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Health memo to COAG part one: it’s time to tackle waste and inefficiency

With health reform high on the agenda of the forthcoming COAG meeting, it is worth reminding ourselves about why we need it.

It is also worth  being reminded that simply spending more money is no guarantee of better health or even better health care. We currently waste much money on treatments of dubious or uncertain value, often at some significant cost to patients.

Read more about some of the areas that COAG should be examining in this  series of discussions between public health expert Professor Stephen Leeder, Canadian health policy consultant Professor Steven Lewis and Melbourne specialist Dr Richard Barnes.

The discussion began with this article, recently published in the Medical Journal of Australia by Professor Steven Lewis and Professor Stephen Leeder, which argued that:

• Traditional health care is fragmented, marred by quality and safety defects, with a failure to provide evidence-based care, and huge and unjustifiable variations in practice.

• There is abundant evidence that traditional means of delivering health care are obsolete.

• Concerns are deepening about persistent and widening gaps in health status that health care cannot overcome.

• Increased spending on health care has never definitively solved the problems of access, quality, or equity.

• Non-medical determinants of health indicate that the solutions to health problems lie mainly outside health care.

• The current financial crisis may create the urgency and courage to both eliminate the fundamental problems in health care delivery and reduce health disparities.

According to Leeder, the article provoked more response than any other he had written.

This is one of the comments that flew in, from a Melbourne anaesthetist, Dr Richard Barnes. He wrote:

“I believe it is one of the most important articles published in the MJA in a long time; the issues you raise deserve wide, thorough and extensive discussion, not just by doctors and health administrators, but by the general public.

I’d like to comment on one aspect of your article.

You suggest that we, via government, should look particularly to cut  areas of absolute waste – the zero or negative return domains rather than risk the middle-class backlash from cuts to marginally effective services. At face value, your recommendation seems unarguable, yet it may be more complex than is immediately apparent.

For many health interventions, the evidence which would enable us to  assess their effectiveness simply doesn’t exist. Often the research  simply hasn’t been done. In many cases, research has shown a particular treatment to be effective, but the therapy is now applied to groups outside the subject group of the original research. For example,  I often wonder how much benefit octogenarians gain from treatment with statins. (And every second 80-year-old seems to be taking them!)

Earlier in the year, Elshaug et al published “Identifying existing health care services that do not provide value for money” (MJA 2009; 190: 269-273). Disappointingly, but not surprisingly, the table which lists interventions clearly shown to be of no benefit, is most striking for its inability to identify any “really big stuff”.

The authors go on to list some much juicier areas for further research, to which could be  added some other obvious topics, such as the whole area of medical therapy versus Percutaneous Coronary Intervention versus coronary artery graft surgery for ischaemic heart disease. The combination of complexity  and vested interests makes it highly unlikely that definitive answers will be available any time soon.

Many treatments, on the other hand, have been or can be shown to be  of marginal benefit. Prolonged, complex and expensive treatments in the very premature  and very old are obvious examples but it is my impression that a  large amount of what we do in acute tertiary hospitals is futile or  of very marginal benefit.

A few years ago, an anaesthetist colleague made a preop visit to an old man who was scheduled to undergo thoracoabdominal repair of a suprarenal “aortic aneurysm”. How do patients undergoing this operation usually get on? asked the old man. When informed that of the past six done at the relevant hospital, four were dead, one was paraplegic and one was well, the patient discharged himself. In one sense, the proposed procedure offered a marginal benefit; one in six patients had a successful outcome. But the old man had made the entirely correct evaluation, that the benefit did not come without a cost – not just in pain and suffering for all ten, but loss of life, or loss of quality  of life, for the other nine.

The average layman is not unaware of these issues – they are among the main themes of Jodie Picoult’s “My Sister’s Keeper”, for example. Tools such as QALYs (quality-adjusted life year, used to measure disease burden) can be used to add some sophistication  to the evaluation of a particular treatment or therapy.

What of an intervention with virtually no risk, but very little  benefit, involving children: MRI scan under general anaesthetic for assessment of developmental delay. I have anaesthetised hundreds of children for this procedure. An audit I performed of a series of such scans confirmed what the limited  published data also say: the majority will have evidence of hypoxic-ischaemic encephalopathy; the minority will have no MRI abnormality;  in some, the scan will afford some prognostic information; rarely,  the scan will suggest a diagnosis with implications for genetic  counselling; rarely, if ever, will the scan lead to an unexpected diagnosis of a condition for which there is a helpful therapy.The general anaesthetic probably has a 1:100,000 risk of causing death, but the scan costs perhaps $2,000 and every tertiary paediatric hospital in the  developed world has an unmanageable waiting list for paediatric MRIs under GA.

I’m sure all of us have our pet  examples of treatments of dubious value.

What I’m saying is that we should not focus solely on eschewing treatments of proven zero value but we should also lead our colleagues, health administrators and the public (in reverse order) to well-informed, dispassionate discussions and decisions about the costs – including the opportunity costs – versus the benefits of the many medical treatments on or  near the flat of the curve.”

