Is Making the Exact Diagnosis Always the Right Thing to Do?
Is Making the Exact Diagnosis Always the Right Thing to Do?
Dr Basco: You also suggested in your paper that the public psyche, a belief that advances in science and technology are always beneficial, plays a role. Having spent some time learning about European healthcare systems and talking to people there, it is clear to me that US healthcare consumers have very different expectations. How could providers counter that expectation for more testing and more diagnoses in their day-to-day practice?
Dr Schroeder: I think that we need to do a better job of opening people's eyes to the harms of healthcare. When a patient gets a test that establishes a diagnosis, very few people stop to think that maybe it wasn't beneficial to have done the test and been given the diagnosis. Patients assume it's a good thing to know what they have. Even if it means getting more tests and more treatments, it can only be good to have established that diagnosis.
We must open people's eyes to the harms of additional days in the hospital because of the hypoxemia found on pulse oximetry, additional days of intravenous antibiotics because of the bacteremia that occurred with the urinary tract infection, additional days in the hospital because a child with a Glasgow Coma Scale of 15 got a head CT that showed questionable bleeding. We have to start opening both physicians' and consumers' eyes to these potential harms.
I agree with you completely that our country has very high expectations for immediate healthcare and immediate diagnoses. Until we can better understand these harms and convey these harms, I don't think that's going to change.
Dr Quinonez: I think it must start with the physician. There's published evidence showing that patients who are provided good explanations of harms vs benefits understand it and are less likely to seek unnecessary therapy. I think a lot of it is on us. We need to do a better job of explaining harm.
We're very good at telling patients and families when we are about to prescribed a drug how this medication is going to be a benefit. But we are not doing enough to explain the other side of it—how this diagnostic test, this imaging study, or this medication may actually cause harm when there is the potential for that to happen.
Dr Basco: We've talked about the provider and the patient side. What are some system or payer efforts that could play a part in moving the needle to limit overdiagnosis?
Dr Schroeder: It is a really important issue. The evidence from health services research in this country certainly would suggest that there is tremendous variability in Medicare spending around the country, but that outcomes aren't any better in regions that spend more; this suggests that more testing, and getting paid more to do that testing, is not necessarily benefiting patients. It would be only natural to assume, then, that a push toward accountable care organizations, where we're paid for outcomes rather than for the tests and treatments that we provide, would limit overdiagnosis and overtreatment. I hope that happens. We have to move there.
I've heard some health policy experts suggest that culture change will never occur until we have finance reform. I think we could start to explore that hypothesis by looking at physician behavior in HMOs, such as Kaiser. I don't think physician test ordering is dramatically different in those systems from that in more traditional fee-for-service systems, suggesting that it's not just the financial incentives that are driving excessive care. But it's certainly a component, and moving toward reimbursement schemes that are outcome-based rather than simply paying physicians for doing more is an important part of this discussion.
Dr Quinonez: A lot of those outcomes are going to be based on quality metrics. We're developing quality metrics for pediatrics. Several have been developed for adults and used by third-party payers to decide whether a clinician or institution is performing well. There's a lot less of it in pediatrics. But what we've seen so far focuses on the other side—the provision of care and services rather than limiting them. Most published quality metrics in pediatrics tell you things we should be doing more of. As we develop more quality metrics for pediatrics, we have to also focus on those that highlight overuse.
We are not saying that one half or some other arbitrary number of those quality metrics need to look at overuse. But a good percentage of them should because certainly, in a lot of pediatric conditions, lack of care is not the problem. Too much care is the issue.
Are Patients, Parents, and Payers Driving Overuse?
Dr Basco: You also suggested in your paper that the public psyche, a belief that advances in science and technology are always beneficial, plays a role. Having spent some time learning about European healthcare systems and talking to people there, it is clear to me that US healthcare consumers have very different expectations. How could providers counter that expectation for more testing and more diagnoses in their day-to-day practice?
Dr Schroeder: I think that we need to do a better job of opening people's eyes to the harms of healthcare. When a patient gets a test that establishes a diagnosis, very few people stop to think that maybe it wasn't beneficial to have done the test and been given the diagnosis. Patients assume it's a good thing to know what they have. Even if it means getting more tests and more treatments, it can only be good to have established that diagnosis.
We must open people's eyes to the harms of additional days in the hospital because of the hypoxemia found on pulse oximetry, additional days of intravenous antibiotics because of the bacteremia that occurred with the urinary tract infection, additional days in the hospital because a child with a Glasgow Coma Scale of 15 got a head CT that showed questionable bleeding. We have to start opening both physicians' and consumers' eyes to these potential harms.
I agree with you completely that our country has very high expectations for immediate healthcare and immediate diagnoses. Until we can better understand these harms and convey these harms, I don't think that's going to change.
Dr Quinonez: I think it must start with the physician. There's published evidence showing that patients who are provided good explanations of harms vs benefits understand it and are less likely to seek unnecessary therapy. I think a lot of it is on us. We need to do a better job of explaining harm.
We're very good at telling patients and families when we are about to prescribed a drug how this medication is going to be a benefit. But we are not doing enough to explain the other side of it—how this diagnostic test, this imaging study, or this medication may actually cause harm when there is the potential for that to happen.
Dr Basco: We've talked about the provider and the patient side. What are some system or payer efforts that could play a part in moving the needle to limit overdiagnosis?
Dr Schroeder: It is a really important issue. The evidence from health services research in this country certainly would suggest that there is tremendous variability in Medicare spending around the country, but that outcomes aren't any better in regions that spend more; this suggests that more testing, and getting paid more to do that testing, is not necessarily benefiting patients. It would be only natural to assume, then, that a push toward accountable care organizations, where we're paid for outcomes rather than for the tests and treatments that we provide, would limit overdiagnosis and overtreatment. I hope that happens. We have to move there.
I've heard some health policy experts suggest that culture change will never occur until we have finance reform. I think we could start to explore that hypothesis by looking at physician behavior in HMOs, such as Kaiser. I don't think physician test ordering is dramatically different in those systems from that in more traditional fee-for-service systems, suggesting that it's not just the financial incentives that are driving excessive care. But it's certainly a component, and moving toward reimbursement schemes that are outcome-based rather than simply paying physicians for doing more is an important part of this discussion.
Dr Quinonez: A lot of those outcomes are going to be based on quality metrics. We're developing quality metrics for pediatrics. Several have been developed for adults and used by third-party payers to decide whether a clinician or institution is performing well. There's a lot less of it in pediatrics. But what we've seen so far focuses on the other side—the provision of care and services rather than limiting them. Most published quality metrics in pediatrics tell you things we should be doing more of. As we develop more quality metrics for pediatrics, we have to also focus on those that highlight overuse.
We are not saying that one half or some other arbitrary number of those quality metrics need to look at overuse. But a good percentage of them should because certainly, in a lot of pediatric conditions, lack of care is not the problem. Too much care is the issue.