard Medical School in Boston.
This dogma-challenging, evidence-based, awareness-raising movement is building momentum at a critical time. Although the problem of wasteful healthcare isn’t unique to the United States, multiple experts have pointed out the big disconnect between the nation’s top ranking in per capita healthcare spending and only middling scores in a long list of healthcare outcomes.2
In their damning 2008 commentary, “The Perfect Storm of Overutilization,” National Institutes of Health bioethicist Ezekiel Emanuel, MD, PhD, and Stanford economist Victor Fuchs, PhD, laid out the argument that overutilization was the most important contributor to high healthcare costs in the U.S.3 A greater volume of interventions and unnecessary costs both contributed to this overuse, the authors suggested.
Subsequent reports by Thomson Reuters in 2010, an Institute of Medicine (IOM) roundtable on evidence-based medicine in 2011, and the RAND Corporation in 2012 largely agreed. Based on its report, “The Healthcare Imperative: Lowering Costs and Improving Outcomes,” the IOM laid out a particularly sobering analogy to the degree of waste found in medical care.2 If other prices had grown as quickly as healthcare since 1945, the report estimated, a gallon of milk would now cost $48. Yet, of the $2.5 trillion spent on healthcare in 2009, the report estimated that 30%, or $765 billion, was wasted. Of that number, the report suggested that unnecessary healthcare services accounted for $210 billion, or 27%.
A Culture of “More”
What contributes to so much unnecessary overuse? Drs. Emanuel and Fuchs cite multiple factors:
- Physician training and culture;
- The fee-for-service payment structure;
- Aggressive marketing by developers of tests, drugs, and procedures;
- Defensive medicine;
- A cultural preference for technological solutions; and
- A lack of transparency on the true costs of care.
The authors contend that each factor reinforces and amplifies the others, resulting in a “perfect storm of ‘more.’”
A major driver, several doctors agree, is a culture that has long embraced the “more is better” mantra. Brandon Combs, MD, assistant professor of medicine at the University of Colorado School of Medicine in Denver, puts it this way: “More information is better. More interventions are better. More scans are better. More surgery is better. More pills are better—this concept that if I’m getting more, if I’m spending more, if it costs more, then it must be kind of like a Mercedes. It must actually be better.” A collective “cultural blind spot,” he adds, leaves both doctors and patients unable to focus on anything beyond the upsides of care.
At the same time, medicine has reinforced the notion among trainees and attending physicians alike that doctors can never be wrong or miss a diagnosis.
“Diagnostic uncertainty really feeds into a system where we have ready access to lots of things,” Dr. Combs says. “We have such a supply of tests, whether that’s blood tests, whether that’s imaging tests, whether that’s access to consultations with subspecialists—we have a system that can supply whatever demand we seem to have.”
Dr. Shah calls it a “hidden curriculum” that imposes its will on doctors’ discretion. Case studies, for example, routinely focus on doctors ordering multiple tests in search of exceedingly rare causes of disease instead of being good stewards of limited resources.
“When you’re criticized by your colleagues or by your mentors, it’s always for things that you didn’t do but could’ve done, and it’s never about the things that you did do but didn’t have to,” he says.
Anthony Accurso, MD, instructor of medicine at the Johns Hopkins Bayview Medical Center in Baltimore, says the current system grew out of an apprenticeship model of medical training that dominated for much of the 20th century.
“You learn to do things the way they’ve always been done,” he says. About 20 years ago, however, healthcare providers began shifting toward evidence-based medicine. “That was a retreat from doing things the way they had always been done and a movement toward doing things that proved themselves to be effective though evidence and study,” he says.
High-value care is now emerging as a third outgrowth along the medical training pathway. “It says if there are two evidence-based treatments, both of which are effective but which have different costs, then it is rational and in fact prudent to do the one that costs less,” Dr. Accurso says.
The existing evidence base is far from complete, however, meaning that some decisions must be made without clear guidelines. And beyond the remaining uncertainties, doctors often struggle to keep up with evidence that’s constantly in flux.
“Things that are doctrine right now might be considered blasphemous in 10 or 15 years as we learn more,” says Robert Fogerty, MD, MPH, an academic hospitalist and assistant professor of medicine at Yale University School of Medicine in New Haven, Conn.
