The opioid crisis rocked America, bringing addiction and overdose into the spotlight. But it also highlighted the overtreatment of pain: Medical and dental providers alike overprescribed opioids after procedures and for chronic conditions. Out of that overtreatment came an epidemic.
In American health care, overtreatment is common. Recently though, there has been a subtle shift in the opposite direction. It’s possible that “less is more” is catching on.
For many Americans, it can be challenging to even access care: Treatment is expensive, insurance is confusing, and there aren’t enough providers. But ironically, we often use too much care, too.
Now, some providers are asking what the line between necessary and unnecessary really is. The results are encouraging, suggesting that, in some cases, it may be possible to achieve the same health outcomes with less treatment — and fewer side effects, too.
This shift is particularly noticeable in cancer care.
Recently, physician researchers successfully conducted a large scale de-escalation trial for rectal cancer patients. The standard treatment is to receive radiation, surgery, and chemotherapy, but pelvic radiation comes with terrible side effects, including bladder issues, infertility, and impaired sexual function. So, some patients were assigned to not receive radiation and there were no differences in quality of life after 18 months or in 5-year survival rates.
Another example is treatment for head and neck cancer caused by HPV. Patients with HPV-related head and neck cancer are often younger and healthier than the average patient, so less intensive treatment may still be effective while also being more sustainable. Providers are exploring several alternative treatment plans for these patients, with varying success.
One promising approach is a modified radiation treatment plan called DART. Preliminary results show that DART participants have excellent survival outcomes and better quality of life compared to standard treatment. Equally important, DART is cheaper and less time-consuming, saving patients from non-physical side effects as well.
Beyond cancer, reducing the high rate of cesarean deliveries, or C-sections, is also of pressing concern.
In 2021, about one-third of births in the United States were C-sections. Increasing maternal complexity may be contributing, but most experts don’t think that’s the whole story. Nonclinical factors such as provider preferences and fear of malpractice suits are leading to high C-section rates. So is hospital-specific culture. A Harvard study found that whether unit managers take a proactive or reactive approach to the unpredictable nature of birth matters for delivery outcomes.
The World Health Organization released guidelines in 2018 aimed at reducing C-section rates worldwide. They argued for evidence-based clinical guidelines, including a mandatory second opinion before proceeding with a C-section; minimizing the financial incentives of C-sections; and emphasizing a collaborative care model including midwifery.
A few Massachusetts hospitals have had success reducing their C-section rates through policy changes. South Shore Hospital implemented the TeamBirth Project, which focuses on patient education and having a documented birth plan. The hospital saw a 4% reduction in C-sections in the first year. In a pilot study, Boston Medical Center also implemented documented birth plans along with hourly evaluations during active labor. This cut the length of labor in half and reduced the likelihood of C-section from 20% to 8%.
Treatment de-escalation is a promising strategy, but it’s not a simple one. For example, some intensive care units are trying to reduce the amount of antibiotics patients are prescribed. Some research shows patients do better when care teams intentionally de-escalate antibiotic use, but other studies don’t show any benefit.
Cutting back the amount of treatment a patient receives is also a challenging narrative shift. “More” has been the norm for so long — more treatment and more complex treatment — especially for cancer. You “battle” cancer, fighting with every weapon possible, no matter the cost. So, suggesting the opposite may feel irresponsible to providers and patients alike.
Beyond complicated medical tradeoffs, patient preferences play a big role. Patients may not feel comfortable deviating from the norm. They may feel like they’re taking a risk with their health, and even their survival. This is not untrue; treatment protocols exist for a reason. As providers figure out how to de-escalate treatment successfully, patients accept the risk that it might not work.
The conversation around de-escalation would also benefit from stepping back and looking at treatment more holistically. Not only do aggressive treatment plans have significant physical side effects, they also have non-physical side effects. Treatment impacts a patient’s life outside the exam room: It costs them time, money, and independence. Alongside efforts to minimize fatigue, infertility, and the like, providers should seek to minimize time spent traveling to appointments and medical debt.
Some patients do need aggressive treatment to get healthy. But not all do, and aggressive treatment isn’t risk-free. Providers owe it to patients to consider if less really is more.
Elsa Pearson Sites, MPH, is the policy director of the Partnered Evidence-based Policy Resource Center with Harvard T.H. Chan School of Public Health.