Archivi Categorie: Health Technology Assessment

Incidentalomas: The real cost of ordering tests @Medici_Manager @SIHTA_Italia @kevinmd


I recently read a very good article in the New York Times about a patient found to have the classic incidentaloma, a small mass in the adrenal gland.  This is estimated to be seen in 4% of abdominal CT scans, and is rarely serious but typically leads to recommendations for additional testing and follow up CT scans to assure that it is not either a metastatic cancer from another area or a hormone secreting tumor of the adrenal gland itself. It is so common that the NIH has a formal recommendation article to guide physicians on how to manage a small adrenal mass found on imaging modalities, what they refer to as adrenal incidentaloma, and even have an acronym “AI.”

The term incidentaloma is a tongue-in-cheek to denote an incidental finding on an imaging test.  –oma is the suffix used in the name of any tumor or enlargement.  Examples are lipoma, condyloma, meningioma, teratoma, and dozens of others. The root of the term obviously refers to the fact that it was an incidental finding on a test looking for something else altogether.

Classic incidentalomas include:

  • Tiny solitary pulmonary nodules. Commonly on chest x-ray or chest CT scan a small pulmonary nodule is seen.  Most times these are the result of a prior fungal infection or previous inflammation, but often require follow up imaging.
  • Small ovarian cysts seen on pelvic ultrasound.  The ovaries of women of child bearing age form an ovulatory cyst each month, and commonly these normal cysts, or other small cysts of questionable importance are noted on pelvic ultrasounds done for evaluation of uterine fibroids, evaluation of abnormal bleeding, or other concerns where ovarian cyst or cancer is not the primary concern.  Follow up ultrasounds, occasional surgery, and lots of emotional angst are the most common outcomes.
  • Renal cysts. Abdominal CT scans often show “lesions” in the kidney that require further evaluation to determine if they are simple renal cysts or possibly solid tumors.  They usually are cysts, but are common incidental findings on CT scans done to look for kidney stones, diverticulitis, or other problems. Again additional evaluation with ultrasound and sometimes monitoring over time or even biopsy are done to further evaluate these incidentalomas.
  • Lab test abnormalities, though not referred to as incidentalomas are other common incidental findings that often lead to a cascade of follow up testing.  The most common example in my practice is minor elevation of liver enzymes called transaminases, or liver function tests.  When abnormal these are usually repeated along with testing for viral hepatitis C and B.  If they remain abnormal liver imaging, sometimes liver biopsy are often done.  The usual outcome is a diagnosis of fatty liver, with advice to stop drinking alcohol, and lose weight.  This is advice that could have been given without even knowing the liver enzymes were elevated.

The whole incidentaloma problem is just one example of the real cost of ordering tests, especially tests like CT scans and MRIs that are so sensitive that they often find insignificant minor abnormalities or normal variants that lead to yet more expensive and sometimes invasive evaluation.

Edward Pullen is a family physician who blogs at

When is an Innovation? @Medici_Manager @timkastelle

by  on 3 March 2013 in innovation

Greg and I have been talking about whether or not innovation needs a purpose.  While we agree on many points, we can see two differing views on the question.  I will argue that within an organisation, innovation does need a purpose, and here is Greg’s post arguing the other side.

Let’s start by looking at a case study.  When Watson and Crick published their paper revealing the structure of DNA in 1953, they close the paper by saying:

It has not escaped our notice that the specific pairing we have postulated immediately suggests a possible copying mechanism for the genetic material.

In their annotated version of the paper, the fantastic Exploratorium in San Francisco says this about Watson and Crick’s statement:

This phrase and the sentence it begins may be one of the biggest understatements in biology. Watson and Crick realized at the time that their work had important scientific implications beyond a “pretty structure.” In this statement, the authors are saying that the base pairing in DNA (adenine links to thymine and guanine to cytosine) provides the mechanism by which genetic information carried in the double helix can be precisely copied. Knowledge of this copying mechanism started a scientific revolution that would lead to, among other advances in molecular biology, the ability to manipulate DNA for genetic engineering and medical research, and to decode the human genome, along with those of the mouse, yeast, fruit fly, and other research organisms.

In many respects, even though these applications were noticeable in 1953, it’s really only been in the past 10-15 years that we’ve started to see a significant economic impact from the discovery of the structure of DNA.

So, was the discovery of the structure of DNA an innovation?

DNA double helix horizontalDNA double helix horizontal (Photo credit: Wikipedia)

There are two ways to look at this.  Some say that it’s not an innovation if there isn’t an economic payoff.  Or even more strictly, that without a new product, it’s not innovation.  Others say that innovation is driven by discoveries like this – that we must engage in search and discovery activities even though we have no idea what practical applications will arise.

Even though these seem like opposites, you must do both –  This is another innovation paradox.

On the one hand, if you want to stay in business, the ideas that you execute need to create value.  Then you have to convert that value into something that helps you pay the bills. If you’re not innovating around your core, you are vulnerable to competition from people that are.

So while it’s not true that you’re not innovating if it doesn’t create a new product, it is true that you need to create value with your innovations so that you can generate some sort of return.

When we think about corporate groups that have engaged in pure search and discovery, the two big examples are probably Bell Labs and Xerox PARC.  It’s no coincidence that both parent firms effectively had monopolies when they made these investments – they didn’t have to care as much about returns.

The answer to the question: was the discovery of the structure of DNA an innovation? depends a lot on timing.  And it raises three important points about managing innovation.

  1. Innovation is a process.  I’ve said before that innovation is actually the process of idea management.  Lukas Fittl tackles this issue nicely by talking about the distinction between ideation and execution – what he refers to as the flipping the ideation switch:the_ideation_switch1For our purposes here, ideation is the period when you are doing the searching, which may not have much of a market focus, and execution is when you zero in on building a profitable business model for your idea. Fittl talks about this as a very directed process even in the exploratory state.
  2. You face uncertainty throughout this entire process.  There are a couple of persistent, damaging ideas that pop up here. One is that when you get to the execution phase of an idea, there isn’t any uncertainty anymore.  Unfortunately, this is not true.  Any time we are working with new ideas, we can never be certain that they will work.Roger Martin addresses this in a great post about strategy and uncertainty:

    Contrary to popular opinion, strategy is not about turning uncertainty into certainty. Lots of bureaucratically inclined board members and corporate executives want and expect this to be the case. When reviewing strategies, you can hear them asking for proof that the strategy will be successful.
    The reality is that strategy is about making choices under competition and uncertainty. No choice made today can make future uncertainty go away. The best that great strategy can do is shorten the odds of success.

