Avoiding low-value healthcare: sometimes less is more
By Vamini Selvanandan
You can’t get enough of a good thing. Or can you? In Canada, we use public funds to pay for diagnostic tests, surgeries and many medical treatments so it is natural to assume that more medical care is better. The more you get tested, diagnosed and treated, the healthier and longer your life will be. No, not necessarily! Some medical tests and treatments can be a waste of precious healthcare dollars and can result in harm to patients.
In the United States, it is estimated that around $100 billion per year is wasted on unnecessary medical care. This money could have been used to provide medical care that people really need. Furthermore, eliminating low-value diagnostic tests and treatments can reduce the healthcare sector’s carbon footprint and contributions to global warming.
Low-value care refers to tests and treatments that have no evidence of providing benefit to patients and may cause physical or psychological harm. They can take the form of blood tests, imaging, medications or surgical procedures. For example, getting x-rays or CT scans for low risk back pain within the first 6 weeks of symptoms will not change how the patient is treated, as most back pain will improve in this time frame, but exposes them to unnecessary radiation.
Antibiotics can save lives when used appropriately but can cause unwanted side-effects, serious complications or even death in some people. Antibiotics do not work agains viruses, the cause of all colds and flu infecitons, almost all sinus infections, and most cases of bronchitis. So, the risks of antibiotics outweigh their benefits when used for most cases of nasal congestion, cough, or sinus pain.
Opioids are potent pain killers and can help in situations of severe pain like immediately after surgery or cancer pain. However, they are not the best option for chronic pain related to arthritis, low back pain or migraines. Opioids can lead to addictions, withdrawal symtpoms and side effects like decreased alertness, nausea and constipation. Similarly, sleeping pills may be appropriate in acute situations of poor sleep for a few days, but when used over long-periods, lose their effectiveness and can cause falls and cognitive decline in seniors.
The media, the medical establishment, and not-for-profit cancer organziations have for years unequivocally broadcast the message that cancer screening saves lives. But the reality is more nuanced. A recently published paper analyzing 18 studies involving 2.1 million people and looking at six common cancer screening tests for breast, colon, lung and prostate cancer showed that only one test - sigmoidoscopy for colon cancer - increased overall lifespan, and that by only 110 days. The other cancer tests, did not result in people receiving cancer screening living longer.
Patients, and even some doctors, assume that cancer screening tests are always beneficial and can cause no harm. But we know that all medical tests, procedures and treatments come with risks and benefits. Cancer screening can result in false positives requiring more invasive testing – like biopsies, with bleeding and infection as potential complications. Screening can also result in overdiagnosis and overtreatment – meaning providing unnecessary treatment for a condition that is not life-treatening or would never have caused symtpoms. In fact, people participating in cancer screening are many times more likely to experience a false positive, overdiagnosis or overtreatment than having their lives saved by screening.
The decision to have a screening program is based on the benefits of lives saved at the population level, but the risks may not be acceptable at an individual level. For example, screening 1000 women aged 50-69 for breast cancer every two years with a mammogram for 7 years, saves one life, but results in 3 women treated unnecessarily for breast cancer because we don’t know which cancers once diagnosed will progress to cause serious illness or death.
Does this mean that one should never participate in cancer screening? No, because some individuals do benefit from early cancer detection and treatment. It may be your life that is saved. So shared decision-making needs to take place between individuals and their doctors to explore the risks and benefits of testing, the patient’s specific risk profile and their values and preferences.
To keep our healthcare system sustainable and accessible for effective and medically necessary care, we need to eliminate low-value care and transfer those resources to high-value health investments.
Investing in the health of children whether it be in early childhood education, prenatal nutrition, or childhood immunizations pays high dividends for lifetime population health. Similarly promoting healthy lifestyles and preventing diseases such as hypertension, diabetes and heart disease has big payoffs. Boosting the social determinants of health by providing adquate income, quality education and decent housing, improves health in ways that many low-value tests and treatments do not. Let’s choose wisely in how we spend our healthcare dollars.
Vamini Selvanandan is a family physician and public health practitioner in Alberta.