Archive for category Excessive medical testing

The Perils of Over-Treatment — diabetes and hypertension

excessToo much treatment is dangerous just like too little treatment.  Treating blood pressure too early or too aggressively increases the risk of death.  Treating elderly patients with diabetes with too much medicine increases episodes of low blood sugar that damage the brain and leads to broken bones from falling.

In 2014 the national guidelines for blood pressure treatment were changed to allow a higher blood pressure.  Similarly, a recent study found increased mortality for elderly patients treated too strongly for diabetes.

This is not rocket science.  Imagine a blood pressure medication that could lower the blood pressure to any level.  Knowing that zero blood pressure means you are dead, it stands to reason there is a point where treating blood pressure goes from helpful to dangerous.  Same for blood sugar.

Sometimes this problem is called “treating the test“.  In essence prescribers just look at the numbers and write a prescription, but ignore symptoms of weakness or spells of altered consciousness.  Hypertension and diabetes are good examples but this happens with lots of other conditions.

Examples of over-treatment include treating a sore throat with antibiotics, treating mild asthma with oral steroids, or treating an elevated lyme serology test with antibiotics.  It takes time to make a correct diagnosis and time to explain treatment to patients — some health care providers simply don’t take the time to do either.

Most drugs have a “therapeutic windowopenwindow.  As long as the window is open the patient gets benefit.  But, the window closes due to side effects and advanced age.

If a person is over 80 or in poor health excessive medical treatment is a substantial risk.  In this group even the thought of a low cholesterol diet is foolhardy.   It’s all about risks and benefits.

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Sleep Apnea — unreasonable testing

manwithcpapU.S. healthcare has gone crazy with testing for sleep apnea!   No wonder:  the standard test for the condition makes sleep specialists $1000 a pop.  Talk about a “hammer”, anyone that snores or is overweight is a “nail”.  People should be asking for 2 things before going down the testing road.

 

  1. A standard sleep apnea screening questionnaire.
  2. A night-time screening home oximetry test.

If  the questionnaire and the oximetry are called “low probability” then stop the testing.

Sleep apnea is real and the people that suffer from the condition do need treatment.   But, here’s the problem:  mild sleep apnea does not need treatment.  Yet, community sleep specialists have equated any sign of sleep apnea with the need for extensive testing and at least some type of treatment.

Well controlled scientific studies show that testing and treatment for sleep apnea are cost effective.  Indeed, that may be true, but community sleep specialists are not following the guidelines as in the large studies.  And, case-finding by community primary care is mostly based on the presence of snoring.  Once the person is sent to a specialist it seems to be implied that an in-center sleep test (polysomnography) is warranted.

Here are some disturbing facts:

  • 25% of the U.S. population snores
  • 25% of people who start CPAP treatment stop treatment
  • Pre-testing questionnaires are common but testing is done despite a low probability of the condition
  • Sleep specialists only consider the expensive in-center sleep test as adequate for their purposes (other outpatient home tests work well for many patients)
  • Surgery and dental prosthesis fail 50% of the time and are not recommended for first-line treatment.  Yet, people are often sent to surgeons and dentists without trying CPAP (the gold standard) or APAP.

 

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