Epidemic of low value medical care and wastage of medical resources.

      Epidemic of low-value medical care and wastage of medical resources. 

                                                   DR KS Dhillon

What is unnecessary/ Low-value medical care?

Some investigators use the term unnecessary medical care but the majority prefer to use a milder term known as low-value medical care. Low-value medical care is defined as a service with little or no benefit or a service where the risk of harm outweighs any potential benefit. The risk is sometimes directly from the service and sometimes indirectly where the service will lead to extra tests and procedures which will provide little or no benefit to the patient but it may contain risks. Low-value medical care also increases health care spending without providing benefit to the patients.

What is wastage?

Wastage can be defined as an irrational, uncontrolled, and inconsequent use of valuable resources. The use of valuable resources should have a clear objective, purpose, and need, failing which the resources would be wasted. Inefficiency occurs when more resources than necessary are used to obtain a result and wastage occurs when resources are carelessly squandered by using resources for unproductive and wrong purposes.

The extent of the wastages

There is no literature available in Malaysia, on wastages of medical resources. However, in the USA, experts have estimated that the U.S. healthcare system wastes about $765 billion annually and this constitutes about a quarter of all the money that is spent on health care. A report by the National Academy of Medicine USA in 2012 estimated that $210 billion goes to ‘unnecessary or needlessly expensive care’ or to ‘interventions that do not benefit patients’ [1].

Healthcare budget

The healthcare allocations in Malaysia are given to the Ministry of Health and for 2018 the health ministry’s allocation was RM26.58 billion, a 9.5% or 1.7 billion increase compared to what it received in the 2017 budget [2]. This constitutes about 9.5% of the total allocation for the country of Rm 280.25 billion. Of the Rm 26.58 billion allocations for health care about RM4.1 billion (15%) goes to ‘medicines, drugs, medical aids and other consumables’[2]. The Malaysian government healthcare spending stands at about 4% of the nation's GDP (Gross Domestic Product).
The spending on health care, in 10 of the highest-income countries (United Kingdom, Canada, Germany, Australia, Japan, Sweden, France, the Netherlands, Switzerland, and Denmark) ranged from 17.8% of GDP to 9.6% of the GDP in 2016. The spending was highest in the US at 17.8% while in other countries it varied between 9.6% (Australia) to 12.4% (Switzerland)[3].
It is generally agreed that a government should spend about 5% of its GDP for the nation to progress to universal health care [4]. There is a range of studies which suggests that to achieve universal health care, public health expenditure should be between 6% to 7% of GDP [5].
 A recent report by WHO did data envelopment analysis (DEA) which assesses and compares the performance of a nation on certain agreed indicators for service coverage and financial protection, relative to a country’s level of public spending on healthcare in per capita terms [6].
They studied the latest validated and published data (2012 or most recent) from 83 low and middle-income countries.
The DEA model identifies the best performing countries who have achieved greater performance relative to the level of sending as compared to their peers. The best performing countries are given a score of 100%. A score of 100%, however, does not imply that they have achieved or are even close to achieving UHC. It simply means that they have outperformed countries with similar levels of public spending on health care.
The six best ‘performer countries’ identified were Myanmar, Cambodia, Malawi, Rwanda, Thailand, and Cuba. Among the 27 upper middle countries studied Malaysia came in at 24 out of 27. Thailand and Cuba came at number 1 with a score of 100%. It, however, remains unclear why low-spending countries with similar levels of public spending have significant variations in performance. Inefficiency and wastages could be partly responsible for these variations.
At the hospital level, wastages are not uncommon and they come in the form of low-value care.

The epidemic of low-value care

Some investigators use the term unnecessary medical care but the majority prefer to use the term low-value medical care. Low-value medical care is defined as a service with little or no benefit or a service where the risk of harm outweighs any potential benefit. The risk is sometimes directly from the service and sometimes indirectly where the service will lead to extra tests and procedures which will provide little or no benefit to the patient but it may contain risks. Low-value medical care also increases health care spending without providing benefit to the patients. In recent years several investigators have studied low-value medical care.
Schwartz et al [7] studied a random 5% of the 2008–2009 Medicare beneficiaries claims data to analyze the extent of low-value medical services provided to Medicare patients. They found that in 2009, Medicare spent at least $1.9 billion on 26 types of tests and procedures which offered few or no health benefits to patients. They analyzed the data of 1.3 million Medicare patients and found that at least one in four patients received one of these ‘low value’ services.
When a narrower definition of low-value services was used, 25 percent of patients received at least one of the 26 wasteful services costing  $1.9 billion. On the other hand when a wider definition was used 42 percent of patients received at least one of the 26 wasteful services costing $8.4 billion.
Among the hundreds of health care services know to provide little or no benefits to patients only 26 procedures were analyzed in this study. In this study six service categories were analyzed which included ‘low-value cancer screening; low-value diagnostic and preventive testing; low-value preoperative testing; low-value imaging; low-value cardiovascular testing and procedures; and other low-value surgical procedures’ [7]. The list of 26 types of tests and procedures which offered few or no health benefits to patients that were analyzed included:

