Eating My Words

How often have I said: “There is no Consumer Reports guide to healthcare—and with good reason"? Often I add that “rating refrigerators is a lot easier than measuring the quality of care provided by a hospital or doctor.”

Guess what?

Consumer Reports has just launched a new online "compare your hospital" tool  (Thanks to Gary Schwitzer, who reported this on Schwitzer Health News Blog over the week-end.)

And where did Consumer Reports get their information?  They’ve taken it from the Dartmouth research on treatment, overtreatment and outcomes that I cite so frequently.

I have always liked Consumer Reports--ever since I was a young bride buying my first air-conditioner. It didn’t let me down then, and, I’m glad to say, it hasn’t let me down now.

Consumer Reports’ health website doesn’t claim that this is the “report card” that can give you the skinny on the hospitals where you will receive the “best care.” Instead, it cautions readers:  “This tool gives you one way to compare hospitals, but it's not designed as a quality indicator.”

If you’re looking for charts that rank quality, it sends you to the Federal government’s “Healthcare Compare” website where you will find some helpful information. But since research that looks at the quality of health care is still quite new, the indicators are fairly thin. They measure what can be measured, leaving out many of the most important and more subtle measures of good care.

Today these indicators may tell us whether the patient received antibiotics after the operation. But ultimately, we need to ask “Did he need the operation in the first place?” And if the patient died, one would like to know whether he was in pain. Did he receive palliative care?

But while Consumer Reports doesn’t claim that it has developed the ultimate “quality report card” that we’ve all been waiting for, it makes very clear that the Dartmouth research on individual hospitals offers priceless information:

“Most Americans die in old age of serious chronic conditions that worsen over months or years, such as diabetes, heart failure, dementia, or many types of cancer,” the report on hospitals explains. “With careful medical management, patients with these diseases can spend most of these months or years outside the hospital, with their symptoms under control.”

Conservative vs. aggressive care

“The data you'll see here, from The Dartmouth Atlas of Health Care, shows that not every hospital practices conservative care,” the Report continues. “Many patients with these long-term serious illnesses are repeatedly hospitalized and seen by many different physicians. The Dartmouth research has shown that aggressive care does not necessarily improve patient outcomes and can sometimes shorten life. That's because it exposes people to a greater risk of hospital-acquired infections and the medical errors that can occur when too many doctors test and treat patients in an uncoordinated way.”

Consumer Reports stresses that “It's important to understand that the distinction between aggressive and conservative care does not apply to medical emergencies such as a heart attack, stroke, broken hip, or inflamed appendix. All hospitals everywhere address these conditions immediately and with the full arsenal of treatments at their command.”

The Report then offers a very helpful table:

10 Overused Tests and Treatments

Here, Consumer Reports lists what it calls “medical rip-offs.” This doesn’t mean that no one should undergo these tests or treatments. But often, they are over-used, and in some cases there is little or no evidence that they are more effective than less invasive, less expensive strategies.

1
BACK SURGERY. Don't rush to surgery for a simple slipped disk. In 90 percent of cases, the pain goes away on its own within six weeks. In stubborn cases, surgery, which can cost $20,000 plus physician's fees, can relieve pain somewhat faster than physical therapy and medication, a recent study showed. But it also found that both groups of patients wound up with similar improvements after two years.

2
HEARTBURN SURGERY. Doctors surgically tighten a sphincter muscle that blocks stomach acid from backing up into the esophagus. But research shows the operation, which costs $14,600 or more, provides no better long-term relief than taking a proton-pump-inhibitor drug such as omeprazole (Prilosec OTC), which costs less than $1 a day.

3
PROSTATE TREATMENTS. Prostate cancer is often overtreated by surgery that costs $17,000, or by radiation therapy for $20,700 or more, plus physician's fees, without adequate discussion of the alternatives or the high risk of distressing side effects such as incontinence or impotence. Because prostate cancer can grow slowly, sometimes the best approach is "watchful waiting."

4
IMPLANTED DEFIBRILLATORS. These devices, which automatically shock the heart back to normal rhythm, cost some $90,000 over a lifetime. Yet one-third of people who get them might not really need them, according to research reported in 2007. This year Medicare will pay for an estimated 50,000 of the devices.

5
CORONARY STENTS. Billions are spent each year inserting tiny mesh tubes to prop open coronary arteries. The procedure plus heart drugs turns out not to work any better to prevent future heart attacks than heart drugs alone for patients with stable coronary artery disease, researchers reported in 2007.

6
CESAREAN SECTIONS. They cost almost $7,000, about 55 percent more than a natural delivery, and constituted a record high of 30.2 percent of births in 2005. Most are performed because labor is progressing too slowly. But several less-invasive approaches might be enough to speed up labor.

