Ever heard of the “therapeutic illusion”? I hadn't until I read a Perspective article in last week's New England Journal of Medicine that should be required reading for any healthcare executive serious about moving his or her organization from volume-driven to value-based care.
Dr. David Casarett of the University of Pennsylvania's Perelman School of Medicine described the therapeutic illusion as physicians believing “their actions or tools are more effective than they actually are. … Their therapeutic illusion facilitates continued use of inappropriate tests and treatments.”
He also wrote that it will take more than exhortations like the Choosing Wisely campaign to get physicians and hospitals to change unscientific practices.
A study last week in JAMA Internal Medicine describes a disturbing example of the persistence of the therapeutic illusion, one that leads to tens of thousands of unnecessary procedures a year.
A retrospective study examined the treatment patterns for nearly 200,000 older patients who, before going into surgery between 2009 and 2014, were given a prophylactic catheterization angiogram because they were considered at risk for a heart attack or stroke. Though more than 60% had no symptoms of heart disease before the procedure, nearly half were identified as having a coronary blockage; and half of those, or nearly a quarter of the entire group, underwent treatment, either during the catheterization procedure itself or in a chest-opening operation.
There is some intuitive logic behind sending these at-risk patients to the cath lab for the test. There are an estimated 1 million cardiac events each year among those who undergo noncardiac surgery—a 2% event rate. Cardiac events are the leading cause of death in the first 30 days after surgery.
There was once even a reason to think an angiogram and follow-on treatment might help. A 1,000-patient clinical trial in the 1980s showed reduced cardiac incidents in the wake of general surgery if the patients were tested and treated for coronary artery disease before their operations.
But subsequent larger trials found no benefit to the prophylactic intervention. Clinical practice guidelines published jointly by the American College of Cardiology and the American Heart Association oppose the prophylactic use of cardiac catheterization prior to surgery, except in rare circumstances.
Despite the guidelines, practice hasn't changed. An accompanying editorial in JAMA Internal Medicine speculated that the reason may be financial incentives for hospitals and invasive cardiologists, or physician and patient's incorrect perceptions of the potential benefits. They concluded that routine cardiac evaluation prior to noncardiac surgery should be given a Choosing Wisely “less is more designation because it has associated harms and lacks any evidence of benefit.”
However, Casarett warns it is unrealistic to rely on campaigns like Choosing Wisely or clinical practice guidelines written by medical societies to curb the wasteful, expensive and potentially harmful practices associated with therapeutic illusions. But his solutions—making physicians aware of guidelines through electronic health records and better training for the next generation of physicians—are not likely to have much of an impact, at least in the short run.
Hospital officials talk a lot about getting physician buy-in for their moves toward value-based care. But isn't the real issue here payment policy? If you can bill for the cath lab procedure as well as the operation, your organization is a lot better off financially in our fee-for-service reimbursement system.
This week, the CMS begins its mandatory orthopedic bundled payments program in 67 markets. When payment covers the entire episode of care, hospitals have a powerful incentive to eliminate unnecessary tests and procedures that used to be billed separately.
By all means, encourage your physicians to choose wisely. But eliminating the therapeutic illusions that lead to unnecessary cardiac procedures may have to wait until bundled or episode-of-care payments are imposed on all forms of surgery.