Patients and physicians alike often have lofty expectations and aspirations about the effectiveness of a prospective treatment. But, as a new article in the Annals of Family Medicine argues, those expectations contribute significantly to both the increasing costs of healthcare and avoidable harms suffered by patients.
At the core of the healthcare cost crisis right now is an unavoidable fact, writes Steven Woolf, MD: The cost of obtaining healthcare, and in particular health insurance, is far outpacing inflation and any other growth in government expenditures.
Woolf, who practices family medicine at Virginia Commonwealth University's School of Medicine, says many cost-limiting proposals have been considered, but most ignore what he refers to as "unrealistic expectations about the effectiveness of tests and treatments."
Earlier studies, noted Woolf, have shown that primary care patients frequently overestimate the effectiveness of tests and therapies, and in particular screenings and medication. In one study cited by Woolf, "The minimum benefit from screening that respondents deemed acceptable was less than their known benefit."
Even as patients overestimate the effectiveness of treatments, they also routinely underestimate the probability of harms. "Many Americans … are quite willing to receive false positive results and unnecessary biopsies for the chance to detect cancer," observes Woolf.
Part of the problem is that many clinical guidelines are put together by specialists in their respective fields of practice, who Woolf argues are more likely to deal with advanced-stage patients on a regular basis and thus discount the effects of a treatment or screening regimen on healthier patients.
"Whereas epidemiologists consider the population denominator to put the numerator in perspective, the world of specialists is conditioned to the numerator, giving them a skewed basis for judging the population prevalence of diseases or benefit-risk ratios," he wrote. As an example, Woolf cites prostate cancer screening beginning at age 40 instead of 50. The shift, he says, would only avert one death per 1,000 men.
The other part comes down to clinical evidence, which Woolf says is often in short supply when making important, patient-centered decisions. More data, and in particular comparative effectiveness research data, can allow patients to weigh benefits, risks and scientific certainty.
The data may not come from pharmaceutical or medical device companies, said Woolf. New campaigns spearheaded by physician groups are beginning to identify treatment regimens seen as suspect and generating new patient-focused treatment materials aimed at using clear, plain language.
"Time will tell whether such efforts succeed and whether the medical profession will emerge as the change agent that brings more realistic expectations to patient care," concluded Woolf. "It is a straightforward economic argument, but it can also save lives."