Knee arthroscopy is a classic example of inappropriate practice being driven by financial incentives, fear of litigation and the ‘herd mentality’, an orthopaedic surgeon has told a conference devoted to ‘winding back the harms of too much medicine’.
But Professor Ian Harris told the Preventing Overdiagnosis 2019 meeting in Sydney that simple policies that promote ‘social acceptance’ of doing less can be implemented to reduce rates of the procedure that he said is still overused for degenerative knee conditions.
The conference, which brought together experts on overdiagnosis from around the world, looked at the harms of too much medicine and how to prevent it.
In an interview with the limbic, Professor Harris said the overmedicalisation of musculoskeletal conditions such as back pain and degenerative conditions was driven by a lack of understanding of the scientific literature, commercial interest and defensive medicine.
“There is a default to medical intervention when there is uncertainty,” said Professor Harris, of the University of NSW.
“We do that because it’s in everybody’s interest – private hospitals get paid a lot more to have a high turnover, surgeons for example get paid much more to operate than they do to not operate, and it’s in the doctors interest to be seen to be acting – to be seen to be treating – because there is a misapprehension in society that treating is always better than not treating.”
He also pointed to a ‘herd-safety’ mentality.
“You are less likely to be questioned or to be in any kind of trouble if you do what everyone else does – if everyone else is doing a certain procedure then you are on safe ground by doing it and you fit in.”
Speaking at the conference about the overuse of knee arthroscopy Professor Harris said rates for the controversial procedure – which clinical evidence shows has little benefit for degenerative conditions – have fallen since 2011. But there is still room for improvement, particularly for patients with degenerative conditions.
“There is a fairly good consensus of evidence that arthroscopy is not better than non-operative surgery for degenerative conditions in the knee such as osteoarthritis and undisplaced degenerative meniscus tears,” he said.
“It is being done much less for those conditions but there are areas where knee arthroscopy is still being done very commonly, so while rates have come down the practice change that we have seen has not been uniform.”
In Australia around 70,000 knee arthroscopies are performed every year, and Professor Harris noted that more than half (55%) are for people over 50, a population in whom degenerative changes such as osteoarthritis and meniscal tears are common.
At the conference, he presented the outcomes of a controlled before-and-after study that looked at the effect of a clinician-led intervention to reduce knee arthroscopy procedures. Professor Harris showed that one Sydney health district was able to cut rates by almost 60% in patients aged 50 years or over following the introduction of a very simple policy change.
The policy required hospital department head approval for knee arthroscopy surgery for patients aged 50 years or older. Additionally, a letter was written to all GPs in the local health district explaining the evidence against knee arthroscopy in this group and against unnecessary investigations like MRI.
Professor Harris said the study showed there was a ‘clear drop’ in knee arthroscopy volumes – ranging from 7% to 58% – in the intervention hospitals after 2011 when the policy was introduced.
The largest decrease saw knee arthroscopy procedures reduced from 1.4 to 0.5 per 1000 population in some pubic hospital areas. A similar drop in private hospitals from the same district was also observed between 2011 and 2014, from 3.6 to 2.3 per 1000 population, which was also the largest reduction among all districts in NSW.
Noting that the intervention was not complex or one requiring large investments Professor Harris said it was a simple clinical governance and education process that most probably led to reconsideration of the indication for arthroscopies and referral to surgeons.
“It wasn’t that the policy made it difficult to do the surgery it was more that it made it easier not to do the surgery,” he said.
“It gave surgeons an excuse to say, ‘well we don’t do them anymore’ and that made it easier to tell the patient.”
It is this ‘social acceptance’, says Professor Harris, that really drives practice change.
“Changing clinical practice is a very social phenomenon, it has to do with a lot of social factors like acceptance, diagnostic comfort and not standing out – not wanting to be different to your colleagues.
“We have to understand these factors when we’re trying to change clinical practice because scientific evidence is not enough.”
The conference also heard from rheumatologist Professor Rachelle Buchbinder of Monash University, who said there need to be embedded policy frameworks and processes to address overuse in healthcare systems.