What are the knowledge gaps in avoiding avoidable care?

Moderator: Rita Redberg, MD, MSc, Professor of Medicine, University of California, San Francisco Medical Center; Chief Editor, Archives of Internal Medicine

Research on unnecessary services has been sparse, though it appears to be increasing recently. How much of the $2.7 trillion we spend on health care is wasted on unnecessary services? Several groups have offered estimates that range from 10 to 30%. Is precise knowledge about the scope and drivers of unnecessary care important? For example, how big a part does defensive medicine play? How much is outright fraud? Patient demand? What is the scope of harm caused by unnecessary care? Would better metrics encourage physicians, employers, and patients to face the problem head on? Should we recommend a systematic research program to investigate the knowledge gaps, and if so, who should fund it?

Panel presentations:

What are the knowledge gaps in affordable care? – Eric Larson, MD, MPH, MACP

Knowledge Gaps and Overuse – Salomeh Keyhani, MD, MPH

What are the Knowledge Gaps? – Albert G. Mulley, Jr., MD, MPP

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Complexities of avoiding avoidable care

April 22, 2012   Stephen.Schoenbaum   No comments

I’m delighted that discussion of the issue of avoiding avoidable care is beginning to happen.  Its roots go back many years, and I would hope that no one is under the illusion that minimizing, let alone eliminating, avoidable care will be easy.

Beginning about 25 years ago, important work was done in this area by Bob Brook and his colleagues at RAND when they developed and applied the RAND Appropriateness Guidelines for various surgical procedures and invasive diagnostic procedures – e.g., coronary angiography, CABG, carotid endarterectomy, hysterectomy, and others.  The RAND criteria were applied to a huge number of clinical scenarios that might lead to a particular procedure, and performing the procedure for patients with that scenario was then categorized as appropriate, uncertain, or inappropriate/unnecessary.  A major problem was that very few instances were considered inappropriate/unnecessary – i.e., situations in which evidence or expert opinion indicated overwhelmingly that the risks outweighed the benefits.  In the early 1990’s, reviews of patients who had coronary angiography in New York State and also at Harvard Community Health Plan, showed only about 6 percent of the procedures to have been “inappropriate” (Noonan SJ et al: Relationship of Anatomic Disease to Appropriateness Ratings of Coronary Angiography.  Arch Internal Med 1995;155:1209-1213).   Much larger percentages of persons undergoing such a procedure either were of “uncertain” appropriateness, 16 percent, or “appropriate,” 78 percent.  A major question, however, is how many of the procedures are absolutely necessary – i.e., absolutely unavoidable.  We do not have good evidence for knowing that, and I fear that we still have not put in place the necessary processes such as shared decision-making and large outcomes databases for gaining that evidence, which, by the way, for the most part will not come from randomized controlled clinical trials (Schoenbaum SC:  Toward fewer procedures and better outcomes.  JAMA 1993;269:794-796).

The point I want to emphasize is that if a discussion of avoiding avoidable care is limited to the relatively small number of things for which there is blanket evidence that they are always unnecessary, it will be a discussion of the top of the tip of the iceberg.  I hope it will quickly become evident that a) we need to develop better evidence of what is necessary in what circumstances; b) we need to learn how to have difficult conversations with each other and with patients about what we do and do not know about benefits, risks, and costs; and c) we need to have difficult conversations among professionals about errors of omission, commission, and risks of malpractice in order to made significant inroads into avoiding avoidable care.

What are the knowledge gaps? – Panelist presentation

April 21, 2012   Avoidable Care Admin   No comments

Be sure to check out Dr. Larson’s “Knowledge gaps” panelist presentation:

Knowledge Gaps Panel Presentation
Eric B. Larson, MD, MPH, Executive Director, Group Health Research Institute


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