In Medicine, Sometimes More is Less

Gary Li , MD

Regional Director

Published May 01, 2013

In most of the prior blogs you have heard a lot about the inexorable forces of change in our healthcare system which are leading to consolidation of health care entities, integration of service lines, accountable care organizations, and so on. Fundamentally, these forces are the oft-state three mandates of improving quality, improving access, and decreasing costs. Keith Bontrager of mountain bike building fame used to say “strong, light, cheap—pick two out of three.” Well, perhaps carbon fiber has changed that paradigm for bikes. Going forward, in medicine, we are also expected to go three for three. Here I would like get into the weeds a bit and ponder resource utilization in clinical practice and the relationship with the Acute Care Continuum.

Analogous to fast food “supersize” meals, more medical care does not always mean better care. Gradually, many healthcare providers and members of the public are beginning to understand this. The “Choosing Wisely” initiative of the American Board of Internal Medicine Foundation is indicative of this recognition and concern. In this program, each medical specialty identifies five diagnostic or therapeutic interventions that may be of questionable value. Programs like this are encouraging medical providers to let go of tests and procedures that are not helpful, may be harmful, and are expensive.

Excess or inappropriate utilization of resources directly affects cost and quality and has a secondary effect upon access -- lower costs presumably free up more money within the overall healthcare system to improve access. For providers, with more shared risk coming down the pipeline (e.g. “bundled payments” or ACOs), there will be direct financial incentives to improve value. Currently, most focus remains on a volume or fee-for-service model, due to the balance of incentives and penalties. But entities or individual providers who do not recognize and prepare for the fundamental paradigm shift will not be successful in the near future.

The cost component of improving resource utilization is intuitively clear; no one wants to pay for tests or treatments that do not add value. But the harm done by inappropriate utilization is more complex. Complications of over-testing, over-diagnosing, false positives, and over-treating are real concerns. Recent studies have shown associations between increased ED utilization, increased ED LOS, and poorer outcomes (Pitt, et. al. Annals of EM 2012, Sun, et. al. Annals of EM 2012, BMJ 2011). Though there is no proven cause-effect in these studies, we would all agree that we should never do what is unnecessary or harmful.

I would also advocate caution in how we utilize new technology or incorporate well-intentioned new recommendations into clinical practice. Sometimes these can create a vicious cycle of further increasing utilization and potential harm. Take sepsis, for example. Yes, we can and should do better. However, as we include more low-acuity patients as “septic,” we will invariably have better outcomes simply because they are less ill. We then may come to the false conclusion that the more aggressive screening and management are beneficial, leading to an even more aggressive process. In this example, individual patients who may not need treatment are also exposed to the potential harm of unnecessary treatment. Such situations remind me of the Will Rogers’ quote “when the Oakies left Oklahoma and moved to California, it raised the IQ of both states.” No one really got smarter.

So, what to do? Decreasing utilization in a system and society accustomed to “more is better” will be hard work. Ultimately, we will need to communicate and collaborate better across the entire Acute Care Continuum in order to decrease unnecessary utilization. Although integration of the players into single entities may be helpful, lack of such integration should not slow our efforts.

Our default should be to do less unless there is reasonable evidence that doing more is valuable. We must keep abreast of the latest evidence. For example, the Society of Hospital Medicine has already come out with its initial list of questionable tests and treatments and the American College of Emergency Physicians is currently developing one.

Locally, we need to work on narrowing the bell-shaped curve of practice variation to a range that is supported by the evidence. This will require valid data, discussion, feedback, and education. In our own clinical practices we should always consider the risks, benefits, and harms of each and every test and treatment ordered and have realistic discussions with our patients. For example, my physician group has such an initiative for decreasing CT utilization.

Reducing overutilization will not be a simple task and raises other questions. For example, how can we practice with such restraint and still protect ourselves from malpractice suits? And how do we deal with patients and families who continue to demand more? Also, we are stuck with many regulatory mandates that may be of dubious value. Nonetheless, if we as clinicians do not take the initiative, we will risk harming patients, being hurt financially, and others (like regulators and legislators) will prescribe and proscribe patient care in ways that are in no one’s best interest.

What can we do to balance all these varying pressures on resource utilization? I welcome your thoughts.

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