Unwise Medical Choices Stubbornly Defy Eradication

Studies suggest both physicians and patients are reluctant to give up low-value healthcare services that waste money and can do more harm than good.

Turns out, it's not so easy to make wise choices about healthcare. Several new studies find that, even with urging, doctors and patients are having a hard time passing on low-value services, including many identified in the Choosing Wisely campaign.  

Not that it should be a surprise. You don't need an MD to know that change is difficult.

The specialty societies of the Choosing Wisely campaign have offered up a menu of low-value services they suggest patients can live (well) without. The trick is to convince providers and patients to abandon superfluous old-reliables and "might-as-well" tests. They waste money and can do more harm than good.

Somehow, the message isn't getting through.

A study out of University of California-Davis found that doctors who were coached on how to avoid low-value care were just as likely to order the tests as uncoached doctors. In a January Mayo Clinic study, nearly half of the doctors surveyed at Choosing Wisely CME sessions said they get daily requests for low-value services. They reported that a shrinking percentage of patients "always or almost always" followed their advice to skip the tests.

What About Decision Aids?
Researchers at the University of North Carolina, Chapel Hill set out to compare the efficacy of four different "evidence-based decision supports sheets" for prostate cancer screening in men 50 to 69 years old, osteoporosis screening in low-risk women ages 50 to 64 years old, and colorectal cancer screening in men and women between the ages 76 and 85 years. None of the support sheets had any impact.

Stacey L. Sheridan, MD, is a researcher at UNC's Sheps Center for Health Services Research and lead author of the study. Changing what patients and providers know about low-value services may not be enough to result in change the use those services.

Much more is required, she told me. "What the larger literature suggests is that it takes widespread change in culture and change in organizational structure and leadership to support… deimplementing low-value services," she says.

In the age of more-is-less in healthcare, we now need to deimplement, roll back, and undo. When a service is underused or not used, it is changed through implementation. When something is over-used, it needs to be deimplimented.

Good Luck With That
It's one thing to flip-flip on dietary advice about the health benefits of coffee, carbs, and fat. Try telling a woman that she didn't need the mammogram that found a breast tumor when she was 45. She'll tell you it saved her life and will hear nothing about overdiagnosis or indolent tumors.

We've had the concept of early detection so drummed into our heads, we can't get it out.

The downside of mammography is somewhat difficult for people to grasp. The message on prostate cancer screening is not.

PSA tests can lead to procedures that leave men incontinent and impotent. Patients might say 'Go for it; better safe than sorry.' But increasingly, they are holding off. Both screening for the condition and prostate cancer detection dropped significantly after 2008, when the US Preventative Services Task Force (USPSTF) recommended men over age 75 skip the PSA test.

The rate of screening dropped 20% between 2010 and 2013. So did the mortality rate. The National Cancer Institute reports that death rates dropped an average 3.5% each year between 2003 and 2012.

Still, PSA testing is seen as the low-hanging fruit of useless tests. Several critics charge that the Choosing Wisely advice doesn't go deep enough and ignores high-priced, but  questionable procedures.

You have to start somewhere. Joshua Fenton, MD, is a member of the Department of Family and Community Medicine at the University of California Davis Health System. He led a study that measured the impact of "patient-centered techniques" designed to help doctors address patient concerns about low-value tests.

His group sent faux patients to 61 doctors and had them request inappropriate spinal MRI or DEXA—dual-energy X-ray absorptiometry—for low back pain. Fenton and his team discovered that the doctors who had been trained to use the patient-centered techniques were just as likely to order the tests as the doctors in the control group.

Fenton says the message may have been too complicated for a brief intervention. He also thinks it may not have addressed some of the other factors driving that testing, including a doctor's fear of malpractice.

"They don't perceive a clear downside to doing the test, and the patient is asking for it," Fenton says. "There are potential upsides. If I miss something, I could get into a lot of trouble. So, I better just do this test. The patient wants it anyway, and they are going to be happy with me if I get them this test."

Engaging the Patient
So, will patient engagement have any impact? Can patients embrace the idea that more care is not necessarily better care and stop asking for tests?

It depends, says patient advocate Dave deBronkart, co-chair of the Society for Participatory Medicine. The engaged patient is not always the informed patient, he says.

"When you let people have opinions, you can get people who want stupid things," he says.

Some of this is driven by conflicting messages aimed at patients.

DeBronkart points to direct-to-consumer medical marketing and to me—the media. I can't own all of it, but he's right. There is a lot of awful consumer healthcare reporting out there, and much of it perpetuates the demand for so-called breakthroughs and other forms or marginally effective and low-value care.

Stories overselling health screening are constantly getting slammed on the Health News Review, a website run by a group of journalists and clinician who fact check health news stories and press releases. The site aims to "improve the public dialogue about health care by helping consumers critically analyze claims about health care interventions."

So, deBronkart notes that many patients are still learning.

"It's a mistake to judge someone's potential by problems they have when they are rookies," he said. "We have to change the culture so the people who we are newly enfranchised as a part of this process learn to get a clue about the basics of science."

Seeking Consistency
Or, make the science clearer. The American College of Obstetrics and Gynecology held a private meeting at the end of January with several other unnamed groups to try to bring some consistency to the conflicting advice about mammography.

Deimplementation of mammography for women under 50? Not likely. But hopefully the groups can reach some consensus that will offer a path for patients toward a better understanding of the test's value.

The shift away from low-value treatment will also take widespread culture change at the provider level. And nothing drives culture change like money. Under the fee-for-service payment model, testing, scans, X-rays, and biopsies all bring in revenues.

Will the shift to value-based payments get us away from low-value testing?

A lot of pieces need to fall in place for that to happen, Sheridan of UNC says, but she thinks it's "a positive step in aligning the incentives and reward structure in a way that that reinforces the right thing."