In the United States we are faced with the highest per capita health costs in the world. One would think that massive expenditures could provide the best care and treatment outcomes, but this is not the case. In many aspects the US is worse or no better than countries spending 50% of what we do on health care. One reason is that we often inappropriately provide costly evaluation and treatment interventions. We provide surgery too frequently on conditions that could be treated more cost-effectively. Having a step- care model (using the least invasive and potentially harmful, and most cost-effective approaches first) for various conditions would offer models of care for the majority of problems whilst still allowing for modifications in unusual circumstances. —Dr. Norman Marcus
By Ryan Sabalow
Some doctors estimate the national rates of unnecessary hysterectomies and back surgeries are even higher than the 25 percent cited by state health officials questioning the Redding area’s high rates of the procedures.
Dr. Ernst Bartsich, a clinical associate professor of obstetrics and gynecology at Weill Cornell Medical College in Manhattan, N.Y., said as many as one in three women in the U.S. has had her uterus removed by the time she’s 60. That number increases to one in two by 65.
Bartsich, an outspoken critic of what he calls the overuse of hysterectomies, said he believes that 85 percent of such procedures could have been avoided through less invasive methods, such as removing painful fibroid tumors from the uterine wall or through medication.
Bartsich said the U.S. hysterectomy rates are triple those of other industrialized nations.
“The question is why take a healthy uterus out when it’s normal otherwise?” he said.
Bartsich points to a study published in 2000 in the association’s Obstetrics & Gynecology journal. It found that of 497 women who had the operation between August 1993 and July 1995 in Southern California, 376 didn’t meet a panel of doctors’ standards for appropriateness.
Some 70 percent of the procedures also didn’t meet the American College of Obstetricians and Gynecologists’ standards, the study reported.
But hysterectomy surgeries appear to be on the decline.
The American College of Obstetricians and Gynecologists reported last year that between 1980 and 2006, hysterectomy rates dropped nationally by nearly a third. The report came a year after the association changed its guidelines to reflect the increasing availability of alternative hysterectomy treatments.
Dr. Howard T. Sharp, a spokesman for the American College of Obstetricians and Gynecologists, said rates on the national level have long since fallen, due largely to doctors being urged to discuss alternative treatments with their patients.
“If you’re not really offering the options, you’re not providing complete, informed consent,” said Sharp, the vice chairman of the University of Utah School of Medicine’s Department of Obstetrics and Gynecology.
While hysterectomy rates nationally have fallen, the numbers of back surgeries are “unquestionably” climbing, said Dr. Charles Branch, a spinal surgeon at Wake Forest University in North Carolina and former president of the North American Spine Society.
But he said that climbing rate isn’t necessarily bad.
“The question is why,” Branch said.
While national data shows the rates are increasing, there have been no studies done to determine what’s driving the trend, he said.
It could be that technology has made the surgeries safer and easier allowing more people access to the procedure, Branch said.
It’s also unknown whether more surgeries have translated to higher or lower rates of patient satisfaction, he said.
“It would be a major concern if we saw this spike in the use then we said, ‘This is bad,’ ” he said. “Now we’re going to restrict access (to the procedure), but we’re not going to finish an analysis of why it’s happening.”
But Dr. Norman Marcus, a pain management doctor in New York and a vocal critic of the overuse of spinal surgery, counters that the analysis has been done, and it’s shown that half of all patients who had a spinal fusion or laminectomy surgery say they ended up no better or worse off after the procedures.
The problem is so apparent, Marcus said, that the national medical community has adopted the term “failed back surgery syndrome” as a diagnostic and billing code.
He said Americans in 2005 spent $86 million on back surgeries, as much as they spent that year on cancer treatment.
“We operate 40 percent more than any other country in the industrialized world on our backs,” said Marcus, who advocates alternative, muscle-based treatments for chronic pain.
Bartsich, the hysterectomy critic, said part of what’s driving the trend toward the overuse of hysterectomies is that women often demand the elective procedure as an easy fix for their reproductive health problems.
Other times, doctors, driven by insurance company reimbursements, get locked into regional trends among their peers, he said.
That means that women, even those who seek a second opinion, will get the same diagnosis from one of the doctor’s local colleagues, he said.
“They go to the doctor who’s across the street, but he’s golf partners with the last doctor,” Bartsich said.
Patients are at a terrific disadvantage in such situations, said Dr. David Goodman, a principal investigator for the Dartmouth Atlas of Health Care, which tracks surgery trends.
Short of going completely out of the area for other medical opinions, Goodman advised that patients use what’s known as patient decision aids.
The third-party informational programs, geared toward providing patients with an unbiased perspective on treatment options, are available through such organizations as the nonprofit Foundation for Informed Medical Decision Making.
But Sharp cautions that in some cases, a hysterectomy is the right diagnosis. While patients should be counseled that there are alternative treatments, they should also be told that sometimes those alternatives won’t work. For instance, the procedure is the only surefire way to stop excessive uterine bleeding, he said.
“If the patient really wants one, it’s the only option that has a 100 percent guarantee,” he said.
Reporter Ryan Sabalow can be reached at firstname.lastname@example.org, November 2009
This blog post brought to you by:~ Norman Marcus, MD Norman Marcus Pain Institute, New York NY “Your New York City Pain Relief Doctor”
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