If less is more, which health care should be cut?

In a national survey of primary care physicians that the Archives of Internal Medicine published last month, nearly half agreed: Their own patients are getting too much care.

The study drew widespread attention as Americans struggle with health care’s drag on our economy. At Group Health’s Annual Membership Meeting, Commonwealth Fund President Karen Davis, PhD, said the United States is paying twice as much per capita for health care as other industrialized countries. Yet 15 nations outrank us in quality of care. Clearly, we could do better with less. But how do we decide which care to eliminate?

Most of us have seen or experienced examples of medical excess. Here's a typical story of an active fellow who saw a specialist for shoulder pain. The doctor immediately ordered an MRI, which impressed my friend. His insurance covered the expensive specialty visit and imaging. But after the test showed no structural problems, the doctor recommended no further care: no follow-up with primary care, no advice or referral for approaches that might actually relieve his pain through either self care or professionally directed physical therapy. After a course of physical therapy he's better, but this is after several weeks of worsening symptoms and function.

Another example: a 97-year-old great-grandmother who developed extreme weakness. Finding anemia, the doctor ordered a blood transfusion to help the elderly woman feel better. The hospital staff also started setting up an electrocardiogram (ECG), an everyday routine to check cardiac function.  Her daughter asked the staff, “Why are you doing that? My mother is 97 years old. She has an advance directive that says if her heart stops, she wants no resuscitation. So what will this machine tell you that you need to know?”  The staff member stopped, thought about the question, and then wheeled the ECG away.

I believe such considerations are too rare in medicine today. Too many providers are on “automatic pilot,” following routine protocols without thinking of the individual patient’s unique situation, needs, and values.  Whether determining if a child’s sore throat requires an antibiotic, or asking whether a frail, elderly patient needs or wants an invasive test or procedure, providers must help each patient get the care that’s best for them.

It was in this spirit that a group called the National Physicians Alliance (NPA) recently initiated a project called “Promoting Good Stewardship in Clinical Practice.” They recently published lists of the “top 5” activities in primary care (family medicine, internal medicine, and pediatrics) that could improve both care and “use of finite clinical resources.” After field-testing showed physician support for these evidence-based, cost-saving, easy-to-implement activities, the group published their lists August 8 in Archives of Internal Medicine, with simple guidelines like:

• Don’t do imaging for low back pain within the first six weeks unless red flags are present.
• Don’t obtain blood chemistry panels or urinalyses for screening in asymptomatic, healthy adults.

• Don’t order annual ECGs or any other cardiac screening for asymptomatic, low-risk patients.

• Don’t use bone-density screening for osteoporosis in women under 65 or men under 70 with no risk factors.
• Do use only generic statins when starting lipid-lowering drug therapy.

Group Health has long endorsed many of these common-sense practices.  In fact, decades ago, we were among the first in the country to do away with routine chest X-rays for healthy adults. And recently, with funds from the Partnership for Innovation, GHRI researchers worked with Group Health Physicians and the delivery system to launch and evaluate an initiative to reduce unnecessary imaging and protect patients from overexposure to radiation. The knowledge we gain from this initiative and its evaluation will be shared nationwide, helping others understand how cutting unnecessary care can mean higher quality and lower costs.

With our nation’s fiscal crisis and aging population, health care cost cuts are inevitable.  Using an analogy familiar to Northwesterners, many question whether this should be done by “clear-cutting”—uniform reductions across broad swaths of the health care landscape—or “thinning”: strategically eliminating care that does not provide value and may do more harm than good.  Here at Group Health Research Institute—with our expertise in comparative effectiveness research and our strong partnership with Group Health Physicians and the delivery system—we can lead the way toward the more strategic approach, which results in better care at lower cost.

Read “Too Little, Too Much? Primary Care Physicians’ Views on U.S. Health Care” in Archives of Internal Medicine.
Read “The ‘Top 5’ Lists in Primary Care: Meeting the Responsibility of Professionalism” in the Archives of Internal Medicine.

Read Dr. H. Gilbert Welch’s classic 1991 essay, “Should the Health Care Forest Be Selectively Thinned by Physicians or Clear Cut by Payers?”