Saturday, September 1, 2012

Testing and technology over basic efficacy

In an earlier post, I compared modern classrooms to modern appliances--lots of high-tech bells and whistles; deteriorating basic machinery. Two New York Times opinion pieces about the medical establishment suggest a similar comparison.

First, in a recent Op-Ed piece, Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice, and a co-author of “Overdiagnosed: Making People Sick in the Pursuit of Health,” writes about trendy treatments that sometimes backfire:

In 2002, a randomized trial showed that preventive hormone replacement caused more problems (more heart disease and breast cancer) than it solved (fewer hip fractures and colon cancer). Then, in 2009, trials showed that P.S.A. screening led to many unnecessary surgeries and had a dubious effect on prostate cancer deaths.
And about the systematic failure to test the efficacy of novel treatments in general:
The problem goes far beyond these two. The truth is that for a large part of medical practice, we don’t know what works. But we pay for it anyway. Our annual per capita health care expenditure is now over $8,000. Many countries pay half that — and enjoy similar, often better, outcomes. Isn’t it time to learn which practices, in fact, improve our health, and which ones don’t?
And about how the current profit flow in the Medical Industrial Complex (my term) favors novelty for the sake of novelty:
Medical research is dominated by research on the new: new tests, new treatments, new disorders and new fads. But above all, it’s about new markets.
Next up, Tara Parker-Poper, in Tuesday Well Column, writes about an epidemic of testing and overtreatment:
But an epidemic of overtreatment — too many scans, too many blood tests, too many procedures — is costing the nation’s health care system at least $210 billion a year, according to the Institute of Medicine, and taking a human toll in pain, emotional suffering, severe complications and even death.
She cites a woman who was given a CT scan for a black eye, a stroke victim whose multiple medications were making him hallucinate and show signs of dementia, and a premature baby who was subjected to "a battery of tests for symptoms that other doctors had dismissed as normal for her condition":
Recently, when doctors suggested an M.R.I. that would require that their daughter be anesthetized, Ms. Gullo and her partner, Katie Ingram, said they asked two key questions: “What new information will this give us?” and “Will it change what we are doing?” After talking to the doctor, they declined the M.R.I.
“What new information will this give us?” and “Will it change what we are doing?” These are questions that patients absolutely must ask, because too few doctors are. I'm reminded of autism research, where so much of the focus is on early identification of autism rather than effective interventions. And I'm reminded of the Educational Industrial Complex's obsession with testing for the sake of testing. What good is testing in the absence of effective follow-up procedures?

Of course, I'm also reminded of the tendency of the Educational Industrial Complex to view novel technology as the panacea for all its ills.

When it comes to technology and testing in the Medical Industrial Complex, Gilbert Welch recommends skepticism:
Mammograms are increasingly finding a microscopic abnormality called D.C.I.S., or ductal carcinoma in situ. Currently we treat it as if it were invasive breast cancer, with surgery, radiation and chemotherapy. Some doctors think this is necessary, others don’t. The question is relevant to more than 60,000 women each year. Don’t you think we should know the answer?
Or how about this one: How should we screen for colon cancer? The standard approach, fecal occult blood testing, is simple and cheap. But more and more Americans are opting for colonoscopy — over four million per year in Medicare alone. It’s neither simple nor cheap. In terms of the technology and personnel involved, it’s more like going to the operating room. (I know, I’ve had one.) Which is better? We don’t know.
Welch's recommendations?
We don’t need to find more things to spend money on; we need to figure out what’s being done now that is not working. That’s why we have to start directing more money toward evaluating standard practices — all the tests and treatments that doctors are already providing. 
Here’s a simple idea to turn this around: devote 1 percent of health care expenditures to evaluating what the other 99 percent is buying. Distribute the research dollars to match the clinical dollars. Figure out what works and what doesn’t.
Maybe we could do the same for education. (And do it right; i.e., not via the What Works Clearing House.)


ChemProf said...

I don't know, Katharine. This article is as if an ed school dean wrote an op-ed saying that we won't get anywhere in education until ed schools get more money for research. And some of what she cites is deeply misleading -- there were TWO major studies of PSA testing that came out in 2009. One showed no effect on mortality, and the other one showed a 20% decline. She only chooses to cite the one that makes her point, but not the one that shows that it often take a lot of these studies before we really know what is going on. The hormone replacement study was exceptional because the results were so striking they actually stopped the study to get everyone off of hormone replacement.

Anonymous said...

Problems. Most invasive ductal carcinomas begin as DCIS. There is currently no biochemical or genetic marker to determine which DCIS lesions will become invasive. Could we find one? Possibly, but it would require large randomized trials. Are you going to volunteer to be the control? How do you tell thousands of women that you are not going to treat their DCIS? Mammography is a very poor way to differentiate DCIS from invasive ductal carcinoma, so if you choose to follow a series of women with DCIS, many will develop metastatic disease. Are you volunteering?

PSA is almost always elevated in prostate cancer, but it also increased with prostatic hypertophy and infections of the prostate gland, so it is a matter of where you set your threshold. To low a level and you will have a lot of unnecessary biopies. To high and cancers will go indetected, so the cut-off is set at a level that physicians and patients can be comfortable with, that will catch most cancers.

This highlights the discord between what patients want for themselves as individuals and what healthy people rationalize to save costs. If it is your DCIS or elevated PSA your perspective is different than the perspective of a healthy education professor who has read a single study and is looking at it from a societal cost point of view. It is also a good demonstration of the actual cost of preventive care. Screening tests like mammography, PSA and colonoscopy are wildly expensive, and can lead to significant false positives and unnecessary invasive procedures and follow-up tests. They also find a lot of cancers, and people want them. Who should receive screening tests and who should pay for them is very controversial, and will become more so in the next several year as more genetic testing becomes available and government becomes more and more responsible for paying.