    Greg has made the point that strategy and innovation are often conflated. In this case, Martin’s comments on strategy do apply to innovation as well.

  3. The business problem with exploration is that the gap between the discovery and the economic payoff is usually very long.  This gap is almost always longer than we expect.  Look at the DNA example.  Watson and Crick published in 1953, and at the time, they noticed that the idea had commercial potential.  But the first biotech firm, Genentech, wasn’t founded until 1976, and their first product didn’t come out until 1982 – nearly 30 years after Watson and Crick’s article!Sketch-DiffusionIf Watson and Crick had been working for a company in 1953 when they made their discovery, how would it have managed to stay in business until 1982? You’d need a lot of venture capital to support that…

One way to address this is to manage your innovation activities as a portfolio using a 70/20/10 split in your innovation effort.  70% goes to improving your core business with incremental innovations, so that you can continue to stay in business.  20% goes to finding adjacent markets that you can extend into.  And 10% goes to blue sky ideas that might change the world, but we just don’t quite know how yet.

Once again, it’s not an either/or question – it’s both/and.  We need to be both evolutionary and revolutionary.

However, in practical terms this means that innovation does need to have a purpose.  You can do all the discovery that you want, but if you don’t use it to create value, you won’t be in business for long.

About Tim Kastelle

Idea Connector – Studies innovation networks – author, speaker & consultant on innovation – University of Queensland Business School – links to academic papers, twitter, and so on can be found here.

Readmissions and mortality @Medici_Manager @IncidentalEcon


Much has been made about the relationship between hospital readmission rates and mortality. Dead people can’t be readmitted, suggesting a negative correlation. On the other hand, decreases in both seem to be measures of quality, suggesting a positive correlation.

Harlan Krumholz and colleagues published a JAMA article last month that examines the correlation between risk-adjusted, 30-day readmission rates and mortality rates, both calculated on a fee-for-service Medicare cohort using CMS’s methodology. In particular, they examined patients discharged with a diagnosis of heart failure (HF), acute myocardial infarction (AMI), or pneumonia (PN). Correlations were not statistically significantly different from zero between mortality and readmission rates for the AMI and PN disease cohorts. For the HF cohort, the correlation point estimate was -0.17. Wanna see it?

readmit mort HF

(Dashed lines are medians. The blue line is a cubic spline smooth regression. The shaded area designates the 95% confidence interval.)

The authors conclude that mortality and readmission rates measure different, nearly orthogonal aspects of quality.

From a policy perspective, the independence of the measures is important. A strong inverse relationship might have implied that institutions would need to choose which measure to address. Our findings indicate that many institutions do well on mortality and readmission and that performance on one does not dictate performance on the other.

Ashish Jha has another perspective. A quote doesn’t do justice to his argument, but here’s the key passage:

So if one measure of quality is external validity – being at least somewhat correlated with the gold standard (mortality rates) — how does the readmission measure do? In a paper published recently in JAMA, we see that readmission rates don’t do so well at all. Readmission rates are un-correlated with mortality rates. In fact, for one of the three conditions, the readmission rate seems to go the wrong way: the best hospitals for heart failure (i.e. those with the lowest mortality rates) have readmission rates that are actually higher. Not perfect. Readmissions seem to have little external validity as a quality measure. Readmissions are, however, correlated with two things: how sick your patients are, and how poor your patients are. We now have good data that the Hospital Readmission Reduction Program disproportionately penalizes big academic teaching hospitals (that care for the sickest patients) and safety-net hospitals (that care for the poorest).

Ashish goes on to suggest readmission rates can still play a helpful role in motivating hospitals and health systems to improve. Maybe! I worry that they can also be gamed. Since they’re hardly correlated with mortality, we may not easily detect when they are.

NIHR HTA Conference 2013 @SIHTA_Italia @Medici_Manager

The NIHR Health Technology Assessment (HTA) Programme is celebrating its impact in clinical and public health research by holding a milestone conference on 9-10 October 2013 in central London.

The emphasis of the conference will be to:

  • Examine the impact, nationally and internationally of the programme in clinical effectiveness research
  • Consider the influence of the HTA Programme within the NHS and on UK clinical research

This event celebrates the contribution made by the HTA Programme to the NIHR mission to improve the health and wealth of the nation. It will raise the national and international awareness and prestige of the programme, its projects and published research findings.

In conjunction with the conference The Lancet will be publishing a themed issue on clinical effectiveness research.

Who should attend?

  • Active HTA researchers
  • Prospective HTA researchers and trainees
  • NHS leaders and commissioners
  • NHS decision makers
  • Patient groups
  • Organisations who run trials nationally and internationally

View more information about the HTA Programme at

Alla ricerca dell’informazione di qualità @Medici_Manager

La buona informazione è la migliore medicina. “La disponibilità di informazioni affidabili e validate – considera Carlo Favaretti – può generare valore aggiunto solo se questa disponibilità viene ‘catturata’ da tutti coloro che, nella pratica quotidiana, devono combinare al meglio le risorse disponibili con i bisogni e le domande dei cittadini”. Ben venga quindi una guida come La ricerca documentale, rivolta a tutte le figure professionali sanitarie, su come trovare nel mare magnum web-based l’informazione di cui si ha bisogno in una prospettiva evidence-based oriented.

La presentazione di Carlo Favaretti go

Acquista il libro a soli 12 € go

Reactions to Choosing Wisely® @Medici_Manager @muirgray

On February 21st, seventeen medical specialty societies announced new lists of things physicians and patients should question as part of the ABIM Foundation’s Choosing Wisely campaign. This marks the second release of lists from the campaign; at least 18 societies will release new lists later in the year.

