In a review of thousands of case histories that raises serious questions about medical competence, RAND Corp. researchers reported today that three common medical procedures are often performed unnecessarily--in one instance nearly a third of the time.
The authors of the study said it raises far-reaching concerns about the extent of unnecessary medical treatments and underscores the need for patients to question their doctors closely and seek second opinions.
Moreover, they concluded that the findings have "important implications for current health care policy" and point the way toward "substantially improving the quality of care . . . and perhaps simultaneously controlling costs."
The study of elderly patients, one of the most meticulous of its type ever conducted, focused on three procedures: carotid endarterectomies, the surgical removal of blockages in the major arteries to the brain; coronary angiography, an X-ray technique in which a tube is inserted into the heart arteries and dye injected through it; and upper gastrointestinal tract endoscopy, an examination of the digestive organs with a fiber-optic-lighted tube.
Unnecessary surgery was most common in the carotid endarterectomies, which are performed to reduce the risk of stroke, the study found.
Researchers concluded that 32.4% of the carotid endarterectomies were inappropriate and in an additional 32.3% of the cases, indications for the surgery were "equivocal." More than 100,000 of the carotid surgeries are performed in the United States each year.
The Santa Monica-based research team also concluded that about 17% of the coronary angiography procedures, performed to diagnose blockages in heart arteries, were unnecessary. A like percentage of inappropriate procedures was discovered for upper gastrointestinal tract endoscopy. More than 500,000 coronary angiograms and 1 million endoscopies are performed in the United States annually.
"This is the first study which has attempted to measure appropriateness in a medically detailed, scientific way and found this level of inappropriateness," Dr. Mark R. Chassin, the leader of the research team, said in an interview. "It raises the possibility that we can both improve quality and control costs by trying to reduce inappropriate care."
The study also undercuts the commonly held belief that high levels of inappropriate procedures are linked to the frequency with which the procedures are performed, Chassin said. The researchers found no significant difference in the percentage of unnecessary treatments in areas of the country where the procedures were more common and areas where they were more rare.
Covered by Medicare
The $3-million, five-year RAND project evaluated care for elderly and disabled patients insured under the federal Medicare program. It involved reviews of about 5,000 randomly selected medical records from the year 1981 in sites across the country. Panels of expert physicians developed ratings for necessary and unnecessary care based on detailed reviews of existing medical knowledge.
The 54 data collectors followed strict procedures to maintain confidentiality; the final report does not even indicate which procedures were surveyed in which areas of the country. The study was reported in a series of articles that take up most of the current issue of the Journal of the American Medical Assn.
In all, 819 physicians--90% of those who were approached--agreed to the review of as many as 20 of their patients' medical charts; 227 hospitals--99% of those approached--also agreed to participate.
A procedure was judged appropriate if its "expected health benefits," including increased life expectancy and pain relief, exceeded its "expected negative consequences," including death, infection and a worsened condition, by a "sufficiently wide margin," according to the report.
35% Ruled Appropriate
Overall, 35.3% of all carotid endarterectomies, a surgery with a mortality rate of between 1% and 3%, were judged appropriate.
About three-quarters of coronary angiograms, a procedure with a death rate of 2 per 1,000, were judged appropriate, as were a similar number of endoscopies, a procedure with a death rate of one per 10,000. In almost all cases, the office and hospital medical records were judged sufficiently detailed for rating the appropriateness of the procedures studied. In a related finding, there was little evidence of fraudulent billing, a problem that has plagued government health insurance programs for the poor.
The researchers specifically excluded cost considerations from their ratings scales so that the determinations of appropriateness could be made on a "purely medical" basis. The report acknowledges that the "ratings of appropriateness might have been lower" if the panelists had been asked to include cost considerations as well.