1.Cancer screening for patients with chronic kidney disease (CKD) receiving dialysis
2.Cervical cancer screening for women over age 65
3.Colorectal cancer screening for adults older than age 85 years
4.Prostate-specific antigen (PSA) testing for men over age 75
5.Bone mineral density testing at frequent intervals
6.Homocysteine testing for cardiovascular disease
7.Hypercoagulability testing for patients with deep vein thrombosis
8.Parathyroid hormone (PTH) measurement for patients  with stage 1-3 CKD (chronic kidney disease)
9.Preoperative chest radiography
10.Preoperative echocardiography
11.Preoperative pulmonary function testing (PFT)
12.Preoperative stress testing
13.Computed tomography (CT) of the sinuses for uncomplicated acute rhinosinusitis
14.Head imaging in the evaluation of syncope
15.Head imaging for uncomplicated headache
16.Electroencephalogram for headaches
17.Back imaging for patients with non-specific low back pain
18.Screening for carotid artery disease in asymptomatic adults
19.Screening for carotid artery disease for syncope
20.Stress testing for stable coronary disease
21.Percutaneous coronary intervention with balloon angioplasty or stent placement  for stable coronary disease
22.Renal artery angioplasty or stenting
23.Carotid endarterectomy in asymptomatic patients
24.Inferior vena cava filters for the prevention of pulmonary embolism
25.Vertebroplasty or kyphoplasty for osteoporotic vertebral fractures
26.Arthroscopic surgery for knee osteoarthritis

Their findings appear to be consistent with the believe that wasteful practices are pervasive in the US healthcare system. The authors believed that this was just the tip of the iceberg and that such practices were much more common. They were also surprised that these wasteful services were so prevalent in the United States [8].
Although similar studies have not been done in Malaysia anecdotal evidence suggests that the practice here in Malaysia is very similar to that in the US.
Elshaug et al [9]  reviewed a total of 5209 articles from the literature and they identified 156 potentially ineffective and/or unsafe medical services which are being provided to patients. The authors believe that low-value services have to be identified and low-value care has to be reduced so that the limited resources can be diverted to ‘more beneficial or cost-effective services, thus maximizing health gain’ [9].
Chassin et al [10] randomly sampled Medicare beneficiaries who had coronary angiography, carotid endarterectomy, and upper gastrointestinal tract endoscopy in 1981 to study the appropriateness of the use of these procedures. They did a detailed review of the medical records and found significant levels of inappropriate use of these procedures. Inappropriate care was seen in 17% of cases of coronary angiography, 32% for carotid endarterectomy, and 17% for upper gastrointestinal tract endoscopy.
There is no doubt that large amounts of money can be saved if these wasteful practices can be abandoned in the Malaysian government hospitals and the money thus saved can be diverted for use elsewhere in the healthcare system.
In the private health care system (excluding charity hospitals) in Malaysia, wastages is more difficult to stop because wastages bring in more income for companies managing the hospitals.

Patient safety, unnecessary surgery, and wastages

“There are many forces coming together to harm or even to kill the patients---their physician should not be one of them”
                                                       Arnold S. Relman, MD (1923-2014)
                                                       Editor Emeritus
                                                       The New England Journal of medicine
Medical errors and surgical complications remains a major problem in medicine due to ‘lack of physician-driven initiatives aimed at recognizing, preventing and mitigating’ these problems [11]. It is disheartening to know that it is ‘significantly safer to board a commercial airplane, a spacecraft, or a nuclear submarine than to be admitted to a U.S. hospital’ [11]. Medical errors rank as the 3rd leading cause of death, after heart disease and cancer, in the United States [12].
A medical error has been defined as an unintended act of either omission or commission, an act which does not achieve its intended outcome, an error of execution, an error of planning or a deviation from a process of care which would prevent harm to the patient [12]. One of the easiest ways to reduce errors, complications, and death would be by avoiding unnecessary surgery. Avoiding unnecessary surgery will also reduce cost and wastage.
Unnecessary surgery has been defined as surgery which is not indicated or needed and is not in the patients best interest. The scientific community has been aware of unnecessary surgery since the 1950s when Dr. Paul Hawley, the Director of the American College of Surgeons (ACS), said that “the public would be shocked if it knew the amount of unnecessary surgery performed (…)” [13].
Due to space constraints, only some examples of unnecessary surgery in orthopedics are analyzed and listed below.