Those realities work against the natural desire to be right and safe, which can lead to redundant tests, extra therapeutics, and additional monitoring. “Because there’s so much that we don’t know, sometimes we like to ask more questions by ordering more tests to try and find the answer,” Dr. Fogerty says. “So it’s almost an endless quest for knowledge, an endless hope that the answer’s under some rock if we just turn over enough rocks.”
As reform advocates are finding, however, even ample evidence isn’t always enough. Dr. Shah points out that healthcare providers have known about the importance of hand washing, for example, for well over a century. And yet the field is still battling noncompliance.
“I feel very strongly, actually, that for physicians to improve the value of care we’re delivering, it doesn’t require a new set of knowledge,” he says. “It doesn’t require training in health policy or health economics; it’s stuff that we already know.”
It may require intervention before practice patterns become deeply engrained, however. According to Medscape’s Physician Compensation Report for 2012, two-thirds of the more than 24,000 respondents rejected the idea of cutting back on testing to contain costs. Roughly 43% responded, “No, because these guidelines are not in the patient’s best interest,” while 24% said, “No, because I am still going to practice defensive medicine.”
Medical students and residents receive great training on how to diagnose and treat diseases, says Stephanie Chen, MD, an internal medicine resident at Johns Hopkins Bayview Medical Center in Baltimore. “We don’t have good training on how to interpret tests and understand the sensitivity and specificity of the tests that we order—how those tests can influence our clinical management,” she says.
Dr. Accurso agrees. “My recollection of my training, which would have only been seven years ago, is that there wasn’t much discussion of when not to order,” he says.
Although defensive medicine and the fee-for-service payment structure clearly aren’t helping anti-waste efforts, Dr. Shah says they’re often used as excuses to mask other issues. Residents in an academic medical center, for example, don’t make any more money from over-ordering and are relatively protected from medical malpractice. And yet, he says, overutilization is rampant there too. Why?
After talking to residents around the country, he and his Costs of Care team tallied 10 contributing factors, most of which the group believes can be addressed more easily than either tort reform or payment reform. Among the factors, the group found that residents often use preemptive or prophylactic ordering to save time or minimize future workloads. In a busy ED, it’s often easier and faster to order five tests at once than to order each one sequentially after careful thought.
Vineet Arora, MD, MAPP, FHM, a hospitalist at the University of Chicago, has seen the prophylactic testing phenomenon at work when providers order an EKG or MRI ahead of time to hold their spot in line, just in case they might need the test before discharging a patient. That strategy can backfire, however, if everyone uses the same tactic and needlessly delays access for patients who really need it, or if the extra testing yields incidentalomas that require additional workup and extend the patient’s hospital stay.
Hospitals also contribute to the problem through duplicate ordering or repeating tests performed elsewhere.
“Instead of requesting outside films and outside studies, it’s easier to repeat it,” says Dr. Arora, who serves as director of educational initiatives for Costs of Care. “That just speaks to the fact that we don’t have good electronic systems that actually allow for those care transitions to take place.”
In a joint editorial entitled, “First, Do No (Financial) Harm,” Drs. Arora, Shah, and Moriates drive home the point that these lapses have very real—and avoidable—consequences for patients.4
Signs of Progress
Calming the “perfect storm” of overutilization will take time and multiple tactics, but hospitalists involved in the effort say they’re starting to see some blue sky. Among the reasons for optimism, Dr. Moriates cites increasingly strong engagement from medical students, residents, and young faculty members and a cultural shift in how providers are viewing care delivery and payment schemes.
Under the Caring Wisely program, established in 2012 at UCSF, he and his colleagues helped launch six projects designed to identify and reduce waste. One major initiative, dubbed Nebs No More After 24, began after the division’s finance administrator informed the group that it had spent more than $1 million in direct costs on nebulized bronchodilator therapies in 2011 for non-ICU patients.5
“We all kind of looked at each other and said, ‘Really? That’s crazy. I had no idea,’” Dr. Moriates recalls.
The medical center, they realized, was spending an inordinate sum despite good evidence that many of the patients could be safely switched from nebulizers to metered dose inhalers.
“That was one of those areas where we found a quick win-win,” he says. After an intervention that included an extensive education effort aimed at patients, physicians, respiratory therapists, and nurses, the division cut its nebulizer rate by more than half and saved roughly $250,000 annually on a single medical ward.
