Physicians Continue to Prescribe Low-Value Treatments

 By Jamie Santa Cruz

Before ordering interventions, physicians must critically assess their value.

Physicians continue to prescribe a variety of unnecessary medications and other treatments proven to be low in value, according to a new physician survey published in the Annals of Internal Medicine.1 The top three most commonly prescribed low-value treatments, as cited in the survey, are antibiotics, nonpalliative treatments for patients with limited life expectancy, and medications for chronic pain management.

The new findings should prompt discussion about the prevalence of overuse and the need to pursue higher-value treatments, says Amir Qaseem, MD, PhD, MHA, FACP, vice president for clinical policy at the American College of Physicians (ACP) and lead author of the study. "Whenever we are ordering any of these tests, we need to look into the value of the intervention. Value is a function of the benefits, harms, and costs of any intervention together."

For the survey, conducted by e-mail and sent to 5,000 randomly selected physician members of the ACP, respondents were asked to identify two treatments that are frequently used by internists but are not likely to offer high value to patients. Of those who received the survey, more than 1,500 responded. After exclusion of responses naming diagnostic procedures and respondents who did not see patients in practice, the final sample numbered 1,130 (representing 22.6% of total recipients).

In total, the survey identified 15 commonly used low-value treatments. By far the most commonly cited treatment was unnecessary antibiotics, with more than 27% of respondents saying they are often used in low-value contexts, namely for treatment of upper respiratory infections.

That physicians acknowledge overuse of low-value treatments isn't a surprise, according to Michael Munger, MD, FAAFP, president-elect of the American Academy of Family Physicians. "We've really started to see a lot of information come forth recently" about overuse of specific treatments like antibiotics, Munger says. In particular, the Choosing Wisely campaign sponsored by the ABIM Foundation has drawn attention to the issue, and there is now increasing awareness of the problem both in the medical community and in the general public.

In the new survey, physicians were asked about treatments frequently used by internists in general; their responses indicate no admission that they themselves offer low-value treatments to patients. Prior research, however, suggests that physicians see themselves—and not just other physicians—as part of the problem: A 2011 study in the Archives of Internal Medicine, for example, found that 42% of primary care physicians believed patients in their own practice were receiving too much care.2

Factors Contributing to Use of Low-Value Treatments
There are a variety of reasons physicians might offer treatments that are low in value, Qaseem says. In some cases, physicians may lack knowledge of new guidelines related to specific treatments and in other cases, a physician's low confidence in his or her own clinical skills may play a role. Other factors such as patient expectations of a particular treatment and physicians' fear of medical malpractice also contribute.

"I do not believe that a physician would knowingly prescribe something that would be harmful to a patient," Munger says. But dissemination of updated information on the clinical utility of treatments takes time. Meanwhile, longstanding practice patterns can make it difficult for physicians to adapt. "For 25 years, you have been taught and trained and told that the best evidence was that this was an appropriate treatment, and now new evidence is coming out—it's a change in your practice pattern and practice style," Munger says.

Further contributing to the continuing use of low-value treatments is that guidelines for many treatments are not as clear cut as they may seem at first. Munger points to issues surrounding mammography screening as an example. Although mammography represents a diagnostic tool rather than a treatment, Munger notes that there are several different national organizations that have slightly different recommendations about the intervals at which screening should be conducted, at what age screening should start and stop, and so on. Thus, he says, in some cases physicians must sort through conflicting information to arrive at the best course of action.

Meanwhile, physicians experience a subtle pressure to err on the side of treatment and to avoid the appearance of doing nothing. "We were all trained [to] do no harm," Munger says. "But also, you want to provide relief for the patient. You want to make sure that they have not only the best care but that they can be as comfortable as they can moving forward. As a physician, you're a caring person and you want to try to help."

Harms of Low-Value Interventions
Although offering low-value treatments may often be the easiest course, Qaseem says physicians should actively work to avoid low-value care due to the harms that result to patients and to the broader public in general. "Any intervention is associated with its own adverse effects," Qaseem says. "There is broad variation. It could be a minor side effect depending on the intervention, but it could be a severe adverse effect with some treatments." Among the more dramatic and well-publicized examples of side effects is the bacterial resistance to antibiotics stemming from the overuse of antibiotics, but even when the stakes aren't so high, there is always the potential for harm. "There is no intervention that will not have side effects," he says.

Aside from actual physical harm, use of interventions in a low-value context also produces harms in another way, by contributing to the rising costs of health care. According to Qaseem, physicians don't bear all or even most of the blame for the inflation of health care costs; many of the factors driving costs—including advances in diagnostic and therapeutic technologies, lengthening lifespans, the increased prevalence of certain diseases, an aging population, and rising administrative costs—are outside of physician control. Nevertheless, he says, overuse and misuse of diagnostic tests and therapeutic treatments are significant contributors to ballooning costs, and physicians have a responsibility to see that resources are used in a cost-effective manner.

What Counts as Low Value?
Though the financial costs of treatment are a real concern, Qaseem is careful to clarify that the value of a treatment does not directly correlate with its economic cost. Expensive interventions can legitimately provide good value, such as treatments for HIV, which provide sufficient benefit to patients to justify the cost. The reverse holds true as well: Treatments that are low in cost, such as antibiotics, can be low in value. "It's not the cost; it's the value proposition," Qaseem says. "If you're going to provide any intervention, any treatment, is it going to have any impact on the clinical outcomes of the patient?"

Steps Toward Higher-Value Care
For physicians seeking to increase the value of care they provide to patients, the essential first step is to stay up to date with relevant clinical guidelines from major national organizations. But guidelines can take physicians only so far, according to Qaseem. Doctors will inevitably have to exercise their own judgment—and rightly so. "Patient care is not like a factory assembly line," he says. "The problem is the variation with each individual patient plays a role."

Rather than following guidelines by rote, Qaseem suggests physicians should focus on identifying the benefits and the harms of a given treatment for each patient. Questions to ask include the following: Will this treatment change the patient's outcome in any way? What is the probability of a worse outcome? Am I giving this treatment only because the patient wants it?

As for ways to work through patient expectations and help patients understand why lower-value care is undesirable, Qaseem underscores the importance of simply having a conversation. "As a nation, we do believe more is better. But there is also research that if you sit down and talk to your patient and explain, most patients do not want to get unnecessary care." In practice, good communication is difficult, he acknowledges, considering physicians often have very limited time with patients. However, he says, physicians need to do their best. "It comes down to sitting down with your patient and talking and explaining."

Munger agrees, suggesting physicians should embrace every opportunity to share decision-making with patients—even when it means patients might challenge physician recommendations. "This is a collaboration; we're in a partnership," he says. "One of the most important things we can do is continue to work on that comprehensive ongoing relationship with the patient."

— Jamie Santa Cruz is a freelance writer based in Englewood, Colorado.

References
1. Qaseem A; High Value Care Task Force of the American College of Physicians. Appropriate use of therapeutic interventions to foster high-value care. Ann Intern Med. 2016;165(11):831-832.

2. Sirovich BE, Woloshin S, Schwartz LM. Too little? Too much? Primary care physicians' views on US health care: a brief report. Arch Intern Med. 2011;171(17):1582-1585.