The overtreaters

22 Feb

When all you have is a hammer, everything looks like a nail.

Patient Recognition Month Poster

Patient Recognition Month Poster (Photo credit: Army Medicine)

President of the Conseil National de l’Ordre des Médecins, the French national board for private practice physicians, has said in a recent interview on the topic of breath cancer screening: “one would better have too much chemotherapy than not enough”. This statement from a French health policy stake holder could hint that France is not enough mobilized against the issue of over treatment, unnecessary treatment and non pertinent treatment (although other stake holders are aware of the problem as shown in the document, issued by the former National Physician Adviser of one of the greatest health insurance scheme of France, entitled “Pertinence des actes par delà la polémique” cited in the work consulted list below).

Yet the pertinence of a treatment is a very relevant issue that health insurance companies have to deal with, be they private or public. A great amount of literature has already been released treating of the subject and health insurance policy makers are more and more concerned in the hope to cut some spending and improve the quality of care all in a same move by addressing the issue of overuse of medical care.

Unfortunately, to distinguish which procedure is really needed from which is non relevant requires, when it comes to a single patient, a high level of medical expertise and skill all along associated with a very high responsibility in case of misjudgment . That’s the reason why the better way for the health care benefits manager to solve the problem is to ask for a second medical opinion. And that’s how an almost patient is transformed in a non patient at all. Using such a procedure a benefit manager glorifies himself having avoided to a dozen of his insured the bistoury of their surgeon.

If a surgeon appears to show a high trend to operate although there is no particular need, the benefit manager enlist him in a “do not use” list. Four procedures are now under high scrutiny in the US: Stents for Stable Angina, Complex spinal fusion for stenosis, Hysterectomy for uterine fibroids, and Knee arthroscopy for osteoarthritis.

Surgeons are not automatically guilty of a willing of harm their patient but the bias can be resumed as follows: “when all you have is a hammer, everything looks like a nail”.

But surgeons are not alone exposed the trend of over treating. Pharmaceutical firms try systematically to open new market shares either by widening the indication of an old molecule with large and expansive multicenter studies or by widening the field of extension of a common disease which was not very known by the public and the health care providers until the drug maker undertakes a nation wide disease mongering campaign. And as Richard Lehman notes in his Blog post of February 20th2012, pharmaceutical companies are ready to put a lot of money to do that: “It took 60 centres in 11 countries to recruit 227 subjects for that PRIMO trial of paracalcitol (“Zemplar,” Abbott). This is not at all unusual in trials run by pharmaceutical companies on products still under patent, when the prize might be a large extension of indication.” Unfortunately for the company, the results of this large multicenter study were negative while a more modest less funded study showed that amoxicillin shorten by only three days the course of  acute rhino sinusitis versus placebo.

And my conclusion will be: in medicine “the more the better” is a maxim that has to be pronounced cautiously.

Works consulted:

1) Keep your docs off ‘do not use’ lists

2) Four surgeries to think about avoiding.

3) White Coat, Black Hat: Adventures on the Dark Side of Medicine.

4) Take patients away from the overtreaters.

5) Quant aux chimiothérapies, il vaut mieux en faire un peu trop que pas assez ! affirme le docteur Legmann, Président du CNOM.

6) The Treatment Trap: How the Overuse of Medical Care Is Wrecking Your Health and What You Can Do to Prevent It.

7) Amoxicillin for Acute Rhinosinusitis; a Randomized Controlled Trial

8) Vitamin D Therapy and Cardiac Structure and Function in Patients With Chronic Kidney Disease; the PRIMO Randomized Controlled Trial

9) Richard Lehman’s journal review – 20 February 2012 by BMJ Group

JAMA  15 Feb 2012  Vol 306

10) Fait-on trop de dépistage du cancer du sein ?

11) Pertinence des actes par delà la polémique; le regard de l’assurance maladie.


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