Sarah Miller, RN and Laura Covarrubias
Is more medical care really better? What about all these new, expensive drugs and high-tech surgeries? Do they save lives or improve health?
If you answered yes to these questions, you are not alone, but you may not be correct. A study done by the American Institutes for Research on insured adults between ages 18 and 64, found that most thought that more care, newer medical technology, and more expensive care were better. In addition, the adults interviewed believed that all care met minimum quality standards, and they were skeptical of evidence-based medical guidelines.
A typical response was “I don’t see how extra care could be harmful to your health. Care would only benefit you.” Although this belief is widely held, it is not accurate. For example, if a healthy 80-year old man or woman without cancer symptoms is screened for various types of cancer, any abnormal findings are likely to result in treatment that is unlikely to benefit them. That is why the U.S. Preventive Services Task Force usually recommends against screening 80-year olds for these cancers, although they recommend diagnostic testing for patients of all ages if they have symptoms.
“You get what you pay for” is another popular opinion, with many people assuming that more expensive care is superior. However, care that is far less expensive is sometimes just as good or even better. One example of this is robotic prostatectomy, a surgery for men with prostate cancer that is done by a robot operated by the surgeon. Many men want this type of surgery, which costs $2,600 more than a regular prostate surgery. Some studies have shown that men who have the robotic surgery have lower rates of complications after the surgery, but others have shown that there is no difference. Most researchers who have conducted studies on this agree that the robotic surgery has not yet been proven to be any better than regular prostate surgery.
Even if robotic surgery isn’t worse than the regular surgery, is it worth the extra $2600? Consider this: for every two insured men that choose to have regular rather than robotic surgery, the cost savings could more than pay for one uninsured man with prostate cancer to have this life-saving surgery.[5] This is important to consider in the United States, where many people are not able to afford their medical care.
A similar idea that many patients have is “if it’s newer, it’s better.” While it may seem like new treatments would be chosen because they are better, this is rarely true. For example, cetuximab (also called Erbitux) was introduced in 2008 as a new addition to treatment for lung cancer patients. Although the drug was called a breakthrough in treatment for lung cancer, the average patient taking the drug lived only 1.2 months longer than patients not taking the drug. And in the many months of taking the drug, 85% of patients experienced skin toxicity, which often caused great discomfort (Fojo & Grady). And despite the small possible advantages of the drug, it cost $80,000 for just a few months of treatment, resulting in huge medical bills that many families could not afford. Avastin for Stage 4 breast cancer is an even more dramatic example. Avastin is used for many cancers, but after several years, it became clear that on average, the breast cancer patients taking it were not living any longer and were more likely to have a stroke or other very serious and debilitating reaction to the drug that could make their last months much more painful physically and psychologically.
Cereal companies regularly add “New” in big letters on cereal boxes, because that sells more products (even if what is new might be a new toy inside). Patients should be more cautious. While some patients may want to take the chance that a new drug might be better, but many would rather know what the risks are before trying a new medication that could be worse than the tried and true treatments.
Evidence-Based Guidelines
Medical guidelines are usually established by a group that is considered expert in the subject of the guidelines. Medical guidelines are usually based on evidence from scientific research and are written according to the agreement a group of experts comes to about what the research tells them is the best for patients.
Unfortunately, research indicates that many adults are skeptical about guidelines. Many seemed to think that asking providers to use guidelines did not allow them to make decisions based on their own expertise and that they could be used to ration care so that people did not “take” too much. One participant said that medical guidelines are “taking your choice away and putting it in someone else’s hands.”
Contrary to the mistaken belief that providers were restricted to actions dictated by the guidelines, in reality, guidelines are meant to guide providers by making suggestions based on the best evidence. Providers are still able to make the final recommendation to patients based on their professional expertise.
