7 questionable hospital procedures that are harming patients


Low-value hospital procedures cause significant harm to patients through complications as well as wasting resources, Australian research shows.

The questionable procedures are among seven highlighted by Choosing Wisely programs as being of low value, but clinicians also need to see them in terms of the risk they pose to patients through in-hospital complications, say the authors of an analysis from Sydney University.

Published in JAMA Internal Medicine, the 7 procedures selected for evaluation were:

  1. Endoscopy for dyspepsia in people younger than 55 years;
  2. Knee arthroscopy for osteoarthritis or meniscal tears;
  3. Colonoscopy for constipation in people younger than 50 years;
  4. Endovascular repair of abdominal aortic aneurysm (EVAR) in asymptomatic, high-risk patients;
  5. Carotid endarterectomy in asymptomatic, high-risk patients;
  6. Renal artery angioplasty;
  7. Spinal fusion for uncomplicated low back pain.

The researchers assessed 9330 such procedures undertaken in the NSW public hospital system in terms of hospital-associate complications. While some low value procedures such as endoscopy, colonoscopy and knee arthroscopy had low rates of hospital associated complications (0.1, 0.5 and 0.3% respectively), others had high rates. One in seven EVAR procedures (15%) and 1 in 13 carotid endarterectomies (7.7%) were associated with significant complications. Likewise, low-value renal artery angioplasty (8.5% of episodes and spinal fusion (7.1% of episodes) were also associated with high complication rates.

And when complications did occur they created a significant burden for patients and hospitals, the researchers noted. While procedures would usually be done on the same-day basis or with an overnight stay, patients with complications of knee arthroscopy spent 13.8 more days in the hospital on average than similar patients with no complications. Patients with complications of spinal fusion spent a mean of almost 30 days in hospital if they had complications.

The most common complication was hospital-acquired infection (26% of all complications), and the procedures with the highest rates were renal artery angioplasty (8.4%) and EVAR (5%). Other common complications included cardiac complications, delirium, gastrointestinal bleeding and surgical complications.

The researchers said the findings were likely just the tip of the iceberg when it comes to the full burden of harms with questionable hospital procedures.

“Although we restricted this study to seven low-value procedures and measured only some immediate in-hospital complications associated with these procedures, we found high rates of harm in some cases, with substantial additional lengths of stay,” they said.

“Low-value care is driven partly by physicians’ bias toward taking action despite risks and the tendency to overestimate benefit and underestimate harm.”

“Reporting harm directly associated with low-value care emphasises to both physicians and patients that these procedures have risks and helps raise conversations about whether the procedures are appropriate, which is a major aim of Choosing Wisely,” they concluded.

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