In addition to the announcement of new lists, Consumer Reports—which has worked with the medical specialty societies to create patient-friendly translations—published new brochures that now cover more than 30 specific topic areas.

The National Business Coalition on Health and Pacific Business Group on Health also unveiled new a Choosing Wisely Employer Toolkit to help employers educate their employees about steps they can take to avoid overused or unnecessary tests or procedures.

The announcement of new society lists was covered widely in the media and inspired reactions ranging from cautiously optimistic to skeptical that the campaign could achieve its goals.

A brief sampling:

The New York Times’ The New Old Age Blog For the Elderly, Medical Procedures to Avoid
“It is an attempt to alert both doctors and patients to problematic and commonly overused medical tests, procedures and treatments. It took an elegantly simple approach: By working through professional organizations representing medical specialties, Choosing Wisely asked doctors to identify ‘Five Things Physicians and Patients Should Question.’”

Huffington Post Choosing Wisely, Indeed
“This long overdue and welcome effort is launched to inspire conversations between patients and doctors about the necessity—or lack thereof—of many commonly-ordered diagnostic tests and medical approaches.”

Modern Healthcare Curbing Overuse (subscription required)
“We have created a medical ecology based on overprescription and overconsumption on the part of both physicians and patients,” Dr. Blair Erb said. “What Choosing Wisely has done is legitimize our ability to cut back on what’s unnecessary.”

Stand Up For Health Care Blog “Just in Case” Can Mean More Money and No Benefit
Choosing Wisely is something we can all do to improve our own care and improve our health care system at large.”

Albany Herald Staff Editorial: More Isn’t Always Better in Medicine
“For American health care to be what it should be, its core has to reside in truthful communication between a patient and the doctor he or she trusts.”

Akron Beacon Journal Editorial: The Doctors’ List of Don’ts
“The premise of Choosing Wisely is that good information, presented in language that the average layman can grasp, will lead to intelligent conversation and good decisions about appropriate treatment. The project is appealing as an ongoing exercise in determining what is worth the money in medical care. It is especially appealing because when the recommendations come from practitioners themselves, it helps to strip a sensitive discussion of the toxic exaggerations so often the currency of the political arena.”

The Economist: Democracy in America Waste Lots, Want Lots 
“The Choosing Wisely campaign is bravely entering the fray, but its ambition is modest. It hopes to convey that not all care is good care. Slowly, the culture among physicians and patients may change. But the campaign has no teeth. Its suggestions are phrased in the gentlest possible manner, listing treatments that ‘patients and physicians should question.’”

For updates on the campaign, follow #ChoosingWisely on Twitter (@ABIMFoundation), “Like” us on Facebookand subscribe to The Medical Professionalism Blog.

@ProfAlanMaynard on NICE approval: Lucentis for Macular Oedema why not Avastin? @Medici_Manager

NICE approves eye drug for diabetes

By James GallagherHealth and science reporter, BBC News

A drug that can save the sight of people with diabetes may now be made available on the NHS in England and Wales – reversing an earlier decision.

At least 50,000 people in the UK have diabetic macular oedema which can leave people unable to read, work or drive.

In 2011, the National Institute for Health and Clinical Excellence (NICE) said ranibizumab, which is sold as Lucentis, was too expensive.

A final decision will be made in February.

Macular oedema occurs when fluid leaks from the small blood vessels in the eye.

Diabetes can trigger changes to the blood vessels leading to fluid collecting in the central part of the retina called the macular area.

Saving sightProf Carole Longson, from NICE, said the manufacturers had agreed to reduce the price which led to a review of the guidance.

“NICE is pleased to recommend ranibizumab as a treatment option for some people with visual impairment caused by diabetic macular oedema in new draft guidance.”

Clara Eaglen, eye health policy and campaigns manager at the charity RNIB, said: “We believe NICE has thrown a lifeline to the growing number of people with diabetes facing blindness.

“Currently people are needlessly losing their sight from diabetic macular oedema.”

Barbara Young, the chief executive of Diabetes UK, said: “We are delighted that NICE have reconsidered their previous decision, and that this draft guidance recommends that Lucentis is made available on the NHS, as this would mean more people with diabetes would have a better opportunity to preserve and possibly improve their vision.”

Selling Proton Therapy to the Public: High Costs Without Benefit @Medici_Manager

In Trentino si sta mettendo in funzione la protonterapia! Auguri per la sostenibilità!

Written by Daniel Wolfson on March 20, 2013

Arriving in a train station in a Northeast city the other day, I was struck by the number of advertisements for proton therapy at a local academic medical center (AMC) plastered throughout the station and in local subways. The ads feature a bicycle racer with the tag line: “THE WIND IN YOUR FACE IS WORTH PROTON THERAPY: A cancer treatment that has fewer side effects.”

A bold statement, I thought, considering several studies have shown that proton therapy provides no long-term benefit over traditional radiation and comes with significantly higher cost for most conditions. There are a limited number of conditions—such as pediatric oncology—where proton therapy is shown to be effective.  Most striking, however, was the fact that this ad was specifically created to target a public that is not aware of the proton therapy’s marginal benefit and in what limited conditions it is effective.

“Marginal benefit” is when two procedures have small differences in benefits but large cost differences. Usually the more expensive intervention yields more benefits, like fewer side effects. But in this case, we have a procedure with no added benefits that is a lot more expensive.

Proton therapy uses atomic particles to treat cancer rather than X-rays. The particle accelerator is the size of a football field and costs about $180 million. According to the Yale study, Medicare pays over $32,000 for the treatment compared to under $19,000 for radiation. When applied to treat prostate cancer, outcomes were no different than intensity-modulated radiotherapy. Urinary function side effects were slightly better within six months but those advantages disappeared with 12 months post-therapy.

The ad directly contradicts the findings of this study and claims that proton therapy has fewer side effects than traditional therapy. This claim is true for pediatric cases but not for prostate cancer, the one primarily targeted by these ads.