***

Steven Lewis replied:

“Your points are indeed well-taken, and particularly the relative paucity of “blockbuster” no-value-added interventions and services.  However, I do think there are a number that get very close to this, especially if we are talking about NET zero or negative value (i.e., some positive benefit but also harm that equals or exceeds the positive benefit, as in the case you cite).

Here the candidates include:

1.  Off-label use of drugs, e.g., the notorious Bextra for which Pfizer has just paid a $2.3 billion fine for misleading marketing.

2.  Substitution of more expensive drugs for cheaper drugs, e.g., ranitidine vs. cimetidine for acid reflux, where the latter – older and far cheaper – is just as effective in well over 90% of cases and should always have remained the drug of first resort before switching.

3.  Mammography for women under 50 (I know this may be somewhat controversial but there appears to be growing consensus that the sceptics were always right); same for universal or population-based (as opposed to targeted) PSA screening

4.  X-rays for suspected broken ankles (if you follow the Ottawa Ankle rules)

5.  A great deal of precautionary MRI and CT scanning (these are of course of great value when used appropriately and there are gray areas but I think it would not be difficult for expert panels to eliminate a third of all utilization with simple algorithms based on experience to date)

6.  Arthroscopic knee surgery (pretty much all of it) and a good deal of back surgery

7.  The use of BEERS drugs in the elderly (BEERS is a list of medications that may be inappropriate for use in the elderly).

Now, it is very likely true that compiling a comprehensive list might not add up to more than 10% of health care spending, although that is no small change given current expenditure levels (that would be $18 billion in Canada, which could transform both child care and post-secondary education).

But there are other forms of outright waste, as in, avoidable hospitalizations and length of stay, achievable not by denying people what they need, but by giving them what they need when they need it (hence the famous comparison of Kaiser Permanente vs. NHS expenditures a few years ago, which found, remarkably, roughly equal per capita costs, with the Kaiser performance attributable entirely to doing a lot more on the prevention and health maintenance end and using 1/3 of the hospital days per capita).

But as you point out, the implicit issue is whether we should declare something to be “useless” or “valueless” unless it can be proven (not merely suggested) that it is unhelpful or harmful almost all of the time.

Well, we do this quite regularly, mainly in the area of drug formulary decision-making, where the main criterion is usually, it’s not worth it (rather than, it’s entirely useless or adds no value in no cases compared to existing products).  If we apply the standard of absolute sensitivity and specificity to our definitions, there won’t be very much to eliminate categorically.

Hence the real discussion – much more nuanced than we were able to make in our short piece, and in any case I suspect Steve and I would have to have many dinners, some randomly assigned to include a lot of good wine and other potions to test for the effect on our wisdom, before we could agree on exactly where we would draw the line conceptually, let alone empirically, on the issues of probability and risk.

The real challenge is to reduce the “number needed to treat” to achieve positive benefits.  If you prescribe Ritalin to enough kids you will generate a positive effect on ADD, but if we systematically overdiagnose ADD we will cause harm and/or be less efficient.  A vastly oversimplified but nonetheless, I would suggest, reasonable description of contemporary health care is that it is fixated on sensitivity and indifferent to specificity.

In any event, your remarks have done what good remarks should – they have stimulated further thinking.  I can imagine a great 2-day symposium on conceptual and empirical issues in eliminating health care waste, ending in a consensus statement on how to go about (yes I am on occasion an optimist).”

Comments 2

  1. Ian Haywood says:

    cimetidine/ranitidine is a bad example: cimetidine is barely available now, and there are good reasons for junking it: the very large numbers of interactions with other drugs. Ranitidine is long off-patent so the cost savings are minimal anyway.
    A better example would be the later iteration of peptic ulcer treatment: omeprazole vs. esomeprazole, the (pharma-sponsored) studies don’t compare equivalent doses so obviously esomeprazole comes out better, and there is no putative mechanism for why it would work better.

    Off-label prescribing is a complex issue, as listed indications often have more to do with the commercial exigencies of the manufacturer rather than want the drug is actually useful for. The biggest issue is that many manufacturers don’t bother getting a paediatric listing, so much of paediatric (and pretty much all child psychiatric) prescribing is off-label.

    Even in adults off-label prescribing is pretty common, much of it is inappropriate, sure, but much isn’t. For example, consider psychotic depression. It’s not schizophrenia or bipolar, so technically none of the newer antipsychotics are listed. If off-label was forbidden these patient would have to be on older drugs which have much more severe side-effects. Yet if the same patient later had a manic epsiode, without psychosis, magically the newer antipsychotics would be ‘allowed’ (under the bipolar listing), even though this makes no sense clinically.

