And the beat goes on......

There is an old joke about the husband who scolds his wife for buying expensive clothes. Confident that she can defuse this claim, she drags him to the closet and challenges him to pick out the most expensive dress. He picks out a plain, unassuming dress with the tags still attached. "Aha!", she exclaims as she relishes explaining to him that that dress is well below average in cost. He retorts that it is the most expensive because it has hung there, unworn, for six months; the most expensive things we buy are the things that we do not use.

America has the most expensive health care in the world. There are many reasons for this but the most pressing is the fact that so many of our advanced treatments do no good--in fact, many of them do harm. The Dartmouth Atlas, published annually, tracks the variation in use of invasive, high tech therapies across the country. It demonstrates an unbelievably high variation in use; paradoxically, it further demonstrates that the higher the use of these procedures, the worse are the outcomes. In short, excessive use of some procedures can be toxic to your well-being. What happened to the dictum: "First, do no harm."?

The most expensive health care that we provide is the care that does not work...and even more expensive is the care that does harm. We are way too slow in learning this lesson. Why did it take over 30 years to figure out that routine Hormone Replacement Therapy was killing women? How quickly we have forgotten the politically charged issue of bone marrow transplants for metastatic breast cancer from a decade ago. The issue quietly went away when it was conclusively shown that these transplants actually shortened survival.

Coronary Artery Stents are one contemporary example. They are incredibly effective in certain circumstances. However, the indications for their placement have grown so wide as to undercut their rationale. We place about 3 times as many as other developed countries; yet, the long term goals of avoiding heart attack and or death are no different. This is clearly overuse....and,boy, are they expensive. Many other examples abound.

The British have an institute called the National Institute of Clinical Excellence (NICE) which objectively evaluates the utility of procedures, medications and treatments. Based on their findings, they may limit or deny the use of modalities which are not effective. Can you imagine an institute like that here? Not likely as the special interests would have a stroke. Meanwhile, the overuse of dubious treatments threatens to bankrupt our health care system....and the beat goes on. When will we become smarter about the allocation of our resources? Probably, when they are gone. Contrary to what you hear, eliminating treatments which do not work is not rationing. It is time to clean out the closet.