Friday, October 13, 2006
Explaining More, Doing Less
BY ALICE DREGER

As if we didn’t have enough reasons to wish for better informed consent practices in the United States, here’s another: evidence that, if physicians spent more time seeking truly informed consent – telling patients what the best available studies show about their options – their patients might frequently opt out of  optional procedures that cost the private and public insurance systems millions of dollars.

What does informed consent have to do with the fiscal health care crisis?

This spring, the New York Times reported with surprise that many Medicare patients are turning down an expensive operation for emphysema even though Medicare has agreed to pay for the procedure. Lung volume reduction surgery “involves cutting out sections of diseased lungs to give healthier tissue room to expand.” Faced with the fact that this procedure and its related health care services cost about $50,000 a pop, Medicare decided – in a controversial move – to study whether it actually helped patients.

The study ultimately showed the operation comes with a fairly high mortality rate – about 8 percent – and results in some benefits for a subset of patients, and no benefits for others. In response, Medicare agreed to cover the costs of the procedure for those patients who matched the subset of study subjects who benefited. Surgeons expected a rush of patients as a result; instead, as the Times reported, interest dwindled to a trickle.

Patients turn out to be wary of a nearly one-in-ten risk of death, and unwilling to take this risk in exchange for a chance at a couple of extra years of life and/or improved lung function. In other words, some patients who are told the facts about an optional procedure turn out to make sensible health care decisions that also happen to cost the system less.

One has to wonder how often this would be the case in other realms of care. If doctors really went over the facts about the efficacy and safety of various medicines and procedures with their patients, how often would their patients realize the real uncertainty and risks in what they’re being offered, and opt for watchful waiting or some other relatively inexpensive option? Imagine, for example, if physicians discussed with their patients the evidence for (or more precisely, against) the necessity, efficacy, and safety of episiotomies in vaginal births, of human growth hormone for “idiopathic short stature,” of statins for primary prevention of heart disease – of many CT scans.

The tendency in the U.S. consumption culture has been to equate more with better. But more health care does not always make you healthier. The more patients are helped to understand this, the less likely they are to believe that the most expensive option is always the best for them.

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