Public Shaming Reduces Unnecessary Medical Tests For Cancer In Sweden: A Possible Model For The US?
As the price tag for unnecessary medical tests in the U.S. approaches the tens of billions of dollars, medical organizations are rallying to reverse the trend. Changing doctors' perceptions on when to order diagnostic imaging is one possible avenue, given that this practice grew at "a faster rate than any other physician service in the Medicare population."
A joint study between New York University (NYU) and Swedish medical researchers may have found an easy strategy for curbing unnecessary imaging for prostate cancer, which could be used as a general model for reducing extraneous tests in the U.S.
The investigation centered around a campaign implemented by the Swedish National Prostate Cancer Register (NPCR) in 2000 that aimed to discourage the overuse of imaging tests for patients with low-grade, slow-growing prostate tumors.
Prostate cancer is most dangerous when it metastasizes — spreads to other places like bone or lymph nodes — but this rarely occurs with low-grade tumors. Therefore, full-body, hi-tech scans for satellite tumors pose an inessential cost to these patients and do not improve overall healthcare.
"Imaging is very important for men with high risk prostate cancer to find out whether it has spread and guide how they are treated," said co-author Dr. Stacy Loeb, also a urologist at NYU. "However, due to prostate cancer screening, most prostate cancer is now diagnosed at an early stage. Low-risk prostate cancer is very unlikely to have spread, so imaging is not necessary, causing undue burden for the patients and costs for the healthcare system."
The NPCR devised a simple plan to curb this financial burden that focused on showing physicians their mistakes. At local urology meetings, doctors were provided with the statistics on inappropriate screening for their district.
According to the researchers, this provided a sense of accountability that was one part competition and one part shame, as doctors did not want to wind up on the 'bottom of the barrel' of their local statistics.
"I think you could consider the tactic a way of "gentle shaming" of the health care providers who did not follow the guidelines," said Makarov.
Makarov and his colleagues examined the medical records of 100,000 Swedish men diagnosed with prostate cancer between 1998 and 2000 to see if the NPCR's plan had worked.
Over the nine years that followed the plan's implementation in 2000, the percentage of unneeded scans dropped from 45 percent to three percent for low-risk prostate cancer patients.
But the plan isn't quite perfect. Diagnostic imaging also dropped — from 63 percent to 47 percent — for patients at high-risk for metastasis.
"The caveat here is that when guidelines are implemented to limit the inappropriate use of a healthcare resource, the appropriate use of that resource should be simultaneously encouraged," said Makarov. "Otherwise those patients who most need the resource may no longer have access to it."
Last year, the ABIM Foundation, which is dedicated to improving healthcare by advancing medical professionalism, started the Choosing Wisely initiative to open channels between patients and physicians so they decide on how to choose the best care. This new research could guide future recommendations from this campaign and other national programs to reduce overspending on healthcare.
"In the United States we have guidelines about the overuse of imaging tests, but lack a roadmap for their implementation," said Makarov. "We could learn a lot from what the Swedes have done."
Source: Makarov DV, Loeb S, Ulmert D, Drevin L, Lambe M, Stattin P. Prostate Cancer Imaging Trends After a Nationwide Effort to Discourage Inappropriate Prostate Cancer Imaging. Journal of the National Cancer Institute. 2013.