Thursday, June 18, 2020

Less medicine, more health? COVID-19 pandemic provides a natural experiment

One of my favorite health care books of 2015 was Less Medicine, More Health: 7 Assumptions That Drive Too Much Medical Care, by Dr. Gil Welch, a general internist who was then a health services researcher at Dartmouth. After resigning his position at the college in 2018 in the wake of an at-best-questionable accusation of plagiarism, he joined the Center for Surgery and Public Health at Brigham and Women's Hospital and has continued to produce excellent work, including an insightful analysis of prostate cancer mortality trends and more recently, a CNN opinion piece with Dr. Vinay Prasad about "the unexpected side effect of COVID-19." In their CNN piece, Welch and Prasad pointed out that the much lower utilization of the U.S. health care system during the pandemic has provided a unique opportunity to for researchers to examine if certain high-volume medical interventions (e.g., physicals, cancer screenings, orthopedic surgery, and surgery for low-risk cancers) actually improve health outcomes:

After Covid-19, if we dare imagine the day, it will be important to ask who was harmed by delayed and forgone medical care. But the severe financial strains on individuals and public budgets make it just as essential to ask who benefited from avoiding interventions with no salutatory effect. ... Covid-19 provides a once in a lifetime opportunity to study what happens when the well-oiled machine of medical care downshifts from high to low volume in order to focus on acutely ill patients. It will be comfortable for physician researchers to study what was lost. It will be courageous for them to study what was gained.

If a physical necessarily includes laying hands on patients, I haven't done one in more than 3 months, as my practice has shifted almost entirely to telehealth. To tell the truth, I haven't missed these physicals much. I've long been a skeptic of the value of a general health checkup in adults, even though in our fee-for-service payment system they are essential to primary care practices paying the bills (and their absence has led to many practices facing bankruptcy as the pandemic grinds on). It's not just that physicals are often a waste of time and money, though - sometimes, they can even be harmful.

In a 2014 JAMA essay that was re-published in this year's theme issue marking 40 years of of "A Piece of My Mind," Dr. Michael Rothberg recounted the near-fatal cascade of testing that began with his 85 year-old father's checkup with a new primary care physician. This doctor, who felt a possible aortic aneurysm on the abdominal examination, ordered an ultrasound scan (which revealed no aneurysm, but saw something in the pancreas), followed by a CT scan (which revealed a normal pancreas, but saw a lesion on the liver), followed by a liver biopsy that revealed a hemangioma, a benign but extremely vascular tumor that bled profusely and required the transfusion of 10 units of blood. He spent a painful week in the hospital not being able to urinate without a catheter and received a $50,000 bill for his troubles - inspiring the essay's title, "The $50,000 Physical."

I could tell you several similar stories of testing cascades that went wrong from my own decade-and-a-half in practice; probably every general internist or family physician who isn't fresh out of residency has at least one. Of course, no organization recommends screening for an aortic aneurysm in a healthy 85 year-old man, but no one recommends ordering a chest x-ray or electrocardiogram at a physical either, or doing a Pap smear in a woman younger than 21 or older than 69, and these "low value" (really, "no value") screening tests still happen far too often. A retrospective cohort study published last week in JAMA Internal Medicine found that adults in Ontario who received those 3 particular tests ended up having significantly more subspecialist visits and subsequent (likely unnecessary) diagnostic tests or procedures in the next 90 days.

"De-implementation" is the formal health services research term for "figuring out how to do fewer things to patients that do more harm than good." Just as COVID-19 has accelerated an overdue transition to providing more health care virtually, I hope that it will also inspire researchers to "study what was gained" from postponed or cancelled appointments with family doctors and surgeons. If the pandemic has a silver lining, this might be it.