Is a doctor’s individual experience more valuable than guidelines? That’s hard to say, but usually it would not be. Guidelines are based on evidence from medical research comparing large groups of people who have had different types of treatment. Therefore, guidelines based on science will, on average, provide the best care for most people. However, a physician with impressive expertise may be able to predict which patients are more likely to benefit from other types of treatment.
For example, for years, it was recommended that women between 40 and 69 years of age have a mammogram every year to screen for breast cancer. In 2007, however, the American College of Physicians changed their guidelines to leave it up to physicians to decide whether women between 40-50 needed annual mammograms. In 2009, the US. Preventive Services Task Force wrote new guidelines, based on research evidence from thousands of women. The new guidelines recommended that women age 40-49 should not have regular mammograms to screen for breast cancer unless they had an especially high risk of breast cancer, and that women age 50-75 should have screening mammograms every two years – extending the age to older women but cutting the frequency from annually to every other year.
Many people challenged the new guidelines believing they could substantially delay the detection of cancer, especially for women under 50. Isn’t it always better to have a chance to detect cancer earlier?
The answer is yes and no. Although mammograms save the lives of many women (including those in their 40’s), they also expose women to harmful radiation that can actually cause cancer over the course of women’s lifetimes. The researchers considered other forms of harm as well, such as the emotional trauma of a “false positive” results that result in stressful and expensive biopsies. They concluded that the potential for harm outweighed the potential benefits of mammograms for the average women under age 50 and over 75, as did annual rather than biyearly mammograms for women age 50-75.
Many people did not agree with the U.S. Preventive Services Task Force’s interpretation of the evidence, however. It is partly a matter of interpretation. The U.S. Preventive Services Task Force was advising average women, and some cancer advocates believe that it is too difficult to predict whether a person is at high risk or not. As a result, groups such as the American Cancer Society prefer to err on the side of over-treatment and radiation exposures, rather than on the side of potential under-treatment and reducing radiation exposure.
Health care providers are able to judge the two sets of guidelines and decide what to recommend for specific patients. For example, a woman in her 30’s who has many family members with breast cancer, including some at a young age, may be advised to have digital mammograms every other year in their 30’s (because they are more accurate than traditional mammograms and use less radiation) and annually after that.
“All care meets minimum quality standards” is another common belief. Most could imagine providers making an occasional mistake, but few thought that there were any providers who consistently delivered a quality of care that did not meet basic standards.[1] Unfortunately, research shows that health care varies from doctor to doctor, and many do not meet minimum quality standards. The quality of care that doctors provide varies by the type of clinic where they work (publicly or privately funded, for instance), the communication skills of the doctor, and even how much sleep the doctor has been getting (Manusukhani; Kenny; Philipson).
What Can We Learn From This?
This study gives some insight into why we spend so much on health care and why efforts to improve medical care are often opposed as “rationing” or “death panels.” Unfortunately, most patients want the newest and most expensive care, and don’t understand that it may not be as safe or as effective as older, less expensive treatments.
In the United States, we spend more per person on health care than any other country, and yet our citizens are not as healthy as those in Japan, France, and Cuba, countries that spend far less per person on health care.
In addition to wasting money on treatments that are no better, and are sometimes inferior, our wasteful spending also means that we have less money for other essential services, such as education, housing, and national security.4
Of course, there is a lot of very expensive medical care that is medically necessary and could save a person’s life, such as trauma care in an emergency room for someone who has been in a serious car accident. But, there are also popular treatments that are expensive and not necessary, like a woman having labor induced for convenience when it would be safer and less expensive to have a natural birth. The key is to eliminate the unnecessary care so that we can continue to afford the necessary, beneficial care.
When it is not clear whether more expensive care actually helps or is just a waste of money, medical research can point us in the right direction. That’s why it is a good strategy to require “comparative effectiveness research” to determine whether, for example, robotic prostate surgery is better than regular surgery, or just needlessly more expensive. It is often not obvious which treatments are the best, and sometimes they are the most expensive treatments but other times they may be the least expensive treatments or no treatment at all.
