Pandemic leads doctors to rethink unnecessary treatment

Covid-19 is opening the door for researchers to address a problem that has vexed the medical community for decades: the overtreatment and unnecessary treatment of patients.

Numerous studies have shown that overtreatment causes unnecessary suffering and billions of dollars in unnecessary health care costs.

But never before, said researcher Allison Oakes, has there been such a large database to compare patients who received a particular test or treatment with those who did not.

Oakes was a principal author of an October paper in Health Affairs by the Research Consortium for Health Care Value Assessment. The paper noted that covid provided an important new measurement — examining outcomes for patients who received treatment before hospitals canceled care because of covid and those who had their care canceled.

Areas ripe for study, said Oakes: colonoscopies done on patients older than age 85; hemoglobin blood work for Type 2 diabetes patients; semi-elective surgeries, such as knee arthroscopy for articular cartilage surgery; and yearly dental X-rays. All were done less often because of covid, she said.

"There are two sides of the pie: low-value care and care that people get in trouble if they don't get," said Oakes, who expects researchers to take advantage of all the data provided from covid on "both types of care."

One recent study looked at Veterans Affairs patients who had elective surgeries canceled because of covid. The study found they were no more likely to visit hospital emergency departments than patients who had undergone those surgeries in 2018.

Dr. Heather Lyu of Brigham and Women's Hospital and Harvard Medical School said much testing and care was cut back by patients' fears of contracting covid in a medical setting and because medical facilities and staffers were fighting just to keep up with covid cases.

"There are some procedures, tests, and exams that cannot be delayed in any situation," Lyu said in an email. For example, she pointed to the screening, surveillance and treatment of cancer patients.

However, she said other tests and treatments can be delayed or canceled without negative effects. Lyu oversaw a 2017 survey of 2,000 physicians, with half the doctors saying the percentage of unnecessary medical care was higher than 20.6% and half saying it was lower.

Unnecessary treatment or overtreatment can result from several factors, the doctors in Lyu's survey said. Concerns about malpractice lead doctors to test even for unlikely problems to avoid missing something, they said. Sometimes health providers have difficulty assessing patients' prior medical records. Then there is the incentive for the health industry to boost revenue, sometimes to help pay for expensive testing equipment, the doctors said.

Leaps in technology are a major factor.

Dr. Jill Wruble, a radiologist at Johns Hopkins Medicine in Baltimore, said a CT scan that provided 30 or 40 images when she began practicing in the 1990s now provides thousands of high-resolution images.

"We now see things that we would have never seen before, like a lesion that may never become a problem," Wruble said.

Wruble said some patients still opt for aggressive medical treatment for things like that questionable lesion.

"Patients … often resist advice to 'watch and wait' and will demand surgery even when the operation itself comes with potentially dire consequences," Wruble said. The consequences are not only higher costs but potentially years of physical discomfort and pain, along with diminished physical abilities, she said.

Susan Gennaro, dean and professor at the William F. Connell School of Nursing at Boston College, said covid provides not only opportunities to study unnecessary medical care, but also opportunities to examine areas of insufficient care. She cites a lack of mental health resources for covid patients suffering through difficult treatment and even facing death without friends or family.

"When we are thinking of new ways to treat, we all need to think about our fascination with surgery and invasive procedures and start thinking more holistically about health," Gennaro said.

Covid's upending of scheduled non-covid care hit hard in March and April last year, when the pandemic first began to overwhelm hospitals. Cancer surgery scheduled in April for Krista Petruzziello, for example, was postponed due to the focus on covid care.

Instead of surgery, the 49-year-old real estate agent from Lowell, Massachusetts, received hormonal treatment usually reserved for breast cancer patients with larger tumors.

"It was concerning for sure," said Petruzziello. "Who knew a year ago how long it would be until surgery would be available for patients like me?"

It was only about six or seven weeks later when she had successful surgery to remove a tumor shrunken by the hormonal treatment. A recent follow-up scan found her clear of cancer, she said.

"Maybe there will be cases where the tumor disappears altogether [from hormonal treatment], allowing the surgery to be canceled," Petruzziello said. "Wouldn’t that be a good thing?”

Dr. Harold Burstein, an oncologist at Dana-Farber Cancer Institute in Boston who treated Petruzziello, said breast cancer surgery will remain a key component of treatment for the foreseeable future. But he said hormone treatment "before surgery" can shrink the tumor and "hopefully make for less extensive surgery."

Covid, he said, forced health care providers to "think outside the box."