Monday Aug 29, 2016
Family Physicians Can Cut Unnecessary Surgeries
In 1954, JAMA published an article(archsurg.jamanetwork.com) that explored unnecessary and inadequate breast cancer surgery. In those days, surgeons favored more aggressive procedures such as radical mastectomies with removal of a high number of lymph nodes.
During that same era, tonsillectomies were common in children with throat infections. In the six decades since then, we have learned that breast-conserving surgeries with medical management result in better outcomes for patients with early-stage cancer, and tonsillectomies should be reserved for children with more severe, recurrent throat infections (or sleep disorders).
We have this knowledge because of strides made in evidence-based medicine -- specifically, robust clinical trials that demonstrate relevant outcomes of surgery. Does the surgery extend a patient's life? Does the surgery decrease a patient's pain? Does it improve the patient's quality of life?
Answering these questions, along with weighing risks and other treatment options, should help guide decisions regarding whether to pursue surgery. But even with better data, unnecessary surgeries are still common.
One of the most common examples is spinal fusion, where vertebrae are joined together to treat low back pain caused by issues such as degenerative discs. Various trials have shown that the surgery is not necessarily superior to nonsurgical managements(www.ncbi.nlm.nih.gov), including physical therapy or even cognitive therapy. And yet more than 400,000 of these operations take place annually in the United States, with the aggregate cost for related hospital stays totaling $12.8 billon(www.hcup-us.ahrq.gov).
Even otherwise life-extending surgeries can be considered unnecessary when performed in the wrong patient populations because they provide only dubious benefits. A 2011 JAMA study(jama.jamanetwork.com) found 22.5 percent of people who received an implantable cardioverter-defibrillator did not meet evidence-based criteria for implantation. These patients had a higher risk for complications and longer hospital stays.
Overall, the reasons for unnecessary surgeries are not as sinister as claimed by mainstream media such as USA Today, which in 2013 chalked up unnecessary surgeries to immorality, incompetence or indifference(www.usatoday.com).
So what is driving unnecessary surgeries? Simply put, the fee-for-service health care system rewards physicians and facilities for doing more procedures. And surgeons feel an implicit expectation that, by the time patients reach them, they are leaning toward an operation.
Accountable care organizations (ACOs) have looked at this issue. ACO expert David Muhlestein, Ph.D., J.D.(khn.org), concluded, "Reducing unnecessary surgeries might be better achieved by helping primary care physicians change their referral patterns rather than targeting the surgeons themselves."
Indeed, one primary care doctor per 10,000 people can reduce surgeries by 7 percent(health.usnews.com), according to an article published last year in U.S. News & World Report.
Family physicians can play a prominent role in counseling patients on surgical and nonsurgical treatment options. We are able to take a holistic, unbiased and evidence-based view. However, many primary care physicians defer to a surgeon to provide education because of time constraints in the current fee-for-service environment. Educational sessions with decision aids are often difficult to fit into a 15-minute office visit.
Patients also play a role in the demand for surgeries of questionable value. Our culture has convinced patients that more care equals better care. Every family physician knows the delicate art of debunking that dogma.
I recently had a patient with classic low back pain. Her physical therapy sessions were a time-consuming part of her busy schedule, and she was tired of taking OTC meds. She requested a consult with a spinal surgeon. Knowing this wasn't the best option, I encouraged her to try a few more session of PT, weight loss and even consider nontraditional treatments such as acupuncture. But the patient wanted a quick, aggressive fix and I suspected she felt as though my resistance to refer meant I was withholding care from her. So I referred her to a surgeon I knew would reiterate what I already had advised.
I'm not alone. More than half of primary care physicians have made unnecessary referrals to subspecialists because of patient demands(www.ajmc.com).
So how do we create a system that curbs unnecessary surgeries? The burden cannot fall on our surgery colleagues alone; it will require system changes.
A team-based approach to care offers a reasonable solution. Consistent messaging from the patient's primary care physician, subspecialist and other clinicians involved in the patient's care may demonstrate which treatments are ineffective and which are supported by research.
Payers are only starting to tackle this issue. Medicare pays for second (and third) opinions(www.medicareinteractive.org) before surgery. And, of course, more emphasis on value-based reimbursement will foster an environment in which time is allowed for shared decision-making driven by evidence.
Finally, as family physicians, we have to help patients view their health care with a wider lens -- to appreciate outcomes, not actions.
Natasha Bhuyan, M.D., is a board-certified family physician in Phoenix. You can follow her on Twitter @NatashaBhuyan(twitter.com).
Posted at 01:41PM Aug 29, 2016 by Natasha Bhuyan, M.D.