Spine surgery

Gamache [14] in 2012 reviewed over a 14-month period, 155 patients who presented to his clinic for a second opinion and found that 69 (44.5%) of the patients did not need the spine surgery that was recommended to them by other spine surgeons.
Epstein NC [15] reviewed 437 patients with cervical or lumbar complaints who presented to the neurosurgical services over a 20-month period. Two hundred and fifty-four (58.1%) patients come for first opinions and 183 (41.9%) patients come in for second opinions. The author found that in 111 (60.7%) patients the surgery recommended by the previous surgeon was  “unnecessary”, in 61 (33.3%) patients “wrong” surgery was advised and only in 11 (6%) of the patients the “right” operation was advised. A “wrong” operation included operations that were overly extensive (multiple levels), or the approach (anterior or posterior approach) to the spine was wrong.
Arts et al. [16] in a study involving 82 patients who underwent additional spinal fusions for failed back surgery found that 65% of the patients had unsuccessful outcomes, which the authors classified as “unnecessary” spinal operations.
There have been several clinical trials which showed that spinal fusion for back pain is no better than conservative treatment [17,18]. Despite such evidence, the spinal fusion rates in the USA continue to dramatically increase [19].
Besides the spine, the other example where increasing rates of unnecessary surgeries are carried out is the knee.

Knee surgery

Arthroscopic partial meniscectomy

Arthroscopic partial meniscectomy is probably the most commonly performed surgical procedure in the world [20]. In the United States, more than 700,000 arthroscopic partial meniscectomies are carried out every year despite very good evidence (level 1) that arthroscopic partial meniscectomy in patients with degenerative meniscal tears is no better than sham surgery [21].

Arthroscopic debridement of the knee

Arthroscopic debridement of the knee joint for osteoarthritis is another operation that is commonly performed despite the presence of high level (level 1) clinical evidence that it provides no benefit to the patient [22,23].

Knee replacement

Riddle et al [24] studied the appropriateness of knee replacement in 205 patients. They found that the knee replacement was an appropriate procedure in 44% of the patients. It was inappropriate in 34.3% of the patients and in 21.7% of the patients, the appropriateness was inconclusive. The study showed that about a third of the patient had an inappropriate or unnecessary knee replacement.

Shoulder surgery

Arthroscopic subacromial decompression of the shoulder for subacromial shoulder pain is a commonly performed operation. In England, the number of patients undergoing subacromial decompression increased 7 times from 2,523 in 2000 to 21,355 in 2010 [25]. In the past, there have been controversial reports of the effectiveness of this surgical procedure and its value in the treatment of subacromial pain was uncertain. However in 2017 Beard et al published the outcome of a multicentre placebo-controlled trial which evaluated the effectiveness of arthroscopic subacromial decompression for subacromial shoulder pain [26]. They divided the patients into three groups, one group had arthroscopic decompression, the other only arthroscopy without decompression and the third group had no treatment. They found that the two surgical groups had a slightly better outcome as compared to no treatment group but the difference was of no clinical importance. The slightly better outcome was probably due to the placebo effect because the arthroscopy group had no surgical treatment.
The authors questioned the value of this operation and were of the opinion that this information must be shared with the patients who present with subacromial pain.
Even for the treatment of traumatic tears of the rotator cuff, there is no good evidence that surgery is better than conservative treatment. Recently there have been two prospective randomized studies which compared surgical and conservative treatments for rotator cuff tears and they found that there was no clinically significant difference in outcome between the two groups [27,28].

Removal of orthopedic implants

Implant removal after fracture union is one of the most common elective orthopedic procedure. A Finnish study showed that implant removal constituted about 30% of all planned orthopedic operations and 15% of all operations performed in their department [29].
A review of the literature shows that deep-seated stable implants are usually asymptomatic and most authors recommend that they should be left in situ even in children. Removal of implants is not as innocuous as is often believed. Besides anesthesia-related complications, there are surgery-related complications in 3% to over 40% of the patients. Implant removal is also associated with increased cost and time off work. In patients who complain of pain around the site of the implant, the actual cause of the pain is often not known and it could be due to the effect of the injury rather than the implant itself. In symptomatic patients removal of implants resolve the symptoms in only about 50 % of the patients [30].
There is no scientific evidence to support a routine removal of deep-seated orthopedic implants after fracture union though it is a common practice in many hospitals. Essentially, routine removal of asymptomatic deep-seated implants after fracture union can be classed as another example of unnecessary surgery which is quite rampant.
There are many other examples of unwarranted procedures, in other disciplines as well, which are frequently carried out such as tonsillectomy, appendectomy, CABG, hemorrhoidectomy, herniorrhaphy, prostatectomy, carotid endarterectomy, hysterectomy and cholecystectomy [31].

