Tuesday, December 2, 2014

Cutting More But Not Saving More

There's an epidemic in American health care, and I don't mean the commonly lamented ones like obesity, diabetes, or even Ebola.  It's surgery.

It would be easy to think I am referring to cosmetic surgery.  After all, according to the American Society of Plastic Surgeons, there were some 15.1 million cosmetic procedures in 2013, more than double the number in 2000.  One can question what all those cosmetic procedures say about our society's values, especially with some of the stranger procedures being done or the reasons for wanting them (selfies!) but at least cosmetic surgery is usually patient-driven and paid for out-of-pocket.

No, I'm concerned about the increase in supposedly medically necessary surgeries.

What started me thinking about this was an article in The Wall Street Journal detailing the increase in women with early stage cancer in one breast who are having both breasts removed.  The proportion rose from 2% in 1988 to 11% in 2011.  For most women -- unless they have a BRCA genetic mutation -- the double mastectomy doesn't appear to improve chances of survival.

Experts speculate that women may be making the decision out of fear or anxiety rather than objectively looking at their risk, but it still make one wonder why that percentage is rising so fast.  Is breast cancer more scary than it used to be?

Breast cancer is a very emotional diagnosis, and I can't really put myself in those women's places.  If it was just this trend, I'd leave the topic alone, but there are sizable increases in many other types of surgery as well.  Here are some examples:
  • Cesarean sections:  In 1996, the C-section rate in the U.S. was 20.7% of all births; in 2011, it had risen to 31.3%, after reaching a high point of 32.9% in 2009.  In 1965 it was 4.5%,  The WHO recommends that the rate should be no more than 15%.  Many blame the dramatic rise on mother's requesting C-sections, more medical need for them, or physicians performing them out of malpractice concerns, but Childbirth Connection disputes all those arguments.  
  • Spinal surgery for spinal stenosis:  Use of spinal fusion increased 67% in Medicare patients from 2001 to 2011, according to a report from the Dartmouth Atlas Project.  Even more telling, rates for spinal decompression vary eight-fold across the U.S., while rates for spinal fusion vary fourteen-fold.  It would appear something other than medical necessity is in play.  
  • Knee replacements: These have soared from 250,000 annually fifteen years ago to over 600,000 in 2012.  The fastest growing population is not the elderly but those 45-64, whose rates have increased 205%, versus "only" 95% for the 65+.  According to a study by researchers at Virginia Commonwealth University, as many as one-third of knee replacements may not be appropriate.
  • Heart Stents: Over the past 25 years, annual use of stents to help narrowed coronary arteries has grown from virtually none to over 500,000.  Even the AMA and the Joint Commission think that is too many, reporting that 10% may be inappropriate and another one-third are questionable. Nortin Hadler, a professor of medicine at UNC, told Bloomberg News: "Stenting belongs to one of the bleakest chapters in the history of Western medicine,"  
  • Bariatric surgery: In 2000, there were only 36,700 bariatric surgeries, versus an estimated 179,000 in 2013 (although that number may have peaked at 200,000 in 2008 and 2009).  Evidence for its effectiveness is mixed, with some studies indicating that the surgery may not have the long term positive impact on costs and longevity that many expected. 
I'm sure more clinically oriented readers can come up with other examples; the list is meant to be illustrative, not exhaustive.

Why is this happening?  There are lots of possible explanations, starting with the fact that we're simply not very good about evaluating risk.  Our brains evolved to deal with a different set of risks than surgery.  Those same brains also evolved to focus on immediate gratification over long term benefits, so when faced with a choice of surgery versus lifestyle changes or treatments that might take longer, well, it's easy to go for the perceived quick fix.

It doesn't help that there rarely are meaningful data on the risks/benefits of the surgery, the specific surgeon, and the non-surgical options.  It's hard to make informed decisions without the right information.

Another reason for the increase in surgeries could be simply because we're developing new and better ways of doing them.  Cataract surgeries are on the rise, but would anyone want to go back to how they were done in the 1960's?  Anyone not want to have minimally invasive options for a host of procedures?  There are truly marvelous surgical approaches available, requiring incredible skills from our surgeons, and it almost seems like a waste not to use them.


Finally -- and there's no avoiding it -- there is the money.  Surgeons tend to be among the highest paid physicians.  The Wall Street Journal exposed significant financial conflicts of interest for spine surgeons back in 2010, which the recent Open Payments data released by CMS have only made more troubling -- and not limited to spine surgeons.  We like to think we're not getting surgery because the surgeon stands to make a lot of money from it, but we'd be foolish to think it doesn't factor into the recommendation.

In a previous post (Mistaking Failure for Success), I had suggested that we should look at hospitalizations as a sign of failure, arguing that each admission should be accompanied by a review of what could have been done to avoid it.  I propose that we should view surgeries in the same way.

Certainly some surgeries are inevitable -- if you are shot or are born with a hole in your heart, chances are you better have surgery -- but I'd be very curious about what percentage a careful analysis might find actually are truly necessary.  A 2013 USA Today study estimated 10-20% of surgeries in some specialties might be unnecessary, and I'd bet a more in-depth review would produce an even larger share.

Any way you look at it, there's more cutting going on than there should be.

Mayo Clinic co-founder Charles H. Mayo once (supposedly) said: "It is the surgeon who benefits most from elective surgery."  That sure sounds like a recipe for an epidemic of surgeries.  More and better data on risks and benefits would be a good start to addressing the issue, so that we could at least try to make rational decisions.

I suspect, though, that we won't make real progress on avoiding unnecessary surgeries until they go from being a revenue source for providers to being a cost center.  If we were paying providers to keep us well, not to do more things to us, surgery might not be as attractive to them.

As surgeon Norman M. Kenyon once said: "The hardest thing about being a surgeon is knowing when not to do something."

To be fair, I could have equally discussed the large increases in procedures (e,.g., colonoscopies) or imaging (e.g., CT scans), for much the same reasons.  Doing more, not necessarily better, seems to be the hallmark of our health system.

Maybe we should spend less time worrying about Ebola and more time worrying about these health system-induced epidemics.

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