Too Much Surgery

Abstract

Unnecessary healthcare in the United States represents one of the greatest sources of excessive spending and preventable harm to our patients. By some estimates, over $100 billion is spent (ie, wasted) on unnecessary services each year.1 Recognizing an opportunity to improve care and reduce spending, the Choosing Wisely campaign galvanized a movement to reduce low-value, unnecessary care. With recommendations against routine use of over 600 low-value healthcare services, this effort is credited with modest success in reducing some imaging, laboratory testing, and medical care.2 While 17 surgical societies participated in Choosing Wisely, less than 5% of recommendations target low-value surgical procedures.3,4 Not operating on patients with little or nothing to gain from surgery might seem like an obvious win as we combat wasted healthcare spending. However, even in cases where surgery is clearly low-value per guidelines or randomized trials, deimplementation is not assured. For example, despite recommendations against contralateral prophylactic mastectomy for average-risk women with unilateral breast cancer rates continue to increase.5 Similarly, knee arthroscopy continues to be commonly performed for patients with osteoarthritis, meniscal tears, and knee pain despite multiple randomized trials showing no benefit as compared with medical management.6 In most circumstances, the multilevel factors (patient, provider, and system) contributing to persistent overuse are unknown. These could be supply-side driven (eg, surgeon habits and training, financial, concerns about malpractice, and industry influence), demand-side driven (eg, patient expectations and preferences, perceived pressure from referring providers), or a combination of the two. The higher stakes for patients undergoing low-value surgery compared with nonprocedural services create mounting pressure to address these uncertainties. The objectives of this surgical perspective are to discuss the unique aspects of surgical care delivery acting as barriers to deimplementation and suggest potential strategies to reduce low-value surgery in the United States. SPECIFIC CONSIDERATIONS FOR DEIMPLEMENTATION OF LOW-VALUE SURGICAL PRACTICES Earlier Widespread Adoption of Procedures Before Establishing Efficacy In contrast to the pathway to market for new drugs, new surgical procedures undergo limited to no efficacy-based scrutiny prior to clinical use. This can lead to early adoption and entrenched practice before efficacy or value is known. In these cases, surgeons may be reluctant to accept emerging evidence of limited efficacy or value in favor of their anecdotal personal experiences with the procedure. For instance, use of robotic-assisted procedures has increased nearly 3-fold despite limited high-quality evidence demonstrating superiority over other minimally invasive and less costly approaches.7 Although the robotic platform may be of high value in some cases, there is substantial evidence that its use has encroached upon or replaced higher value alternatives for a number of surgical indications. The Lake Wobegon Effect In interpreting surgical trials, surgeons may more readily attribute a lack of efficacy to the inferior surgical skill of the participating surgeons as compared with their own. In the Social Psychology literature, “The Lake Wobegon Effect” is the natural tendency to overestimate one's abilities as compared with others, and is more likely to occur when performance is difficult to measure objectively, such as driving ability.8 This can lead to overuse if surgeons believe the procedure to yield superior value “in their hands.” In contrast, drug effectiveness, or lack thereof, is generally not felt to be due to the prescribing ability of particular providers. The Lake Wobegon Effect can also contribute to overtreatment when it is applied to the patient—surgeons may continue to offer ineffective procedures believing that the unique or special nature of their patie