In 2011, Yale’s Dr. Fogerty and colleagues created a friendly competition called the Interactive Cost-Awareness Resident Exercise, or I-CARE, to emphasize the desirability of accounting for both accuracy and cost consideration when working up clinical cases.6 By design, the educational tool rewards medical residents and other providers who reach the correct diagnosis using the least amount of resources.
To help disseminate its own message, the Providers for Responsible Ordering (PRO) group at Johns Hopkins has handed out pocket cards summarizing best practice guidelines, compiled literature reviews, and other educational resources on its website. One recent PRO-backed project used a three-phase process to dramatically reduce unnecessary cardiac enzyme testing at the medical center.7
First, the group gave physicians informational pocket cards. Next, one of the group’s leaders, assistant professor of medicine Jeffrey Trost, MD, gave grand rounds and presented guidelines suggesting no creatine kinase (CK) or CK-MB tests for patients suspected of having acute coronary syndrome, and no more than three troponin tests except in rare circumstances. Finally, the medical center removed CK and CK-MB altogether from its standard physician order entry. As a result, the total orders fell by 66% in the first year, saving an estimated $1.25 million in patient charges.
Internal medicine resident Sonali Palchaudhuri, MD, another PRO member at Hopkins, says an evidence-based approach isn’t always simple. “But our goal with PRO is, 1) to make sure that the evidence is at everyone’s fingertips to at least tailor their decisions based on the evidence that’s out there, and 2) to encourage an environment where we are looking for the evidence more than remaining in the state of practice [that existed] before we knew some of the newer data,” she says.
Other efforts like the Do No Harm Project are helping both medical trainees and attending doctors “celebrate restraint” by emphasizing problem solving that focuses more on what is probable than on what is possible.
“On rounds, an attending might say, ‘Why didn’t you order that or do that?’” Dr. Combs says. “Sometimes, it’s the right thing to do. But not often enough do we say, ‘Good job. I’m glad that you didn’t get that, because that wasn’t necessary, and here’s why.’”
Researchers, meanwhile, are helping to sharpen the distinctions between low and high-value care. “The progression has been first to define what constitutes low-value care, then develop measures of low-value care, both to understand its prevalence and to what extent it’s a problem,” says William Schpero, a PhD student in health policy and management at Yale University. The next step, he says, will be using these measures to inform and evaluate quality improvement efforts at the hospital or clinic level and to provide feedback for physicians working to reduce low-value care within their practices.
Many physicians warn that diplomacy and good communication are essential for getting buy-in from providers. Instead of framing their projects as efforts to reduce unnecessary care, for example, Dr. Moriates and colleagues have described them as stewardship projects designed to ensure that providers are following the best guidelines and providing exceptional patient care.
“Suddenly, everybody can rally around that, because everybody wants to provide the best care,” he says. “And so you’re giving people an opportunity to give the best care rather than taking away something that they have, like transfusions.”
Likewise, framing an issue primarily in financial terms without emphasizing its toll on patients can put many physicians on the defensive.
“We don’t like to think of ourselves as being motivated by cost,” Dr. Combs says. He also urges caution when discussing high-value care. “When a person, especially a lay person, hears ‘value,’ I think it’s very easy to construe that as cost savings or reducing costs or doing it on the cheap,” he says. Instead, when talking to medical trainees, he likes to define high-value care by quoting Bernard Lown, MD, founder of the Brookline, Mass.-based Lown Institute: “As much as possible for the patient, as little as possible to the patient.”
Perhaps the biggest sign of success in getting that message to stick will come when the flood of cautionary tales becomes a trickle once again.
Bryn Nelson is a freelance medical writer in Seattle.
References
- Niess MA, Prochazka A. Preoperative chest x-rays: a teachable moment. JAMA Intern Med. 2014;174(1):12.
- Institute of Medicine (US) Roundtable on Evidence-Based Medicine; Yong PL, Saunders RS, Olsen LA, editors. The healthcare imperative: Lowering costs and improving outcomes: workshop series summary. National Academies Press (US); 2010. Available at: http://www.ncbi.nlm.nih.gov/books/NBK53920/. Accessed May 14, 2015.
- Emanuel EJ, Fuchs VR. The perfect storm of overutilization. JAMA. 2008;299(23):2789-2791.