What bothers me the most is that an AMC is peddling a more expensive procedure with no clear added benefit to the public through a massive advertising campaign. Isn’t there a moral imperative for an AMC to work in the best interest of their community based on the best available clinical evidence? Isn’t this supposed to be the era of value services? If they must advertise the therapy (possibly to recoup some of their costs or at least break even), why not target referring physicians rather than an unsuspecting public that is prone to request the latest and greatest technology just because it’s new? Perhaps referring physicians are wise to the lack of proton therapy’s marginal benefit and the AMC is hoping they will acquiesce to their patients’ demand for this marginal procedure. Is the public to know what cases are best for this type of therapy and for which conditions it is not well suited?

We should expect more and we should demand better. Proton therapy is clearly a more expensive procedure where a just-as-effective procedure exists. Quality and safety has not been raised, only the cost of medicine.

The Effective Health Care Program (AHRQ) @Medici_Manager

Comparative effectiveness research is designed to inform health-care decisions by providing evidence on the effectiveness, benefits, and harms of different treatment options. The evidence is generated from research studies that compare drugs, medical devices, tests, surgeries, or ways to deliver health care.

There are two ways that this evidence is found:

  • Researchers look at all of the available evidence about the benefits and harms of each choice for different groups of people from existing clinical trials, clinical studies, and other research. These are called research reviews, because they are systematic reviews of existing evidence.
  • Researchers conduct studies that generate new evidence of effectiveness or comparative effectiveness of a test, treatment, procedure, or health-care service.

Comparative effectiveness research requires the development, expansion, and use of a variety of data sources and methods to conduct timely and relevant research and disseminate the results in a form that is quickly usable by clinicians, patients, policymakers, and health plans and other payers. Seven steps are involved in conducting this research and in ensuring continued development of the research infrastructure to sustain and advance these efforts:

  1. Identify new and emerging clinical interventions.
  2. Review and synthesize current medical research.
  3. Identify gaps between existing medical research and the needs of clinical practice.
  4. Promote and generate new scientific evidence and analytic tools.
  5. Train and develop clinical researchers.
  6. Translate and disseminate research findings to diverse stakeholders.
  7. Reach out to stakeholders via a citizens forum.

Common questions about comparative effectiveness research

Q: Why is comparative effectiveness research needed? What problem is it trying to solve?

  • If you don’t get the best possible information about your treatment choices, you might not make an informed decision on what treatment is best for you.
  • When you shop for a new car, phone or camera, you have lots of information about your choices. But when it comes to choosing the right medicine or the best health-care treatment, clear and dependable information can be very hard to find.
  • It’s true that some treatments may not work for everyone, and that some treatments may work better for some people than others. This research can help identify the treatments that may work best for you.

Q: What are the practical benefits of comparative effectiveness research?

  • You deserve the best and most objective information about treating your sickness or condition. With this research in hand, you and your doctor can work together to make the best possible treatment choices.
  • For example, someone with high blood pressure might have more than a dozen medicines to choose from. Someone with heart disease might need to choose between having heart surgery or taking medicine to open a clogged artery. Reports on these topics and others include the pros and cons of all the options so that you and your doctor can make the best possible treatment decision for you or someone in your family.
  • Every patient is different — different circumstances, different medical history, different values. These reports don’t tell you and your doctor which treatment to choose. Instead, they offer an important tool to help you and your doctor understand the facts about different treatments.

Reducing Waste in Health Care @Medici_Manager @nedwards_1

A third or more of what the US spends annually may be wasteful. How much could be pared back–and how–is a key question.

What’s the issue?
Health care spending in the United States is widely deemed to be growing at an unsustainable rate, and policy makers increasingly seek ways to slow that growth or reduce spending overall. A key target is eliminating waste–spending that could be eliminated without harming consumers or reducing the quality of care that people receive and that, according to some estimates, may constitute one-third to nearly one-half of all US health spending.Waste can include spending on services that lack evidence of producing better health outcomes compared to less-expensive alternatives; inefficiencies in the provision of health care goods and services; and costs incurred while treating avoidable medical injuries, such as preventable infections in hospitals. It can also include fraud and abuse, which was the topic of a Health Policy Brief published on July 31, 2012.

This policy brief focuses on types of waste in health care other than fraud and abuse, on ideas for eliminating it, and on the considerable hurdles that must be overcome to do so.

What’s the background?
Many studies have examined the characteristics and amounts of wasteful or ineffective US health care spending in public programs, such as Medicare and Medicaid, and in care paid for by private insurance as well as out-of-pocket by consumers. By most accounts, the amount of waste is enormous.THE COST OF WASTE: By comparing health care spending by country, the McKinsey Global Institute found that, after controlling for its relative wealth, the United States spent nearly $650 billion more than did other developed countries in 2006, and that this difference was not due to the US population being sicker. This spending was fueled by factors such as growth in provider capacity for outpatient services, technological innovation, and growth in demand in response to greater availability of those services. Another $91 billion in wasteful costs or 14 percent of the total was due to inefficient and redundant health administration practices.

By looking at regional variations in Medicare spending, researchers at the Dartmouth Institute for Health Policy and Clinical Practice have estimated that 30 percent of all Medicare clinical care spending could be avoided without worsening health outcomes. This amount represents about $700 billion in savings when extrapolated to total US health care spending, according to the Congressional Budget Office.

More recently, an April 2012 study by former Centers for Medicare and Medicaid Services (CMS) administrator Donald M. Berwick and RAND Corporation analyst Andrew D. Hackbarth estimated that five categories of waste consumed $476 billion to $992 billion, or 18 percent to 37 percent of the approximately $2.6 trillion annual total of all health spending in 2011. Spending in the Medicare and Medicaid programs, including state and federal costs, contributed about one-third of this wasteful spending, or $166 billion to $304 billion (Exhibit 1). Similarly, a panel of the Institute of Medicine (IOM) estimated in a September 2012 report that $690 billion was wasted in US health care annually, not including fraud.

