Disentangling too much and too little medicine

Jack O’Sullivan, DPhil Student

Around the world, healthcare is rapidly becoming unaffordable. In the US, for example, per capita Medicare spending grows at an at average of 3.5% annually(1). In universal health services, health expenses are also growing exponentially; NHS England and others estimate that by 2020/21 an annual £30 billion mismatch between resources and patient need will exist(2).

While drivers of increasing expenses are complex, one truth is universally accepted: waste exists within all healthcare systems (3,4). Rather than in a material sense – throwing away a recently opened packet of unused equipment – significant and costly waste exists more substantially within unnecessary practices (tests and treatments) and care pathways(4).

Unnecessary practices are tests and treatments which cause no net benefit for patients. These practices are the most common opportunities to cause patient benefit or patient harm. An inappropriate test can harm a patient through a direct adverse reaction (e.g. contrast nephropathy) or harm indirectly, by diverting resources from necessary interventions. Thus, tests that cause no direct harm (and no benefit) are still inappropriate because the resources utilised on these tests detract from other potentially beneficial interventions. Inappropriate treatments can cause harm by the same mechanisms. In total, approximately 20% of clinical practice is estimated to be unnecessary, causing no net benefit to patients(3).

On a population level, identifying practices that cause no net benefit is challenging. With the emergence of evidence-based medicine over the last 20 years, most accept that healthcare decisions should be based on high quality evidence. Thus, practices ordered not in line with high quality evidence, with some exceptions, are potentially unnecessary.

Furthermore, variation in clinical practice has become a surrogate for potentially unnecessary care. In regions with similar disease burden and demographics, differences in the number of surgeries performed or tests ordered implies that one region is doing too many or one region is not doing enough (or both). In the UK and the US(5,6), we know lots of variation in practice exists. For instance, in the UK, there is a 1,000 fold difference in the rate of fasting blood glucose tests ordered from primary care(7). Variation such as this implies that not everyone in the UK nor in the US receives high quality care.

How can we disentangle this current state of too much and too little medicine? There is no simple answer, and there is definitely no straight forward solution. However, as always, we rely on high quality data and evidence. One solution that has emerged is the identification of practices of no net benefit. Tests or treatments that are performed at varying rates across geographical regions or are commonly performed not in line with high quality evidence need to be identified. Identification can facilitate removal, which can reduce unnecessary harm to patients and lessen the burden on stretched healthcare systems.

References
1. Fisher ES, Bynum JP, Skinner JS. Slowing the growth of health care costs–lessons from regional variation. N Engl J Med [Internet]. 2009 Feb 26 [cited 2016 May 3];360(9):849–52. Available from:
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2722744&tool=pmcentrez&rendertype=abstract
2. NHS. Five Year Forward View. 2014;(October).
3. Berwick D, Hackbarth AD. Eliminating Waste in US Health Care. JAMA [Internet]. American Medical Association; 2012 Apr 11 [cited 2015 Oct 8];307(14):1513. Available from: http://jama.jamanetwork.com/article.aspx?articleid=1148376
4. Colleges A of MR. Protecting resources, promoting value: a doctor’s guide to cutting waste in clinical care [Internet]. 2014 [cited 2016 May 18]. Available from: http://www.aomrc.org.uk/dmdocuments/Promoting value FINAL.pdf
5. Fisher ES. The Implications of Regional Variations in Medicare Spending. Part 1: The Content, Quality, and Accessibility of Care. Ann Intern Med [Internet]. American College of Physicians; 2003 Feb 18 [cited 2016 May 3];138(4):273. Available from: http://annals.org/article.aspx?articleid=716066
6. Right Care. Reducing unwarranted variation to increase value and improve quality [Internet]. 2015 [cited 2016 May 18]. Available from: http://www.rightcare.nhs.uk/atlas/RC_nhsAtlas3_HIGH_150915.pdf
7. NHS Right Care. Diagnostics: The NHS Atlas of Variation in Diagnostic Services. 2012;(November):220.
8. Alderwick H, Robertson R, Appleby J, Dunn P, Maguire D. Better value in the NHS The role of changes in clinical practice. 2015;(July).