Exploring the harmful effects of health care

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A commentary in the current issue of JAMA uses that headline to open a discussion about how "it is time to address the possibility of net health harm by elucidating more fully aggregate health benefits and harms of current health care."

Excerpts and bullet points from the commentary:

  • Unlike health, health care is not an unalloyed good.

  • Determinants of well-being transcend health care.

  • Harm may occur as a direct or indirect consequence of health care. Direct harm includes adverse physical and emotional effects, generally to individuals, as a by-product of health care delivery. Indirect harm is a collateral effect on individuals and communities not directly involved in care. Indirect harm is closely associated with excess health care costs, which may induce harm by competing with other health-producing services.

  • Physical harm is a by-product of routine care processes. Some aspects of physical harm (eg, adverse drug effects and medical errors) are better known than others (eg, untoward effects of radiation from computed tomography). Although physical harm is an accepted risk of treatment with increasingly powerful medications and interventions, much consequent harm is avoidable when treatments are overused or used without sufficient evidence of effectiveness.

  • Some overtreatment happens when physicians lack evidence about the ineffectiveness or risks of a treatment.

  • Percutaneous coronary intervention (angioplasty, stents, etc.) is likely being overused in the Medicare population. Contrary to national guidelines, more than half of Medicare patients with stable coronary disease lack noninvasive documentation of ischemia before elective percutaneous coronary intervention.

  • End-of-life care provides another example of medical excess. One study found that only 30% of hospitalized patients older than 80 years wanted care to prolong life, but 63% received life-prolonging care such as intensive care unit admissions, intubation, surgery, and dialysis. Wide variation exists in end-of-life care.

  • Although the potential for harm is substantial, both physicians and patients generally embrace technology enthusiastically--implicitly trusting in its benefit before adequate assessment is made.

  • Unnecessary care can also cause emotional harm, including anxiety from testing or treatment and from creating inappropriate expectations. Emotional harm, although less well studied than physical harm, has important effects on patient well-being.

  • A diagnosis of hypertension made through screening resulted in more office visits and sick role behavior without improved medication adherence or blood pressure control. Spinal magnetic resonance imaging often reveals alarming but clinically irrelevant findings, and adults with back pain who receive magnetic resonance imaging results may experience worse dysfunction than those not given the results. Likewise, many unproven screenings, such as the prostate-specific antigen test, remain commonly used; although relatively inexpensive and often sought by patients, they are unlikely to help and may induce harm, including anxiety associated with false-positive results. Exaggerated fears and "medicalizing" normal phenomena are as harmful as unrealistic expectations and are fostered frequently by marketing hype and sometimes inadvertently by health care clinicians.

  • Although health care's objective should be to improve health, its primary emphasis has been on producing services.

  • The possibility that health care might cause net harm is increasingly important given the sheer magnitude of the modern health care enterprise.

It's a thoughtful commentary. Read the entire piece if you have the chance (although it requires a JAMA subscription).

1 Comment

As a 29-year veteran of the healthcare business, I don't think the solution to our problems is hard to find.

Simply emphasize preventative benefits (maybe even make it mandatory), increase usage of HSAs and provide tax incentives for those that are insured.

It will work!

About this Entry

This page contains a single entry by Gary Schwitzer published on July 1, 2009 9:31 AM.

Remember the Jupiter trial? CRP? Think again. was the previous entry in this blog.

Three significantly different takes on spine surgery study - one headline emphasizing risk, one cost, one sales is the next entry in this blog.

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