Home' The Source : Third Quarter 2016 Contents TEAMWORK TOOLS MANAGEMENT MATTERS
As screening and diagnostic technology
advance to the point where clinicians can
detect the smallest of abnormalities, patients
are being overtreated for conditions “that
are not destined to ever bother them.” That’s
how H. Gilbert Welch, M.D., defines over-
diagnosis in his 2011 book, Overdiagnosed:
Making People Sick in the Pursuit of Health.
“Since doctors don’t know who is over-
diagnosed and who is not, overdiagnosed
patients tend to get treated,” he writes.
“But an overdiagnosed patient cannot ben-
efit from treatment. There’s nothing to be
fixed—he will neither develop symptoms
nor die from his condition—so the treatment
is unneeded. An overdiagnosed patient can
only be harmed. And the simple truth is that
almost all treatments have the potential to
do some harm.”
In the book, he points to prostate cancer
screening that measures the prostate-spe-
cific antigen (PSA) serum levels as one of
the most egregious examples of cancer
screening with good intentions but bad
results. “The fastest way to get prostate can-
cer is to be screened for it,” Welch writes.
The U.S. Preventive Services Task Force,
which issues recommendations for screen-
ing and diagnostic testing based on relative
benefit and harm recommends against
PSA-based screening for prostate cancer.
It concluded in its 2012 final recommen-
dation that PSA-based screening leads to
substantial overdiagnosis and overtreatment
of prostate tumors which, had they been
undetected, would have never progressed
to the point of harm.
“Even for men whose screen-detected
cancer would otherwise have been later
identified without screening, most experi-
ence the same outcome and are, therefore,
subjected to the harms of treatment for a
much longer period of time,” according to
the task force.
IS THAT STENT NECESSARY?
Interventional cardiologist Gaurav
Aggarwala, M.D., at Magnolia Health
Systems in Palestine, Texas, is well aware
that overdiagnosis (and the corresponding
treatment with angioplasty) is a problem
for patients with stable cardiac disease. By
some estimates, about a third of all stents
placed annually are unnecessary.
That’s why before any stent is placed,
Aggarwala always measures the fractional
flow reserve (FFR) of the artery blockage.
It’s an extra step, but one that gives him con-
fidence and objective data on which to base
his clinical decision. “If the FFR is abnormal,
we feel comfortable that the patient got a
stent for the right reason,” he says.
Aggarwala indicates angiograms can carry
a high level of observer variability—he might
see an 80 percent blockage where another
cardiologist might see a 50 percent blockage.
That’s why it’s important to have “a modal-
ity that people can’t argue with,” he says.
FFR is one way; another is an intravascular
ultrasound, which can also help measure
the severity of blockage.
He started requiring the practice after
reading about government investigators,
including the Centers for Medicare &
Medicaid Services, cracking down on inap-
propriate stenting. “I started thinking about
how I could protect myself if my practice
was ever scrutinized,” he says.
Government investigators are interested
in unnecessary stenting from both cost and
patient safety perspectives. About 1 to 2 per-
cent of angioplasty patients will experience
procedural risks, such as blood clots, bleeding
or a tear in the artery. On top of that, most
patients who undergo the procedure are pre-
scribed blood thinners for at least 12 months
after the stent is placed, which carries addi-
THE PROBLEM WITH
Curbing unnecessary care in a value-based care setting
The National Cancer Institute’s Surveillance,
Epidemiology and End Results (SEER) Program has
been tracking cancer deaths and cancer diagnoses
since 1973. For each of the 30 types of cancer it tracks,
there’s a table showing the diagnosis and deaths over
time. Diagnosis of many of those cancers—including
thyroid, kidney and melanoma—have skyrocketed, yet
deaths have remained relatively unchanged. Glancing at
those tables, you might be tempted to think that modern
medicine has won the war on cancer and that treatment
has advanced so much that it’s preventing deaths. But a
growing consensus among healthcare providers suggests
another problematic conclusion: overdiagnosis.
Continued on page 62
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