- Moriates C, Shah NT, Arora VM. First, do no (financial) harm. JAMA. 2013;310(6):577-578.
- Moriates C, Mourad M, Novelero M, Wachter RM. Development of a hospital-based program focused on improving healthcare value. J Hosp Med. 2014; 9(10):671-677.
- Fogerty RL, Heavner JJ, Moriarty JP, Sofair AN, Jenq G. Novel integration of systems-based practice into internal medicine residency programs: the Interactive Cost-Awareness Resident Exercise (I-CARE). Teach Learn Med. 2014;26(1):90-94.
- Larochelle MR, Knight AM, Pantle H, Riedel S, Trost JC. Reducing excess cardiac biomarker testing at an academic medical center. J Gen Intern Med. 2014;29(11):1468-1474.
A trickle of anecdotes has become a flood of cautionary tales.
There’s one about the patient in intensive care who didn’t have a cardiac condition yet still had a troponin blood test on 26 consecutive days. Guidelines, of course, suggest that three tests in a 12- to 24-hour period are sufficient to diagnose or rule out a heart attack.
Here’s another: A schizophrenic patient complaining of abdominal pain was sent to the ED. After a normal CT scan, she was admitted to the hospital for further workup and pain control. Amid discussions over whether the doctors should order an MRI or surgery consultation, a review of her records revealed 40 CT scans over the previous five years. All had turned up nothing, and the patient’s family confirmed that her frequent bouts of abdominal pain went away on their own.
Then there’s the story about a middle-aged man with an asthma diagnosis from years before; he was scheduled for surgery to correct his painful umbilical hernia. As part of the patient’s evaluation in a pre-operative clinic, his surgeon ordered a chest X-ray (CXR), despite a lack of any respiratory symptoms. The results suggested a possible lung nodule, leading to a follow-up CT scan that revealed normal lungs but instead showed a potential adrenal gland nodule. A second CT scan showed only a benign lesion, but the series of false alarms effectively delayed his hernia surgery by six months.
In the subsequent report on the latter case, included in the “Teachable Moments” section of JAMA Internal Medicine, the co-authors concluded, “Despite the evidence that pre-operative CXR is unlikely to be beneficial, it continues to be used in daily practice. Exposing a patient to multiple, additional studies prolongs surgical delay, increases exposure to radiation, prolongs and exacerbates underlying anxiety, and increases the likelihood of additional incidentalomas.”1
Unnecessary overuse of medical care, in other words, can cause both waste and harm.
Some of the stories highlight egregious examples, while others meditate on more nuanced cases. All are zeroing in on needlessly wasteful healthcare that can negatively impact patients physically, emotionally, and financially.
“I think for a long time we thought, ‘Might help, can’t hurt,’ and we’re seeing time and time again that that is just totally false,” says Christopher Moriates, MD, assistant clinical professor in the division of hospital medicine at the University of California, San Francisco.
Increasingly, like-minded hospitalists and other physicians are launching groups and projects around the country with names like Caring Wisely, Providers for Responsible Ordering, Costs of Care, the Do No Harm Project, and I-CARE. Each group takes a slightly different approach toward reframing clinical decisions in a way that considers both the potential benefit and the accompanying risks and costs.
The Caring Wisely program, which Dr. Moriates leads, supports innovations that reduce healthcare costs while improving patient health. The nonprofit organization Costs of Care, meanwhile, is trying to change professional norms by pointing out the ethical downsides of overuse.
“I’ve never heard anybody get called unethical for wasting a healthcare resource, but that’s where we need to go,” says Neel Shah, MD, MPP, founder and executive director of Costs of Care and an assistant professor at Harvard Medical School in Boston.
This dogma-challenging, evidence-based, awareness-raising movement is building momentum at a critical time. Although the problem of wasteful healthcare isn’t unique to the United States, multiple experts have pointed out the big disconnect between the nation’s top ranking in per capita healthcare spending and only middling scores in a long list of healthcare outcomes.2
In their damning 2008 commentary, “The Perfect Storm of Overutilization,” National Institutes of Health bioethicist Ezekiel Emanuel, MD, PhD, and Stanford economist Victor Fuchs, PhD, laid out the argument that overutilization was the most important contributor to high healthcare costs in the U.S.3 A greater volume of interventions and unnecessary costs both contributed to this overuse, the authors suggested.
