Wednesday, September 2, 2009

What is "too much" health care?

At first blush, inappropriate health care sounds like a contradiction in terms. Isn't "care" by definition something that is necessary and appropriate, and if so, how is it possible to get too much? Such talk inevitably invites accusations of "rationing," drawing unfavorable comparisons to the United Kingdom's National Institute for Health and Clinical Excellence (NICE), an agency that determines whether or not to pay for benefits in the UK's government health system, based on clinical and cost-effectiveness standards. Cost-effectiveness is an important issue that both sides of the health reform debate have unfortunately not addressed, but inappropriate health care isn't necessarily expensive care. It's care that does nothing to improve your health.

Although many preventive health services (screening tests and counseling for health behavior change) have been shown to improve quality and length of life, many remain unproven or are associated with significant harms. In particular, screening for prostate cancer with the prostate-specific antigen (PSA) test, which has been performed on millions of American men since it became common medical practice in the early 1990s, is often inappropriate. While the potential benefits of PSA screening (fewer deaths from prostate cancer) are still being debated by experts, the harms - diagnosing slow-growing tumors that would never have caused symptoms or affected health - are no longer in doubt.

A recent study in the Journal of the National Cancer Institute shows why. Some experts have argued that the decline in the prostate cancer death rate seen in the U.S. over the past 2 decades proves that screening and early detection are saving mens' lives. Assuming that this were true, the authors calculate that for every life saved by screening, more than 20 men had to be diagnosed with prostate cancer (and more than 75% of these men chose to be treated with surgery or radiation).

Let me put this information in plainer terms. If you were told by your doctor that having the PSA test could lead to detection of prostate cancer, but that 19 times in 20, treatment would make no positive difference to your health, would you choose to have this testing? (In fact, the number may be as high as 47 in 48, according to a recent European study.) Consider that up to half of all men who are treated for prostate cancer experience erectile dysfunction or urinary incontinence. Unfortunately, this message isn't getting through to clinicians or patients - more than 75% of U.S. men over 50 have had at least 1 PSA test in the past 3 years. By any measure, that's too much health care.

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