The “Overtreated” Movement Gains Steam

Kenneth Bummel-Smith, MD
Charlotte Edwards Maguire Professor of Geriatrics, College of Medicine

Shannon Brownlee, an investigative health writer, published “Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer” in 2008. It was pretty controversial but was expertly documented. Other writers such as John Abramson (Overdosed America), Norton Hadler (Rethinking Aging: Growing Old and Living Well in an Overtreated Society), and H. Gilbert Welch (Overdiagnosed: Making People Sick in the Pursuit of Health) have written similarly comprehensive, and damning, exposes of the state of modern medicine in America. Now some of the major medical journals and medical societies have taken up the call to expose medical treatments and diagnostic tests that ought to be stopped. This movement is long overdue and is a potential solution to the exorbitant rise in health care costs that continues, even in spite of the slow-down seen since the Affordable Care Act was passed.

It has been estimated that 30% to 40% of all health care is not based on evidence. Certain surgeries, such as fusion surgeries for back pain, c-sections (granted, not commonly seen in our population), stents inserted into the coronary or carotid arteries and the abdominal aorta, and arthroscopic knee surgery are often unnecessary and lead to even worse outcomes than other treatments! In an amazing study, J. Bruce Moseley and colleagues randomized 180 patients with knee osteoarthritis into three groups: arthroscopic debridement (cleaning of the cartilage), arthroscopic lavage (washing out the knee joint) or sham surgery. That’s right, they just made a cut into the skin and then sewed it up. Over the next 24 months, at no point did either of the intervention groups report less pain or better function than the placebo group. It is very unfortunate that few surgeries, which accounts for a huge portion of health care costs, have been the subject of randomized sham surgery trials.

Even though randomized trials are commonly done with medications, unfortunately overtreatment is still all too common. Perhaps one of the main reasons is because many misunderstand the difference between an outcome that is statistically significant and an outcome that is clinically meaningful. Here’s an example – if a randomized trial showed that 2 subjects out of 100 in the control group have an event (say, a heart attack) and only 1 out of a hundred have the event in the intervention group, one can truthfully say there was a 50% relative risk reduction due to the intervention. That’s usually the way the drug companies sell the results. But the reality is that there really was only a 1% absolute risk reduction. This example is not farfetched. For instance, low dose statin therapy for high cholesterol in primary prevention (i.e., the patient has no history of stroke, heart attack or kidney disease) is associated with a 1-2% risk reduction. (WOSCOPS study) That means 98 to 99 people will not have the adverse event even if they don’t receive treatment! When you add in the fact that 5-10% will have muscle aches and pains that may limit their exercise, then you have to question whether starting low dose statins are beneficial in healthy elders as primary prevention. Then add in another fact – that the risk reduction seen from engaging in 150 minutes of exercise a week, or adopting a Mediterranean diet, will lower the risk at least as much as statins and you can see the risk of overtreatment.

There are numerous similar situations where the benefits of treatment of mild conditions either are not that much better than no treatment, or are even outright harmful. Aggressive lowering of blood pressure (<140 mm Hg systolic) for most type-2 diabetics has no overall benefit in mortality (ACCORD study). Aggressive lowering of hemoglobin A1C (a measurement of glucose over time) to less than 7.5% (the number often recommended by insurance companies) overall has no benefit and may worsen outcomes. (ACCORD, ADVANCE, VADT) Niacin, ezetimibe and fibrates can lower lipid numbers but have no effect on clinical outcomes. (ACCORD, AIM-HIGH, ENHANCE) And for those of you that think supplements are the answer unfortunately omega-3-fatty acid supplements don’t reduce the risk of cardiovascular disease (3 trials), salt restriction in heart failure worsens outcomes and mortality (HEART 2012), and there are no studies showing that salt and fat restriction reduces the chance of heart disease. If you want to lower your risk of stroke and heart disease, and you don’t have moderate to severe high blood pressure, exercise, a Mediterranean diet, and not smoking are your best bets. Metformin for type-2 diabetes has been shown to lower the risk of strokes and heart attacks, but only about 5% over 5 years (UKPDS). None of the other diabetes medications do that. Finally, we definitely should not be keeping people on preventive drugs like statins when they are in hospice. You might be thinking who would ever do that? But more than 30% of patients with cancer had a statin prescription within the last 30 days of life! A recent randomized trial clearly showed that statins could be safely discontinued in the setting of advanced, life-limiting illness and not only were there cost savings and no increased deaths, but there was improved quality of life measures in the group whose statins were stopped. Another burgeoning area of overtreatment is in overtesting. CT scans and MRI scans have skyrocketed in the last 10 years. Lab tests are being ordered routinely as part of “check-ups.” If the person is healthy and stable, there is almost no reason for “routine” lab tests, especially if done more frequently than once a year. Routine tests upon admission to a hospital are often unnecessary. The Society of General Internal Medicine has stated that it is not necessary to have a routine preoperative testing before low-risk surgical procedures. They also state that it is not necessary for a patient to perform home glucose monitoring with Type 2 diabetes not using insulin. Routine PSA screening for prostate cancer is not recommended by numerous medical societies and the US Preventive Services Task Force. In order to promote successful longevity, we have to promote patients receiving the right care. Unnecessary tests and treatments can lead to unsuccessful lives. We have to remember that the right care is not just what has been shown to be beneficial in randomized trials. The essential ingredients of “right care” are the patient’s values, the clinician’s experience, and the evidence from high quality, clinically-meaningful studies. The American Board of Internal Medicine Foundation, through its Choosing Wisely campaign (www.choosingwisely.org) is trying to influence doctors to make educated decisions about tests and treatments. Other groups, such as the Lown Institute (www.lowninstitute.org), and the Campaign to End Unwanted Treatment (www.endumt.org) are doing similar work. The medical journal JAMA Internal Medicine has launched a “Less is More” series and the British Medical Journal (BMJ) has the “Too Much Medicine” campaign. We must educate our patients and clients that they have a choice and that they can avoid unnecessary and unwanted medical interventions. In fact, we owe it to ourselves to do the same.