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COMMENTARYExploring the Harmful Effects of Health CareCharles M. Kilo, MD, MPHEric B. Larson, MD, MPHWHILE VARIOUS FORMS OF HARM RESULTINGfrom health care are well known, the fullnature of such harm and the magnitude ofhealth care’s aggregate adverse healtheffects deserve more exploration. On balance, the dataremain imprecise, and the benefits that US health carecurrently deliver may not outweigh the aggregate healthharm it imparts. In this Commentary, we discuss potentialharms from health care, suggest a taxonomy forhealth care harm, and suggest that investigators startaddressing this issue.This concern is raised with great respect for health careprofessionals. To be sure, ill intent is rare, and many healthservices are effective. Nonetheless, it is time to address thepossibility of net health harm by elucidating more fully aggregatehealth benefits and harms of current health care. Thisinformation should help clinicians, health care leaders, policyexperts, and politicians improve health outcomes by allowingmore explicit consideration of the trade-offs involvedin health interventions and expenditures, and help guidehealth care reform efforts.Unlike health, health care is not an unalloyed good. Fisher 1estimates that perhaps one-third of medical spending is for“services that don’t appear to improve health or the qualityof care—and may make things worse.” Although health carecontributes to health through disease prevention and treatment,the aggregate effect on health may be smaller thangenerally assumed.Determinants of well-being transcend health care. Theyinclude the complex interaction over time between genetics,social circumstances, education, income, housing, publicsafety, job satisfaction, behavioral patterns, and environmentalquality, in addition to access to appropriate healthcare services. 2 For example, since health care contributesonly about 10% toward reducing premature death, even aperfectly designed delivery system would prevent only a modestproportion of premature death. 3A Taxonomy of Health HarmHarm may occur as a direct or indirect consequence of healthcare. Direct harm includes adverse physical and emotionaleffects, generally to individuals, as a by-product of healthcare delivery. Indirect harm is a collateral effect on individualsand communities not directly involved in care. Indirectharm is closely associated with excess health care costs,which may induce harm by competing with other healthproducingservices.Direct HarmPhysical Harm. Physical harm is a by-product of routine careprocesses. Some aspects of physical harm (eg, adverse drugeffects and medical errors) are better known than others(eg, untoward effects of radiation from computed tomography).Although physical harm is an accepted risk oftreatment with increasingly powerful medications and interventions,much consequent harm is avoidable when treatmentsare overused or used without sufficient evidence ofeffectiveness.Some overtreatment happens when physicians lack evidenceabout the ineffectiveness or risks of a treatment. Forexample, encainide and flecainide were widely used beforetheir harmful effects were elucidated and more than 50 000individuals were estimated to have died from their cardiovasculareffects. 4 Rofecoxib had a similar trajectory. Medicationharm may become apparent only long after widespreaduse.Data on the safety and efficacy of procedures or devicesmay be similarly delayed. The Swan-Ganz pulmonary arterycatheter was introduced in 1970 for hemodynamic management.In the 1990s, an estimated 1.2 million were soldannually at a cost of approximately $2 billion. 5 Althoughstudies suggested that patients fared worse with them, it tookuntil 2005 to clearly demonstrate their lack of benefit evenin patients with severe heart failure. 6 Demonstrating the lackof utility took decades, while consuming substantial resourcesand adversely affecting many individuals.Similarly, percutaneous coronary intervention is likelybeing overused in the Medicare population. 7 Contrary to nationalguidelines, more than half of Medicare patients withstable coronary disease lack noninvasive documentation ofischemia before elective percutaneous coronary intervention.Author Affiliations: The Trust for Healthcare Excellence and GreenField Health,Portland, Oregon (Dr Kilo); and Group Health Center for Health Studies, Seattle,Washington (Dr Larson).Corresponding Author: Charles M. Kilo, MD, MPH, The Trust for Healthcare Excellenceand GreenField Health, 9427 SW Barnes Rd, Ste 590, Portland, OR 97225(chuck.kilo@greenfieldhealth.com).©2009 American Medical Association. All rights reserved. (Reprinted) JAMA, July 1, 2009—Vol 302, No. 1 89Downloaded from www.jama.com at University of Wisconsin -Madison on July 6, 2009
