Hospitals in Boston and across the country routinely perform unnecessary medical tests and procedures that offer patients little or no benefit, despite years of attention to the issue and evidence that overuse of medical services can be harmful.
An analysis from the Lown Institute, a Brookline health care think tank, found that the problem remains widespread. Many of the institutions typically considered among the best in the country, including Massachusetts General, failed to crack the top 100 in the Lown Institute’s ranking of hospitals avoiding overuse of medical services.
Overall, however, hospitals in New England tended to perform better than hospitals in other parts of the country, such as the South. Beth Israel Deaconess Medical Center ranked second of more than 3,100 hospitals nationwide, and Tufts Medical Center ranked 13th in the nation.
“Overuse is ubiquitous,” said Dr. Vikas Saini, president of the Lown Institute. “Nearly every hospital is doing at least some things that patients don’t really need.”
“There is improvement,” he added, “but it is very slow and it is very uneven.”
A test or procedure is considered low-value or unnecessary if it isn’t likely to help a patient become healthier or live longer — but introduces the potential for side effects or other risks.
Experts who study overuse attribute the problem to myriad factors, including a health care payment system that rewards doctors for doing more tests and procedures, and a culture that supports the notion that “it can’t hurt to take a look.”
In fact, sometimes, it can. Every imaging test or surgery introduces new risks for patients, from added costs and inconvenience, to the potential for serious complications, including loss of limb or life, said Dr. Rita Redberg, editor of the journal JAMA Internal Medicine, which documents overuse of medical care.
Overuse is baked into every part of the US health care system, she said, and while awareness has grown, little progress has been made.
“Our system hasn’t changed at all,” Redberg said. “We still teach the same way, we still practice the same way, our culture is the same, and we still reimburse for unnecessary procedures and practices.”
In addition to the impact on patients, unnecessary medical services drive up health care costs. A 2019 estimate published in JAMA said overtreatment and low-value care cost the US health care system $75.7 billion to $101.2 billion per year.
The Lown Institute analyzed claims data for Medicare patients between 2016 and 2018, focusing on 12 medical services that often are overused. These include hysterectomies for patients without cancer, coronary stents to treat stable heart disease, head imaging for fainting, knee surgery for arthritis, and spinal fusions for low back pain.
Mass General is sixth on the US News & World Report list of top hospitals in the country, which ranks institutions based on patient outcomes, nurse staffing levels, and other factors. But it is 126th in the country for avoiding overuse, according to the Lown Institute.
Dr. Elizabeth Mort, senior vice president of quality and safety at Mass General, said the Lown analysis relies on a narrow slice of data and doesn’t allow for nuance.
“We have been working on overuse for a long time,” she said. “What we’re trying to do is provide appropriate care — not too much, not too little, just right.”
To book certain operations at Mass General, she noted, surgeons must fill out a form that explains why the procedure is appropriate and necessary.
Leaders of hospitals that are most effective in avoiding overuse attributed their success to a collaborative culture among care providers, strong protocols that guide doctors in deciding when to order tests and surgeries — and the reality that they can’t afford to waste limited resources on unnecessary care.
“We don’t have as many buildings or operating rooms or major imaging equipment as some of our competitors,” said Peter Healy, president of Beth Israel Deaconess Medical Center. “We need to prioritize that use for our mission,” which is to provide specialized care to the sickest and most complex patients.
Sometimes the need to do a test or procedure is very clear, but often, it’s not. The same test — for example, a lung CT scan — could be wasteful for one patient and life-changing for another, depending on the patient’s medical history and other factors, said Dr. James Rawson, vice chair of radiology at Beth Israel Deaconess.
Doctors must make treatment decisions based on clinical guidelines, patient preferences, and their own experience and judgment.
Instead of rushing to surgery, doctors should try to offer physical therapy or an exercise routine when possible, said Dr. Erik Garpestad, the interim chief medical officer at Tufts Medical Center.
At Tufts, physicians hold morning meetings where they review, for example, each planned hysterectomy, an operation to remove the uterus. Together, they debate: is the patient going to benefit from this procedure?
“Sometimes, discussing with a patient why you’re not going to do something takes longer and is more complex than just doing it,” Garpestad said. “Your goal is to make sure the patient leaves there understanding.”
Saini, of the Lown Institute, said he hopes more attention on overuse will push hospitals to do better.
“We’re trying to create new norms for what it means to be a good hospital,” he said.