Unnecessary surgeries, also known as overtreatment or overutilization, refer to medical procedures that provide little to no benefit for patients. They are surgeries that could have been avoided without negatively impacting the patient’s health outcomes. There are a few key terms used to describe unnecessary surgeries:
Overdiagnosis
Overdiagnosis is when people are diagnosed with conditions that will never actually cause them harm or require treatment. It leads to overtreatment when these overdiagnosed individuals receive unnecessary therapies and procedures. For example, some cases of detected early stage prostate and breast cancers may never progress enough to require surgery or other intensive treatments. Treating these overdiagnosed cases is considered overtreatment.
Overtreatment
Overtreatment refers to the use of medical care that is unnecessary and provides little or no benefit to patients. It tends to occur when doctors recommend treatments that are not supported by evidence to be effective, are inappropriate for the patient’s situation, or pose more risks than potential benefits. Examples include excessive use of antibiotics, imaging tests, cancer screenings, and elective surgeries.
Unnecessary Procedures
An unnecessary procedure is any surgical intervention or medical test that is excessive, improper, or lacks a clear medical rationale. It provides little to no benefit to the patient and may expose them to preventable harm. Some examples of common unnecessary procedures include:
- Spinal fusion surgery for uncomplicated lower back pain
- Hysterectomy for benign conditions when less invasive options are available
- Cesarean sections without clear medical need
- Arthroscopic surgery for osteoarthritis of the knee
- Repetitive screening or imaging tests beyond recommended guidelines
Inappropriate Surgery
Inappropriate surgery refers to operations that are not clinically indicated or for which the risks outweigh potential benefits. They do not align with evidence-based guidelines for when surgery is appropriate. For example, performing a hysterectomy when hormone therapy could effectively treat heavy uterine bleeding would be considered inappropriate. Unnecessary surgeries are a type of inappropriate surgery.
Overutilization
Overutilization refers to the excessive use of medical care beyond what is needed or supported by evidence. It includes unnecessary services, treatment, procedures, or repeat testing. Overutilization is a major driver of excess healthcare costs as well as patient harm from overdiagnosis and overtreatment. Examples include overuse of specialty care, frequent MRI scans when not truly needed, or admitting patients to the hospital for conditions that could be effectively managed outside the hospital.
Why Do Unnecessary Surgeries Occur?
There are a number of factors that contribute to the performance of unnecessary surgeries and procedures in healthcare:
- Financial incentives – Fee-for-service payment models reward providers for doing more procedures, even if unneeded.
- Fear of malpractice – Providers may order extra tests and treatments viewed as defensive medicine to avoid potential litigation.
- Patient demand – Consumer advertising and patient pressure can drive overutilization of elective surgeries like cesarean sections or spinal surgery.
- Limited accountability – Lack of mechanisms to track and provide feedback regarding surgeons’ inappropriate procedure rates.
- Practice culture – Habit and local practice styles can perpetuate use of unproven surgical interventions.
- Lack of guidelines – Gaps in evidence and guidelines for when surgery is truly needed can lead to variation in practice.
Potential Harms of Unnecessary Surgeries
Undergoing unnecessary medical procedures can seriously harm patients in multiple ways:
- Complications – Any surgery carries risks of infection, bleeding, pain, and other surgical complications.
- False positives – Follow-up testing after overdiagnosis detects “abnormalities” that trigger stress and anxiety for patients.
- Lost time/income – Time off work for needless pre-op testing and surgical recovery results in lost wages and productivity.
- Pain and stress – Unneeded interventions undermine patients’ quality of life and psychological well-being.
- Higher costs – Wasteful overtreatment is a major contributor to rising healthcare spending for patients and payers.
Examples of Common Unnecessary Surgeries
Some categories of surgeries have come under scrutiny for being overutilized despite limited evidence of benefit. Common potentially unnecessary surgeries include:
Orthopedic Surgery
- Knee arthroscopy for osteoarthritis – Evidence does not support benefits over conservative treatment.
- Spinal fusion for uncomplicated back pain – Little proven advantage over structured rehabilitation.
- Rotator cuff surgery for partial thickness tears – Many heal successfully without surgery.
Cardiovascular Procedures
- Stents for stable heart disease – No proven benefits over optimal medical therapy alone.
- Pacemakers for fainting due to vasovagal syncope – Low likelihood of benefit.
- Carotid endarterectomy in low risk asymptomatic patients – Questionable stroke prevention value.
Women’s Health Surgery
- Hysterectomy for fibroids or menstrual issues without trying alternative therapies first.
- Oophorectomy to prevent ovarian cancer in low risk women – Not recommended for population.
- Robotic surgery for endometrial cancer – No evidence of advantages over conventional laparoscopy.
Other Examples
- Thyroid surgery for small papillary thyroid cancers – Active surveillance often appropriate.
- Surgery for silent gallstones lacking acute attacks – Watchful waiting preferred initial approach.
- Breast surgery for high risk lesions like atypical ductal hyperplasia – Close monitoring an option.
- Prostatectomy for localized prostate cancer in older men – Potential overtreatment risk.
Estimates of Unnecessary Surgeries
It is difficult to quantify the exact rate of unnecessary surgeries, but various studies have produced concerning estimates:
- A 2016 British Medical Journal analysis estimated over 20% of medical procedures across several common conditions offer no benefits to patients.
- Up to 1 in 4 knee replacements, 1 in 3 cesarean sections, and 1 in 5 hysterectomies in the U.S. may be unnecessary, according to some experts.
- A 2012 Washington Health Alliance report found knee arthroscopy rate variations from 13% to 60% across different regions in Washington state, indicating major overuse.
- A Consumer Reports study found significant overuse of cardiac stress tests, antibiotics, and CT scans across multiple U.S. metropolitan areas relative to clinical guidelines.
- The OECD estimates $200 billion is spent annually in the U.S. on unnecessary care yielding no patient benefit.
While the exact overuse frequencies are uncertain, research continues to demonstrate widespread overutilization that signals a need for improved approaches to curb unnecessary surgeries.
Reducing Unnecessary Surgeries
There are a number of promising healthcare policy and practice changes that can help reduce overtreatment:
- Reform provider payment models to eliminate financial incentives for unnecessary volume.
- Increase use of evidence-based shared decision making tools to individualize treatment plans.
- Strengthen criteria and reduce variation around surgical indications.
- Implement peer review and feedback on appropriate surgery rates.
- Limit direct-to-consumer marketing about elective surgical procedures.
- Focus on patient education to build understanding of overtreatment risks.
- Increase research on comparative effectiveness and development of clear clinical guidelines.
Curbing overtreatment will require a multifaceted approach engaging patients, clinicians, professional societies, policymakers and researchers alike. But reducing avoidable surgeries promises to both enhance patient outcomes and restrain runaway healthcare spending growth driven by overutilization.
Conclusion
Unnecessary surgeries encompass a range of medical procedures performed without clear rationale or patient benefit. Major drivers include financial incentives, liability concerns, patient demands, and lack of definitive guidelines. Potential harms range from surgical complications to missed workdays, excessive healthcare spending, and patient anxiety. While difficult to quantify precisely, researchers estimate up to 20-30% of many common surgeries are unnecessary. Promising solutions center on reforming payment incentives, implementing peer review and decision tools, increasing patient education, and generating better comparative clinical evidence around surgical necessity. Curbing overtreatment will require sustained effort but shows great potential to avoid patient harm and wasteful healthcare spending.
