When less can mean more

Sometimes truth is stranger than fiction. In the United States a few weeks ago, nine leading doctors’ groups published lists of the top five overused tests and treatments within their specialty areas.1 What’s more, they did it with enormous fanfare and in partnership with one of the world’s most powerful health consumer groups, the US Consumer Reports.

The cardiologists urged doctors not to offer cardiac screening tests to those at low risk and without symptoms, and warned that using stents in certain patients could increase the chance of an early death. Physicians recommended against a range of commonly used, yet unnecessary, imaging scans for conditions including low back pain. Meanwhile, family doctors called for an end to unnecessary use of antibiotics in many cases of sinusitis (mostly due to self-resolving viral infections), and recommended against using dual-energy x-ray absorptiometry screening for osteoporosis in women under 65 years, because it is not cost-effective.

With credible estimates that one-third of health spending in the US is wasted, there’s clearly an urgent need to stop squandering resources on unnecessary tests and procedures, as two key proponents of the Choosing Wisely campaign point out in a recent JAMA editorial.1 Underpinning the campaign is powerful evidence from regional variation studies showing that people in high-spending areas receive up to 60% more interventions than similar folk in low-spending areas, without any benefit from the excess care.2

Notwithstanding differences between Australia and the US — which now spends almost twice what we spend on health as a proportion of gross domestic product — the dangers of too much are just as real on this side of the Pacific. Unnecessary antibiotic use remains widespread,3 the Medicare watchdog has warned of the high number of computed tomography scans ordered “without clinical justification”,4 and it’s likely that cholesterol-lowering drugs for those at low risk are overprescribed.5

“It’s a very important topic and we’re very interested in it right now”, said Dr Jim Cameron (President, Cardiac Society of Australia and New Zealand, personal communication, 26 April 2012), who has recently returned from an international conference where Choosing Wisely was discussed. The group is currently preparing changes to its guidelines, to build in warnings about inappropriate use of tests and treatments, although unlike the Americans, the antipodeans aren’t using the language of “unnecessary care”. Cameron takes the view that overuse is more a possibility in Australia, rather than a reality. “We think we should pre-empt anything developing here”, he said.

Similarly, Alasdair MacDonald said that though he didn’t doubt there were cases of overinvestigation in Australia, medicine here was generally not practised as defensively as in the US (Dr Alasdair MacDonald, spokesman for the Royal Australasian College of Physicians, personal communication, 26 April 2012). The College is not currently contemplating any campaigns on overuse, though it is working on a related front to reduce overhospitalisation.

The need for more concerted action on overuse is, however, being strongly pushed by Brisbane general practitioner and president of the Australasian Medical Writers Association, Justin Coleman, who recently launched a blog with the Croakey website called The Naked Doctor, profiling overdiagnosis and overtreatment. He says the beauty of Choosing Wisely — initiated by the American Board of Internal Medicine Foundation — is that it includes doctors talking to doctors about reducing harmful overuse, “rather than a government bureaucracy intervening to try and save money”. One of those who inspired the campaign, Texas-based Howard Brody, has argued along similar lines in the New England Journal of Medicine, stressing the value of doctors taking the lead, to “demonstrate to a skeptical public that we are genuinely protecting patients’ interests and not simply ‘rationing’ health care, regardless of the benefit, for cost-cutting purposes”.6

The campaign against overuse is enjoying much acclaim, but it has also attracted criticism from those concerned that it may inhibit clinicians’ abilities to tailor care to individuals. Here in Australia, Stephen Leeder agrees that recommendations against overuse can be useful, and he supports clinicians being “good managers”, but has “reservations about encouraging them to be the arbiter of competing demands on the health dollar”. “They are the patients’ only advocates: if they become arbiters of thrift on behalf of a payer, they are placed in an ethical bind” (Professor Stephen Leeder, University of Sydney, personal communication, 24 April 2012).

As moves to wind back medical excess intensify in the US, it’s inevitable that this debate will continue to spill over here too, ideally helping to produce systematic reforms that reward good care, not more care.