Subsequent reports by Thomson Reuters in 2010, an Institute of Medicine (IOM) roundtable on evidence-based medicine in 2011, and the RAND Corporation in 2012 largely agreed. Based on its report, “The Healthcare Imperative: Lowering Costs and Improving Outcomes,” the IOM laid out a particularly sobering analogy to the degree of waste found in medical care.2 If other prices had grown as quickly as healthcare since 1945, the report estimated, a gallon of milk would now cost $48. Yet, of the $2.5 trillion spent on healthcare in 2009, the report estimated that 30%, or $765 billion, was wasted. Of that number, the report suggested that unnecessary healthcare services accounted for $210 billion, or 27%.
A Culture of “More”
What contributes to so much unnecessary overuse? Drs. Emanuel and Fuchs cite multiple factors:
- Physician training and culture;
- The fee-for-service payment structure;
- Aggressive marketing by developers of tests, drugs, and procedures;
- Defensive medicine;
- A cultural preference for technological solutions; and
- A lack of transparency on the true costs of care.
The authors contend that each factor reinforces and amplifies the others, resulting in a “perfect storm of ‘more.’”
A major driver, several doctors agree, is a culture that has long embraced the “more is better” mantra. Brandon Combs, MD, assistant professor of medicine at the University of Colorado School of Medicine in Denver, puts it this way: “More information is better. More interventions are better. More scans are better. More surgery is better. More pills are better—this concept that if I’m getting more, if I’m spending more, if it costs more, then it must be kind of like a Mercedes. It must actually be better.” A collective “cultural blind spot,” he adds, leaves both doctors and patients unable to focus on anything beyond the upsides of care.
At the same time, medicine has reinforced the notion among trainees and attending physicians alike that doctors can never be wrong or miss a diagnosis.
“Diagnostic uncertainty really feeds into a system where we have ready access to lots of things,” Dr. Combs says. “We have such a supply of tests, whether that’s blood tests, whether that’s imaging tests, whether that’s access to consultations with subspecialists—we have a system that can supply whatever demand we seem to have.”
Dr. Shah calls it a “hidden curriculum” that imposes its will on doctors’ discretion. Case studies, for example, routinely focus on doctors ordering multiple tests in search of exceedingly rare causes of disease instead of being good stewards of limited resources.
“When you’re criticized by your colleagues or by your mentors, it’s always for things that you didn’t do but could’ve done, and it’s never about the things that you did do but didn’t have to,” he says.
Anthony Accurso, MD, instructor of medicine at the Johns Hopkins Bayview Medical Center in Baltimore, says the current system grew out of an apprenticeship model of medical training that dominated for much of the 20th century.
“You learn to do things the way they’ve always been done,” he says. About 20 years ago, however, healthcare providers began shifting toward evidence-based medicine. “That was a retreat from doing things the way they had always been done and a movement toward doing things that proved themselves to be effective though evidence and study,” he says.
High-value care is now emerging as a third outgrowth along the medical training pathway. “It says if there are two evidence-based treatments, both of which are effective but which have different costs, then it is rational and in fact prudent to do the one that costs less,” Dr. Accurso says.
The existing evidence base is far from complete, however, meaning that some decisions must be made without clear guidelines. And beyond the remaining uncertainties, doctors often struggle to keep up with evidence that’s constantly in flux.
“Things that are doctrine right now might be considered blasphemous in 10 or 15 years as we learn more,” says Robert Fogerty, MD, MPH, an academic hospitalist and assistant professor of medicine at Yale University School of Medicine in New Haven, Conn.
Those realities work against the natural desire to be right and safe, which can lead to redundant tests, extra therapeutics, and additional monitoring. “Because there’s so much that we don’t know, sometimes we like to ask more questions by ordering more tests to try and find the answer,” Dr. Fogerty says. “So it’s almost an endless quest for knowledge, an endless hope that the answer’s under some rock if we just turn over enough rocks.”
As reform advocates are finding, however, even ample evidence isn’t always enough. Dr. Shah points out that healthcare providers have known about the importance of hand washing, for example, for well over a century. And yet the field is still battling noncompliance.
“I feel very strongly, actually, that for physicians to improve the value of care we’re delivering, it doesn’t require a new set of knowledge,” he says. “It doesn’t require training in health policy or health economics; it’s stuff that we already know.”