Exhibit 1
Download Powerpoint Slide

CATEGORIES OF WASTE: Researchers have identified a number of categories of waste in health care, including the following:

  • Failures of care delivery. This category includes poor execution or lack of widespread adoption of best practices, such as effective preventive care practices or patient safety best practices. Delivery failures can result in patient injuries, worse clinical outcomes, and higher costs.A study led by University of Utah researcher David C. Classen and published in the April 2011 issue of Health Affairs found that adverse events occurred in one-third of hospital admissions. This proportion is in line with findings from a 2010 study by the Department of Health and Human Services’ Office of Inspector General (OIG), which found that Medicare patients experienced injuries because of their care in 27 percent of hospital admissions.

    These injuries ranged from “temporary harm events,” such as prolonged vomiting and hypoglycemia, to more serious “adverse events,” such as kidney failure because of medication error. Projected nationally, these types of injuries–44 percent of which were found to be clearly or likely preventable–led to an estimated $4.4 billion in additional spending by Medicare in 2009, the OIG found. Berwick and Hackbarth estimate that failures of care delivery accounted for $102 billion to $154 billion in wasteful spending in 2011.

  • Failures of care coordination. These problems occur when patients experience care that is fragmented and disjointed–for example, when the care of patients transitioning from one care setting to another is poorly managed. These problems can include unnecessary hospital readmissions, avoidable complications, and declines in functional status, especially for the chronically ill.Nearly one-fifth of fee-for-service Medicare beneficiaries discharged from the hospital are readmitted with 30 days; three-quarters of these readmissions–costing an estimated $12 billion annually–are in categories of diagnoses that are potentially avoidable. Failures of care coordination can increase costs by $25 billion to $45 billion annually. (See the Health Policy Brief published on September 13, 2012, for more information on improving care transitions.)
  • Overtreatment. This category includes care that is rooted in outmoded habits, that is driven by providers’ preferences rather than those of informed patients, that ignores scientific findings, or that is motivated by something other than provision of optimal care for a patient. Overall, the category of overtreatment added between $158 billion and $226 billion in wasteful spending in 2011, according to Berwick and Hackbarth.An example of overtreatment is defensive medicine, in which health care providers order unnecessary tests or diagnostic procedures to guard against liability in malpractice lawsuits. A September 2010 Health Affairsstudy led by Harvard University researcher Michelle M. Mello estimated that in 2008, $55.6 billion or 2.4 percent of total US health care spending was attributed to medical liability system costs, including those for defensive medicine.

    Overtreatment can also result from overdiagnosis, which results from efforts to identify and treat disease in its earliest stages when the disease might never actually progress and when a strategy such as watchful waiting may have been preferred. For example, in July 2012 the US Preventive Services Task Force recommended against prostate-specific antigen-based screening for prostate cancer because of “substantial overdiagnosis” of tumors, many of which are benign. Excessive treatment of these tumors, including surgery, leads to unnecessary harms, the task force said.

    Overtreatment also includes intensive care at the end of a person’s life when alternative care would have been preferred by the patient and family, or excessive use of antibiotics.

    Another form of overtreatment is the use of higher-priced services that have negligible or no health benefits over less-expensive alternatives. When two approaches offer identical benefits but have very different costs, the case for steering patients and providers to the less costly alternative may be clear–for example, using generics instead of brand-name drugs.

    There is also provision of many services that may once have been considered good health care but that now have been discredited as lacking in evidence of benefit. Under the umbrella of the American Board of Internal Medicine Foundation’s “Choosing Wisely” initiative, nine different medical specialty groups and Consumer Reports have identified a series of regularly used tests or procedures whose use should be examined more closely. In 2013, 21 additional medical specialty groups will release similar lists in their respective fields.

    The National Priorities Partnership program at the National Quality Forum, a nonprofit organization that works with providers, consumer groups, and governments to establish and build consensus for specific health care quality and efficiency measures, has produced a list of specific clinical procedures, tests, medications, and other services that may not benefit patients. The next step is for physicians and payers to change their practices accordingly.

    After requesting public input, CMS on November 27, 2012, posted on its website a list of procedures or services that may be overused, misused, or provide only minimal health care benefits. They include lap-band surgery for obesity, endoscopy for gastroesophageal reflux disease, and lung volume reduction surgery. CMS said that these services may be evaluated to determine whether they should continue to be reimbursed under Medicare.

  • Administrative complexity. This category of waste consists of excess spending that occurs because private health insurance companies, the government, or accreditation agencies create inefficient or flawed rules and overly bureaucratic procedures. For example, a lack of standardized forms and procedures can result in needlessly complex and time-consuming billing work for physicians and their staff.In an August 2011 Health Affairs article, University of Toronto researcher Dante Morra and coauthors compared administrative costs incurred by small physician practices in the United States, which interact with numerous insurance plans, to small physician practices in Canada, which interact with a single payer agency. US physicians, on average, incurred nearly four times more administrative costs than did their Canadian counterparts. If US physicians’ administrative costs were similar to those of Canadian physicians, the result would be $27.6 billion in savings annually. Overall, administrative complexity added $107 billion to $389 billion in wasteful spending in 2011.
  • Pricing failures. This type of waste occurs when the price of a service exceeds that found in a properly functioning market, which would be equal to the actual cost of production plus a reasonable profit. For example, Berwick and Hackbarth note that magnetic resonance imaging and computed tomography scans are several times more expensive in the United States than they are in other countries, attributing this to an absence of transparency and lack of competitive markets. In total, they estimate that these kinds of pricing failures added $84 billion to $178 billion in wasteful spending in 2011.
  • Fraud and abuse. In addition to fake medical bills and scams, this category includes the cost of additional inspections and regulations to catch wrongdoing. Berwick and Hackbarth estimate that fraud and abuse added $82 billion to $272 billion to US health care spending in 2011.
What are the issues?
Although there is general agreement about the types and level of waste in the US health care system, there are significant challenges involved in reducing it. Much waste is driven by the way US health care is organized, delivered, and paid for and, in particular, by the economic incentives in the system that favor volume over value. An additional problem is that attacking “waste” usually means targeting someone’s income.In its September 2012 report, the IOM offered 10 broad recommendations for creating a very different health care system in which research, new incentives, partnerships between providers and patients, and a culture that supports continuous learning and development could lead to real-time improvements in the efficiency and effectiveness of US health care.

