More not always better
More Care Is Not Always Better
What’s the Issue?
It is easy to assume that the real problem with the healthcare system is “not enough” – not enough physicians, not enough MRIs, not enough money in the system. But what does the evidence show? What is the right amount of healthcare? And what kind of care are Canadians getting?
A growing number of studies show that more healthcare is not always better and the more expensive drug is not necessarily the right choice. In fact, the evidence suggests that sometimes more care, care that you don’t need, can be harmful and expose patients to unnecessary risks.
So what is the “right amount” of care? Getting the “right amount” of healthcare means that you are getting as much care as you need, but no unnecessary care. Here are some examples: Getting antibiotics for an infection that is helped by antibiotics is the “right amount” of care. Getting antibiotics for a condition that is not helped by antibiotics – such as the common cold – would be unnecessary care. Staying on schedule with the preventive care and screening tests that are recommended for your age and health condition is the “right amount” of care. Having preventive care and screening tests more often than recommended would be unnecessary care.
- For detailed information on overuse in the healhcare system, visit Lown Institute – Overuse 101. Overuse is a catchall term for medical tests, treatments, and other services that patients don’t need or don’t want.
- A March 2014 editorial published in Annals of Internal Medicine has examined the problems of figuring out how much is enough medicine and how to think about guidelines. See: Controversy Over Clinical Guidelines: Listen to the Evidence, Not the Noise by Dr. Eliseo Guallar and Dr. Christine Laine, Editor in Chief.
- Tools for Practice provides biweekly articles for its members that summarize medical evidence on a clinical question. Tools for Practice is sponsored by the Alberta College of Family Physicians (ACFP).
- Doctor (123456789), a parody of Tommy Tutone’s song Jenny (867-5309) addresses the critical information we need to know about cardiovascular disease risk prevention. Bottom line, we need to know our percent risk of heart attack/stroke with NO treatment versus our percent risk ON treatment and the chance of harm.
- Journalist Ann Silversides in the article Mammography screening: Weighing the pros and cons for women’s health, wades through the recent controversies about mammography screening, explaining the issues and summarizing the evidence. This article won the “Best Online Story” at the 2012 Media Awards sponsored by the Registered Nurses Association of Ontario (RNAO).
- Many Canadians believe we have one of the best health care systems in the world, but in recent international rankings for health care quality, Canada places in the middle or at the bottom of the pack. So it is not surprising that provincial and territorial governments are increasingly focusing on quality improvement to move their systems towards better quality and at the same time find efficiencies and cost savings. This 2013 report, “Which way to quality? Key perspectives on quality improvement in Canadian health care systems“, builds on the Health Council of Canada’s interviews and surveys of senior Canadian health care leaders about their perspectives and experiences with system-wide quality improvement. It highlights activities and approaches being taken across Canada, and reveals innovative practices and initiatives in different jurisdictions for readers. To see the infographic “Which Way to Quality?” click here.
- See the Canadian Foundation for Healthcare Improvement (CFHI) Mythbuster focused on the Myth: C-sections are on the rise because more mothers are asking for them.
Synopsis: The rate of Cesarean sections performed in Canadian hospitals has increased by nearly 10% from 1995–1996 to 2008–2009, and it’s not because women are clamoring for them. The preferences of physicians, not maternal preferences, are driving the numbers up. Many obstetricians believe that C-sections are as safe as natural childbirth. A belief not supported by scientific evidence. Surgery always has risks. Canada’s healthcare system could save close to $25 million if the rate of first-time, let alone, repeat C-sections, could be reduced by 15%.
- Steven Birnbaum, a radiologist notes: A spiral scan of the abdomen or pelvis exposes a patient to about 10 mSv of radiation. The risk of one or two studies is negligible. But in young patients, five of these studies exposes a patient to the amount of radiation that produced carcinogenic effects in the atom bomb survivors of Hiroshima and Nagasaki. In the United States, an estimated 60 million CT studies were done in 2006. Many doctors-including radiologists-have limited knowledge of the doses and of the potential consequences of the massive increase in diagnostic medical radiation exposure.
- Two medical ethicists have recently shown that drugs which pharmaceutical companies market most aggressively to physicians and patients tend to offer less benefit and more harm to most patients.
- Healthcare in Canada 2010: Evidence of progress, but care not always appropriate: Regional variations highlight potentially unnecessary surgical procedures.
- Atul Gawande, an American surgeon has described the characteristics of McAllen, Texas, one of the most expensive health-care markets in the United States. Here Medicare spends $15,000 per year on every enrollee. Gawande found patients in McAllen got more of pretty much everything (more testing, more surgery, more home care, etc) and he found no evidence that residents were healthier, or the quality of care they received, was better.
- See the Canadian Foundation for Healthcare Improvement Mythbuster focused on the Myth: In Healthcare, More is Always Better. Note: the Mythbusters are a series of essays giving the research evidence behind Canadian healthcare debates. Synopsis: when it comes to invasive procedures, and even diagnostic testing, “less is more…and better.”
- A recent report from the Health Council of Canada highlights the need for more monitoring of drug safety and effectiveness in Canada noting that while pharmaceuticals can offer significant health benefits, “there are also many risks associated with their use.”
- See the Canadian Foundation for Healthcare Improvement Mythbuster focused on the Myth: Generic drugs are lower-quality and less safe than brand-name drugs.
Synopsis: medicinal or active ingredients must meet the same Health Canada standards whether the drug is a generic or brand-name.
- The Canadian Agency for Drug and Health Technologies showed an over-use in blood glucose test strips, which greatly increases costs without providing any benefit.
- See also from the Canadian Foundation for Healthcare Improvement: Reference-based drug insurance policies can cut costs without harming patients.
Synopsis: Reference pricing of drugs is one successful way for insurers to cut costs without negatively affecting patients, allowing public funds to be better spent on effective treatments.
Are medications helping or hurting children with ADHD?
Over the past twenty years, mental disabilities have overtaken physical disabilities as the leading cause of activity limitations in children. Today, Attention Deficit Hyperactivity Disorder (ADHD) is three times more likely than asthma to be contributing to childhood disability in the United States.
Most medications prescribed to children have not been adequately studied
The development of new therapies has provided our health care system with enormous advances, such as insulin for diabetes, antibiotics for infections or chemotherapy for many cancers. Yet these therapies may also cause potential harm, even death, so the benefits have to be carefully weighed against the risks.
The best health advice you’ll get today?
I was about to call it a day when an email arrived with the following in the subject line: “The Best Health Advice You’ll Get Today.” That caught my attention. I was curious. And I’m a sucker for free health advice.
When first introduced four decades ago, breast cancer screening with mammography was widely regarded as an important tool in the fight against this terrible disease. It seemed obvious that the earlier it could be diagnosed the more lives could be saved. Aggressive treatment, it was thought, would prevent the cancer from spreading through the body.