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Antibiotics and narcotics are often prescribed when they aren’t the best option for patients and may do more harm than good, a survey of U.S. physicians suggests.
The survey asked doctors to identify treatments that they see routinely used despite guidelines recommending against the interventions and little or no value for patients.
Overuse of antibiotics topped the list, with 27 percent of doctors identifying this as a common problem. Prescribing narcotics and opioids for chronic pain was another treatment of limited value, according to 7.3 percent of physicians surveyed.
“We need to start concentrating on high-value care,” said lead study author Dr. Amir Qaseem, vice president of clinical policy and chair of the high value care task force for the American College of Physicians.
This isn’t just about money.
“The value of any intervention is when you look at the benefits and harms and cost together,” Qaseem said in a telephone interview.
“For example, HIV treatment is very expensive but that doesn’t mean it’s low value because it’s very effective,” Qaseem added. “Antibiotics can be very cheap but they can be low value because they often aren’t necessary.”
His team’s findings, from an online survey completed by 1,582 doctors, were published online December 5th in Annals of Internal Medicine.
Participants were asked to identify the two treatments they most often observed being used for patients that were unlikely to offer high value.
Overuse of aggressive care in patients with limited life expectancy was identified as a problem by 8.6 percent of participants, making it second only to overuse of antibiotics.
This mostly included life-support measures near the end of life such as feeding tubes, intubation and resuscitation; treatments to prevent long-term complications in patients with little time left to live, such as dialysis or invasive heart procedures; and chemotherapy for patients with advanced or metastatic cancer.
About 5 percent of doctors also identified overuse of dietary supplements including vitamin D, niacin, fish oil, calcium, multivitamins and folic acid.
Roughly 5 percent of doctors also cited overuse of statins and other cholesterol-lowering medications in the elderly or to prevent health problems.
Other low-value interventions cited in the survey include invasive cardiac procedures, diabetes treatments other than the drug metformin, and overuse of bisphosphonates to treat osteoporosis, and over-managed or inappropriately controlled blood pressure.
One limitation of the study is its cross-sectional design and self-reported survey data, which makes it impossible to assess how closely the results mirror actual overuse of low value interventions in the real world, the authors note.
Even so, the results suggest that general internists are aware of clinical guidelines and on board with the concept of avoiding low-value care, said Dr. David Levine, a researcher at Brigham and Women’s Hospital and Harvard Medical School in Boston who wasn’t involved in the study.
“Clinicians who stray from guidelines may, or may not, have good reasons for doing so,” Levine said by email. “The guidelines may not be applicable to the patient in front of them, or they may not realize the newest recommendations now counsel against a treatment or procedure they learned in medical school.”
Patients shouldn’t be shy about questioning doctors, said Dr. Sharon Levine, executive vice president of The Permanente Federation at Kaiser Permanente in California.
“Every one of us should feel comfortable asking any one of a series of questions when a physician proposes a therapy,” said Levine, who wasn’t involved in the study. She listed them: “Why are you recommending this treatment? What are the potential risks associated with it, and what is the likely benefit? Are there other approaches you considered, including no treatment? And what would be the risks and benefits compared to what you are recommending? What should I look for in terms of side effects or adverse reactions?”
“These types of questions promote a healthy dialogue about the probability that a recommended therapy will result in an outcome that is high value for the patient,” Levine added by email.