Your health is too important to be left to your doctors.
For example, almost all chiropractors and physical therapists treating on a lien basis are useless, according to the 2016 book CROOKED: Outwitting the Back Pain Industry and Getting On the Road to Recovery.
The recent news that stents inserted in patients with heart disease to keep arteries open work no better than a placebo ought to be shocking. Each year, hundreds of thousands of American patients receive stents for the relief of chest pain, and the cost of the procedure ranges from $11,000 to $41,000 in US hospitals.
But in fact, American doctors routinely prescribe medical treatments that are not based on sound science.
The stent controversy serves as a reminder that the United States struggles when it comes to winnowing evidence-based treatments from the ineffective chaff. As surgeon and health care researcher Atul Gawande observes, “Millions of people are receiving drugs that aren’t helping them, operations that aren’t going to make them better, and scans and tests that do nothing beneficial for them, and often cause harm.”
Of course, many Americans receive too little medicine, not too much. But the delivery of useless or low-value services should concern anyone who cares about improving the quality, safety and cost-effectiveness of medical care. Estimates vary about what fraction of the treatments provided to patients is supported by adequate evidence, but some reviews place the figure at under half.
Naturally that carries a heavy cost: One study found that overtreatment — one type of wasteful spending — added between $158 billion and $226 billion to US health care spending in 2011.
The stunning news about stents came in a landmark study published in November, in The Lancet. It found that patients who got stents to treat nonemergency chest pain improved no more in their treadmill stress tests (which measure how long exercise can be tolerated) than did patients who received a “sham” procedure that mimicked the real operation but actually involved no insertion of a stent.
There were also no clinically important differences between the two groups in other outcomes, such as chest pain. (Before being randomized to receive the operation or the sham, all patients received six weeks of optimal medical therapy for angina, like beta blockers). Cardiologists are still debating the study’s implications, and more research needs to be done, but it appears that patients are benefitting from the placebo effect rather than from the procedure itself.
Once a treatment becomes popular, it’s hard to dislodge
Earlier cases in which researchers have called into question a common treatment suggest surgeons may push back against the stent findings. In 2002, The New England Journal of Medicine published a study demonstrating that a common knee operation, performed on millions of Americans who have osteoarthritis — an operation in which the surgeon removes damaged cartilage or bone (“arthroscopic debridement”) and then washes out any debris (“arthroscopic lavage”) — worked no better at relieving pain or improving function than a sham procedure. Those operations can go for $5,000 a shot.
Many orthopedic surgeons and medical societies disputed the study and pressed insurance companies to maintain coverage of the procedure. Subsequent research on a related procedure cast further doubt on the value of knee surgeries for many patients with arthritis or meniscal tears, yet the procedures remain in wide use.
Other operations that have continued to be performed despite negative research findings include spinal fusion (to ease pain caused by worn disks), and subacromial decompression, which in theory reduces shoulder pain.