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More Treatment—Better Care?
The Case
The patient is a 27-year-old female who presented to a 250-bed community hospital with numbness and tingling of her hands and feet. She was promptly evaluated by a neurologist and diagnosed with Guillain-Barré syndrome. Once the diagnosis was established, she was started on plasmapheresis using a Quinton catheter placed by interventional radiology. She received six treatments over 12 days, then another two treatments a week later. The patient's indwelling catheter remained in for the entire course of therapy. Toward the end of the 3rd week of treatment, she developed a fever of 101 degrees and an elevated white blood cell count (WBC). Vancomycin was started empirically and the Quinton catheter removed for a presumed line infection. After 48 hours, she was afebrile, and her WBC returned to normal. Blood cultures were negative.
At the time that the diagnosis was made, the Medical Director of Case Management contacted the neurologist to provide him with the 2010 evidence-based guidelines on the use of plasmapheresis in Guillain-Barré syndrome published by the American Society of Apheresis (http://www.ncbi.nlm.nih.gov/pubmed/20568098). This guideline recommends five to six treatments over 10–14 days, with data indicating that additional treatments are only indicated for relapse. The Medical Director reviewed the risks of plasmapheresis with the physician and asked him to follow the recommended treatment course rather than treating the patient as he had treated the previous Guillain-Barré syndrome patient, who had received 20 treatments over 40 days. At that time, when the neurologist and nephrologist who ordered this were asked why so many treatments were given, they both responded that the patient was improving so they felt that more treatments would help him recover even more.
The Commentary
It is widely assumed in the United States that if some medical care is good, more must be better. This case of overtreatment with resultant harms of a young woman with Guillain-Barré syndrome adds to the long list illustrating the dangers of that assumption.
Guillain-Barré syndrome (GBS) is a rare disorder in which the body's immune system attacks part of the peripheral nervous system, usually occurring after a respiratory or gastrointestinal viral infection. It can be associated with vaccine use, and was reported after the government-mandated widespread swine flu vaccinations in 1976. The course of GBS is variable. While there is no cure, most cases recover with time on their own. Therapies such as plasmapheresis can lessen the symptoms of GBS. Like most diseases, the aggressiveness of treatment is related to the severity of symptoms.
In this case, the patient was a young healthy woman with fairly mild and non–life-threatening manifestations of GBS. Invasive treatment, such as apheresis (which requires hospitalization and placement of an indwelling catheter, with concomitant risk of complications and infection), tends to be reserved for serious cases, often ones with respiratory muscle involvement. There are evidence-based guidelines for use of apheresis to facilitate high quality care of patients with GBS, which the Medical Director of Case Management reviewed with the treating neurologist. However, the neurologist chose to extend the apheresis treatments beyond the guideline recommendations, requiring a longer hospitalization and use of the indwelling catheter, which led to a serious infection.
The desire to "do something" is so strong in medicine that the neurologist ignored the evidence-based guidelines. Unfortunately, this situation is common in medicine. The Archives of Internal Medicine "Less is More" series highlights many examples of medical care with no known benefit and definite harms.(1) We have published 148 articles and commentaries in the series since its inception less than 18 months ago (Table). Another recent example discussed in the series is the continued use of percutaneous coronary intervention in stable patients 3 to 28 days after myocardial infarction (2), despite guidelines classifying late reperfusion (> 24 hours) as Class III (i.e., not indicated and inappropriate) indication. This case fits the Less is More (LIM) framework, as there is no benefit to the extended apheresis treatments (and one could question whether this young woman with tingling needed any invasive treatment at all).
LIM focuses on the harms of unnecessary treatment. For many reasons, we are more comfortable doing too much and tend not to consider the harms in such an aggressive approach. We need to understand that at times more health care can be harmful. The most effective way to reduce well-intentioned yet inappropriate care is to consider the risks of such care.
Some have argued that—in light of the increasingly tenuous financial position of our health care system—the movement to purge unnecessary care should focus on the cost implications of such care. But, patients and physicians show little interest in not wasting money for unnecessary health care, for reasons related to the vagaries of our third-party payer health care system, exacerbated by a fee for service system that rewards unnecessary care as generously as life-saving care. Moreover, patients and some advocacy groups often frame (and even caricaturize) efforts to cut care—even unnecessary care—as "rationing," a third rail in today's American political system. This means that a focus on the harms rather than the costs of unnecessary, non–evidence-based care may be more effective politically.