Although the IOM committee that prepared the report did not estimate cost savings, it predicted that implementing these measures would improve care and reduce expenses. The panel’s recommendations included the following:

  • Improve providers’ capacity to collect and use digital data to advance science and improve care.
  • Involve patients and their families or caregivers in care decisions. Increasing comparative effectiveness research may help physicians, patients, and their families make more informed decisions. (See the Health Policy Brief published on October 8, 2010, for more information on comparative effectiveness research.)
  • Use clinical practice guidelines and provider decision support tools to a greater extent.
  • Promote partnerships and coordination between providers and the community to improve care transitions.
  • Realign financial incentives to promote continuous learning and the delivery of high-quality, low-cost care. Numerous efforts are underway among public and private payers to move from the traditional fee-for-service mechanism, which pays based on the volume of services performed, and toward those that pay based on value and outcomes. (For more information, see theHealth Policy Brief published October 11, 2012, on pay-for-performance, and the Health Policy Brief published January 31, 2012, on accountable care organizations.
  • Improve transparency in provider performance, including quality, price, cost, and outcomes information. In a May 2003 Health Affairs article, Gerard F. Anderson from Johns Hopkins University, Uwe E. Reinhardt from Princeton University, and coauthors compared US health care spending with those of other member nations of the Organization for Economic Cooperation and Development. They found that the United States spent more on health care than any other country and that the difference was caused mostly by higher prices.

One way to improve transparency and reduce prices is through “reference pricing,” in which an employer or insurer makes a defined contribution toward covering the cost of a particular service and the patient pays the remainder. The objective is to encourage patients to choose providers with both quality and costs in mind. In a September 2012 Health Affairs article, University of California, Berkeley, researchers James C. Robinson and Kimberly MacPherson reviewed how this approach is being tested.

Many of the measures described above are in process, although they are playing out at different rates in different regions and systems around the country. There are widespread concerns about how replicable and scalable some new payment models are, and how soon they will make a major difference in the way care is provided and in what amount. There are also cross-cutting trends, including consolidation of hospital systems and their employment of physicians, which could lead to the provision of more unnecessary services, not fewer.

For example, in a May 2012 Health Affairs article, Robert A. Berenson, an institute fellow at the Urban Institute, and coauthors found that dominant hospital systems and large physician groups can often exert considerable market power to obtain steep payment rates from insurers.

FEAR OF RATIONING: In theory, a focus on eliminating waste in health care could skirt the issue of rationing because wasteful activities, by definition, carry no benefit to consumers. However, there may be a fine line between health care that is of no benefit and situations where the benefits are relatively small, especially in comparison to the cost.

A common example involves continued chemotherapy treatments for patients having certain advanced cancers. These treatments can cost tens of thousands of dollars but extend a patient’s life by only a few weeks. However, restricting the use of such treatments or services can lead to accusations of “rationing.”

To address many Americans’ fear that the Affordable Care Act would lead to rationing, the law specifically forbids the federal government from making decisions on “coverage, reimbursement, or incentive programs” under Medicare that take cost-effectiveness into account, and “in a manner that treats extending the life of an elderly, disabled, or terminally ill individual as of lower value than extending the life of an individual who is younger, nondisabled, or not terminally ill.” The law is silent on any of these activities going on outside of Medicare.

What’s Next?
Efforts to extract waste from the health care system will in all likelihood continue along a range of federal government initiatives, including information technology adoption, pay-for-performance, payment and delivery reforms, comparative effectiveness research, and competitive bidding. Similar programs are also being initiated by state Medicaid agencies and by private payers. In the view of many experts, even more vigorous efforts to pursue the reduction of waste in health care are clearly warranted.
Anderson, Gerard F., Uwe E. Reinhardt, Peter S. Hussey, and Varduhi Petrosyan, “It’s the Prices, Stupid: Why the United States Is So Different from Other Countries,” Health Affairs 22, no. 3 (2003): 89-105.Bentley, Tanya G.K., Rachel M. Effros, Kartika Palar, and Emmett B. Keeler, “Waste in the US Health Care System: A Conceptual Framework,” Milbank Quarterly 86, no. 4 (2008): 629-59.

Berenson, Robert A., Paul B. Ginsburg, Jon B. Christianson, and Tracy Yee, “The Growing Power of Some Providers to Win Steep Payment Increases from Insurers Suggests Policy Remedies May Be Needed,” Health Affairs 31, no. 5 (2012): 973-81.

Berwick, Donald M., and Andrew D. Hackbarth, “Eliminating Waste in US Health Care,” JAMA 307, no. 14 (April 11, 2012): 1513-6.

Classen, David C., Roger Resar, Frances Griffin, Frank Federico, Terri Frankel, Nancy Kimmel, et al., “‘Global Trigger Tool’ Shows That Adverse Events in Hospitals May Be Ten Times Greater Than Previously Measured,”Health Affairs 30, no. 4 (2011): 581-9.

Elmendorf, Douglas W., “Options for Controlling the Costs and Increasing the Efficiency of Health Care,” Statement before the Subcommittee on Health, Committee on Energy and Commerce, US House of Representatives, March 10, 2009.

Farrell, Diana, Eric Jensen, Bob Kocher, Nick Lovegrove, Fareed Melhem, Lenny Mendonca, et al., “Accounting for the Cost of US Health Care: A New Look at Why Americans Spend More,” McKinsey Global Institute, December 2008.

Hoffman, Ari, and Steven D. Pearson, “‘Marginal Medicine’: Targeting Comparative Effectiveness Research to Reduce Waste,” Health Affairs 28, no. 4 (2009): w710-18. DOI: 10.1377/hlthaff.28.4.w710.

Institute of Medicine, “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America,” September 6, 2012.

Kelley, Robert, “Where Can $700 Billion in Waste Be Cut Annually from the US Healthcare System?” Thomson Reuters, October 2009.

Levinson, Daniel R., “Adverse Events in Hospitals: National Incidence among Medicare Beneficiaries,” Department of Health and Human Services Office of Inspector General, November 2010.

