Simple Steps to Safer and Better Care

There is much evidence that many of the tests and treatments performed in the US healthcare system have no benefit for certain conditions. However, despite this evidence, these procedures continue to be used resulting in not only no benefit but possible harm. This impacts not only patient outcomes but also impacts the cost of care in the US. Recent figures put the cost of healthcare in the US at 17.3% gross domestic product (GDP). It is estimated that nearly one third of this healthcare delivery could be saved without depriving patients of benefit. (1)

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In the January 28, 2010 New England Journal of Medicine it is proposed that professional societies in major areas of medicine develop a top five list of procedures known to have no benefit and publicize this list to providers and patients. (2) Examples brought up in this article include arthroscopic surgery for osteoarthritis of the knee and some computed tomography (CT) scans for certain indications. These procedures for the wrong indications or reasons have high cost, little or no benefit and possible harms.

In many of our recent articles we have discussed the changes in recommendations for screening in breast cancer, cervical cancer and prostate cancer. The less is more approach has been recommended to be as certain as possible we are performing procedures that will result in the most good, the least harm and at the most effective cost.

We have discussed this issue in previous articles in New Millennium Health Care Village with the proposal that a list of procedures and the benefits and risks be explained fully to patients in a checklist approach. (3) This approach and the top five list that is discussed in the current article would allow patients access to the best information to allow them the opportunity to make decisions about their care with their provider with the fullest possible informed consent.

It is likely there will be resistance to these approaches for the following reasons:

• It will get in the way of the doctor patient relationship.
• It will get in the way of physician autonomy.
• It is big government and insurance industry dictating what can be done.
• We don’t have enough evidence to implement such a system.
• Malpractice concerns.

In the accompanying audio we discuss these issues.

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1)      Fisher ES, Bynum JP, Skinner JS. Slowing the growth of health care costs — lessons from regional variation. N Engl J Med 2009;360:849-852.

2)      Brody H. Medicines Ethical Responsibility for Healthcare Reform – The Top Five List. N Engl J Med 2009;2010;362:283-285

3)      Assessing the Appropriateness of Care—Its Time Has Come; Robert H. Brook, MD, ScD; JAMA. 2009;302(9):997-998.