In addition to the vagaries of the payment system, there are many other driving factors for overtreatment in our current health care system. There is usually little criticism for getting an extra test or procedure (in this case, the Medical Director tried to offer guidance but had no particular reinforcement mechanism). Patients have come to equate more care with better care, we have a fascination with technology, and rushed and harried doctors believe it is faster to order a test than talk with our patients.
Physicians often ignore guidelines with the best of intentions—our medical culture values doing something over doing nothing even when that "something" has risks. Physicians often make clinical judgments that their particular patient has special characteristics that warrant non-guideline care, there is a strong belief in the supremacy of technology and another that patients expect or want more care. Moreover, the economic incentives and defensive medicine driven by our present payment and malpractice systems, respectively, are important contributors.
Because of the risks of inappropriate and overly aggressive care, patient-centered decision-making with truly informed consent would help decrease such care. In this case, it is unlikely that this young woman knew she was getting more treatments than the professional society guidelines recommend and that the risks of the continued treatment was continued hospitalization and line-related infection without known benefit. That is why it is especially important to have an honest and informed discussion of risks and benefits before any procedure or treatment. Studies show that when informed patients are given the choice between more aggressive care and a less invasive approach, they prefer the less invasive one.(3-8)
Conservative estimates are that 30% of all health care is unnecessary, based on lack of clinical effectiveness. Without any discussion of costs, one could accomplish the goal of improving quality of care and decreasing costs by decreasing or eliminating unnecessary care. Linking reimbursement to evidence of benefit is one way to refocus our health care system on improving patient outcomes, instead of rewarding high-volume high-tech care without consideration of quality. Similarly, performance measures that focus more on outcomes and overuse than on processes and underuse can help decrease inappropriate care. We must make it easier for physicians to provide evidence-based care by tailoring our system to encourage such behavior (the same way we make good behavior easier from our kids, by making the environment conducive to such behavior). The most successful way to change physician behavior is to realign incentives. Clinical decision support (which will increasingly be delivered through computerized medical records), as well as payment incentives/reimbursement, should all be tailored to reward evidence-based treatment.
Take-Home Points
- Caregivers should share the risks and benefits of their recommended treatment with their patients and be sure the patients concur, particularly if they plan to deviate from evidence-based guidelines.
- Clinicians should consider whether they could achieve the same outcome (treatment of GBS) with less testing or treatment (or no testing or treatment). Do not assume that more treatment is always better!
- Clinicians should reflect on how a recommended test or treatment will positively impact outcomes in a clinically meaningful way (i.e., by helping their patient feel better or live longer).
Rita Redberg, MD, MSc Professor of Medicine
Director, Women's Cardiovascular Services
UCSF Medical Center, Division of Cardiology
References
1. Grady D, Redberg RF. Less is more: how less health care can result in better health. Arch Intern Med. 2010;170:749-750. [go to PubMed]
2. Deyell MW, Buller CE, Miller LH, et al. Impact of National Clinical Guideline recommendations for revascularization of persistently occluded infarct-related arteries on clinical practice in the United States. Arch Intern Med. 2011;171:1636-1643. [go to PubMed]
3. O'Connor AM, Bennett CL, Stacey D, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2009:CD001431. [go to PubMed]
4. Morgan MW, Deber RB, Llewellyn-Thomas HA, et al. Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease. J Gen Intern Med. 2000;15:685-693. [go to PubMed]
5. Waljee JF, Rogers MA, Alderman AK. Decision aids and breast cancer: do they influence choice for surgery and knowledge of treatment options? J Clin Oncol. 2007;25:1067-1073. [go to PubMed]
6. Deyo RA, Cherkin DC, Weinstein J, Howe J, Ciol M, Mulley AG Jr. Involving patients in clinical decisions: impact of an interactive video program on use of back surgery. Med Care. 2000;38:959-969. [go to PubMed]
