The looming epidemic of overdiagnosis

DRUG BUST
by Alan Cassels

Lately, I’ve got overdiagnosis on my mind.

Currently, we’re living through a perceived doctor shortage in BC, a crisis affecting as many as 600,000 British Columbians. In 2010, the governing BC Liberals promised that, within five years, everyone in BC who needed a family doc would get one. They even made this promise part of electioneering in 2013. How’s that plan worked out?

Well, it hasn’t. A few people may have been helped by a dating service set up to connect doctors and patients, but it was universally considered a bust. Despite promised government fixes, we have about 100,000 more people today without a doc they can call their own than we did five years ago. In early 2015, the government basically acknowledged it was a failure.

If you are among the thousands of people currently getting health care at walk-in clinics, emergency rooms, or not at all, and if you’re someone with complex medical needs and no one is there to coordinate the healthcare you need, the lack of a family doctor might be the biggest sign the system isn’t working for you.

Dr. Rick Hudson, a retired GP in Victoria, worked for over a decade as a medical advisor in the Ministry of Health. He certainly doesn’t think there’s a doctor shortage. “We have more doctors per capita than we ever had. Besides, a lot of primary care could be delivered other ways: over the phone with others, with nurse practitioners and with teams of other professionals,” he says. Those who have studied the doctor access problem agree with him, noting if doctors focused on what they did best, and worked in teams with other people with a variety of skills, there would be no doctor shortage.

But he sees another problem with the way we deliver medicine – what Dr. Hudson calls “the tyranny of the 10-minute consultation.” He explains that cramming complex care into a 10-minute visit with a doctor leads to episodic, unorganized care, and often a new diagnosis and new prescription on each visit whether they are justified or not. The built-in bias towards overdiagnosis leaves everyone unhappy, even the physician who may feel well compensated but sees, in so many ways, how the system fails patients every day.

Overdiagnosis is what follows from diagnosing “disease” that would never have gone on to cause symptoms or death during a patient’s lifetime. When you’re looking for early forms of disease – as what happens with lab tests, cancer screening and other forms of screening – finding something unusual (an X-ray’s shadow, an abnormal cholesterol reading, etc.) can begin a cascade of medical care, labelling, treating and prescribing. Even when those being screened are unlikely to benefit, the overdiagnosis that results means an enormous amount of waste, duplication and excessive healthcare.

We spend a huge amount of money on the health system in Canada, projected to reach $219.1 billion in 2015, which works out to about $6,105 per person. Those costs mostly go towards hospitals, doctors and drugs, but what if a large portion of that is wasted? And what are governments doing to stop excessive and inappropriate healthcare spending?

BC health policymakers have done little about reducing excessive, inappropriate care, but they have proven their mastery at cost shifting. Let’s see, rising pharmaceutical costs? Bring in an income-based Pharmacare and shift those rising costs to individuals. Want to brag that you’re not raising taxes? Shift rising health care costs by raising the monthly health premium while pretending it’s not a tax. Want to try to tackle the problem of delivering primary complex care in BC and stop the conveyor-belt of fee-for-service primary care that leaves everyone – doctors and patients – miserable? Then give doctors more incentives to treat people with chronic illnesses, a concept known as “pay-for-performance.”

BC established a $240-million program of incentive payments to improve the care of people with chronic diseases, but did it work? Course not. When researchers at UBC analyzed this particular form of bribery, they found a sorry failure: giving more money to doctors to care for more complicated patients actually increased the rates of hospital admissions and did nothing to reduce costs per patient. Sadly, this is not the kind of system tweaking that even comes close to stemming the inexorable tide of scripts, tests, specialists visits and, of course, overdiagnosis.

As Dr. Rick Hudson says, “The problem is piecework,” which he maintains may have worked when Medicare in Canada started, but doesn’t now. “The system forces doctors to solve a complicated problem in 10 minutes. And that leads to overtreatment and overdiagnosis.”

The overdiagnosis problem has many adverse effects, such as the issue of medication affordability for patients. On that front, the BC Ministry of Health funds a reasonably good service called Healthlink BC, which gives many bits of good advice around how to make your medication more affordable, but there is very little effort or money put into what counts: high-quality, independent advice to the public and prescribers about rational drug use that would go far in eliminating unneeded prescribing. The waste in the prescribing system is enormous, and some have estimated we could easily save one third of our $1.5 billion annual budget on drugs if we were serious about providing high-quality prescribing information to doctors. Unfortunately, that’s not part of the BC Liberal’s song sheet.

One of the biggest ways to avoid overtreatment is to incorporate patient values in health decisions, i.e. “Grandma, do you really want to be taking 14 drugs every day? No? So let’s do something about that, OK?” Despite a lot of lip service, we still have largely a top-down system where an “informed patient,” who learns the rates of potential benefit and harm of a prescribed drug, is rare. There are a zillion examples of overtreatment – the prescription used to get the patient out the door, an unjustified screening test, an X-ray that isn’t medically necessary or a questionable surgery, such as that on a torn meniscus – that do nothing to improve the life of the patient. Physicians I know want to be part of the solution to the problems of overtreatment, but there is virtually no leadership from the one place you’d expect it: the Doctors of BC who are asleep at the switch when it comes to turning the tide on overdiagnosis or overtreatment.

Solving these problems – the doctor shortage, medication affordability, high health care expenses and waste – requires leadership and the recognition that overdiagnosis is a problem. We have seen fine examples of leadership in Canada, such as the Quebec Medical Association, which is hosting the annual Preventing Overdiagnosis conference in Quebec City next summer. Many provinces have put money and effort into supporting the “Choosing Wisely” initiative where specialty groups have identified things that are harmful and unnecessary and have created lists of things that doctors should stop doing. Choosing Wisely is all about eliminating waste, inefficiency and overtreatment and finding ways to do something about it.

So how’s that working out in BC? It isn’t. It seems the Doctors of BC and the BC Ministry of Health pay lip service to Choosing Wisely, but have put no effort or money into supporting or promoting it. In fact, despite the obvious failures in our system where people can’t find a doctor, where doctors are incentivized to provide care that makes no difference, and where there is incredible waste, those who should be showing leadership are notably lame and ineffective.

As part of writing this column, I tried to find out what the BC Ministry of Health thinks of overdiagnosis. I mostly wasted my time. Despite my pleading and repeated emailed questions, not a single individual in the Ministry would talk to me. Health Ministry spokesperson Lori Cascaden wrote to say, “While the Ministry of Health does not have an overarching policy addressing over-diagnosis, providing the most appropriate, evidence-based treatment, resulting in the best patient outcomes, is the underlying principle in all decisions regarding patient care.”

Really? All decisions? That’s like saying we’re totally committed to reducing the impact of climate change while building pipelines and massively inappropriate dams. Come on, we’re not stupid. Despite all the yapping about reducing waste and inefficiency, when are you going to show some cojones and start delivering some serious revisions around primary care, such as removing doctors as cogs in the overdiagnosis machine and actually reducing waste and inefficiency?

Do we spend six billion per year on unnecessary lab tests, prescriptions, speciality referrals or treatments? I hope we’re not wasting a third of our healthcare budget. Just imagine how we could direct even a sliver of that waste into things that would actually make a difference in our lives.

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Alan Cassels writes about pharmaceutical policy in Victoria and is the author of Seeking Sickness: Medical Screening and the Misguided Hunt for Disease. www.alancassels.com