Why do surgeons continue to perform unnecessary surgery?

The often asked question is, how can a procedure which is contraindicated by research be so commonly carried out? Stahel et al [32] have framed the question very well when they asked: “Why would a reasonable surgeon consider performing unneeded surgical procedures?” They have come up with two answers from the surgeon’s perspective.
1. Surgeons perform surgery because they have been trained
to do so and that they have always been doing it that way and do not know any better. In German phycology, it is known as “Funktionslust” [33].
2. The other reason is that the surgeons are ‘incentivized to perform surgical procedures, either for financial gain, renown, or both’ [32].
It is obvious that it would be difficult to get people to do the right thing when they’re paid to do the wrong thing. Doctors are in a powerful position because of information asymmetry. Doctors know much more about medical treatment than patients do, hence doctors can recommend care which is of little or no value to enhance their incomes, partly out of habit and partly because doctors incorrectly believe in it. Unfortunately, many doctors have stopped being doctors and have become businessmen.
Besides the financial aspects, “availability heuristic,” also play a role. This term was coined by Nobel laureate psychologists Amos Tversky and Daniel Kahneman. It simply means that it is human instinct to base an important decision on an example which is dramatic and easy to recall even if that example is irrelevant or incredibly rare.

There is an avalanche of unnecessary medical care which is harming patients physically as well as financially. It also drains a large portion of the country’s healthcare budget.
Is there something that can be done about it?

Second Surgical Opinion Programs (SSOP)

Second surgical opinion programs were first introduced in the USA in 1974 specifically to reduce the rate of unnecessary surgery. Medicare and Medicaid programs strongly recommended the use of SSOP. By 1984 private health insurers also began to offer second opinion programs.
However, over the years enthusiasm for SSOPs cooled as more and more payers found that saving from this programs was not relevant and in some cases, it cost more than the savings [31].
 After the failure of SSOP to reduce the rate of unnecessary surgery, many believed that the introduction of practice guidelines may be of value.

Practice Guidelines

There is a lot of high-level scientific evidence available in the literature to guide appropriate treatment of patients. The challenge is to get doctors to assess this information and effectively use the information. The development of medical practice guidelines was an attempt to overcome this challenge. Now there are excellent practice guidelines easily available online from various professional specialty societies. The challenge now is to get doctors to treat their patients based on the best evidence available in these guidelines.
To date, however, there is no evidence that these guidelines have been effective in reducing the numbers of unnecessary surgeries.

Review of health care benefits

Another way to reduce unnecessary low-value medical care would be for the health insurers to stop paying for services which have been found to be of no value to the patients. The Australian government is taking steps in this direction by reviewing the Medicare Benefits Schedule to remove ineffective medical services from the schedule so that taxpayers do not have to pay for these services. The money thus saved can be more effectively used to fund more effective care.

Choosing Wisely

Choosing Wisely is an initiative of the ABIM Foundation which by advancing medical professionalism hopes to improve health care. Choosing wisely is one of ABIM Foundation’s most famous initiative. They help to promote conversation between patients and their doctors so that the patient can choose and get medical care which is supported by evidence, free from harm and is truly necessary. The various American specialist societies have provided recommendations, for the patients and the doctors, about what should not be done in the management of various medical conditions [34].
This initiative is relatively new and only time will tell if it is effective in reducing low-value medical care.

Tackling waste and inefficiencies in the ministry of health in Malaysia.

