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How Healthcare Might Be Like Garlic

 |  By cclark@healthleadersmedia.com  
   August 04, 2011

On vacation last week, I took a drive up the California coast to Gilroy for the famous Garlic Festival, a raucous celebration of the summer harvest of "the stinking rose."

Frankly, I wanted to get my mind away from the debt ceiling debate, healthcare reform, and the regulatory challenges facing hospitals and doctors—at least for a bit. I wanted to learn about garlic, its growing season, storage tricks, the best grating and cooking strategies, and which species have the most allicin, the ingredient aligned with its potency.

I'll get to how this all relates to healthcare quality in a second.

Yes, I tasted delicious garlic ice cream, devoured garlic scampi, garlic calamari, sampled garlic dips, consumed several pieces of garlic bread, and even sipped a garlic martini. And I talked with growers and processers, potters who design plates on which to shave the cloves for maximum flavor, and listened intently to several gourmet garlic cooks. It's only fitting that Gilroy, home of the largest supplier of California garlic, calls itself the "Garlic Capital of the World."

I do love garlic.

Despite this gastronomic paradise, I can attest now—in a way impossible before—that there is such a thing as too much garlic.

That's similar to the message we seem to be hearing in healthcare these days. Sometimes, and with increasing frequency, we learn there can be too much care, because we're finding out with chagrin that a lot of what doctors and hospitals have been doing has been unnecessary, and even sometimes harmful.

I returned home to review my usual lineup of journals this week, and noticed that the Archives of Internal Medicine has launched a feature called "Less is More" that draws on a theme that more care and newer technologies are not necessarily better. 

Archives editor Rita Redberg, MD, wrote in her introduction to the section that it was designed to highlight papers "that document cases in which less healthcare results in better health, and offer commentary on the specific implications."

"Clearly, these erroneous assumptions negatively affect health by exposing patients to unnecessary harms of treatment and testing, with no expected benefit; they also increase the total cost of healthcare," she wrote.

The new journal section links to papers, editorials, and other scholarly work about how aggressive treatment approaches should be reconsidered.

It also will have stories from doctors and patients about how findings of abnormalities that would never have been clinically significant end up resulting in unnecessary invasive procedures that caused harm, says Deborah Grady, Archives series editor of "Less is More" in a telephone interview.

Grady, a professor of medicine at the University of California San Francisco, says that one of the authors of a paper published in this section used this analogy: "A man is walking down the street doing nothing wrong. The cops come along and throw him in jail. He gets out, and now he's really happy because he's out."

The patients are happy because think they've escaped a disease or condition. But we know there's a lot of healthcare that’s being provided by doctors and hospitals, who are a bit like those cops, she says. "We are overusing drugs and treatment for people who are unlikely to benefit."

Grady says it's not just that researchers are now overturning dogma. "What typically happens is that we prove a treatment is good in a certain group of people—say people at high risk for heart disease—and then apply that treatment more broadly ... like giving aspirin to a 20-year-old healthy athlete. The risks of taking aspirin, such as GI bleeding, are still there," she says.

Among the latest to be featured in the section is a paper published last week by researchers at Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, with colleagues from Yale University, the University of Miami, and Seoul National University Bundang Hospital in Korea.

They found that screening with coronary computed tomographic angiography, or CCTA, was associated with more invasive testing without any difference in events at 18 months. The paper concludes: "Screening CCTA should not be considered a justifiable test at this time."

Last month, another team found that despite evidence showing no benefit, cardiologists at far too many hospitals are still performing revascularization procedures on stable patients more than 24 hours after their heart attacks, after heart muscle damage has already occurred.

Still another paper chronicled 16 medical reversals documented by papers in the New England Journal of Medicine in 2009 and 2010.

The reversals were defined as evidence that types of care previously thought beneficial are actually useless or harmful. For example, we now know that certain kinds of spine surgery carry higher chances for mortality and in fact may require more surgeries down the line than treating the pain with medication.

The authors noted that the new research permitted reversal of earlier practice in part because earlier research was "improperly controlled."

The phrase medical reversal "implies error or harm to patients who underwent the practice in question, during the years it was considered effective," wrote Vinay Prasad, MD, and colleagues from the departments of medicine at Northwestern University and the University of Chicago.

They wrote that "studies of medical interventions are often followed by studies that either reach the opposite result or suggest the magnitude of effect was initially overestimated."

Now, better study designs, perhaps with tighter control, and more patients enrolled across multiple trial centers that include community as well academic medical settings, offer findings that are more revealing about whether a technique or therapeutic works.

Other examples of care no longer advised include prescribing postmenopausal hormones for asymptomatic women, arthroscopic debridement of the knee, and giving antidepressants to people with only mild rather than severe depression. We now know that the adverse events, costs, pain, and risks these patients undergo are not outweighed by the benefits.

In May 2010, articles in the Archives highlighted serious adverse events from proton pump inhibitors such as an increased risk of fractures, Clostridium difficile infection, and diarrhea, when the drugs are prescribed for nonulcer dyspepsia.

As we hone in on comparative effectiveness research and see where it takes us, we will likely find many examples of how getting more care, which we used to think made us get better, may in fact make us worse. But, as Grady says, the important thing is to educate the public, as we educate doctors and hospitals, to avoid care that won't help.

"I just think people mix all this up,” says Grady. “They think that because it's medical care and I can get more of that, it must be better. Well, it's not really always better. We're trying to make the public a little more skeptical."

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