An Aspirin A Day Revisited: Low Value Medical Care

Tests and medication that are ineffective and/or provide no benefit to medical care are classified as being low value medical care. Rather than help low value medical care can expose people to harm, shift focus away from actual beneficial care, and result in unnecessary costs to both patient and healthcare systems.

Being led to falsely believe Aspirin is the best form of primary prevention, the average risk patient has been shown to actually be exposed to higher risk of bleeding from taking an Aspirin a day. Regular exercise, a healthy balanced diet, managing stress, getting enough sleep, and avoiding smoking are in fact the best protection.

The healthcare system seems to be slow to respond, convincing some doctors to stop making low value care recommendations may be a slow task, as history shows doctor and patient expectations are slow to respond to new information.

Health care systems have actually been shown to be slow to integrate new research into clinical practice, it’s no secret, a study from the early 2000s shows there is a lag of 17 years before research is implemented into regular care.

Changing clinical practice is more than just integrating new information, it requires unlearning and de-opting outdated and ineffective clinical practices; this is the process that healthcare systems struggle with, and also explains why low value healthcare thrives to the lofty tune of $765 billion in unproductive expenditure within the USA in 2013 alone.

Some doctors practise defensive medicine, but part of the challenge in unlearning is it interrupts the status quo. Patients used to undergo yearly physical exams and routine blood work, which was thought to help find disease and keep patients healthier. However research has shown annual exams are low yield, and provide no health benefit to the large healthy subsets of populations. Trying to convince doctors who have invested years into doing these exams believing they were providing a valuable service to move away from the ingrained and fossilized method of medical care is challenging.

Studies investigating the complexity of unlearning among physicians point out the inherent shame and loss of professional self worth that occurs when previous time honoured practices become abandoned and are considered to be obsolete.

The impact of removing practices on patients is also very powerful, as culture can place strong emphasis on more being better: more visits, more exams, more test, more procedures. More is better mentality means when doctors no longer provided care previously considered to be important the pushback from patients can be very strong. Overuse of the healthcare system serves to complicate the matter even more, and allows doctors to protect themselves from malpractice lawsuits.

Clinical reasoning and judgment is being replaced by algorithms increasingly, absence of testing and intervention is becoming harder to justify and is a reflection of how medicine has morphed into an expectation of being “a perfect science rather than imperfect but well thought out art.”

However the cost of defensive medicine is alarmingly staggering, on average the US healthcare system spends $46 billion on care centered around medical liability.  

Campaigns have been launched to try to curb low value care by educating healthcare providers and patients of the harms and drawbacks of overtesting and medical use. These campaigns list low value processes specific to each medical specialty in attempts to break the “this is how it has always been done” mentality that can overwhelm medicine.

Despite launch of these campaigns little change has been seen in the practice habits of physicians and patients. The evidence is clear that for many average risk patients Aspirin is not the best option in preventing heart attacks, clearly convincing doctors, patients, and the healthcare system administrators of it will be difficult.

“Aspirin may not be the best option. The process of unlearning and disengaging from previous practices is hampered by complex interplay of human emotion, individual expectation, legal liability, organizational structure, and simple inertia.” ~Inderveer Mahal, family physician and fellow at the University of Toronto Munk School of Global Affairs.