It may require intervention before practice patterns become deeply engrained, however. According to Medscape’s Physician Compensation Report for 2012, two-thirds of the more than 24,000 respondents rejected the idea of cutting back on testing to contain costs. Roughly 43% responded, “No, because these guidelines are not in the patient’s best interest,” while 24% said, “No, because I am still going to practice defensive medicine.”
Medical students and residents receive great training on how to diagnose and treat diseases, says Stephanie Chen, MD, an internal medicine resident at Johns Hopkins Bayview Medical Center in Baltimore. “We don’t have good training on how to interpret tests and understand the sensitivity and specificity of the tests that we order—how those tests can influence our clinical management,” she says.
Dr. Accurso agrees. “My recollection of my training, which would have only been seven years ago, is that there wasn’t much discussion of when not to order,” he says.
Although defensive medicine and the fee-for-service payment structure clearly aren’t helping anti-waste efforts, Dr. Shah says they’re often used as excuses to mask other issues. Residents in an academic medical center, for example, don’t make any more money from over-ordering and are relatively protected from medical malpractice. And yet, he says, overutilization is rampant there too. Why?
After talking to residents around the country, he and his Costs of Care team tallied 10 contributing factors, most of which the group believes can be addressed more easily than either tort reform or payment reform. Among the factors, the group found that residents often use preemptive or prophylactic ordering to save time or minimize future workloads. In a busy ED, it’s often easier and faster to order five tests at once than to order each one sequentially after careful thought.
Vineet Arora, MD, MAPP, FHM, a hospitalist at the University of Chicago, has seen the prophylactic testing phenomenon at work when providers order an EKG or MRI ahead of time to hold their spot in line, just in case they might need the test before discharging a patient. That strategy can backfire, however, if everyone uses the same tactic and needlessly delays access for patients who really need it, or if the extra testing yields incidentalomas that require additional workup and extend the patient’s hospital stay.
Hospitals also contribute to the problem through duplicate ordering or repeating tests performed elsewhere.
“Instead of requesting outside films and outside studies, it’s easier to repeat it,” says Dr. Arora, who serves as director of educational initiatives for Costs of Care. “That just speaks to the fact that we don’t have good electronic systems that actually allow for those care transitions to take place.”
In a joint editorial entitled, “First, Do No (Financial) Harm,” Drs. Arora, Shah, and Moriates drive home the point that these lapses have very real—and avoidable—consequences for patients.4
Signs of Progress
Calming the “perfect storm” of overutilization will take time and multiple tactics, but hospitalists involved in the effort say they’re starting to see some blue sky. Among the reasons for optimism, Dr. Moriates cites increasingly strong engagement from medical students, residents, and young faculty members and a cultural shift in how providers are viewing care delivery and payment schemes.
Under the Caring Wisely program, established in 2012 at UCSF, he and his colleagues helped launch six projects designed to identify and reduce waste. One major initiative, dubbed Nebs No More After 24, began after the division’s finance administrator informed the group that it had spent more than $1 million in direct costs on nebulized bronchodilator therapies in 2011 for non-ICU patients.5
“We all kind of looked at each other and said, ‘Really? That’s crazy. I had no idea,’” Dr. Moriates recalls.
The medical center, they realized, was spending an inordinate sum despite good evidence that many of the patients could be safely switched from nebulizers to metered dose inhalers.
“That was one of those areas where we found a quick win-win,” he says. After an intervention that included an extensive education effort aimed at patients, physicians, respiratory therapists, and nurses, the division cut its nebulizer rate by more than half and saved roughly $250,000 annually on a single medical ward.
In 2011, Yale’s Dr. Fogerty and colleagues created a friendly competition called the Interactive Cost-Awareness Resident Exercise, or I-CARE, to emphasize the desirability of accounting for both accuracy and cost consideration when working up clinical cases.6 By design, the educational tool rewards medical residents and other providers who reach the correct diagnosis using the least amount of resources.
