Despite a health care system burdened by high costs and patients facing long waits for medical procedures, many Canadians are getting unnecessary diagnostic tests and surgeries that may leave them worse off, physicians say.
Patients in their 40s and 50s who have elective knee-replacement surgery, for example, are at increased risk for early failure of the artificial joint, said Gillian Hawker, a rheumatologist and clinical epidemiologist at the University of Toronto.
Revision surgery to repair the artificial joint is a complex procedure that does not always go well, she said. But try telling that to middle-aged patients who insist they need a new knee or hip so they can ski into their golden years, she added.
“They will keep looking until they find a surgeon who will operate,” Hawker said. “Then they have surgery and are surprised that, when you hit a new joint hard, it wears out fast.”
Knee replacement surgery is on a list of procedures under review by Canadian provinces in a recent push to reduce unnecessary medical treatments and diagnostic tests. The Health Care Innovation Working Group, an interprovincial body, is re-evaluating procedures including MRIs, joint replacements and cataract removal to set new guidelines on when such interventions are necessary and when they are of questionable benefit.
The increased scrutiny coincides with an international movement to curtail rampant overdiagnosis and overtreatment. According to a growing number of researchers, routine use of sensitive scanning technology, exploratory surgeries and potent medications is burdening health care systems and subjecting patients to treatments that may do more harm than good.
In the past two years, “there’s been a groundswell of energy focused on overdiagnosis and overtreatment,” said Alan Cassels, a pharmaceutical policy researcher at the University of Victoria and the author of Seeking Sickness: Medical Screening and the Misguided Hunt for Disease (2012). Another hard-hitting book on the topic is Otis Webb Brawley’s How We Do Harm: A Doctor Breaks Ranks About Being Sick in America.
The United States leads the world in terms of overtreatment and overdiagnosis, said David Henry, president of the non-profit Institute for Clinical Evaluative Sciences in Toronto. But, he added, “Canada is right up there.”
Overdiagnosis and overtreatment stem from medical innovations as well as structural problems in Canada’s health care system, said Henry, who serves on the steering committee of Preventing Overdiagnosis, an international conference organized for this September by Consumer Reports and the British Medical Journal as part of its Too Much Medicine campaign.
Increasingly sensitive diagnostic equipment such as CT scanners and MRI machines send doctors on wild goose chases to investigate abnormalities that are often benign, Henry said. Routine screening tests for various cancers cast the diagnostic net too wide, leading to invasive procedures when cancer is wrongly detected in healthy patients, he added. Compounding the problem, Canada’s fee-for-service approach to compensating doctors creates a “natural incentive” for doctors to err on the side of prescribing a drug, ordering a screening test or performing a medical procedure. “Some of these procedures may actually be unnecessary,” Henry said.
A shift is under way, however. In Ontario and other provinces, health officials are combing through lists of medical tests and procedures published by ChoosingWisely.org, a U.S. initiative to help physicians and patients assess whether a service is truly needed. Since its launch in 2012, more than 40 medical societies have submitted a list of five tests and procedures to be questioned in the doctor’s office.
The website boils down evidence-based research into plain language. For instance, Choosing Wisely notes the low prevalence of ovarian cancer and the invasive interventions required after a positive screening test, and advises: “Don’t screen for ovarian cancer in asymptomatic women at average risk.”
In patients’ eyes, measures to reduce screening tests and medical procedures may smack of rationing. Many Ontarians, for example, protested their province’s decision last year to stop paying for what it considered to be inappropriate MRIs and CT scans of lower backs.
But as Henry pointed out, many widely used tests and procedures are not supported by evidence-based research. In the case of lower back pain, studies have shown that, unless a patient has symptoms of a tumour, fracture or osteoporosis, imaging technology puts the patient at needless risk from radiation exposure and may lead to exploratory surgery based on benign abnormalities found in the scans.
“We’re talking not only about the cost,” Henry said, but “doing harm to people.”
Scandinavian countries tend to have a leaner model in terms of medical screening and interventions because of their focus on preventive medicine and primary care, he pointed out. The Canadian health care system, by contrast, is dominated by hospitals and specialist doctors who are not compensated to recommend alternatives to medical treatment, Henry said.
Sholom Glouberman, president of the Patients’ Association of Canada, noted that the services offered by the Canadian system “are pretty narrow.” If a patient has a sore shoulder, for example, a doctor may not suggest physiotherapy because it is not covered by medicare. For a patient without an extended medical plan, Glouberman said, “the cheapest thing is to have you shoulder operated on.”