7. Kennedy AD, Sculpher MJ, Coulter A, et al. Effects of decision aids for menorrhagia on treatment choices, health outcomes, and costs: a randomized controlled trial. JAMA. 2002;288:2701-2708. [go to PubMed]
8. Barry MJ, Cherkin DC, Chang Y, Fowler FJ, Skates S. A randomized trial of a multimedia shared decision-making program for men facing a treatment decision for benign prostatic hyperplasia. Dis Manag Clin Outcomes. 1997;1:5-14. [Available at]
9. Khera A. Texas atherosclerosis imaging bill: quiet origins, broad implications. Arch Intern Med. 2011;171:281-283. [go to PubMed]
10. Schiff GD, Galanter WL, Duhig J, Lodolce AE, Koronkowski MJ, Lambert BL. Principles of conservative prescribing. Arch Intern Med. 2011;171:1433-1440. [go to PubMed]
11. Mursu J, Robien K, Harnack LJ, Park K, Jacobs DR Jr. Dietary supplements and mortality rate in older women: the Iowa Women's Health Study. Arch Intern Med. 2011;171:1625-1633. [go to PubMed]
12. Hochman JS, Lamas GA, Buller CE, et al; Occluded Artery Trial Investigators. Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med. 2006;355:2395-2407. [go to PubMed]
13. O'Hare AM, Choi AI, Boscardin WJ, et al. Trends in timing of initiation of chronic dialysis in the United States. Arch Intern Med. 2011;171:1663-1669. [go to PubMed]
14. Prasad V, Gall V, Cifu A. The frequency of medical reversal. Arch Intern Med. 2011;171:1675-1676. [go to PubMed]
15. Ray KK, Seshasai SR, Erqou S, et al. Statins and all-cause mortality in high-risk primary prevention: a meta-analysis of 11 randomized controlled trials involving 65,229 participants. Arch Intern Med. 2010;170:1024-1031. [go to PubMed]
16. Grady D, Berkowitz SA, Katz MH. Opioids for chronic pain. Arch Intern Med. 2011;171:1426-1427. [go to PubMed]
17. Katz MH. Failing the acid test: benefits of proton pump inhibitors may not justify the risks for many users. Arch Intern Med. 2010;170:747-748. [go to PubMed]
18. Berkowitz SA, Redberg RF. Dramatic increases in carotid stenting despite nonconclusive data. Arch Intern Med. 2011;171:1794-1795. [go to PubMed]
19. Aguilar I, Berger ZD, Casher D, et al; Good Stewardship Working Group. The "top 5" lists in primary care: meeting the responsibility of professionalism. Arch Intern Med. 2011;171:1385-1390. [go to PubMed]
Table
Table. Less is More (LIM) series topics and categories.
| LIM Topic | Category of LIM | Specifics |
|---|---|---|
| CAC Screening (9) | Harms known to outweigh benefits | No outcomes benefit, risks of radiation (cancer) and incidental findings |
| Conservative Prescribing (10) | Overuse | Think beyond drugs, be skeptical of surrogate markers of drug benefit |
| Dietary supplements and mortality (11) | Harms known to outweigh benefits | Dietary supplements have no benefits on mortality and many (multivitamins, iron) are associated with an increased morality risk |
| PCI in Occluded Infarct-related arteries (2) | Harms known to outweigh benefits | PCI 3 or more days after MI has no benefit (OAT randomized trial [12]), and definite harms, yet practice persists, even after guidelines changed |
| Early Dialysis (13) | Use outside of selected high risk group or started earlier in the course of disease | Dialysis initiated earlier in the course of renal disease, with no benefit and attendant risk of dialysis |
| Medical Reversal—many topics (14) | Tests repeated unnecessarily | |
| Statins for Primary Prevention (15) | Use outside of selected high risk group or for too long than known benefit | Meta-analysis shows no benefit on mortality in primary prevention, even in high risk groups, and known harms—rhabdomyolysis, muscle weakness, memory loss |
| Opioids for Chronic Pain (16) | Harms known to outweigh benefits | Chronic non-malignant pain is common, there is little to no RCT data of benefit for opioids, and harms are clear, including 11,499 deaths in 2007 alone from overdose |
| Proton Pump Inhibitors for nonulcer dyspepsia or for more than 2 weeks (17) | Use outside of selected high-risk group or for too long than known benefit | Used in patients with no known benefit, associate with increased fracture risk and increased pneumonia and clostridium difficile infections |
| Carotid Stenting for asymptomatic stenoses (18) | Procedure not shown to be beneficial | No benefit compared to medical therapy, increased risk of strokes |
| "Top 5" including antibiotics for sinusitis, routine chemistries (19) | The Good Stewardship Working Group list of 5 things to do less of for better quality care |
Abbreviations: CAC=coronary artery calcium; PCI=percutaneous coronary intervention; OAT=occluded artery trial; MI=myocardial infarction; RCT=randomized controlled trial.
