It’s estimated that between 10-30% of medical procedures in the U.S. may be unnecessary. This amounts to billions of dollars in unnecessary healthcare spending each year. Unnecessary surgeries and procedures can expose patients to preventable harm and waste precious healthcare resources. But determining when a surgery is truly “unnecessary” is a complex issue involving many factors. This article will analyze the data and debate around potentially unnecessary surgeries.
Key Statistics on Unnecessary Surgeries
- A landmark 2012 study published in the Archives of Internal Medicine estimated that 11.3% of screening and diagnostic tests were unnecessary.
- A follow up study in 2017 reduced the estimate slightly to 10.5% of medical care being unnecessary, accounting for 25% of medical spending.
- Estimates for the percentage of unnecessary surgeries specifically range from 10-30%, averaging around 20%.
- This amounts to billions in healthcare spending. One estimate put the cost of unnecessary surgeries at $19 billion annually.
- Spinal fusion surgery has among the highest rates of unnecessary procedures. Studies estimate anywhere from 20-70% of spinal fusions may be unnecessary.
- Other common surgeries with high rates of potentially unnecessary procedures include coronary stents, knee arthroscopies, and hysterectomies.
These statistics highlight the widespread issue of overtreatment across healthcare, including substantial numbers of unnecessary surgeries. But accurately determining surgery necessity on a case-by-case basis involves many complex medical and ethical considerations.
Why Are So Many Surgeries Potentially Unnecessary?
There are many contributing factors that drive unnecessary surgeries and other medical overtreatment in the U.S.:
- Financial incentives – The current fee-for-service healthcare model often financially rewards doctors and hospitals for performing more tests and procedures. This encourages overtreatment.
- Defensive medicine – Fear of lawsuits leads doctors to order extraneous tests and surgeries to minimize legal liability, regardless of true medical necessity.
- Patient demand – Consumer advertising and patient demands for surgeries they perceive as beneficial but the doctor may not fully agree are necessary.
- Supply sensitive care – When there are more specialists, hospitals, diagnostic equipment, and surgeries performed in a region, utilization rates increase even without benefit to patient health.
- Unclear guidelines – Lack of clear clinical practice guidelines for when many common surgeries and procedures are appropriate allows excessive discretion and variation in utilization.
These systemic incentives enable overtreatment generally. But assessing the necessity of surgery for individual patients can be a gray area, as the next sections will explore.
Challenges in Determining Surgery Necessity
On a case-by-case basis, assessing whether or not surgery is truly unnecessary can be extremely challenging. There are several factors that make clearly determining necessity complex:
Clinical Uncertainty
Medicine frequently involves diagnostic uncertainty. The evidence base guiding many common surgeries remains limited. Different experts often have conflicting opinions on appropriateness. This clinical uncertainty means even with 20/20 hindsight, necessity cannot always be confidently judged.
Patient Heterogeneity
Medical research studies selectivity enroll homogeneous patient groups. But patients in the real world have diverse comorbidities, variations in anatomy, and不同個人因素. This heterogeneity means care must be customized beyond standard guidelines, including nuanced decisions on surgical necessity.
Evolving Technology
As technology advances, indications for surgeries evolve. Yesterday’s “unnecessary” procedures may become best practice. Conversely, surgeries once deemed necessary may be replaced by superior non-surgical treatment. Continually re-evaluating necessity is required.
Perspective Differences
Necessity is subjective based on one’s values and priorities. A given surgery may seem clearly unnecessary from a public health perspective but be considered highly beneficial for an individual patient’s preferences and symptoms. Integrating these perspectives is complex.
In summary, even for experienced clinicians, determining necessity can be extremely difficult for many common surgeries given clinical uncertainty, patient heterogeneity, evolving science, and different stakeholder perspectives.
Common Surgeries with High Rates of Overuse
While assessing necessity in general is difficult, research has identified certain types of common surgeries that have particularly high rates of likely overuse. These include:
Spinal Fusion Surgery
Spinal fusion rates have skyrocketed in the U.S. despite limited evidence of benefit for common conditions like back pain. Experts estimate between 20-70% of spinal fusions are unnecessary. Fusion surgery can cause serious complications yet frequently fail to resolve symptoms long-term.
Hysterectomy
Up to 70% of the over 600,000 hysterectomies performed annually in the U.S. may be unnecessary. Hysterectomy rates vary widely between regions, suggesting heavy influence by non-medical factors. Alternatives like hormone treatments are often equally effective for conditions like fibroids.
Knee Arthroscopy
The benefit of common knee surgeries like arthroscopic debridement for osteoarthritis is increasingly questioned. Rigorous sham surgery trials found no benefit over placebo for many patients. But knee arthroscopies remain extremely common with questionable necessity.
Coronary Stents
Research suggests up to half of coronary artery stents placed after elective angiography may be inappropriate. Their long-term benefit compared to optimal medical therapy is debated. Stent overuse is estimated to cost over $2 billion annually.
These are a sampling of surgeries prone to overuse. Many experts assert a substantial portion likely provide little patient benefit to justify their risks and costs. But uncertainty around optimal treatment endures.