Morra, Dante, Sean Nicholson, Wendy Levinson, David N. Gans, Terry Hammons, and Lawrence P. Casalino, “US Physician Practices Versus Canadians: Spending Nearly Four Times as Much Money Interacting with Payers,” Health Affairs 30, no. 8 (2011): 1443-50.

About Health Policy Briefs
About Health Policy BriefsWritten by
Nicole Cafarella Lallemand
Research Associate
Urban Institute

Editorial review by
Andrew D. Hackbarth
Assistant Policy Analyst
RAND Corporation

Brent C. James
Executive Director
Institute for Health Care Delivery Research
Intermountain Healthcare

Bob Kelley
Senior Vice President
Truven Health Analytics

Ted Agres
Senior Editor for Special Content
Health Affairs

Susan Dentzer
Health Affairs

Health Policy Briefs are produced under a partnership of Health Affairs and the Robert Wood Johnson Foundation.

Cite as:
“Health Policy Brief: Reducing Waste in Health Care,” Health Affairs, December 13, 2012.

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Inappropriate care requests: The role of health care professionals @Medici_Manager @kevinmd


A guest column by the American College of Physicians, exclusive to

How to reduce the cost of medical care while improving quality is the focus of several initiatives, including the American College of Physicians’ High Value Care initiative, the ABIM Foundation’s Choosing Wisely campaign, and Consumer Reports’ Consumer Health Choices.

The common message is that we can improve the quality of care and lower costs by reducing the use of tests and treatments that provide little or no value to the patient and might even be harmful. Barriers to implementing recommendations on high value care include concerns about liability risk, patient demand (fueled in part by easy access to incorrect information online), lack of adequate time for physicians to talk to patients, and external pressures, including those from direct-to-consumer advertising and health reporting in the media. (For example, in a recent newscast in Rhode Island, an “expert” recommended that men over age 50 should undergo telomere testing.)

One source of external pressure to order tests or treatments that is cited less often is health care professionals themselves – not only physicians, but nurses, physical therapists, pharmacists, and others. Their well-intentioned comments or recommendations often result in unnecessary testing.

Examples of these pressures to test or treat occur frequently in my practice. At a routine follow up with a medical subspecialist, one of my patients mentioned that she had a backache. The subspecialist responded that she should make an appointment with me to get an MRI. Emergency rooms or urgent care centers often discharge patients with recommendations for tests that I should order.

Then there are the radiology reports in which the radiologist recommends a follow up study if a diagnosis is not clear after the original study or if they discover an incidental finding. How about the pharmacist who suggests that their customer with a cough call me so they can get a prescription for an antibiotic? And let’s not forget the health professional relatives and friends of our patients who suggest that they “ask their doctor to order” tests or treatments based on casual conversations at cocktail parties, sporting events, and family gatherings.

I realize that these suggestions are intended to be helpful, and in some cases, they are not recommendations but instances of thinking out loud in front of the patient. However, just as patients often interpret “this drug may cause cough and rarely causes death,” as “this drug will make you cough and will kill you,” when a health care professional says, “your doctor might want to consider ordering…”  the patient may hear “your doctor should order…” That puts the receiving physician, usually the primary care physician, in a difficult position.

While we may not be able to change the behavior of the trial lawyers, Internet “experts,” pharmaceutical companies, or the media, we can have an impact on our own actions and those of our fellow health professionals:

  • Physicians: if you believe that a patient needs a test or treatment, then order it yourself and take responsibility for all that goes with doing so. If you’re not sure, or don’t want to step on the primary care physician’s toes, discuss it with that physician. But don’t put the patient in the middle of it – that’s equivalent tostomping on toes.
  • Physicians: when we order an imaging study, provide enough information to allow the radiologist to interpret the test properly. Radiologists, if we order the wrong test for the clinical question, please let us know before the test is performed, not in the written interpretation. If you find something that may require further testing depending on circumstances, call us so we can discuss it rather than commit us to the test by recommending it in your report. (Ordering physicians, please take that call when it’s made or return it immediately if you cannot.)
  • All health care professionals: Let’s make sure whatever advice we give is within our level of training and expertise and the boundaries of our license.
  • Physicians: do not recommend tests or treatments to friends or family unless you have performed a proper evaluation (which is difficult to do over Thanksgiving dinner), and even if you do, be mindful of your colleague, the treating physician. It is OK to say, “I don’t know,” “I can’t give you advice without a more thorough evaluation,” or “It wouldn’t be appropriate for me to tell your doctor what to do.”

Another part of the solution is to reform the payment and delivery systems in ways that promote the provision of high value care. A system that supports the establishment of long-term trusting relationships between patients and physicians, that does not penalize for spending extra time talking to patients, and that encourages communication among health care providers will ensure that our patients get the tests and treatments that they need and are protected from those that are of little or no value.

Yul Ejnes practices internal medicine in Cranston, Rhode Island, and is the Immediate Past Chair, Board of Regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.

Five Reasons Choosing Wisely® Has Appeal to Physicians @Medici_Manager @ABIMFoundation

We’ve heard from a number of physicians across the country that they are beginning to think through ways to advance the Choosing Wisely campaign. They are embracing the recommendations from the specialty societies and exploring how conversations between physicians and patients about reducing overused or wasteful tests and procedures can be embedded in their practices. More than 30 specialty societies have joined the effort to date, while one society continues to discuss the pros and cons of participating.

Since the launch of the campaign in April 2012, more than 55 peer-reviewed journal articles have included mention of the Choosing Wisely campaign. Much of what has been written in the blogosphere and trade publications has been favorable to the campaign.

The following are five reasons I think can be attributed to this positive reaction. The number five also matches the number of recommendations made by specialty societies taking part in the campaign originated by the National Physician Alliance and described by Howard Brody in hisNew England Journal of Medicine article “Medicine’s Ethical Responsibility for Health Care Reform — The Top Five List”.

1) The campaign emphasizes the patient-physician relationship and conversations between them about overused medical tests and procedures where the risks outweigh the benefits. Physicians welcomed this renewed emphasis on the relationship and communication between patients and physicians.