To help disseminate its own message, the Providers for Responsible Ordering (PRO) group at Johns Hopkins has handed out pocket cards summarizing best practice guidelines, compiled literature reviews, and other educational resources on its website. One recent PRO-backed project used a three-phase process to dramatically reduce unnecessary cardiac enzyme testing at the medical center.7
First, the group gave physicians informational pocket cards. Next, one of the group’s leaders, assistant professor of medicine Jeffrey Trost, MD, gave grand rounds and presented guidelines suggesting no creatine kinase (CK) or CK-MB tests for patients suspected of having acute coronary syndrome, and no more than three troponin tests except in rare circumstances. Finally, the medical center removed CK and CK-MB altogether from its standard physician order entry. As a result, the total orders fell by 66% in the first year, saving an estimated $1.25 million in patient charges.
Internal medicine resident Sonali Palchaudhuri, MD, another PRO member at Hopkins, says an evidence-based approach isn’t always simple. “But our goal with PRO is, 1) to make sure that the evidence is at everyone’s fingertips to at least tailor their decisions based on the evidence that’s out there, and 2) to encourage an environment where we are looking for the evidence more than remaining in the state of practice [that existed] before we knew some of the newer data,” she says.
Other efforts like the Do No Harm Project are helping both medical trainees and attending doctors “celebrate restraint” by emphasizing problem solving that focuses more on what is probable than on what is possible.
“On rounds, an attending might say, ‘Why didn’t you order that or do that?’” Dr. Combs says. “Sometimes, it’s the right thing to do. But not often enough do we say, ‘Good job. I’m glad that you didn’t get that, because that wasn’t necessary, and here’s why.’”
Researchers, meanwhile, are helping to sharpen the distinctions between low and high-value care. “The progression has been first to define what constitutes low-value care, then develop measures of low-value care, both to understand its prevalence and to what extent it’s a problem,” says William Schpero, a PhD student in health policy and management at Yale University. The next step, he says, will be using these measures to inform and evaluate quality improvement efforts at the hospital or clinic level and to provide feedback for physicians working to reduce low-value care within their practices.
Many physicians warn that diplomacy and good communication are essential for getting buy-in from providers. Instead of framing their projects as efforts to reduce unnecessary care, for example, Dr. Moriates and colleagues have described them as stewardship projects designed to ensure that providers are following the best guidelines and providing exceptional patient care.
“Suddenly, everybody can rally around that, because everybody wants to provide the best care,” he says. “And so you’re giving people an opportunity to give the best care rather than taking away something that they have, like transfusions.”
Likewise, framing an issue primarily in financial terms without emphasizing its toll on patients can put many physicians on the defensive.
“We don’t like to think of ourselves as being motivated by cost,” Dr. Combs says. He also urges caution when discussing high-value care. “When a person, especially a lay person, hears ‘value,’ I think it’s very easy to construe that as cost savings or reducing costs or doing it on the cheap,” he says. Instead, when talking to medical trainees, he likes to define high-value care by quoting Bernard Lown, MD, founder of the Brookline, Mass.-based Lown Institute: “As much as possible for the patient, as little as possible to the patient.”
Perhaps the biggest sign of success in getting that message to stick will come when the flood of cautionary tales becomes a trickle once again.
Bryn Nelson is a freelance medical writer in Seattle.
References
- Niess MA, Prochazka A. Preoperative chest x-rays: a teachable moment. JAMA Intern Med. 2014;174(1):12.
- Institute of Medicine (US) Roundtable on Evidence-Based Medicine; Yong PL, Saunders RS, Olsen LA, editors. The healthcare imperative: Lowering costs and improving outcomes: workshop series summary. National Academies Press (US); 2010. Available at: http://www.ncbi.nlm.nih.gov/books/NBK53920/. Accessed May 14, 2015.
- Emanuel EJ, Fuchs VR. The perfect storm of overutilization. JAMA. 2008;299(23):2789-2791.
- Moriates C, Shah NT, Arora VM. First, do no (financial) harm. JAMA. 2013;310(6):577-578.
- Moriates C, Mourad M, Novelero M, Wachter RM. Development of a hospital-based program focused on improving healthcare value. J Hosp Med. 2014; 9(10):671-677.
- Fogerty RL, Heavner JJ, Moriarty JP, Sofair AN, Jenq G. Novel integration of systems-based practice into internal medicine residency programs: the Interactive Cost-Awareness Resident Exercise (I-CARE). Teach Learn Med. 2014;26(1):90-94.
- Larochelle MR, Knight AM, Pantle H, Riedel S, Trost JC. Reducing excess cardiac biomarker testing at an academic medical center. J Gen Intern Med. 2014;29(11):1468-1474.