The above initiatives in US and Australia are for medical care of the citizens in private medical centers which the government pays for through Medicare. It is difficult for the government to control medical care in private hospitals.
In Malaysia, on the other hand, the government hospitals are run by the government and its employees, hence it should be relatively easy to control waste.
The Malaysian Health expenditure report 2013 shows that the public Malaysian healthcare expenditure has increased almost fivefold in 15 years from RM4,317 million in 1997 to RM19,797 million in 2011[35]. The government expenditure on health care as % of total expenditure on health care was 59.0% in the year 2000 and reduced to 55.5% in 2010 while the private expenditure on health as % of total expenditure on health care increased from 41.0% in the year 2000 to  44.5% in 2013 [35].
Pharmaceuticals constitute a large proportion of total health care expenditure in Malaysia as in many other low and middle-income countries. In Malaysia, ‘medicines expenditure has been increasing from MYR 1.61 billion in 2010, 1.76 billion in 2011, 1.98 billion in 2012 and 2.2 billion in 2013’ [36]. In 2012 medicine expenditure accounted for about 11.4% of the operating budget of the Ministry of Health Malaysia [36].
A World Health Organization/Health Action International (WHO/HAI) study in 2007 showed that medicine prices in our private healthcare sector were among the highest in the region. This is partly due to a free market economy where manufacturers, distributors, retailers and other private entities set prices of medications without government control [36].
These high prices not only makes it more difficult for patients to afford these medications but it also leads to wastage of healthcare resources.
In OECD (Organisation for Economic Co-operation and Development) countries, pharmaceuticals constitute a major source of operational wastefulness. The pharmaceutical spending in OECD countries comprises between 6.7 and 30.2% of national healthcare budgets. Bulk purchasing and replacing originator with cheaper generic drugs would be a good way to tackle waste of the healthcare budget [37]. This would hold true for Malaysia too, especially for the Ministry of Health. Switching from originator drugs to generic drugs, which have equal efficacy, can provide extensive price saving possibilities. This, however, requires a change in behavior amongst the doctors, pharmacists and the hospital authorities, over whom the pharmaceutical industry has great influence and traction. The pharmaceutical industry influences the prescribing behavior of the doctors to very large extent [38].
In Greece, the public hospitals have to reach a 50% share of generics in the total volume of drugs administered while in Japan pharmacists are given bonuses when more generics are used. In Greece and Ireland, the people pay for the difference between the cost of the originator and the generic drugs. People can also be persuaded to use generics if the reimbursement for generic drugs is higher than for the originator drugs [37].
There can be huge savings when there is a shift from expensive biologic medicines used in therapies for cancer and rheumatoid arthritis to cheaper biosimilar alternatives. The US and five European countries could save more than €50 billion (US$54.5 billion) by the end of 2020, according to estimates from the IMS Institute for Healthcare if they switch and replace eight key biologics with biosimilars drugs [37].
In the 1960’s, 70’s and 80’ the university hospital, University of Malaya Kuala Lumpur had an effective system of preventing pharmaceutical wastages. There was a drug committee consisting of several senior consultants and the pharmacist, which controlled what drugs should be bought and stocked in the hospital pharmacy. The lower ranking doctors such as medical and house officers could only sign off commonly used widely available drugs which were relatively cheap. Many of these drugs were generics. Prescriptions for any new expensive drugs had to be signed by a senior consultant who always asked for the reasons why the drug needs to be used.
Now I gather that there are no such checks and balance in the university and the government hospitals.
The other factors that contribute to wastages are the system of governance. The “giving and taking of bribes and the abuse of power for personal gain is widespread” in the healthcare industry. Furthermore, there are losses to fraud and error which has been estimated in 2015 to be about 6% of related health expenditure on average in OECD countries [37].
The other area of medical care that needs to be revamped to reduce wastages is the elimination of unnecessary investigations, procedures, and surgery.
Though reducing low-value care is a core component of healthcare reforms in many Western countries there appear to be no such reforms in Malaysia.
In our Malaysian private healthcare sector attempts at reducing wastage due to unnecessary care is unlikely to succeed anywhere in the near future because efforts to reduce overuse of healthcare services run counter to the dominant financial incentives in a fee-for-service system. Here more wastage translates to more revenue for all in the system including the doctors. Low-value care cannot be eliminated without the cooperation of the doctors.
In the public sector, it is much easier to control wastage due to unnecessary investigations, procedures, and surgery. The individual department heads in the university and ministry of health hospitals can have almost absolute control over the type and nature of investigations, procedures and surgery carried out in their department. Academy activities can be held on a monthly basis to update the staff on what is new and what the consensus is in the management of various medical disorders. Such academic activities were common at the University of Malaya hospital in the 1960s, 70s, and 80s. The department heads had sufficient control over the types of investigations, procedures and surgery carried out in their department.
Undoubtedly the efforts to reduce overuse has to be physician-led and increasing the visibility of low-value care, its harms and costs will go a long way to help reduce wastages due low-value health care. Disinvestment in low-value care should be made a priority.

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