National

Jun 7, 2010 4:37 PM by Bea Karnes, News First 5

Overdoing medical tests costly

More medical care won't necessarily make you healthier - it may make you sicker. It's an idea that technology-loving Americans find hard to believe.

Anywhere from one-fifth to nearly one-third of the tests and treatments we get are estimated to be unnecessary, and avoidable care is costly in more ways than the bill: It may lead to dangerous side effects.

It can start during birth, as some of the nation's increasing C-sections are triggered by controversial fetal monitors that signal a baby is in trouble when really everything's fine.

It extends to often futile intensive care at the end of the life.

In between:

  • Americans get the most medical radiation in the world, much of it from repeated CT scans. Too many scans increase the risk of cancer.
  • Thousands who get stents for blocked heart arteries should have tried medication first.
  • Doctors prescribe antibiotics tens of millions of times for viruses such as colds that the drugs can't help.
  • As major health groups warn of the limitations of prostate cancer screening, even in middle age, one-third of men over 75 get routine PSA tests despite guidelines that say most are too old to benefit. Millions of women at low risk of cervical cancer get more frequent Pap smears than recommended; millions more have been screened even after losing the cervix to a hysterectomy.
  • Back pain stands out as the No. 1 overtreated condition, from repeated MRI scans that can't pinpoint the trouble to spine surgery on people who could have gotten better without it. About one in five who gets that first back operation will wind up having another in the next decade.

Overtreatment means someone could have fared as well or better with a lesser test or therapy, or maybe even none at all. Avoiding it is less about knowing when to say no, than knowing when to say, "Wait, doc, I need more information!"

The Associated Press combed hundreds of pages of studies and quizzed dozens of specialists to examine the nation's most overused practices. Medical groups are starting to get the message. Efforts are under way to help doctors ratchet back avoidable care and help patients take an unbiased look at the pros and cons of different options before choosing one.

"This is not, I repeat not, rationing," said Dr. Steven Weinberger of the American College of Physicians, which this summer begins publishing recommendations on overused tests, starting with low back pain.

It's trying to strike a balance, to provide appropriate care rather than the most care. Rare are patients who recognize they've crossed that line.

"Yet let me tell you, with additional tests and procedures comes significant harm," said Dr. Bernard Rosof, who heads projects by the nonprofit National Quality Forum and an American Medical Association panel to identify and decrease overuse.

"It's patient education that's going to be extremely important if we're going to make this happen, so people begin to understand less is often better," he said.

Not even doctors' families are immune.

A hospital appropriately did six CT scans to check Dr. Steven Birnbaum's 22-year-old daughter for injury after she was hit by a car. But the next day, Molly had an abdominal scan repeated as a precaution despite having no symptoms. When a doctor ordered still another, "I blew a gasket," said the New Hampshire radiologist, who put a stop to more.

There are numerous reasons that one of three U.S. births now is by cesarean, but Dr. Alex Friedman blames some on an imprecise monitor strapped to laboring women. Too often, he has sliced open a mother's abdomen fearing the worst, only to pull out a pink, screaming bundle.

"Everyone knows it's a bad test," said Friedman of the Hospital of the University of Pennsylvania. "You haven't done the patient a big service by doing an unnecessary surgery."

Electronic fetal monitors record changes in the baby's heart rate, a possible sign of too little oxygen. They became a tradition - now used in 85 percent of births - years before research could prove how well they work.

Guidelines issued last summer, aiming to help doctors better interpret which tests are worrisome, acknowledge the monitors haven't reduced deaths or cerebral palsy. But they do increase the chances of a C-section. While they should be used in high-risk women, the guidelines say the low-risk could fare as well if a nurse regularly checked the baby's heart rate.

Later this year, the National Institutes of Health will begin a major study to see if adding a newer technology - a type of fetal EKG already used in Europe - to the heart-rate monitor would better identify which babies really are struggling and need rapid delivery.

Undertreatment was in the headlines over the past year as the Obama administration and Congress wrestled with legislation to get better care to millions who lack it.

The flip side, overtreatment, is a big contributor to runaway health care costs. Yet it's one that lawmakers, wary of being accused of rationing, largely avoided in the new health care law. Included were modest steps - studies to compare which treatments work best, some Medicare financial incentives - to push higher-quality, lower-cost care.

"Physicians get up every day with the good intentions of wanting to do what's best for their patients," said Dr. David Goodman of the Dartmouth Institute for Health Policy. "We also live in environments where there are strong financial incentives to deliver certain types of care. We get well-paid for doing procedures. We get paid relatively poorly for spending time with patients and helping them make choices."

Where you live plays a role. Two decades of research from the respected Dartmouth Atlas of Health Care shows that in parts of the country, Medicare pays double or triple the price to treat people with the same illnesses. The differences are not fully explained by big cities' higher cost of living or populations that are poorer, older or sicker. How much care someone gets is a main reason, yet Dartmouth's data shows people in pricier areas don't necessarily fare better.

Dartmouth's check of 2005 Medicare data found that during their last six months of life, older adults in Boise, Idaho, spent 5.3 days in the hospital compared with 17 days in Miami.

Fee-for-service care and local habits aren't the only drivers.

Fear of malpractice lawsuits "has everything to do with it," said Dr. Angela Gardner, president of the American College of Emergency Physicians, whose members face intense pressure to overtest in the life-and-death chaos of the ER.

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