Monday, October 27, 2014

"Too much medicine" potpourri

Last week was a busy one: I presented at the American Academy of Family Physicians Assembly (on lung cancer) and the Family Medicine Education Consortium Northeast Region Meeting (on prevention politics); participated in a Lown Institute-sponsored meeting on improving community care for patients with chronic and complex health conditions; and attended a ceremony recognizing the accomplishments of this year's Pisacano Leadership Foundation scholars. Meanwhile, the collection of articles that I keep as fodder for this blog continued to grow. Here, in no particular order, are some reflections on recent publications that illustrate how providing too much medicine inflates costs, wastes health care resources, and ultimately harms patients.

Cardiac catheterization can be a life-saving procedure for patients in the throes of a heart attack, but it doesn't help persons without cardiac symptoms or improve outcomes in patients with stable angina. So why is this procedure performed so often on these patients? A study in JAMA Internal Medicine qualitatively analyzed discussions about the benefits and risks of coronary angiography and percutaneous coronary interventions (PCI) between cardiologists and patients with stable coronary artery disease. Cardiologists were far more likely to exaggerate the benefits of angiography and PCI than to accurately state that compared to medical management, PCI can reduce anginal symptoms but does not lower patients' risk of death or myocardial infarction. Another study in the same journal evaluated data from a national registry of 544 hospitals that performed PCI between 2009 and 2013. One in four patients who underwent elective angiography reported no symptoms (range, 1 to 74 percent). In addition, hospitals that did more angiograms on asymptomatic patients were also more likely to perform PCI for inappropriate reasons. See it, stent it?

One of the patient-centered medical home criteria that my clinical practice was recently tagged as being deficient on is screening adults and adolescents for depression: we weren't doing enough of it. Although routine screening is recommended by the U.S. Preventive Services Task Force, others, including the Canadian Task Force, have concluded that the evidence doesn't support this position. How could screening for depression possibly be harmful? By leading to overtreatment of persons with few depressive symptoms. A study in the Journal of the American Board of Family Medicine found support for this hypothesis by analyzing data from a randomized trial of depression interventions at primary care practices in California. They found that administration of the 9-item Patient Health Questionnaire (PHQ-9), a commonly used screening tool, was associated with 3 times the odds of making a depression diagnosis and 4 times the odds of antidepressant prescribing for persons who, based on their low PHQ-9 scores, were extremely unlikely to have major depression or benefit from medication.

Overdiagnosis and overtreatment affect patients of all ages. In a commentary published in Pediatrics, several prominent academic pediatricians highlight a variety of childhood conditions that are commonly overdiagnosed, including attention deficit-hyperactivity disorder, food allergy, hypoxemia in bronchiolitis, and obstructive sleep apnea. For example, a randomized trial published in JAMA found that infants with mild bronchiolitis whose pulse oximetry measurements were artificially inflated by 3 percentage points were substantially less likely to be admitted to the hospital, but otherwise did just as well as infants in the control group. These findings suggest that emergency medicine physicians and pediatricians rely too much on oxygen saturation (not shown to increase risk of serious outcomes at 88 percent or higher) and too little on the overall clinical picture in making admission decisions.

Looking at the end of life, a cross-sectional study in JAMA Internal Medicine found that more than half of nursing home residents with advanced dementia were receiving at least one medication with questionable (or zero) benefit, costing $816 per patient every 90 days, more than one-third of all prescription costs during the period of analysis. The most common inappropriate drugs were those for early Alzheimer's disease and cholesterol-lowering medications. These drugs don't improve the quality of life of patients with advanced dementia, but can make them feel worse through bothersome or serious side effects.