Medical procedures under the knife

The safety, efficacy and cost of some common medical procedures has been called into question
 
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01 .Low-value healthcare

medical-procedures-lead

Most people know by now that prescribing antibiotics for colds and flus doesn’t work - the diseases are viral, and antibiotics act on bacteria. Yet doctors still write prescriptions for them, and authorities around the world continue to battle against this ineffective, inappropriate and potentially harmful practice.

Similarly, some medical procedures evaluated and found to be harmful or less effective than alternatives - including doing nothing - are still commonly performed.

Many other widely practiced surgical, diagnostic, screening and monitoring procedures procedures have not been adequately evaluated - unlike pharmaceuticals, which have to undergo clinical trials before they can be sold in Australia.

It’s estimated only about three per cent of the 6000 or so Medicare-funded tests and treatments have undergone comparative evaluation for safety, efficacy and cost-effectiveness.

That's not to say untested procedures are dangerous, dodgy or ineffective. Many of the procedures that haven’t been formally evaluated are mechanical fixes - such as removing a bowel obstruction, suturing a wound or draining abscesses to reduce pain - and it’s clear they work. Subjecting patients to a randomised controlled clinical trial to confirm this may be considered unnecessary and unethical.

Ultimately, though, not evaluating medical procedures leaves consumers potentially wasting their time, paying out-of-pocket costs or suffering unnecessary pain or discomfort for little or no benefit.

Examples of low-value procedures medical-procedure-tools

The Department of Health and Ageing requested researchers to create a list of existing Medicare Benefits Schedule (MBS) procedures and tests that are ineffective, unsafe or used inappropriately. 

The results of the search for so-called "low value" clinical services were published in the Medical Journal of Australia. Of the list of 156 procedures, about half were treatments - mainly operations - and the rest were diagnostic, screening or monitoring investigations.

The examples listed below are not the worst, most expensive or most dangerous items - they've been chosen to illustrate the range of procedures and reasoning behind their inclusion on the list.

Arthroscopic surgery for knee osteoarthritis This typically consists of debridement and lavage, where instruments are inserted through a small incision in the skin and damaged cartilage and bone is removed and washed away. However, the outcomes are no better than placebo surgery or physical therapy and medication.

Vertebroplasty for osteoporotic spinal fractures Plastic cement is injected into spinal fractures caused by osteoporosis, which appears to stabilise the fracture and relieve pain. But it’s no more effective than placebo surgery (sticking the needle in without injecting any cement) and may also increase the risk of future fractures in neighbouring vertebrae.

Chlamydia screening Current national guidelines recommend annual screening for chlamydia for all sexually active people aged 15–25 years, and those of any age reporting a recent partner change or inconsistent condom use. In theory, screening can allow early treatment of the disease and prevent associated problems such as pelvic inflammatory disease and infertility, as well as reduce transmission of the disease and its prevalence in the community. However, there’s no good evidence that screening the general (as opposed to high-risk) population produces these benefits, although a large Australian study investigating this is underway.

Imaging Various forms of imaging - such as X-rays, CT scans, ultrasound and MRI - have been found to have no additional benefit to other diagnostic procedures in certain situations. Excessive exposure to some forms of imaging, such as CT scans and X-rays, may be harmful, and they can also be costly (see our article on medical imaging). Items where risks likely outweigh the potential benefit from additional information include:
  • Routine use of chest X-rays before operations and daily X-rays for intensive care patients – where there are no risk factors
  • Chest X-rays for acute respiratory infections (including pneumonia) and suspected acute coronary syndrome (a blockage of coronary arteries)
  • Imaging for uncomplicated lower back pain, which doesn’t improve the outcomes of treatment (versus no imaging) and may result in inappropriate treatment
  • CT scans for head injuries in children where there’s a low risk of serious brain injury
  • CT or ultrasound scans to diagnose appendicitis

Prostate Specific Antigen (PSA) testing Men aged 75-80 with PSA levels below a certain amount (3ng/mL) are unlikely to suffer from aggressive prostate cancer during their remaining life, and no longer benefit from PSA testing.

Surgery for obstructive sleep apnoea (OSA) If lifestyle changes (weight loss, reducing alcohol, quitting smoking) don’t help, the most effective treatment for OSA is a continuous positive airways pressure (CPAP) machine that delivers higher pressure to your nose to keep air passages open. While there are some successes with the many different forms of surgery for OSA, most perform poorly and there are side-effects. Surgery should only be a last resort if CPAP (or a similar device) fails.

