Illustration: Israel G. Vargas
Stents for heart disease. Spinal fusion for back pain. Vena cava filters for blood clots. Vertebroplasty for osteoporosis. A recent report from the Lown Institute, a nonprofit that focuses on improving healthcare, found that during the pandemic year of 2020, adults on Medicare received 106,474 overused or unnecessary surgeries or procedures—and those were near the top of the list.
According to the Lown Institute, overuse, or low-value care, “refers to medical services that offer little to no clinical benefit or are more likely to harm patients than help them.”
“It’s very easy for doctors and patients to go down the path of doing a medical procedure because it seems like, in theory, it would be safer and better, but that’s not always the case,” says Vikas Saini, MD, a cardiologist and president of the institute. “More medical care isn’t necessarily always better, especially for older adults.”
Given this, it may be helpful to know more about overused procedures so that you can have productive conversations if your doctor recommends one. Here’s a spotlight on the four mentioned previously. (For info on others, see the consumer right full report.)
Stents for Heart Disease
What it is: A clogged artery is cleared and then propped open with a tiny stent that’s left in place. This may be the right call after a heart attack or for people with a significant narrowing of the left main coronary artery, says David Maron, MD, director of preventive cardiology at the Stanford University School of Medicine.
When it’s questionable: If you have coronary artery disease (plaque buildup in the walls of arteries that supply blood to the heart) but it’s stable, you’re unlikely to benefit. (Stable means generally no chest pain or shortness of breath, or only with exercise or stress—and it resolves with rest or medication.) A study co-led by Maron found that people with moderate or severe but stable heart disease who took medication for it were no more at risk of a heart attack or death than those who had procedures like stenting.
Note: If you have stable coronary artery disease and notice worsening symptoms—for example, they begin to occur even when you’re at rest—it’s reasonable to talk to your doctor about a stent, Saini says.
Spinal Fusion for Chronic Back Pain
What it is: This surgery permanently connects two or more vertebrae in the spine—using metal plates, rods, or screws—to eliminate the motion between them that can cause pain.
Spinal fusion is appropriate in situations such as a spinal fracture from a car accident, a severe bone infection, or a tumor that causes part of your spine to collapse, says Steven Atlas, MD, MPH, director of The Primary Care Practice-Based Research & Quality Improvement Network at Massachusetts General Hospital in Boston. But generally, “that’s not when it’s being done,” he says.
When it’s questionable: Surgeons may advise spinal fusion for chronic lower back pain from severe arthritis or age-related wear from spinal disks, Atlas says. But studies suggest that in these circumstances, the procedure is no more effective than nonsurgical approaches such as physical therapy, he notes.
If you have severe chronic back pain and have used measures like PT for six to 12 months without much improvement, however, consider asking your doctor about laminectomy, Atlas says. In that procedure, part or all of the vertebral bone is removed to enlarge the spinal canal and ease pressure on your spinal cord, disks, and nerves.
Vena Cava Filters for Clots
What it is: If you have blood clots in your legs, your doctor may advise that you have surgery to place a small filter in a vein, especially if a clot has travelled up to your lungs in the past. The goal is to prevent clots from making their way to your lungs (known as pulmonary embolism) or brain, where they could cause a stroke. This procedure might be necessary for people who can’t tolerate traditional treatment (oral or injectable blood thinners). “But that’s the exception and not the norm,” says Behnood Bikdeli, MD, MS, a cardiologist at Brigham and Women’s Hospital in Boston.
When it’s questionable: There’s no clear evidence that these filters are more effective than blood thinners, Bikdeli says. A review he co-authored, concluded that while the filters do seem to reduce the risk of pulmonary embolisms, they don’t lower clot-related death rates and can hike the chance that more leg blood clots will develop. Yet they’re still often used. A study Bikdeli authored, involving more than half a million people hospitalized for the embolisms, found that about 1 in 6 people ages 65 or older received a vena cava filter.
Vertebroplasty for Osteoporosis
What it is: Osteoporosis heightens the risk of painful compression fractures, a bone break in the vertebrae. One way to treat them is vertebroplasty, where a surgeon injects special cement into the fractured area to support the spine and help to relieve pain. Some research suggests that it may offer benefits in the case of severe compression fractures, such as those significant enough to require opioid drugs to ease discomfort, says Joshua Hirsch, MD, chief of the Interventional Spine Service at Massachusetts General Hospital.
When it’s questionable: In most cases, vertebroplasty is no more effective at relieving compression fracture pain than a placebo, according to a 2018 Cochrane review of multiple studies. It also noted that vertebroplasty has the potential to cause side effects such as spinal cord or nerve root compression, bone infection, and cement leaking into the bloodstream. That’s why, in general, this procedure isn’t recommended for mild to moderate pain that responds to pain relievers like acetaminophen, ibuprofen, or naproxen, as well as the nasal medicine calcitonin, says Patrick Doherty, MD, associate professor of clinical neurosurgery at the Yale School of Medicine. To prevent future vertebral fractures if you have osteoporosis, he suggests that you get plenty of calcium and vitamin D, avoid smoking, limit alcohol, and, when appropriate, take osteoporosis medication.
Four Questions to Ask Before Any Procedure
If your doctor suggests surgery, you may hesitate to ask many questions. But “every medical procedure or surgery carries risks, especially among older adults,” Saini says. “There’s too much at stake: time, money, and most important, your health—not to voice concerns.” Here are questions he suggests and something to mention.
- If your parent had my condition, would you recommend this procedure?“This forces your physician to take a moment and pause,” Saini says.
- What happens if I wait? If putting surgery off for six months to see if your issue resolves won’t affect the outcome, waiting may be reasonable.
- What could go wrong if I have this procedure?“You want to clearly know what the worst possible outcome could be,” Saini says.
- What alternatives are not quite as good but are still effective in my case?You want to know, for instance, if other appropriate options may be less invasive, cause fewer side effects, or require less healing time.
Also, tell your doctor you plan to get a second opinion. “There are a lot of gray areas in medicine,” Saini says, “and it’s not an exact science. Your physician should welcome other colleagues’ ideas and opinions.”