This document discusses the problem of overtreatment in the US healthcare system. It provides estimates that 30% of hospital care for chronic illnesses, 1/3 of imaging tests, and 12-15% of cardiac stents are unnecessary. This overtreatment costs the US healthcare system between $270-800 billion annually, or 10-30% of total spending. Overtreatment also causes needless harm to patients, with estimates of 3-10 million unnecessary hospitalizations each year resulting in 44,000-132,000 preventable deaths from infections and 21,000-63,000 from medical errors. Variation in rates of procedures between hospitals suggests some hospitals may be overtreating patients. When patients are better informed about options and

1. OVERTREATMENT:
The
Implica4ons
for
Individuals
and
Systems
Shannon
Brownlee,
MS
Senior
Vice
President,
Lown
Ins7tute
Senior
Fellow,
New
America
Founda7on
Instructor,
Dartmouth
Ins7tute
sbrownlee@lownins7tute.org
The Summer Institute
Hanover, NH
2014

3. Es4mates
for
overuse
in
the
U.S.
• 30%
of
hospital-­‐based
care
for
chronic
illness
(Dartmouth
Atlas)
• 1/3
of
imaging
tests
(Slovis
&
Berdon,
Pediatr
Radiol
2002
)
• 12-­‐15%
of
cardiac
stents
are
inappropriate
(Chan
et
al,
JAMA
2011)
• 10-­‐30%
of
total
spending
($270
–
800
billion)
(Dartmouth
Atlas,
Berwick
&
Hackbarth,
JAMA
2012,
Garber
&
Skinner,
J
Econ
Perspect
2008
)

4. 42% of Medicare beneficiaries
received at least 1 of 26 low-
value services per year
May 2014 http://archinte.jamanetwork.com/journal.aspx

5. Needless
harm
to
pa4ents
from
unnecessary
hospitaliza4on
• 3
-­‐
10
million
unnecessary
hospitaliza7ons
annually
• Unnecessary
deaths
from
nosocomial
infec7on:
44,000
–
132,000
• Unnecessary
deaths
from
medical
error:
21,000
–
63,000

7. Stent
and
angioplasty
rates
in
Calif.
hospital
regions
as
%
of
state
average
WHICH
RATE
IS
RIGHT?
http://www.chcf.org/publications/2013/05/medical-variation-
map#6/36.985/-119.421&procedure=eind&region=hsa

8. “Mr. Larsen, it looks like a paper cut, but just to
be sure, I like to do lots of cardiac procedures.”

9.
• 1/3
of
men
who
were
given
a
PSA
test
were
never
asked
if
they
wanted
it.
• Of
men
who
are
asked,
2/3
say
their
doctor
failed
to
mention
possible
harms
from
treatment.
McFall SL. US men discussing prostate-specific antigen tests
with a physician. Annals of family medicine 2006;4(5):433-6.
INFORMED PATIENTS?

10. Unwarranted Variations in
Preference-Sensitive Care• Different
physicians
have
different
opinions
about
diagnosis
and
treatment.
• Information
given
to
patients
is
Inaccurate,
incomplete,
or
poorly
understood.
• Patients’
varying
attitudes
towards:
Risk
Health
outcomes
Desire
to
participate
in
decisions
• Are unknown or ignored.
Variations in rates occur BECAUSE …

12. Pa4ents
make
different
decisions
when
they
are
be_er
informed
• Stable
coronary
angina
–
20%
less
likely
to
choose
PCI
(1
published
RCT)
• Hip
or
knee
arthri7s
–
25%
less
likely
to
choose
arthroplasty
• Early
prostate
cancer
–
50%
more
likely
to
choose
watchful
wai7ng
Stacey, D., et al., Decision aids for people facing health treatment or
screening decisions. Cochrane database 2011(10): p. CD001431.

13. Harm
from
unwanted
surgeries
• 29,000
unwanted
elec7ve
PCIs*
– As
many
as
580
harmed
(1-­‐2%
serious
adverse
events)
• 250,000
unwanted
joint
replacements
–
as
many
as
20,000
harmed
(7-­‐8%)
• 90,000
unwanted
prostatectomy
or
radia7on
for
early-­‐stage
prostate
cancer
– As
many
as
45,000
men
harmed
(20-­‐60%
impotent,
20-­‐50%
incon7nent)
*20% of 245,000 elective PCIs

14. “Our goal must be
to do much for the
patient . . . and as
little as possible to
the patient.”
Bernard Lown, MD
Cardiologist, inventor of the
cardiac defibrillator, winner of
the Nobel Peace Prize

15. Thank
you!