A little more, A little less: Finding "Just Right"

By Eva Martin, MD of Elm Tree Medical, Inc.

Everyone who has ever overdosed on entire pint of Ben & Jerry's knows: you can have too much of a good thing. Modern medicine has brought about miracles, increasing our health and lifespans. However, sometimes, medicine can be too much of a good thing. Too many procedures lead to more complications. Too many medications lead to more side effects. Too many hospitalizations lead to more infections. The list goes on and on. So how can we find a balance between too much and too little in OBGYN?

The RAND study found that Americans access less than 50% of routine recommended primary care. On the other hand, 30% of health care costs are consumed by interventions with no evidence of benefit. I recently read a great article by Dr. Moran, Dr. Main, and Dr. Gee, entitled, "The Goldilocks Quandary of Health Care Resources" exploring this very issue. OBGYN's are responsible for the most common reason for hospitalization in the US (childbirth), the most common surgery (cesarean delivery) and the second most common surgery (hysterectomy). As such, OBGYNs are uniquely well situated to influence the utilization of healthcare. 

In obstetrics, wide variation exists in the utilization of cesarean delivery, episiotomy, labor induction, and labor support methods. ACOG is focusing on creating consensus on best practices in obstetrics. Up first was the recommendation not to induce labor before 39 weeks without a medical indication. Early term inductions for social reasons led to more complications for infants. For instance, in Louisiana, hospitals reported a 30% decrease in NICU utilization after stopping elective inductions <39 weeks, representing tens of millions of dollars in taxpayer savings. What's next? Cesarean deliveries for low risk moms, Patient Safety Bundles, and standardization of diagnosis of labor abnormalities. We are currently under-utilizing safety bundles and practices that support normal vaginal birth.

In gynecology, hysterectomy rates show wide variation across regions. For instance, women in the South are 78% more likely to get a hysterectomy than those in the Northeast. It is estimated that somewhere between 45% and 79% of hysterectomies are "inappropriate," largely due to failure to perform a diagnostic evaluation or to try less invasive treatments first. One hospital demonstrated a 24% decrease in hysterectomies after instituting a protocol of alternative treatments to try first for adenomyosis before hysterectomy. Another over-utilized surgery is removal of the ovaries with the uterus at the time of hysterectomy (40% of hysterectomies). For premenopausal women not at high risk for certain cancers, removal of the ovaries leads to bone loss, cognitive decline, mood dysfunction, and thickening of the arteries. We must work towards a better understanding of the importance of keeping those ovaries! One of the most under-utilized resources in gynecology is Long Acting Reversible Contraception (LARC) like the IUD. Only 10% of US women use LARC, but up to 32% of European women do.

We have a long way to go to reach that balance between too much and too little healthcare in obstetrics and gynecology. We want to hear from you! Have you instituted these changes in your practice?