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Gavin Mooney
Inside Story
Journal Watch
PIJ Commissions 2020
Summer Reading 2019-2020
The Conversation
The Health Wrap
TOO MUCH of a Good Thing
CroakeyGO
#CroakeyGO #NavigatingHealth
#GamblingHarms
#HeatwaveHealth
Mapping CroakeyGo
CroakeyNews
Cultural determinants of health
Digital platforms
Elections and budgets
Federal Budget 2019-20
Federal Budget 2020-21
Federal Budget 2021-22
Global health and climate change
2019-20 climate bushfire emergency
asylum seeker and refugee health
Climate emergency
disasters
Ebola
extreme weather events
flooding 2011
global health
NHS
NZ Election 2017
WHO
health
Healthcare and health reform
abortion
adverse events
aged care
allied health care
Australian Medical Association
cancer
cardiovascular disease
child health
Choosing Wisely
chronic diseases
co-payments
Cochrane Collaboration
complementary medicines
conflicts of interest
death and dying
diabetes
digital technology
disabilities
e-health
emergency departments and care
Equally Well
euthanasia
evidence-based issues
general practice
genetics
health & medical marketing
health and medical education
health and medical research
Health Care Homes
health ethics
health financing and costs
health reform
health regulation
health workforce
HIV/AIDS
hospitals
HRT
infectious diseases
influenza
international medical graduates
journal articles
LGBTIQ
medical marijuana
Medicare Locals
men's health
mental health
MyHospitals website
National Commission of Audit 2014
National Health Performance Authority
naturopathy
NDIS
NHMRC
non communicable diseases
nurses and nursing
oral health
organ transplants
out of pocket costs
pain
palliative care
paramedics
pathology
Pharmaceutical Benefits Scheme
pharmaceutical industry
pharmacy
Pregnancy and childbirth
primary health care
Primary Health Networks
private health insurance
quality and safety of health care
rural and remote health
screening
sexual health
social media and healthcare
suicide
surgery
swine flu
telehealth
tests
TGA
trauma
women's health
youth health
Indigenous health
#CTG10
#NTRC
Acknowledgement
cultural safety
Indigenous education
Lowitja Institute
NT Intervention
social and emotional wellbeing
Uluru Statement
WA community closures
News about Croakey
PIJ Commissions 2021
Public health and population health
#PreventiveHealthStrategy
#UnmetNeedsinPublicHealth
air pollution
alcohol
consumer health matters
COVIDwrap
environmental health
Fetal Alcohol Spectrum Disorders (FASD)
food and nutrition
gambling
Government 2.0
gun control
health communications
health impact assessment
Health in All Policies
health inequalities
health literacy
human rights
illicit drugs
injuries
legal issues
marriage equality
Media Doctor Australia
media-related issues
nanny state
National Preventive Health Agency
obesity
occupational health
physical activity
plain packaging
prevention
public health
public interest journalism
road safety
sport
sugar tax
tobacco control
transport
vaccination
violence
Web 2.0
weight loss products
Royal Commission
Social determinants of health
discrimination
education
justice
Justice Reinvestment
NBN
Newstart
poverty
racism
social policy
Summer reading 2020-2021
Tasmanian election 2021
Testing Croakey News category 1
The Croakey Archives
#cripcroakey
#HealthEquity16
#HealthMatters
#IHMayDay (all years)
#IHMayDay 2014
#IHMayDay15
#IHMayday16
#IHMayDay17
#IHMayDay18
#LoveRural 2014
Croakey Conference News Service 2013 – 2019
2013 conferences
Australian Centre for Health Services Innovation Forum 2013
Australian Health Promotion Association Conference 2013
Closing the Credibility Gap 2013
CRANAplus Conference 2013
FASD Conference 2013
Health Workforce Australia 2013
International Health Literacy Network Conference 2013
NACCHO Summit 2013
National Rural Health Conference 2013
Oceania EcoHealth Symposium 2013
PHAA conference 2013
2014 conferences
#IPCHIV14
AIDA Conference 2014
Congress Lowitja 2014
CRANAplus conference 2014
Cultural Solutions - Healing Foundation forum 2014
Lowitja Institute Continuous Quality Improvement conference 2014
National Suicide Prevention Conference 2014
Racism and children/youth health symposium 2014
Rural & Remote Health Scientific Symposium 2014
2015 conferences
#CPHCEforum
#CRANAplus15
#HSR15
#NRHC15
#OTCC15
Population Health Congress 2015
2016 conferences
#AHHAsim16
#AHMRC16
#ANROWS2016
#ATSISPEP
#AusCanIndigenousWellness
#cphce2016
#CPHCEforum16
#CRANAplus2016
#IAMRA2016
#LowitjaConf2016
#PreventObesity16
#TowardsRecovery
#VMIAC16
#WearablesCEH
#WICC2016
2017 conferences
#17APCC
#ACEM17
#AIDAconf2017
#BTH20
#CATSINaM17
#ClimateHealthStrategy
#IAHAConf17
#IDS17
#LBQWHC17
#LivingOurWay
#OKtoAskAu
#OTCC2017