Editorials

Benefits of Avoiding Unnecessary Medical Care During the COVID-19 Pandemic

 

Am Fam Physician. 2021 May 15;103(10):584-585.

Throughout the world, hospitals and health care professionals continue to confront the acute crisis of caring for patients with COVID-19. Focusing on care for patients who are critically ill has de-emphasized routine medical care, including wellness examinations, chronic disease management, elective surgical procedures, vaccinations, preventive health care, and screening for cancer and other diseases.1 It is estimated that nonemergent medical care decreased by up to 60% during the spring of 2020.1,2

Stringent hospital visitation policies and a fear of becoming infected while in the hospital or clinic have led many patients to defer or avoid necessary medical care, with severe consequences, including death from strokes, heart attacks, and other acute illnesses.3 However, there may be a silver lining to deferring certain types of routine care.4 For many years, studies have shown that the U.S. health care system provides a high volume of low-value care, defined as medical services for which the potential for harm or high cost generally outweighs the benefits.57 Low-value care is not only wasteful but often leads to a cascade of overtesting, overdiagnosis, overtreatment, and increased morbidity and mortality.8,9 Between 10% and 20% of the medical care prescribed in the United States is considered low value at an estimated cost of more than $300 billion annually.10,11

Tests and procedures often cited as providing low value include diagnostic imaging (e.g., magnetic resonance imaging, computed tomography), cancer screening in older patients, and many orthopedic and interventional pain management procedures.1217 The value of the annual adult wellness examination has also been questioned because it does not measurably improve health outcomes and is often accompanied by low-value screening tests, such as electrocardiograms, thyroid function testing, and urinalyses, which often lead to unnecessary evaluations.9,18

Despite progress in identifying overused services through programs such as Choosing Wisely (https://www.choosingwisely.org), the Dartmouth Atlas Project (https://www.dartmouthatlas.org), and American Family Physician's Lown Right Care series (https://www.aafp.org/afp/rightcare), more needs to be done to reduce overuse in clinical practice.

How can the avoidance of routine care during the pandemic benefit patients? More than one in five adult wellness examinations includes an electrocardiogram; however, the U.S. Preventive Services Task Force recommends against performing this test in asymptomatic, low-risk adults because harms outweigh potential benefits.19,20 A decreased number of wellness examinations and nonemergency procedures during the pandemic has been associated with a 46% decrease in the number of patients receiving elective cardiac catheterizations.21 Data show that invasive approaches to managing patients with stable coronary artery disease are no better than appropriate medical management; therefore, it is likely that effects from the COVID-19 pandemic helped reduce costs and procedural risks with similar or better clinical outcomes for many patients.22

The COVID-19 pandemic has caused significant disruptions to our health care system and our lives. It has highlighted and exacerbated health disparities, social injustice, and systemic racism in medicine. We need to learn from the pandemic. Some call the pandemic a natural experiment in our health care system; however, the pandemic has also provided an opportunity to evaluate which medical services are truly necessary and what patients can do without.4 Family physicians need to provide patient-centered, evidence-based care that minimizes waste, overuse, and underuse. When most of the population have received an effective COVID-19 vaccine, the temptation to go back to normal will be difficult to resist. However, the COVID-19 pandemic should encourage clinicians to stop providing ineffective services that have not been demonstrated to improve patients' health.

Address correspondence to Alan R. Roth, DO, FAAFP, FAAHPM, at aroth@jhmc.org. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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2. Mehrotra A, Chernew M, Linetsky D, et al. The impact of the COVID-19 pandemic on outpatient visits: practices are adapting to the new normal. The Commonwealth Fund. June 25, 2020. Accessed December 26, 2020. https://www.commonwealthfund.org/publications/2020/jun/impact-covid-19-pandemic-outpatient-visits-practices-adapting-new-normal

3. Baugh JJ, White BA, McEvoy D, et al. The cases not seen: patterns of emergency department visits and procedures in the era of COVID-19. Am J Emerg Med. 2020;S0735-6757(20)30964-5.

4. Oakes AH, Segal JB. The COVID-19 pandemic can help us understand low-value health care. Health Affairs. October 27, 2020. Accessed December 26, 2020. https://www.healthaffairs.org/do/10.1377/hblog20201023.522078/full/

5. Pandya A. Adding cost-effectiveness to define low-value care. JAMA. 2018;319(19):1977–1978.

6. Schwartz AL, Landon BE, Elshaug AG, et al. Measuring low-value care in Medicare. JAMA Intern Med. 2014;174(7):1067–1076.

7. Reid RO, Rabideau B, Sood N. Low-value health care services in a commercially insured population. JAMA Intern Med. 2016;176(10):1567–1571.

8. Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;307(14):1513–1516.

9. Ganguli I, Lupo C, Mainor AJ, et al. Assessment of prevalence and cost of care cascades after routine testing during the Medicare annual wellness visit. JAMA Netw Open. 2020;3(12):e2029891.

10. Shrank WH, Rogstad TL, Parekh N. Waste in the US health care system: estimated costs and potential for savings. JAMA. 2019;322(15):1501–1509.

11. Carter EA, Morin PE, Lind KD. Costs and trends in utilization of low-value services among older adults with commercial insurance or Medicare Advantage. Med Care. 2017;55(11):931–939.

12. Chou R, Fu R, Carrino JA, et al. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009;373(9662):463–472.

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17. Chou R, Hashimoto R, Friedly J, et al. Pain management injection therapies for low back pain. Agency for Healthcare Research and Quality; 2015.

18. Krogsbøll LT, Jørgensen KJ, Gøtzsche PC. General health checks for reducing morbidity and mortality from disease. Cochrane Database Syst Rev. 2018;(1):CD009009.

19. Bhatia RS, Bouck Z, Ivers NM, et al. Electrocardiograms in low-risk patients undergoing an annual health examination. JAMA Intern Med. 2017;177(9):1326–1333.

20. U.S. Preventive Services Task Force. Final recommendation statement. Cardiovascular disease risk: screening with electrocardiography. June 12, 2018. Accessed February 1, 2021. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/cardiovascular-disease-risk-screening-with-electrocardiography

21. Kadavath S, Mohan J, Ashraf S, et al. Cardiac catheterization laboratory volume changes during COVID-19-findings from a cardiovascular fellows consortium. Am J Cardiol. 2020;130:168–169.

22. Maron DJ, Hochman JS, Reynolds HR, et al.; ISCHEMIA Research Group. Initial invasive or conservative strategy for stable coronary disease. N Engl J Med. 2020;382(15):1395–1407.

 

 

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