7
WHOLE-BODY SCREENS. These CT scans, which can cost $1,000 or more, are promoted for spotting early signs of cancer, heart disease, and other abnormalities. There are no proven benefits for healthy people, the Food and Drug Administration has concluded. Plus CT scans expose patients to far more radiation than X-rays. A few CT scans a year can increase your lifetime risk of cancer.

8
HIGH-TECH ANGIOGRAPHY. Using a CT scan to noninvasively check coronary arteries for narrowing costs an average of $450, according to data from HealthMarkets, which sells health and life insurance through subsidiaries in 44 states. But standard angiography is sometimes still needed to confirm blockages that might require aggressive treatment.

9
HIGH-TECH MAMMOGRAPHY. Using software to flag suspicious breast X-rays would add $550 million a year to national costs if used for all mammograms. But a 2007 study found that this technique failed to improve the cancer-detection rate significantly, yet resulted in more needless biopsies.

10
VIRTUAL COLONOSCOPY. These CT scans are being used to detect signs of cancer without inserting a tube into the colon. But a study of virtual colonoscopy reported in 2007 concluded that standard colonoscopy is better at spotting smaller suspicious polyps. Though less costly than a standard colonoscopy, the virtual test isn't cost-effective because any suspicious finding requires retesting with the real thing.

Comparative-Effectiveness Research

We need unbiased head-to-head research comparing new drugs, devices and procedures to existing treatments.  As the Report points out: “Many developed nations have some kind of national agency that objectively evaluates new treatments and technology and determines coverage policy, such as Britain’s National Institute for Health and Clinical Excellence. Though insurers and medical specialty societies, among others, do such evaluations in the U.S., payment and coverage decisions here are driven mainly by pressure from manufacturers, doctors, and consumers, according to a study published in the November/December 2004 issue of Health Affairs. No one wants to be ‘the one on the block who doesn’t know the new technique,’ a physician told the researchers.

“Some health-policy experts are advocating the creation of a national center devoted to research directly comparing different medical treatments, an idea that Consumers Union, the nonprofit publisher of Consumer Reports, strongly supports.”

If you are concerned about being over-treated and want more conservative care, it’s important to know where you will find it. Check out the Consumer Reports website by clicking here. Then, at the beginning of the second paragraph, click on The Dartmouth Atlas of Health Care (highlighted in blue.)  On the left-hand side of the first page, you’ll find “Data Access Tools.” Scroll down, and click on “Help.” Follow the instructions and you’ll be able to compare hospitals in your region.

Comments

[Matthew Holt]

Maggie. You wait till you see what Michael Millenson writes about this on THCB. Not sure I agree with him but I do find it funny!

[maggiemahar]

Jim--

Yes, I really think we've reached a "tipping point" with Wennberg's work.
Shannon's book,as well as the articles she has been writing have helped.
The fact that Consumer Reports has picked it up is HUGE
And I'm very happy for Wennberg himself. For years, his was a voice in the wilderness. The very intelligent people around him, who were famliar with his work, understood that he was right.

But it was not a message that most doctors--or patients, or health policy makers--wanted to hear.
But he's both a person of great integrity and very, very stubborn.
I wrote a profile of him last fall, when he was stepping down as head of the Dartmouth project. (Though he's still involved).
It's a great "story" with some interesting characters that many of you might enjoy. You'll find it here: http://dartmed.dartmouth.edu/winter07/html/braveheart.php

[jim jaffe]

nice work. wonder if the wennberg material is finally crossing over into the civilian population. certainly the articles in Consumer Reports, which have generated reports in the dailies, and the Brownlee piece in the new AARP magazine suggest it may be so.

[Lisa Lindell]

It's your blog, Maggie, I'm tellin' ya. The world is smaller than it appears.

[Gregory D. Pawelski]

How refreshing!!

[maggiemahar]

Lisa,

Of course I'm not the only person who knows about the Dartmouth Reserach--it really is now well-accepted in medical circles.And other blogs and authors have written about it.

But it's complicated and counterintuitive, and so it's been harder to get the word out to the public.

I'm especially pleased that Consumer Reports decided to use Dartmouth's work as the basis for its comparison of hospitals because people trust Consumer Report--with good reason.

CR's reputation for being "clean" is well-deserved. And it doesn't overcharge for its very valuable information. They easily could--they really have a monopoly on things like reliable comparisons of stoves and refrigerators. Nevertheless, you can still purchase a one-month subscription, on line, for very few dollars.

I'm hoping that CR;s implicit endorsement will cause more reporters to take a close look at the Dartmouth research.

[Lisa Lindell]

I saw this CU report over the weekend and thought "They've been reading Maggie's blog..."