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Study reveals the ubiquity of overtreatment

By Amos Esty

Sirovich was the lead author of a paper reporting the results of a survey of 627 U.S. primary-care physicians.

More than 40% of U.S. primary-care doctors think patients they see receive too much medical care, and more than 25% believe they themselves provide too much care to some patients. That's according to a national survey by a team of DMS researchers. The study, which was published in the Archives of Internal Medicine, highlights problems in the health-care system but also offers cause for optimism, says Brenda Sirovich, M.D., the paper's lead author.

Debate: Sirovich, an associate professor of medicine and of community and family medicine and a primary-care physician herself, says it's important to know what primary-care doctors think. "They are directly or indirectly responsible probably for most treatments, tests, referrals, [and] hospitalizations," she says. "We felt that they were going to be able to give us a pretty well-informed assessment of what was going on." Everyone knows that health-care spending is growing too rapidly to be sustainable, she adds, "but there's a serious debate about whether that means people are getting too much care."

The survey of 627 primary-care physicians found that 42% believe the patients they see are overtreated, when taking into account all the care they receive from all providers. That compared to 6% who think their patients receive too little care and 52% who think the amount of care is just right. A substantial minority—28%—said they practice more aggressively than they'd like, and 29% believe other primary-care doctors in their community practice too aggressively.

The physicians were also asked about the causes of aggressive care. The most common was concern about malpractice, which 76% think contributes to over¥treatment. Over half (52%) believe clinical performance measures lead to too much care, and 40% think that not having enough time with patients is a factor.

Sued: Sirovich says these responses reflect the deep fear within the medical community of malpractice suits. She notes that 83% of those surveyed feel they could be "easily sued" if they do not order a test that is normally ordered, but only 21% feel that's the case if they do order a test not normally done. In other words, malpractice worries seem more apt to cause overly aggressive treatment than undertreatment. "Based on our survey . . . this is something that is really on physicians' minds as informing what they do day to day," Sirovich says.

She found it interesting that physicians cited clinical performance measures as a cause of aggressive care. Such measures are being used increasingly in an effort to improve the quality of care. But, she points out, almost all performance measures are designed to ensure that patients receive enough care—not to avoid providing too much care. "Are you referring the patient enough? Do you have them on enough medicines? Those are the way the measures work," she says. "There are almost no measures that look at the flip side: Are you doing too much?"

Overly aggressive care, Sirovich says, is "not good for people."

Only 3% of respondents said money influences their practice, but most think money does influence the practice of other physicians: 62% said there would be fewer diagnostic tests if tests didn't create revenue for subspecialists, and 39% think the same of primary-care doctors.

Harm: Sirovich says the study's goal was to help determine if unnecessary care is being delivered—care that potentially could be eliminated without harming patients. In fact, she points out, eliminating such care would actually benefit patients. Unnecessary care is "not just bad for the bottom line," she says. "It's not good for people either."

Despite the problems identified by the study, Sirovich believes the findings show that physicians are open-minded. About 75% of those surveyed said they're interested in learning how their own practice style compares to that of other doctors. "We interpret that to mean that they are . . . open to feedback and potentially to changing their practice patterns," Sirovich says. "I think we ended up feeling optimistic . . . that physicians seem to recognize that there is a problem."

She also notes that the survey had a very high response rate, which shows physicians take the issue very seriously. "They're interested in talking about it, in sharing their experiences and opinions, and in looking for solutions," she says.

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