Monday, October 8, 2012

Reducing overtreatment is "the other side of quality improvement"

Introducing several new articles about overdiagnosis and overtreatment, BMJ editor Fiona Godlee recently asked, "How much of what we offer to patients is unnecessary? Worse still, how much harm do we do to individuals and society through overtreatment?" Although prostate and breast cancer screening have been the poster children for for this increasingly recognized phenomenon, there are plenty of other situations where an aggressive approach can lead to unnecessary and potentially harmful care: screening for osteoporosis, treatment of mild hypertension, cholesterol screening in children, and screening for gestational and "pre" diabetes. The excellent 16-minute video below features Shannon Brownlee, Jeanne Lenzer, and fellow AFP and Essential Evidence Plus editor Mark Ebell, among others, discussing the scope of the problem.

For those of you interested in learning more about strategies to reduce overtreatment and rein in wasted health spending, including shared decision-making, I also highly recommend the PBS documentary Money & Medicine. This one-hour documentary, which premiered on September 25th, contrasts the approaches and outcomes of care at UCLA Medical Center in Los Angeles and Intermountain Medical Center in Utah.

A problem is that while health organizations are developing more and more measures to discourage undertreatment (e.g., not prescribing aspirin after a heart attack), it can be difficult to identify overtreatment in a systematic way. Noting that randomized trials have not found improved outcomes from low blood glucose targets in older patients with type 2 diabetes, Leonard Pogach and David Aron proposed in the Archives of Internal Medicine that a hemoglobin A1c of less than 7% be considered "as a threshold measure of potential overtreatment of persons older than 65 years who are at high risk for hypoglycemia." They explain that this measure would appropriately be a "warning signal" rather than an automatic indication of overly aggressive diabetes care. Although I feel that this proposal is modest and common-sense, its adoption would nonetheless be a much-needed first step in addressing what Pogach and Aron call "the other side of quality improvement," too often neglected.