Adenoidectomy for children Removal of adenoids is often performed on children with recurrent or chronic nasal infection symptoms, such as runny nose or obstruction, however there’s no evidence it helps. Children with recurrent episodes of otitis media with effusion, also known as glue ear, may be treated with small ventilation tubes (grommets) inserted into the eardrum, and in many places adenoids are removed at the same time. However there’s no evidence of any improvement in hearing due to the adenoidectomy.

Why are low-value procedures still done?

Why would doctors schedule tests and treatments that aren’t in the best interests of their patient? The example of arthroscopic surgery for knee osteoarthritis gives some clues. A study of Victorian hospitals found that despite mounting evidence over 10 years that arthroscopic procedures for osteoarthritis of the knee is of questionable benefit, its use over this time didn’t decrease, and actually increased for certain groups.

This could be put down to positive personal experiences of surgeons. Other reasons include:

  • delays in evidence being put into practice, via clinical guidelines and health system processes
  • the odd contradictory study that appears to make the consensus less certain
  • the preference of some patients to have surgery rather than trying to lose weight or other self-care treatments.

Similarly, for vertebroplasty for osteoarthritis, doctors practice it because they see it work – their patient gets almost immediate pain relief, at least in the short term. But placebo surgery also works in the short term, and in the longer term surgery is no better than other therapies.

 
 

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MBS Comprehensive Management Framework

The federal government has established the Comprehensive Management Framework (CMF), tasked with ensuring new and existing MBS items are safe, effective, represent value for money and will lead to improved health outcomes in patients.

Now - just like new drugs are put before the Pharmaceutical Benefits Advisory Committee before they can be listed on the Pharmaceutical Benefits Scheme (PBS) - new tests and procedures have to get past the Medical Services Advisory Committee to be listed on the MBS and therefore be eligible for Medicare rebates.

With more than 6000 procedures on the MBS, there’s much work ahead to identify which treatments are ineffective by contemporary standards, potentially do more harm than good, or are less cost-effective than alternatives.

This can be done by means of clinical trials, where a procedure is tested against a placebo treatment. There is also so-called comparative effectiveness research, which compares new or existing procedures to other (non-placebo) treatments. 

The results could mean revising clinical guidelines to reflect best practice or, for those where the main concern is cost, removing them from the MBS - a process called disinvestment. Vertebroplasty for osteoporotic fractures, for example, has already been removed from the MBS, though it’s still practiced.

This will undoubtedly have flow on benefits to healthcare consumers, saving them time and money, and preventing unnecessary pain or discomfort for procedures of little or no benefit.

By freeing up funding for procedures that do help, all health consumers benefit.

What you can do

With doctors not always making appropriate decisions on behalf of their patients, the onus is on patients to take some responsibility for their care – an approach advocated by the Choosing Wisely campaign, created by US physician societies in collaboration with our US sister organisation, Consumer Reports.

This isn't ideal, since many consumers aren’t particularly health-literate or may feel it’s not their place to question a doctor’s authority. But until the CMF has made significant headway on its task of assessing not only new but existing procedures for effectiveness, your best bet is to inform yourself.

• Look up the Choosing Wisely lists, either by speciality (paediatrics, ophthalmology, neurology etc) or condition. For many procedures, the information is relevant for Australians.

• Get a second opinion for any significant tests or surgical procedures.

• Don’t go looking for apparently non-invasive procedures such as CT scans and X-rays. If they’re ordered, ask if it will change the way your condition is managed, or prevent a more invasive procedure (like exploratory surgery).

• Invite a friend or relative to come with you to the doctor. They can take notes for you while you talk, and also help you make sense of what you were told.

International approaches

United Kingdom

The UK’s National Institute for Health and Care Excellence (NICE) is an independent organisation charged with assessing new drugs and treatments as they become available and providing guidelines on how a particular condition should be treated. NICE also maintains a database of clinical practices it recommends should be discontinued or not be used routinely - the "Do not do" recommendations. Practices are included due to evidence of ineffectiveness, or a lack of evidence to support its continued use.

United States

Choosing Wisely colleges and medical specialist societies have compiled lists of five things patients and doctors should question within each speciality, regarding tests, procedures and medications. Consumer-friendly resources on tests, procedures and medications have also been created by our US counterpart, Consumer Reports, in conjunction with these societies.
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