Attempts to Curb Unnecessary Surgeries
In response to estimates of widespread overtreatment and unnecessary surgeries, both public and private sector initiatives are working to develop solutions. These include:
Choosing Wisely Campaign
Choosing Wisely is an educational and awareness campaign by America’s physician specialty societies to encourage doctors and patients to avoid unnecessary tests and treatments. Lists of overused surgeries and procedures have been published for patients to discuss with their physicians.
Clinical Guidelines
Evidence-based clinical practice guidelines that standardize indications for surgeries may reduce inappropriate variation. But developer conflicts of interest and lack of timely updating can limit their impact on optimizing utilization.
Decision Aids
Printed materials, videos, and interactive online tools help patients better understand their treatment options to decide necessity vs. overtreatment. But widespread adoption remains challenging.
Payment Reform
Transitioning away from fee-for-service reimbursement to value-based payment incentivizes doctors to avoid unnecessary care, including surgeries. However, impact has been gradual so far.
Quality Metrics
Tracking hospital and surgeon rates of surgical complications, readmissions, and reoperations can identify outliers potentially related to overuse so corrections can be made. But reporting systems remain suboptimal.
Despite growing efforts to deter unnecessary surgeries, truly assessing appropriateness patient-by-patient remains complex. A balanced, nuanced approach is required to sustainably solve overuse.
Case Examples of Surgery Overtreatment
To illustrate the real-world dilemmas around potential surgical overuse, here are several composite case examples highlighting common scenarios:
Case 1 – Spinal Stenosis Surgery
James, a 67-year-old accountant, has mild lumbar spinal stenosis causing episodic back and leg pain. He feels he can no longer tolerate the symptoms. His MRI shows moderately narrowed spinal canals. Two surgeons he consults offer vastly different advice. One recommends spinal decompression surgery but the other feels it likely won’t help long-term based on James’ imaging and symptoms. The decision on whether surgery is appropriate is unclear.
Case 2 – Hysterectomy for Fibroids
Michelle is a 42-year-old teacher with heavy and painful menstrual periods from uterine fibroids. She is otherwise healthy. After trying iron supplements and NSAIDs without sufficient relief, Michelle consults a gynecologist about potential surgery. The gynecologist notes her fibroids appear small-moderate in size based on ultrasound. While hysterectomy would permanently solve Michelle’s symptoms, the gynecologist also discusses options like hormone treatments or fibroid removal alone that could allow uterus preservation. They agree to start with a hormone IUD trial before deciding on hysterectomy necessity.
Case 3 – Repeat C-Section in Active Labor
Jane is pregnant with her second child and wants to try for a vaginal delivery after a prior C-section. But during her labor, the baby’s heart rate begins showing concerning decelerations. The OB feels an urgent C-section is safest, though Jane wants to continue trying for vaginal delivery since her labor is progressing well. The doctors involves Jane’s spouse in the discussion. They ultimately decide on repeat surgery, prioritizing the baby’s wellbeing, though it likely could have been avoided by earlier scheduling an elective C-section.
Each scenario highlights the intricate balance required to integrate patient preferences, quality of life, medical judgment, and an individualized risk vs. benefit analysis when determining surgery appropriateness.
A Doctor’s Perspective on Appropriate Use of Surgery
To provide direct insights from a practicing physician on the overuse debate, I interviewed Dr. Steven Smith, an orthopedic surgeon, to share his perspectives:
As surgeons, we constantly grapple with the question of necessity. Of course no surgeon wants to perform an unnecessary procedure, potentially subjecting patients to avoidable risks. But at times, surgery may truly be needed to improve quality or quantity of life, despite imperfect evidence. It’s rarely a crystal clear, black-and-white decision. The key is shared decision making with the patient through informed consent and setting appropriate expectations. Surgery seems most “unnecessary” in retrospect when the outcome proves unsatisfactory, despite best efforts. In reality, surgery is a process fraught with uncertainty. Our decisions will always be scrutinized by others through an oversimplified lens. But given the nuanced variables for each patient, responsible surgeons can only do our best to tailor care ethically through open communication, experience, and compassion. Perfection is unrealistic.
Dr. Smith’s candid insights demonstrate the good faith contemplation surgeons devote toward appropriate use of surgery. Though opportunities for improvement always remain, the caricature of money-driven surgeons pushing unnecessary procedures is clearly inaccurate.
Conclusion
Research estimates a substantial proportion of surgeries performed in the U.S. – potentially up to 30% – may be unnecessary. This amounts to billions in avoidable healthcare spending annually. Common surgeries cited for frequent overuse include spinal fusion, hysterectomy, knee arthroscopy, and coronary stents. The problem arises from a mix of perverse financial incentives, legal fear, patient demands, supply-sensitive care, and uncertainty in guidelines. While efforts are ongoing to refine appropriateness criteria, assessing true necessity patient-by-patient remains highly complex given ambiguities in the available evidence, heterogeneity of real-world patients, rapid evolution of technology, and differences in values between stakeholders. Ultimately, open discussions between patients and their care team considering both medical indications and personal preferences are key to determining when surgery is right. While some procedures are likely overused, this does not imply most surgeons are acting unethically. With thoughtful communication and shared decision making, collaborative restraint of unnecessary surgeries is possible, improving outcomes and reducing costs.