Tuesday, July 7, 2009

Is useless harmful?

An interesting paper appeared in last week's issue of the Journal of the American Medical Association (JAMA) entitled "Exploring the Harmful Effects of Health Care" by Kilo and Larson. It was a call to action by two very astute researchers to start setting an agenda for quantifying the full benefit-harm proposition of healthcare in the US. They went so far as to propose a taxonomy for this issue, consisting of direct and indirect harms. Direct harms are defined as adverse physical and emotional effects of healthcare encounters, while indirect ones are "collateral effects on individuals and communities not directly involved in care".

This exploration is very timely as we engage with each other and with policy makers in health reform discussions. We hear a lot about hospital-acquired complications, as well as quality deficits that have resulted in 44,000 to 98,000 unnecessary deaths annually in the US hospitals. We are inundated with information on the emergence of superbugs and the threat they present to humankind. We are very aware of the need to screen for and treat aggressively such public health scourges as diabetes, hypertension and obesity. Ostensibly, we have a lot of information already on what needs to change in our approach in order to improve quality and efficiency of the healthcare system.

Believe it or not, this is a mere tip of an enormous iceberg that is about to challenge the Titanic that is our healthcare system today. While it is clear that some of the answers lie in improving the quality of delivery so as to prevent unnecessary morbidity and mortality in our institutions, this single-pronged approach promulgated by vocal policy think tanks and adopted by most if not all reimbursing and regulatory bodies is doomed to fail. The problems lie far upstream from the fateful contact with this healthcare system. What I mean by that is that we need to examine our assumptions about risks and benefits of the very interventions that bring us to this precipice. Although there is some evidence that it is feasible to control pharmacologically marginally elevated blood pressure in an individual, the evidence of the benefit of such control is scarce. Furthermore, in our zeal to stamp out this silent killer, we generally fail to stop and weigh the potential harms of such treatment against the miniscule, if any, benefits to essentially healthy people. This logic can apply to a wide range of currently recommended "evidence-based" interventions, ranging from the annual physical exam to, you guessed it, screening mammography. And you already know how I feel about the risk that a false positive presents to your health!

One final thought about indirect harms. Yes, we need to think hard about whether or not it makes sense to spend 60% of all healthcare dollars in the last 6 months of life, and yes we would probably agree that there are better ways to allocate the limited healthcare resources. But indirect harm has another more insidious face as well. The famous Roemer's rule states that "a built bed is a filled bed", meaning that the availability of a resource encourages its use. In this context, what is the environmental impact of producing healthcare implements that promise a generous return on investment (through our woefully misaligned incentives), from MRI machines to new hospital facilities, implements that may be promoting at best useless and more likely harmful overuse? And what about the medical waste that is created unnecessarily by this overuse and the polluting chemicals that form in the process of its disposal?

Once again I find myself gravitating toward that adage: "less is more". In this season of healthcare reform buzz let's think hard about the consequences of inaction or wrong action. Because useless in this instance is not just unnecessary, but potentially deadly.

1 comment:

  1. Your closing comment about "less is more" is a mantra to authors, especially of fiction. It's a pity not more of them (along with the healthcare industry) pay scant attention to it.

    ps: I retweeted you this morning!