Physicians weigh in on extent, causes of overtreatment

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Most doctors in the United States believe overtreatment is common and could be driven by fear of litigation, patient pressure and personal profit.

A new study in PLOS One analyzed survey responses from 2,106 physicians in the American Medical Association master file about the extent of overtreatment, as well as causes, solutions and implications for healthcare.

Regarding cardiology, senior author Martin A. Makary, a professor of surgery at Johns Hopkins University, told The New York Times “half of stents placed may be unnecessary.” Makary and colleagues also cited a 2011 JAMA study suggesting 12 percent of PCIs are unnecessary or inappropriate.

The Institute of Medicine IOM in 2010 reported overtreatment was responsible for approximately $210 billion in excess spending each year.

In the new analysis, the surveyed doctors believed 20.6 percent of all medical care was unnecessary, including 22 percent of prescriptions, 24.9 percent of tests and 11.1 percent of procedures.

Nearly 85 percent of doctors said a fear of malpractice contributes to overtreatment. However, recent data suggests only 2 to 3 percent of patients harmed by negligence pursue litigation.

Other common reasons for overutilization, according to the respondents, included “patient pressure/request” (59 percent believed it was a factor) and “difficulty accessing prior medical records” (38 percent).

“On the patient side, the perception that more care is better care is also a factor and can be fueled by goals to achieve high patient satisfaction scores,” Makary et al. wrote. “Studies indicate that focused patient education through shared decision making between patients and physicians results in more conservative care.”

A study of emergency departments in California and Florida, the authors noted, showed the regional exchange of health records reduced repeat CT scans by 8.7 percent, ultrasounds by 9.1 percent and chest x-rays by 13 percent.

“With increased hospital consolidation in recent years, health systems should make data sharing a priority both within and among health systems,” Makary and colleagues wrote. “Complete interoperability of healthcare information nationwide may yield an estimated net savings of $78 billion a year.”

About 71 percent of physicians believed that at least some physicians were more likely to perform unnecessary procedures when they profited from them. On average, the respondents thought 16.7 percent of physicians perform unnecessary procedures with a profit motive.

Attending physicians with more than 10 years of experience and specialists were the most likely to believe fellow doctors engaged in this practice.

Makary and co-authors noted their work didn’t address the issue of undertreatment, which comes with its own set of problems, including increased healthcare spending from patient complications. Also, their sample size wasn’t large enough to compare responses across specialties, and because the data was collected in 2014 it may not reflect the effect of recent initiatives to address overtreatment.

Despite these limitations, the researchers suggested greater physician engagement could help mitigate the problem of overtreatment in healthcare. Seventy-six percent of surveyed doctors believed de-emphasizing fee-for-service payment programs would reduce unnecessary treatments.

“Future work should focus on the most high-volume over-utilized tests and procedures by specialty,” they wrote. “Medical school and training should include guidance on the subject of appropriateness before doctors are exposed to the factors identified in this study as factors contributing to the problem.”