Doctors and patients can be part of improving medical care, by asking whether research conclusively shows which treatment is safer and which is most effective, instead of wrongly assuming that guidelines are aimed at saving money, not improving care.
References:
- Carman, KL; Maurer, M; Mathews, J; Dardess, P; McGee, J; Evers, M; & Marlo, KO, Evidence that consumers are skeptical about evidence-based health care, Health Affairs, 7 1400-6, 2010.
- Centers for disease control and prevention. Births: Final data for 2006, National Vital Statistics Reports.
- Caughney, AB; Sundaram, V; Kaimal, AJ; Cheng, YW; Geinger, A; Little, SE; Lee, JF; et.al. Maternal and Neonatal Outcomes of induction of labor. Evid Rep Technol Assess. 176 pp.1-257, 2009.
- Bodner-Adler, B; Bodner, K; Patiesky, N; Klimberger, O; Chalubinski, K; Mayerhofer, K; & Husslein, P; Influence of labor induction on obstetric outcomes in patients with prolonged pregnancy: A comparison between elective labor induction and spontaneous onset of labor beyond term. The Middle European Journal of Medicine. 117(7-8) pp. 287-92, 2005.
- Bolenz, C; Gupta, A; Hotze, T; Ho, R; Cadeddu, JA; Roehrborn, C; & Lotan, Y; Cost Comparison of Laproscopic, Robotic, and Open Radical Prostatectomy for Prostate Cancer, European Urology, 57 pp. 453-8, 2010.
- Lowrance, WT; Elkin, EB; Jacks, LM; Yee, DS; Jang, TL; Laudone, VP; Guillanneau, BD, Scardino, PT; & Eastham, JA, Comparative effectiveness of prostate cancer treatments: A population-based analysis of postoperative outcomes, The Journal of Urology, 183, 1366-72, 2010.
- Weizer, AZ; Strope, S; and Wood, DP, Margin control in laproscopic robotic prostatectomy: What are the REAL outcomes? Urologic Oncology: Seminars and Original Investigations, 28 pp.201-14, 2010.
- Barocas, DA; Salem, S; Kordan , Y; Herrell, SD; Chang, SS; Clark, PE; Davis, R; Baumgartner, R; Phillips, S; Cookson, MS; & Smith, JA, Robotic assisted laproscopic prostatectomy for clinically localized prostate cancer: Comparison of short-term biochemical recurrence-free survival, The Journal of Urology, 183, 990-6, 2010.
- Murphy, DC; Bjartell, A; Ficarra, V; Graefen, M; Haese, A; Montironi, R; Montorsi, F; Moul, JW; Novara, G; Sauter, G; Sulser, T; & van der Poel, H, Downsides of robot-assisted laproscopic prostatectomy: Limitations and complications. 57 pp. 735-46, 2009.
- Coelho, RF; Chauhan, S; Palmer, KJ; Rocco, B; Patel, MB; & Patel, VR, Robotic-assisted radical prostatectomy: A review of outcomes, British Journal of Urology International, 104, 1428-35, 2009.
- US Preventive Services Task Force, Screening for breast cancer: Recommendation statement 2009. Retrieved from: http://www.ahrq.gov/clinic/uspstf09/breastcancer/brcanrs.htm on July 20, 2010.
- American Cancer Society, American Cancer Society Guidelines for the Early Detection of Cancer: Breast Cancer, 2010, Retrieved From: http://www.cancer.org/Healthy/FindCancerEarly/CancerScreeningGuidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancer on July 20, 2010.
- Smith, S; Newhouse, JP; & Freeland, MS; Income, insurance and technology: Why does health spending outpace economic growth? Health Affairs, 28(5) pp. 1276-84, 2009.
- Aaron, HJ and Ginsburg, PB; Is health spending excessive? If so, what can we do about it? Health Affairs