COMMENTARYEnd-of-life care provides another example of medicalexcess. One study found that only 30% of hospitalizedpatients older than 80 years wanted care to prolong life,but 63% received life-prolonging care such as intensivecare unit admissions, intubation, surgery, and dialysis. 8Wide variation exists in end-of-life care. Comparing themost with the least expensive academic medical centers,average Medicare spending ranged from $53 432 to$93 842 in the last 2 years of life and from $28 763 to$52 911 in the last 6 months of life. 9 The variation was dueto the volume of services provided, not the price per serviceor patient preference.Although the potential for harm is substantial, both physiciansand patients generally embrace technology enthusiastically—implicitlytrusting in its benefit before adequateassessment is made. However, higher-intensity caregenerally does not improve survival, and complications ofmedical care accounted for 1.1 million hospitalizations in2006—costing nearly $42 billion. 10 Medicare spending showswide per-capita variability across the United States, with patientsreceiving 60% more care in high-cost than in lowcostcities. Paradoxically, patients in higher-cost cities aremore likely to die of colon cancer, myocardial infarction,and hip fracture. 11Emotional Harm. Unnecessary care can also cause emotionalharm, including anxiety from testing or treatment andfrom creating inappropriate expectations. Emotional harm,although less well studied than physical harm, has importanteffects on patient well-being.A diagnosis of hypertension made through screening resultedin more office visits and sick role behavior withoutimproved medication adherence or blood pressure control.12 Spinal magnetic resonance imaging often reveals alarmingbut clinically irrelevant findings, and adults with backpain who receive magnetic resonance imaging results mayexperience worse dysfunction than those not given the results.Likewise, many unproven screenings, such as the prostate-specificantigen test, remain commonly used; althoughrelatively inexpensive and often sought by patients,they are unlikely to help and may induce harm, includinganxiety associated with false-positive results. Exaggeratedfears and “medicalizing” normal phenomena are as harmfulas unrealistic expectations and are fostered frequentlyby marketing hype and sometimes inadvertently by healthcare clinicians.Indirect HarmIndirect harm is a by-product of health care, usually by healthcare expenditures that are excessive or of low clinical value.Its magnitude may outweigh that of direct harm, but it isseldom apparent to those who create it or whom it affects.“Opportunity cost” is the trade-off made when decidinghow to allocate resources. When financial resources are limited,as they generally are, deciding to buy one product orservice may preclude buying another that might providegreater benefit. Providing an expensive intervention of marginalvalue to one patient may deprive many others of lessexpensive care that is more effective. Understanding suchtrade-offs is critical to ensuring that resources are used toachieve the greatest benefit.Analyzing opportunity cost requires comparing costs vseffectiveness of different spending options. Such analysesoften compare medical interventions, but rarely weigh themagainst other interventions to address the social or behavioraldeterminants of health. Health care may cause indirectharm by diverting resources from other determinantsof health, such as education, environmental quality, jobs,and income.For example, the cost-effectiveness of education likely exceedsthat of many health care interventions. 13 Health careand education increasingly compete in national and statebudgets. By diverting money from education, excess healthcare spending may risk worsening population health.Likewise, health care costs adversely affect household finances.The average family now spends more of its disposableincome on health care than on housing, food, or clothing.14 In 2007, 62% of personal bankruptcies were due tohealth care costs, with 92% of those individuals having medicaldebts greater than $5000, or 10% of pretax family income.Because personal finances strongly affect the healthof individuals and families, health care’s untoward effect onpersonal finances may degrade health.US health care spending totaled approximately $2.5 trillionin 2008, accounting for nearly 17% of the gross domesticproduct, and is projected to reach 20% by 2016. Despitethese resources, an estimated 46 million individuals(about 15% of the population) lack health insurance and25 million more are underinsured. Increasing health carecosts increase the numbers of uninsured and underinsured—a1% increase in insurance premiums leads to an estimated300 000 individuals losing coverage, thus adverselyaffecting health.Government spending on health care diverts fundsfrom other health-producing services. In 2007, the federalgovernment spent approximately 28% of its total revenueon health care. 15 Medicaid spending accounts onaverage for approximately 22% of state expenditures,compared with 21% for K-12 education, 10% for highereducation, and 8% for transportation. Aggregate statespending on Medicaid increased from $89 billion in 2000to $151 billion in 2007, leaving less money for educationand infrastructure needs.Although health care’s objective should be to improvehealth, its primary emphasis has been on producing services.Health care lacks sufficient measures to assess itsinfluence—either positive or negative—on health at theindividual or community level. To ensure appropriate distributionof resources relative to other health-producinginvestments, it is crucial to understand how the healthproducingeffects of health care interventions vary. Educa-90 JAMA, July 1, 2009—Vol 302, No. 1 (Reprinted) ©2009 American Medical Association. All rights reserved.Downloaded from www.jama.com at University of Wisconsin -Madison on July 6, 2009
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