2) Physicians also welcomed their specialty society taking a leadership position, particularly on issues of determining appropriateness of health care and identifying waste in the system, which can place their patients in harm’s way.

3) The campaign is a refreshing change from the polarizing and sometimes toxic environment that we sometimes see in health care discussions. The campaign has allowed for more thoughtful conversations about the need to create a more sustainable health care system.

4) Choosing Wisely has reinforced the notion that removing waste – things that don’t add value to the patient – improves quality and safety and in most instances, reduces costs.

5) Physicians don’t have to have a divided self as described by Parker Palmer in his book,Courage to Teach. Many physicians say they are asked to perform tests and procedures they knew were wasteful, but feel they needed to accommodate patient requests. Their inner being – their set of professional values don’t match with their outward behavior. The divided self produces psychological pain. Physicians are beginning to have the power, backed by their credible and prestigious specialty societies, to say more isn’t necessarily better.

These are just my five reasons why I think Choosing Wisely is helping move the conversation about managing resources in the right direction, but there are probably others. What do you think are other reasons the campaign resonates with physicians?



How many times have you done this procedure, Doc? @Medici_Manager @kevinmd

Questions such as this from proactive, increasingly knowledgeable patients place a physician on the horns of an ethical dilemma.  Although fellows are closely supervised and trained under a gradually increasing responsibility principle (based upon subjective evaluation), a time will come when there is no one available to back you up in the catheterization lab.

Fact: Someone has to be a physician’s first case of any given type. However, no one really wants to be that person.

Access to extensive medical information on the web has satiated some of our patient’s desire for information and expectations regarding medical procedures, which is a good thing. However, increased transparency and public awareness of medical errors has opened up a Pandora’s box regarding a physician’s skill level and experience.  The September 2012 issue of Men’s Health went as far as publishing peer reviewed data regarding the minimum numbers for particular procedures taken directly from medical journals. Specifically, coronary angioplasty and angiography minimums were reported as 50 and 82 procedures respectively.

Take home message: Hard numbers to meet your first month into fellowship.

Similar experience-responsibility disparities exist in commercial aviation.  However, in contradistinction to the patient-doctor encounter, passengers are neither cognizant of their captain’s flight hours nor face-to-face prior to boarding.  Further increasing the stakes, a new pilot’s first manifest could be 50 passengers or more. In response to public demand for greater safety, the airline industry was an early adopter of systems to increase reliable pilot performance including flight simulation technology and pre-flight checklists, which were quite effective in reducing fatal incidents for air travelers.  As a result, the latest National Safety Council in the U.S.A. calculated the lifetime odds of death for flying to be 1:7178 in 2008 compared to 1:98 for automobile deaths.

Interestingly, even experienced pilots are required scheduled simulation training to maintain their skills and prepare for rare-but-catastrophic events, which cannot be realistically produced in the air.  The auto industry, unique in their in inability to increase motorists’ skills, have been forced to develop safety technology to make the highways safer.

Reality check: Patients do not come with air bags or crash sensors.  Simulation and checklists are proven methods to increase safety.

Virtual reality simulation training programs allow students of all levels to gain familiarity with equipment selection, proficiency of the detailed steps for a given procedure as well as an awareness of the potential pitfalls and crucial moments in a safe environment. Furthermore, under experienced tutelage during practice, a modicum of fingertip finesse may be learned prior to laying hands upon their first patient.

While “ain’t nothing like the real thing” is unarguably the best way to learn any motor skill, having solid theoretical and practical experience makes the transition to live cases easier and might ameliorate the patient’s and the beginner’s shakes.

Max Berry is a vascular and interventional radiology fellow.

Medically necessary: Who should decide? How to decide? @Medici_Manager

Canadian Medical Association Journal

Letture consigliate per l’health technology assessment @Medici_Manager @SIHTA_Italia

Letture consigliate:

Goodmann Cl.: HTA 101 Introduction to health technology assessment, National Library of Medicine, 2004,

Topfer L.A e Auston I. (Eds.): Etext on Health Technology Assessment (HTA) Information Resources, National Library of Medicine, 2006,

Francesconi A.: Innovazione organizzativa e tecnologica in sanità: il ruolo dell’health technology assessment, Franco Angeli/Sanità, 2007

Cicchetti A. (Ed.): Introduzione all’health technology assessment, Il Pensiero Scientifico Editore, 2008

Health Equality Europe: Comprendere l’health technology assessment, Italian Journal of Public Health, 2009

Favaretti C., Cicchetti A., Guarrera G., Marchetti M. e Ricciardi W.: Health technology assessment in Italy, Intl. J. of Technology assessment in Health Care, 2009, 25: Supplement 1, 127-133,

Ricciardi W. e La Torre G.: Health technology assessment: principi, dimensione e strumenti, SEEd, 2010

De Rosa M. e Scroccaro G. (Eds): L’applicazione delle tecniche di HTA alla valutazione di farmaci e dispositivi medici, Infosan, 2010

Cicchetti A. e Marchetti M. (Eds.) Manuale di health technology assessment, Il Pensiero Scientifico Editore, 2010

Drummond M.F., Sculpher M.J., Torrance G.W., O’Bien B.J., Stoddart G.L.: Metodi per la valutazione economica dei programmi sanitari, Il Pensiero Scientifico Editore, 2011, (Edizione italiana a cura di Mennini F.S., Cicchetti A., Fattore G. e Russo P.L.)

Favaretti C.: La valutazione della tecnologia sanitaria: omogeneità o difformità, in Falcitelli N., Gensini G.F., Trabucchi M. e Vanara F. (a cura di): Fondazione Smith Kline Rapporto Sanità 2010 – Federalismo e Servizio sanitario nazionale, Il Mulino, 2010, 201-212

Autori vari SIHTA: Clinical Governance, 2007 (agosto)

Clinical Governance, 2008, 1

Favaretti C., De Pieri P., Fontana F., Guarrera G.M., Debiasi F., Betta A. e Baldantoni E.: La governance clinica nell’esperienza dell’Azienda provinciale per i servizi sanitari di Trento, in Wright J. e Hill P.: La governance clinica, McGraw-Hill,  2005, XXI-LXI,